Infection during ECMO

ECMO patient is a very critically ill patient and exposed to all hospital
acquired infections like other ICU patients.

• Ventilator Associated Pneumonia

• Blood Stream Infection
• Urinary Tract Infection
• Catheter Related Infection
Sepsis and septic shock

Where is our patient?

Infection on ECMO: Are ECMO patients any different?
Potential additional sources of Infections during ECMO

Cannulation site

Circuit

Transfusion

Open chest

Cannulation
procedure
Infection during ECMO

• ECMO patients are obviously extreme fragile and ultimately already

failed either or both cardiac or respiratory system.
• The addition of sepsis can be detrimental.
• Based on ELSO data: mortality on all patient in ECMO with reported
infection ranged from 56-68 %
• So we better take the famous quote from Sun Tzu's The Art of War
seriously : “Know Your Enemy.”
Infection during ECMO: Objectives

• Incidence : based on type, age group, modality etc.

• Recognition of infection
• Treatment and prophylaxis
• ELSO recommendations
• Limitations of ELSO recommendation
• Infection control
What can we do to prevent infection? How to improve our
practice?
ELSO Organization: Infectious Disease Task Force

• Review of ELSO data base: incidence, offending organism

• Survey the existing ECMO centers
• Conducting studies on pre-primed circuits, antibiotic binding
• Literature review
• Specific recommendations for best practices in ECMO infection
prevention
ELSO Infectious Disease Task Force

• Retrospective study of the ELSO database

• ECMO centers linked to ELSO
• 1998-2008
• Culture proven infection
• Data analysis
ELSO Infectious Disease Task Force
ELSO Infectious Disease Task Force

• 1998-2008, during which 20,741 ECMO case was reviewed

• Overall incidence 15.4%
• Overall prevalence 11.7 infection /1000 ECMO day
• Highest incidence by indication: E-CPR in ALL age group > then cardiac >
respiratory
• Lowest -Highest incidence by age: neonatal (8.7- 14.8-17.4 :10.1%)
pediatric(20.5-20.7-22.8: 20.8%) versus adult (26.7-36.7-42.8: 30.6%)
• ECMO runs were far longer in “infected” groups
Neonate Pediatric Adult
Most common Coagulase negative Pseudomonas, Pseudomonas,
organism found in Staphylococcus S. aureus, Candida S. aureus, Candida
positive cultures albicans albicans

Miscellaneous: Enterobacter, Klebsiella, Enterococcus, E.coli

Infection during ECMO

• The available data does not delineate is whether the longer run led to
higher risks of infections, or the reverse, that patients who are either
placed on ECMO for complications of infections already present, or who
developed infections early in their course, leading to sicker patients and
longer ECMO runs.
• highest odds ratio for mortality in the neonatal groups
• This relationship between the risk of infection and length of support, as
well as increased mortality with infection has been demonstrated in many
studies and in all age group specifically in cardiac patients.

1-7 days on ECMO 1-2 weeks on ECMO Over 2 weeks of

ECMO

Incidence 6.1% 15% 30.3%

Different Practical Approaches

• ABX Prophylaxis for cannulation

• ABX Prophylaxis for ECMO run
• Management of cannulation site
• Diagnosis of infection
• ECMO circuit management
• ECMO circuit management during bloodstream infection
Antibiotic prophylaxis

• Tremendous variety in use of prophylactic AB

• No randomized trials examining this issue
• No data support extended routine use of AB
• DOES NOT apply to cardiac patients especially with transthoracic
cannulation through open chests
• AB prophylaxis required for cannulation
• Prophylactic antibiotic should follow standard principles of surgical
prophylaxis: single dose or maximum 24hrs
Circuit management

• Needles hub
• Do not break circuit unnecessarily
• Continuous infusion
• Chlorhexidine disinfectant
• Universal precautions
• Single nursing approach
Difficulties in Diagnosing Infection/Sepsis

Pros Contras Strategies in diagnosing

Altered mental status Sedation
Change of hemodynamics after being
Temperature change Controlled stable
e.g. hypothermia, temperature on
fever ECMO Unexplained lactic acidosis
Tachypnea, dyspnea Neuromuscular
blockade, Lung rest Falling SvO2

Leucopenia, SIRS triggered by Signs of Hypovolemia (unexplained)

Leukocytosis CPB, ECMO circuit

Thrombocytopenia Consumption, Signs of increased metabolism (CO2

Bleeding climbing, need to increase sweep)
Hemodynamics Circulatory supports
Change of cell count after new baseline
ID markers Influenced by SIRS stabilization (Leukocytosis, Leukopenia,
triggered CPB, ECMO Thrombocytopenia)
Basics of Infection Control

• Aseptic handling of ECMO cannulas

• Oral and GI decontamination protocols
• Bundles to prevent CLABSI, VAP, CAUTI
• Early and complete enteral nutrition
• All unnecessary lines, access and devices be removed once the patient is
stable on ECMO
• Regular cultures ( daily to weekly)
Management during blood stream infection

Reported BSI rates are 5-10 times higher then on non-ECMO critically ill
children.
• Presumed sepsis in patients on ECMO, choice of empiric therapy should
strongly consider data obtained by the ELSO database
• Persistently positive blood cultures, clinical sepsis despite appropriate
ABX:
• Looking for hidden source e.g. abscess
• Consideration to change entire circuit as it might become colonized
Pharmacokinetic consideration I.

