Vascular graft infection due to Pasteurella multocida
© Fourreau et al. 2015
Received: 1 April 2015
Accepted: 20 December 2015
Published: 30 December 2015
Vascular graft infections are infrequent complications with important morbidity and mortality rates. Pasteurella multocida, a Gram negative bacillus, is a normal oral commensal of many animals. For mankind, it is a pathogenous bacillus which is rarely implicated in vascular grafts.
We report hereafter the fourth case introduced in the international literature about vascular graft infections caused by P. multocida. The patient was successfully treated with a combination of a surgical graft change and a 6 weeks bi-antibiotic therapy.
There is fours case reported in litterature with quite different antibiotic drugs and duration.
P. multicoda graft infection should be long with initial intravenous drug and mainteance traitement should not be required.
The most common clinical infection of Pasteurella multocida is a local cellulitis subsequent to animal scratches or bite wounds. The second pathological form is a pulmonary localization and affects persons close to animals (Hubbert and Rosen 1970).
The incidence of bacterial vascular graft infection is estimated between 0.5–5 % depending of the graft localization, according to a 5 years follow up (Goldstone and Bowersox 1996). The infection appears 7 months after surgery with a limb’s amputation risk from 10 to 70 % and a mortality rate from 10 to 30 % (Bandyk 2000; Hennes et al. 1996). The most frequently isolated germs are Staphylococcus aureus (30 %) and Staphylococcus epidermidis (17 %). We noticed here an infection of P. multocida vascular graft after an asymptomatic cat scratch.
A 59 years old Caucasian woman was admitted in December 2011 to the emergency department of our institution for a tumefaction in the right scarpa. This painful and fast expending pulsatile tumefaction was developed over a week and was accompanied by fever at 39–40 ℃.
Her case history indicated a left iliofemoral bypass in 2005 and a changed by femoral left right crossover graft in April 2009. Moreover a tobacco addiction and an alcohol intoxication were stopped in 2006 with neither cirrhosis nor chronic obstructive pulmonary disease. In 2008, she had a T2N2aM0 tonsil cancer, treated by surgery and radiotherapy. She has been considered in remission since 2008.
Pasteurella are small Gram negative coccobacilli with bipolar and aerobic-anaerobic respiratory type. These bacteria are able to induce a severe inflammatory reaction and necrotizing lesions probably due to a lipopolysaccharide endotoxin production. P. multocida has a natural resistance to vancomycine and clindamycin but remains sensitive to many antibiotics: β-lactams, fluoroquinolones, tetracyclines and imidazole. Macrolides and aminoglycosides have a lower activity. The β-lactams and tetracyclines—alone or combined with imidazoles–macrolides or aminoglycosides are the antibiotics advised to treat pasteurellosis and infections after bites or scratchs. Doxycycline–bacteriostatic antibiotic—is used sparingly in severe infections, particularly bacteremia. Therefor and in reason of their good pharmacological and pharmacokinetic data, fluoroquinolones are often favored. In vascular graft infection, the choice of the mono or bi therapy antibiotic is not really defined.
Pasteurella are found on the mucous membranes of the mammal and bird aerodigestive tract (Weber et al. 1984). Four species are responsible for most human infections (P. multocida, P. canis, P. stomati and P. dagmatis), but P. multocida is the most frequently isolated in human pathology. Human infection from bites, scratches or licking damaged skins has mainly a feline (60–80 % of cases) or canine origin (90 % of remaining cases) (Weber et al. 1984) and comes exceptionally from plant stings. The infection rate reported after medical consultation for cat or dog bites is between 7 and 17 %. Pasteurella colonization and infections at the respiratory tract’s level, with or without bite or scratch are described among people who have frequent contacts with animals (i.e. veterinarians, owners of small animals and farmers) (Hubbert and Rosen 1970; Jones and Smull 1973).
In human pathology, P. multocida is responsible for several types of infections. It causes abscesses and cellulitis ducts by direct bite inoculation. They are characterized by a short incubation of several hours with a very sore inflammatory pain and the appearance of lymphangitis during the second day. The infection may be spontaneously cured or progress to a subacute form in the absence of antibiotics treatment. Subacute forms appear several weeks after inoculation and are characterized by a reactive arthritis and tenosynovitis with important functional sequelae. There are also blood-borne infections, with significant mortality on immunocompromised patients (specially cirrhosis) (Weber et al. 1984; Stein et al. 1983) where P. multocida has been implicated in lung abscesses, meningitis, brain abscess, but also a few cases of endocarditis. This species can also be grafted on foreign implants. There are several cases reported in the literature mainly orthopedic prosthetic infections but only three published cases are reported for vascular prosthesis infections (Kalish and Sands 1983; Sannella et al. 1987; Kessler et al. 2004).
Main characteristics of the three cases of graft infection in P. Multicoda reported in litterature and our case
Kalish et al. (1983)
Sannella et al. (1987)
Kessler et al. (2004)
Patient reported in our observation
Infected graft localisation
Femoral crossover bypass
Femoral crossover bypass
Time of infection after prosthetic restoration (months)
Via a wound
Fever pain erythema pulses’ abolition
Fever pain pulsatile massquick increase
Ampicilline then ceftriaxone
Duration of antibiotic therapy
Doxycycline for life time
In this case and the one with Sannela et al. (1987), no deep lesion was found either next to the scar or remotely. This situation could tend to suspect symptomatic or asymptomatic bacteremia, with risk of graft infection in patients with vascular prosthesis. Few cases are reported in the literature but when patients are bitten and scratched by animals, prophylactic antibiotics could be discussed for patients with prosthetic material to prevent secondary bacterial graft.
When scratch or animal bites are identified, a bacterial graft infection should be suspected with P. multocida no matter where they are from the scar or material. Then, the antibiotic treatment, such as other bacterial prosthetic infections, should be quite long—mainly 6 weeks—with initial intravenous drug. However the maintenance therapy should not be required. Finally, as few cases have been reported, the use of primary prophylaxis is not significant for all people including those who have animals or prosthesis.
FF: has acted to provide patient care, made diagnosis, administered treatments and written the manuscript. FM: has been involved in drafting the manuscript and criticized all part constructively. JB: reviewed the surgery part. OB: has given his final approval of the version to be published. BP: has given his final approval of the version to be published. All authors read and approved the final manuscript.
F. Jaureguy, F. Robertson. The patient gave written informed consent in medical folder.
The authors declare that they have no competing interests.
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