Chronic Suppressive Antibiotics Research Articles

Systemic Inflammation Response Index (SIRI) and Monocyte-to-Lymphocyte Ratio (MLR) Are Predictors of Good Outcomes in Surgical Treatment of Periprosthetic Joint Infections of Lower Limbs: A Single-Center Retrospective Analysis.

Periprosthetic joint infection (PJI) is a devastating complication that develops after total joint arthroplasty (TJA), whose incidence is expected to increase over the years. Traditionally, surgical treatment of PJI has been based on algorithms, where early infections are preferably treated with debridement, antibiotics, and implant retention (DAIR) and late infections with two-stage revision surgery. Two-stage revision is considered the "gold standard" for treatment of chronic prosthetic joint infection (PJI) as it enables local delivery of antibiotics, maintenance of limb-length and mobility, and easier reimplantation. Many studies have attempted to identify potential predicting factors for early diagnosis of PJI, but its management remains challenging. In this observational retrospective study, we investigated the potential role of inflammatory blood markers (neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI)) as prognostic factors in two-stage exchange arthroplasty for PJI. A single-center retrospective analysis was conducted, collecting clinical data and laboratory parameters from patients submitted to prosthetic explantation (EP) for chronic PJI. Laboratory parameters (PCR, NLR, MLR, PLR, SIRI, SII, and AISI) were evaluated at the explantation time; at 4, 6, and 8 weeks after surgery; and at reimplantation time. The correlation between laboratory parameters and surgery success was evaluated and defined as infection absence/resolution at the last follow-up. A total of 57 patients with PJI were evaluated (62% males; average age 70 years, SD 12.14). Fifty-three patients with chronic PJI were included. Nine patients underwent DAIR revision surgery and chronic suppressive therapy; two patients died. Nineteen patients completed the two-stage revision process (prosthetic removal, spacer placement, and subsequent replanting). Among them, none showed signs of reinfection or persistence of infection at the last available follow-up. The other twenty-three patients did not replant due to persistent infection: among them, some (the most) underwent spacer retention; others (fewer in number) were submitted to resection arthroplasty and arthrodesis (Girdlestone technique) or chronic suppressive antibiotic therapy; the remaining were, over time, lost to follow-up. Of the patients who concluded the two-stage revision, the ones with high SIRI values (mean 3.08 SD 1.7 and p-value 0.04) and MLR values (mean 0.4 SD 0.2 and p-value 0.02) at the explantation time were associated with a higher probability of infection resolution. Moreover, higher variation in the SIRI and PCR, also defined, respectively, as delta-SIRI (mean -2.3 SD 1.8 and p-value 0.03) and delta-PCR (mean -46 SD 35.7 and p-value 0.03), were associated with favorable outcomes. The results of our study suggest that, in patients with PJI undergoing EP, the SIRI and MLR values and delta-SIRI and delta-PCR values could be predictive of a favorable outcome. The evaluation of these laboratory indices, especially their determination at 4 weeks after removal, could therefore help to determine which patients could be successfully replanted and to identify the best time to replant. More studies analyzing a wider cohort of patients with chronic PJI are needed to validate the promising results of this study.

Safety of total elbow arthroplasty in patients with rheumatoid arthritis and prior hip or knee periprosthetic joint infection

