New Case of Endotipsitis: Urgent Need for Clinical Practice Guidelines

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure used for the decompression of portal pressure since the early 1990s. Bacteremia with an infection of the TIPS or endotipsitis is a serious complication with 32% mortality. To date and including the present case, only 56 cases have been reported in the literature. There are concerns regarding underdiagnosis. We report a case of a patient with endotipsitis and recurrent bacteremia treated successfully in our institution. In addition, previous reported cases were reviewed regarding microbiological data and mortality. Clinical practice guidelines including uniform disease definition, prophylaxis, and treatment of this nosocomial prosthetic-related infection are urgently needed.

Transhepatic Revision of Occluded Transjugular Intrahepatic Portosystemic Shunt Complicated by Endotipsitis

“…6,8,9 Endotipsitis is associated with high morbidity, with mortality rates reported at 32%. 7 While prolonged antimicrobial therapy may resolve the infection, liver transplant may be required.…”

“…Endotipsitis is a rare but highly morbid complication of the TIPS procedure, with an estimated incidence of approximately 1 to 10% [1][2][3][4][5][6] and estimated mortality of 32%. 7 The range in incidence of this adverse event is due to the relatively unreported outcomes of the TIPS procedure. Six studies that describe retrospective analysis of all TIPS procedures and suspected endotipsitis cases in six distinct institutions each found a slightly different rate of incidence of the infection.…”

“…8 A review of the literature published in 2017 identified 56 cases of endotipsitis, concluding that the overall mortality of all reported cases at that time was 32%. 7 The use of broadspectrum prophylactic antibiotics in the TIPS perioperative period has been found to be an effective method to prevent infection and are widely used, 4,6 though some institutions prefer to individualize the use of prophylaxis. 2,3,9 Recent case reports suggest that among the most fatal infections documented include Staphylococcus aureas with 63% mortality and Candida species with 67% mortality on the basis of a retrospective analysis of seven patients with S. aureus and eight patients with candida infection.…”

“…Though the incidence is estimated to be 1 to 10%, [1][2][3][4][5][6] it is likely that TIPSrelated infections have been underreported, in part because there has not been a commonly accepted identification or classification of the infection. 2,4,7,15 In their 1998 publication, Sanyal and Reddy define endotipsitis as follows:…”

Recurrent bacteraemia following variceal haemorrhage

“…Tipsitis (also known as endotipsitis), infection of TIPSS, may occur from weeks to months after insertion, with little known about the pathogenesis 1. It is a rare but serious complication of this procedure2: 55 cases have been reported with 32% associated mortality 3. There are no uniform diagnostic criteria for the condition, but tipsitis should be considered as a possible diagnosis in patients who have undergone TIPSS insertion and who present with unexplained bacteraemia 4.…”