(223) Antibiotics for VA ECMO: Necessary Prophylaxis or Breeding Stronger Bugs?

Introduction: Post veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation site vascular complications, infections, and technical considerations are well documented in the surgical literature. However, details of the infections including causative organisms, sensitivities, and antibiotic use during the ECMO run have not been commonly reported.

Methods: This is a single-center, retrospective, observational study that analyzed patients ≥18 years of age who underwent peripheral VA-ECMO from January 2021 to June 2024 and required return to the operating room for a cannulation site infection debridement.

Results: A total of 169 VA-ECMO patients met inclusion criteria with an average age of 57.2, 120 (71%) were male and 17 (10%) had undergone at least 1 cardiac transplantation. There was no difference in age, gender, race/ethnicity, or antibiotic prophylaxis between the patients with and without infection. 6 (3.5%) patients had post-decannulation vascular complications, 4 (2.3%) chronic lymphorrhea, and 9 (5.3%) infections requiring debridement (1 (11.1%) axillary and 8 (88.9%) femoral). 1 of the 9 patients with ECMO site infections received a heart transplant during the hospitalization. 8 (88.9%) of the 9 infections had at least one organism resistant to the prophylaxis the patient had received while on ECMO. The most commonly used prophylaxis at the center was Cefepime (77.5%) and Vancomycin (87%). Among the organisms cultured from the 9 infections were 3 Candida species, 5 Enterococcus faecium VRE, 2 Pseudomonas aeruginosa pan sensitive, 1 Klebsiella pneumoniae carbapenemase, and an MRSA strain that demonstrated MIC creep with a rise from 1 to 2 while on therapy.

Conclusions: This study highlights decannulation site infection as a morbid complication. Despite the almost universal administration of broad-spectrum antibiotic prophylaxis, a high percentage of cannulation site infections demonstrate resistance to that prophylaxis. Future investigation is warranted to evaluate if antibiotic prophylaxis is beneficial or potentially applies selection pressure towards increasingly resistant organisms.