BackgroundThe volumes of upper and lower extremity arthroplasty are increasing. Periprosthetic joint infection (PJI) after TEA remains a substantial cause of morbidity, with certain studies reporting primary total elbow arthroplasties (TEA) PJI rates over 10%. The odds ratio for hip and knee PJI after previous hip or knee PJI is 3 times, and it rises to 15 times for patients on chronic suppressive antibiotics. The risk of PJI for primary TEA in patients with a history of lower extremity PJI is unknown. The purpose of this study, therefore, was to compare the incidence of PJI after primary TEA in patients with a history of lower extremity PJI in a case-control study. MethodsOur institutional joint registry database was queried to identify all patients who underwent primary TEA and had previously undergone treatment for lower extremity PJI between 1974 and 2021. Twelve elbows (10 patients) with a mean follow-up of 8.2 years were identified. There were 9 female elbows (75%) and 3 male elbows (25%) with a mean age of 63 years (range,44-78 years), and all patients had a diagnosis of rheumatoid arthritis. This cohort was 1:7 matched (age, sex, side, indication, and surgical year) to 84 elbows (83 patients) with no history of lower extremity PJI. There were no statistically significant differences between the cohorts with regard to body mass index or operative time. Survivorship analysis free of TEA PJI with death as a competing risk was calculated. ResultsNone of the 12 TEA included in the study group developed PJI. The cumulative incidence of PJI in the matched cohort at 10 years was 6.4% (5 elbows). There was 1 superficial infection in the study group (9.1%) and 5 (5.8%) in the matched cohort. In the study group, 2 elbows underwent revision and 4 underwent reoperation. Eight elbows in the matched cohort underwent revision and 23 underwent reoperation. The study cohort was associated with higher risk of revision and reoperation for any cause, but these differences did not reach statistical significance. ConclusionIn this relatively small case control study, there was no incidence of PJI in patients who underwent primary TEA for rheumatoid arthritis and had previously undergone treatment for lower extremity PJI. The cumulative incidence of PJI in the matched cohort at 10 years was 6.4%. Although underpowered to make firm conclusions, it does draw from a very large population of patients and did not reveal an association between infection after TEA and a prior history of lower extremity PJI.

Outcomes of Concurrent Endocarditis and Periprosthetic Joint Infection: A Retrospective Case Series of 16 Patients.

IntroductionConcurrent diagnosis of periprosthetic joint infection (PJI) of total hip arthroplasty (THA) or total knee arthroplasty (TKA) with infectious endocarditis is a devastating clinical scenario infrequently documented in the literature. To date, no studies have fully described the orthopedic and infectious outcomes of patients with these concurrent diagnoses. The purpose of this study was to conduct a case series of patients with these diagnoses and document the orthopedic and infectious outcomes so that surgeons may effectively counsel patients regarding the gravity of the condition and the expected course of treatment.MethodsThis study is a retrospective case series using patient data from five hospitals within an academic healthcare system in the northeastern United States. Cases of concurrent endocarditis and THA or TKA PJI with a minimum of one-year follow-up were identified from January 2000 to January 2021. Basic statistics such as means, standard deviations, and percentages were used to identify trends within our series. Kaplan-Meier survivorship curves with log-rank tests were performed to determine if there were any differences in two-year mortality and joint survival (defined as needing explant) between patients who had cardiac surgery prior to surgical management for their PJI and those who had surgical management for PJI prior to cardiac surgery.ResultsA total of 18 joints in 16 patients with endocarditis and concurrent TKA or THA PJI were identified. All PJIs were managed surgically, with 14/18 (77.77%) of joint infections initially being managed by debridement, antibiotics, and implant retention (DAIR) and 4/18 (22.22%) of joint infections initially being managed by explant. Within the first six months of PJI diagnosis, 25% (4/16) of patients died of complications related to their infection, and one additional patient died of bacteremia just over a year after the initial PJI diagnosis. Of the 18 PJIs, 72.23% (13/18) had treatment failure, defined as any outcome equal to or worse than requiring chronic suppressive antibiotics for the infection. Due to low statistical power, we were not able to identify any differences in two-year mortality from PJI diagnosis (p=0.311) or joint survival (in terms of requiring explant) (p=0.420) depending on whether cardiac surgery or DAIR was performed first.ConclusionsConcurrent infectious endocarditis and prosthetic joint infection is associated with high morbidity and mortality. Patients with these concurrent infections should be counseled that not only the associated mortality rate is high, but also the surgical treatment of their PJI has a high rate of treatment failure, including an explant following an initial DAIR, an explant with retained spacer, or a requirement of lifelong antibiotic suppression.

Isothermal Microcalorimetry Improves the Time to Diagnosis of Fracture-related Infection Compared With Conventional Tissue Cultures.

Isothermal Microcalorimetry Improves the Time to Diagnosis of Fracture-related Infection Compared With Conventional Tissue Cultures.

