Abstract
Objectives: To report the management of three consecutive patients with relapsing Staphylococcus aureus prosthetic knee infection (PKI) for whom explantation was not feasible who received a phage therapy during a “Debridement Antibiotics and Implant Retention” (DAIR) procedure followed by suppressive antimicrobial therapy.Methods: Each case was discussed individually in our reference center and with the French National Agency (ANSM). The lytic activity of three phages targeting S. aureus, which was produced with a controlled and reproducible process, was assessed before surgery (phagogram). A hospital pharmacist extemporaneously assembled the phage cocktail (1 ml of 1 × 1010 PFU/ml for each phage) as “magistral” preparation (final dilution 1 × 109 PFU/ml), which was administered by the surgeon directly into the joint, after the DAIR procedure and joint closure (PhagoDAIR procedure).Results: Three elderly patients were treated with the PhagoDAIR procedure. Phagograms revealed a high susceptibility to at least two of the three phages. During surgery, all patients had poor local conditions including pus in contact to the implant. After a prolonged follow-up, mild discharge of synovial fluid persisted in two patients, for whom a subsequent DAIR was performed showing only mild synovial inflammation without bacterial persistence or super-infection. The outcome was finally favorable with a significant and impressive clinical improvement of the function.Conclusions: The PhagoDAIR procedure has the potential to be used as salvage for patients with relapsing S. aureus PKI, in combination with suppressive antibiotics to avoid considerable loss of function. This report provides preliminary data supporting the setup of a prospective multicentric clinical trial.
Highlights
Prosthetic-joint infection (PJI) is the most dramatic complication after joint arthroplasty
Three consecutive elderly patients were treated with the PhagoDAIR procedure
After the PhagoDAIR procedure, patients were treated with antibiotics in combination during 6 to 12 weeks, followed by suppressive antibiotic treatment (SAT), according to the IDSA guidelines (Table 1) (2)
Summary
Prosthetic-joint infection (PJI) is the most dramatic complication after joint arthroplasty. Prosthesis explantation is sometimes not feasible, especially for the knee location in elderly patients with multiple comorbidities at risk of dramatic loss of function, reduction of the bone stock, fracture, or death. Debridement Antibiotics and Implant Retention (DAIR) could be used for such patients but the risk of relapse is high due to the bacterial persistence in biofilm on the implant surface, even if suppressive antibiotic treatment (SAT) is usually proposed for these patients (1–4). In this context, the use of new adjuvant therapies that locally target the bacterial biofilm is of great interest as it may increase the success rate of SAT
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