Photo Credit: CIPhotos
As the use of ECMO expands, input from infectious disease clinicians is needed to standardize antimicrobial prophylaxis and infection prevention practices.
“Over the past 10 years, there has been a rapid expansion in the use of extracorporeal membrane oxygenation (ECMO) in the care of patients with refractory cardiac or respiratory failure,” researchers wrote in Clinical Infectious Diseases. “Infectious diseases clinicians must reconcile conflicting evidence from limited studies as they develop practices at their institutions, which has resulted in considerably different practices globally.”
Physician’s Weekly (PW) spoke with Major Joseph Marcus, MD, to discuss the review he and colleagues published on the available literature on nosocomial infections in patients on ECMO.
PW: Can you explain the context of your research?
Major Joseph Marcus, MD: Our manuscript was a narrative review of the literature describing infections in adults receiving ECMO. This technology has been rapidly expanding across the world after the CESAR and EOLIA trials showed that ECMO saved lives for patients with acute respiratory distress syndrome (ARDS) and is discussed in both the US and European ARDS guidelines. With this rapid expansion, infectious disease clinicians are confronted with challenging cases in ECMO, and we wanted to summarize the literature and provide some guidance to infectious disease clinicians.
What questions did you and your colleagues seek to answer?
Our manuscript is a narrative review of the literature on adult ECMO infections. We wanted to summarize the diagnosis, treatment, and prevention of infections on ECMO, as well as infection control and antimicrobial prophylaxis.
How did you carry out your research?
This research involved a team of two adult infectious diseases physicians with leaders in critical care and cardiothoracic surgery. This multidisciplinary team was built to ensure there were experts in all aspects of ECMO care.
What were the primary findings?
There are limited data to guide the infectious management of ECMO-associated infections and a need for multicenter, international collaborations to determine best practices. Key points that infectious disease providers should take away is that patients receiving ECMO are hyperinflammatory due to interactions between the patient’s immune system and the circuit, which leads to immune activation. Traditional markers of infection lack specificity in identifying infections. An additional consideration in treatment is the formation of biofilms on the circuit, which makes treatment potentially more difficult.
What infection and antimicrobial standards exist for ECMO?
Current practices vary widely by center for both antimicrobial prophylaxis and infection prevention. I believe that there probably is not a “one size fits all” solution to either of these questions due to different hosts (different types of infections in neonates vs adults) and geography; for example, Gram-negative bacteremia is more common in Asian ECMO centers compared with European or American ECMO centers.
What questions remain in this area of research?
The use of ECMO in adults is still a relatively young field that is growing rapidly. The first question that must be answered is basic: What is an ECMO infection? Standardizing definitions for infections and transparent reporting of infection prevention, antimicrobial prophylaxis, and culturing practices at the ECMO centers will be key next steps as we move forward.
Is there anything else you would like to mention?
Patients receiving ECMO are critically ill and require complex teams of critical care physicians, cardiologists, and cardiothoracic surgeons, as well as nurses, therapists, and pharmacists. Infectious disease physicians need to work both locally and nationally to create protocols with their ECMO teams to help inform this rapidly growing field.
