In recent years, there has been a notable increase in the use of extracorporeal membrane oxygenation (ECMO) in critically ill patients suffering from acute respiratory distress syndrome (ARDS). So much so that its inclusion in ARDS management guidelines by different societies is a testament to this growth. While this technologically-advanced treatment presents new possibilities, it brings with it the challenge of ECMO-associated infections (EAIs).
As the number of patients benefiting from ECMO rises, it becomes increasingly important for healthcare practitioners, particularly those specializing in infectious diseases, to develop a comprehensive understanding of EAIs, along with strategies for their prevention and management. Complicating the EAI study is the absence of a universal definition, which contributes to reported infection rates varying widely. Presently, there’s no standard EAI definition by the Extracorporeal Life Support Organization (ELSO). The definitions most commonly used in literature are drawn from the Centers for Disease Control and Prevention or the National Health Safety Network.
It is important to note that conventional signs, symptoms, and diagnostic tests can often mislead in terms of diagnosing EAIs, due to the unique clinical context of ECMO. Recognizing the uncertainty around EAIs, infectious disease physicians are best suited to distinguish true infections from colonization. These physicians should play a central role both in local institutions and national panels evaluating EAIs. Multi-disciplinary input is vital in managing the complexities of EAIs.
Proactive diagnostic stewardship, emphasis on alternative noninfectious diagnoses, and careful use and interpretation of diagnostic tests can drastically enhance clinical management. When it comes to treatment, two approaches dominate – prophylaxis and therapeutics. ELSO provides no concrete policy on using prophylactic antibiotics for ECMO patients. Conversely, the treatment should be guided by the focus of the infection, available microbiologic data, and patient’s clinical course.
It is advisable that antimicrobial dosages are customized based on patient-specific dynamics, as multiple factors can impact medication’s pharmacokinetics in ECMO environments. The need of the hour is a substantial research effort with an international collaboration to enhance our understanding, prevention, and treatment strategies of EAIs.
Lastly, it is critically important for healthcare guideline-making bodies to consider establishing standardized definitions and reporting mechanisms for EAIs. The compelling circumstances in the world of ECMO-associated infections highlight the importance of a thorough interdisciplinary approach, myriads of challenges, and directions for the future.