Attention to aseptic technique during ECMO cannulation and commencement is vital, as is ongoing meticulous care of the cannula insertion sites, including minimising bleeding and movement of cannula.

Antibiotics are not specifically prescribed for ECMO initiation or for ongoing prophylaxis against infection.

ECMO patients are at significant risk of hospital-acquired infection. As per other ICU patients, line sepsis is a possibility in ECMO patients however the changing of ECMO cannula conveys significant risk to the patient and, outside of exceptional circumstances, is not to be changed for this single purpose.

Infections are a serious and relatively common complication of ECMO. Studies show an increase in mortality in ECMO patients who acquire significant infections. Vigilance for infections is vital but challenging as usual signs of infection may not be present, such as a fever or a raised white cell count. Therefore, infection should be considered in any unexplained deterioration in an ECMO patient. The commencement of antimicrobials should be considered in ECMO patients if there is a significant suspicion for sepsis. Ideally, antibiotic selection should be done based on local ECMO protocols, which take into account local antibiotic resistance patterns, the patient’s previous antibiotics, and microbiology and with advice from an infectious diseases team.

The ELSO registry suggests Coagulase-negative staphylococci and candida are the two most common causative organisms, with Enterobacteriaceae, Pseudomonas, and Staphylococcus aureus also important.

Antibiotic dosing on ECMO is also problematic with uncertainty as to optimal dosing given the ECMO and potentially concurrent acute renal impairment, although there is limited robust evidence in this area.

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