• lipophilic drugs and highly protein-bound drugs (e.g.,

voriconazole and fentanyl) are significantly sequestered in the
circuit
• hydrophilic drugs (e.g. β-lactam antibiotics, glycopeptides)
are significantly affected by hemodilution and other
pathophysiologic changes that occur during ECMO
• Scarce data existing on PK
Pharmacokinetic consideration II.

• ECMO circuit : drug sequestration and increased volume of

distribution, might lead to a decrease in drug concentrations
during a patient's treatment.
• Altered clearance: RRT, renal insufficiency
• Physiological factors: age, BMI
• Disease specific factors : MOF, hypoalbunemia, edema, altered
organ perfusion
• Pharmacogenetics: Enzyme activity

E. g. Vancomycin, which is the drug of choice for treating beta-

lactam resistant Gram-positive bacteria, is frequently prescribed to
ECMO patients. Data on vancomycin concentrations reported in
ECMO are controversial.
Limitation of recommendation

• not having dates or sources for cultures

• not being able to clearly distinguish infection versus
colonization
• recognizing the not collecting data about high risk conditions
such as open chest and open abdomens or preexisting
infection
• presence of inaccurate and/or insufficient reporting of some
other data points (mode of ECMO e.g.)
• Insufficient recommendation regarding pharmacokinetics
Infection Control on ECMO

Prevention :
What can we do to prevent infection until new studies
awaiting ?
How to improve our practice?
Collect information!
Data collection on Infection on ECMO
2014-2015
• Tertiary care hospital, Cardiac PICU Primary Diagnosis

• neonate/pediatric age group, adult case were HLHS 9

excluded due to insufficient number AVSD 3
(unbalanced)
• Age: 1 week to 2-years TFO 3
• 25 patients TGA 2

• VA-ECMO: 96% HRHS 2

• Cannulation: transthoracic 84%, neck 12%, TGA+IAA 1

femoral 4% TA+IAA 1

• Open chest: 88% w/ AB prophylaxis TA 1

Meconium aspiration 1
• IC bundles for CLABSI, VAP, UTI, SSI in place
• Patients w/ CLS on steroid Diaphragmatic hernia 1

Myocarditis 1
Data collection on Infection on ECMO
2014-2015

• By indication cardiac > E-CPR > respiratory case

• 11 patient had at least 1 nosocomial infection
• Successful decannulation rate : 56%
• Mortality 64%
Average Length of
ECMO, 9.3 days

30

25

20
Days of ECMO

15

10 PICU ECMO 2014-2015

5

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Different Microorganism from positive cultures
2014-2015

E. faecalis 4%
Stenotroph. 4%
S. aureus 4%
Serratia 4%

Enterobacter 4%
Candida 24%

Pseudomonas
16%

Klebsiella 20%

E.coli 12%

S. epidermidis 8%
Source and time of positive cultures

The average of first positive

cultures came back on day 7
3%
9% of ECMO.

12% 1 • ETT
41%
2 • Blood

13%
3 • Urine
4 • Wound
5 • Pleural
22%
6 • Peritoneal
Conclusion
• No specific data on incidence of infection with open chest, transthoracic
cannulation
• Highest incidence :VAP
• Reinforcing enteral feeding: postpyloric tube
• Oral / GI decontamination protocol should be considered?
• Reinforcing VAP bundle
• Other source of contamination?
• Candida species significant 24% v 12%
• Routine antifungal prophylaxis after 1 week or when on ABX+steroids?
• Additional fungal antigen PCR? For early detection
• E. coli, Pseudomonas, Klebsiella species should be covered
• Including MDR
• Staphylococcus species were less significant 4% v 15.9%
• (might suggest effective AB prophylaxis)
Summary
• Know the ELSO data on infection, follow recommendation
• consider oral and GI decontamination protocols
• Bundles to prevent CLABSI, VAP, CAUTI, SSI
• Early and complete enteral nutrition
• All unnecessary lines, access and devices be removed once the patient is
stable on ECMO
• If positive blood culture consider changing circuit
• Minimize the length of ECMO run
• Data collection: microorganism, usual susceptibility, MDR resistant
microorganism specific to the facility
• Preferably ABX with wide therapeutical window or measurable level kept
in mind narrow therapeutical window/toxicity
• Further studies awaiting