Tips on TIPS Infections
Abstract & Commentary
Synopsis: Infection of transjugular intrahepatic shunt devices is caused by a variety of bacteria, mostly of gastrointestinal origin. Inability to remove the device without hepatic transplantation makes management of the infection difficult.
Source: Armstrong PK, Macleod C. Infection of transjugular intrahepatic portosystemic shunt devices: Three cases and a review of the literature. Clin Infect Dis. 2003;36:407-412.
Armstrong and colleagues in New South Wales identified 3 patients with infection of transjugular intrahepatic portosystemic shunt (TIPS) devices from among 154 patients who underwent 180 TIPS procedures. In addition, they identified 21 published cases meeting their diagnostic criteria, which required the presence of sustained bacteremia in the absence of an explanation other than TIPS infection.
Among the Gram-positive etiologic pathogens were Staphylococcus aureus (3), Enterococcus faecalis (8), Streptococcus sanguis (1), Streptococcus bovis (1), Gemella morilorum (1), and Lactobacillus acidophilus (2). Gram-negative infections were caused by Escherichia coli (5), Pseudomonas aeruginosa (2), Klebsiella pneumoniae (2), and 1 each of Klebsiella oxytoca, Acinetobacter calcoaceticus, Citrobacter amalonaticus, and Bacteroides fragilis. Two infections due to Candida glabrata and 1 to Candida albicans were identified. Four of the infections were polymicrobial.
The incubation period ranged from 1 to 1065 days, with most cases occurring more than 2 months after placement of the device. The majority had evidence of occlusive thrombosis or vegetation. The outcomes after antibiotic therapy were variable.
Comment by Stan Deresisnksi, MD, FACP
It is inevitable that we will encounter infections such as these given the increasing use of TIPS devices for the management of portal hypertension. Most are caused by organisms that are part of the gastrointestinal flora. However, an anaerobic pathogen (B fragilis) was isolated from only 1 of the cases described here. Candida was isolated from 3 patients.
The ability to eradicate the pathogen with antibiotic therapy alone is problematic. Removal of the TIPS is not, unfortunately, possible without liver transplantation. As a consequence, patients with relapse of infection after discontinuation of a prolonged course of bactericidal antibiotic therapy may require lifelong suppressive therapy.
Last month I saw a patient with a TIPS device in place who was being treated for his second relapse of E faecalis bacteremia. Evaluation to identify a source of infection other than the TIPS device, which included a transesophageal echocardiogram, was unrevealing. This patient will indefinitely receive lifelong antibiotic therapy in an attempt to prevent further relapse.
Dr. Derenski is Clinical Professor of Medicine, Stanford; Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center.
Infection of transjugular intrahepatic shunt devices is caused by a variety of bacteria, mostly of gastrointestinal origin. Inability to remove the device without hepatic transplantation makes management of the infection difficult.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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