Predictors of Success With Chronic Antibiotic Suppression for Prosthetic Joint Infections

BackgroundManagement of recurrent prosthetic joint infection (PJI) after attempted surgical eradication remains a challenge. Chronic antibiotic suppression (CAS) is regarded as a reasonable treatment option for select patients with persistent infection or multiple comorbidities. The study seeks to compare cohorts who succeed and fail with CAS. MethodsThis retrospective cohort study assesses patients who were treated with CAS for a PJI. Patients were included if they had a culture-proven PJI and received chronic suppressive antibiotics. Failure of suppression was defined as reoperation after initiating CAS or death occurring as result of infection. A Cox proportional hazards multivariate regression model was used to estimate risk of reoperation as a function of risk factors related to patient comorbidities, surgical history, affected joint, and infecting organism. ResultsWe identified 45 PJIs (31 knees, 14 hips) managed with CAS with a median follow-up of 50 (95% confidence interval [CI] 33.61-74.02) months. The overall success rate of managing PJI with CAS was 67% (30/45). Controlling for body mass index and Gram status of the organism, total hip arthroplasty patients were less likely than total knee arthroplasty patients to require reoperation (hazard ratio 0.18, 95% CI 0.01-0.96, P = .04). Patients with Gram-positive infections were less likely than those with a Gram-negative infections to require reoperation (hazard ratio 0.22, 95% CI 0.05-0.88, P = .03). Severe antibiotic side effects were rare. Patients who experienced multiple changes to their antibiotic regimen were more likely to fail with CAS. ConclusionCAS is a reasonable strategy in patients with PJI who lack or refuse further surgical treatment options. Most hips and Gram-positive infections treated with CAS successfully avoided reoperation in this cohort.

252. Joint Decisions: Optimal Duration of Chronic Suppressive Antibiotics in Adults with Prosthetic Joint Infections Who Underwent Debridement, Antibiotics, Irrigation, and Retention of Prostheses

Abstract Background Hip and knee arthroplasties are associated with complications including prosthetic joint infections (PJI). Management ranges from explantation to debridement, antibiotics, irrigation, and retention of prostheses (DAIR). In DAIR, patients receive intravenous antibiotics followed by chronic suppressive antibiotics. Current guidelines on suppressive antibiotic use after DAIR are unclear and based on expert consensus. This study seeks to elucidate the optimal duration of chronic suppressive antibiotics after DAIR. Methods This is a retrospective cohort study of adults in the Southern California Kaiser Permanente System with hip and knee prosthetic joint infections who underwent DAIR from 2007-2017. Culture data and durations of suppressive antibiotics were collected and patients were followed for 1 year after completion. Treatment failure was determined by mortality, re-infection, or prosthesis removal. Patients who received no antibiotics vs. less than 3 months vs 3 to 6 months vs greater than 1 year were compared. Results 350 charts were reviewed and 145 patients were included. There were 87 knee and 58 hip PJIs with 32 patients (22%) who failed treatment. There were more cases of failure when patients didn’t receive suppressive antibiotics (27%) vs those who received any (19%), however the results were not significant. There were no significant differences in failure rates between short vs longer suppressive antibiotic courses regardless of the duration (Staph vs non-Staph, hip vs knee). Patients with Staphyloccocal infections and knee infections were significantly more likely to fail treatment (p=0.0196 & 0.0150, logistic regression). Conclusion This study shows the importance of suppression with oral antibiotics after PJIs are treated with DAIR. The lack of difference in treatment failure between the durations of suppressive antibiotics makes it prudent to consider shorter courses of antibiotics, while placing attention on patients with knee and Staphylococcal infections as they are more likely to fail treatment. Limitations include sample size, difficulty in quantifying extent of initial infection and debridement, and provider dependent prolonging of antibiotic duration. Disclosures All Authors: No reported disclosures

1040. Knee Explant Analysis (KnEA) Using PLG0206 in Periprosthetic Joint Infection (KnEA Study)

BackgroundPLG0206 is a novel engineered cationic antimicrobial peptide being evaluated for treatment of prosthetic joint infections (PJI). This study evaluated the rapid bactericidal activity of PLG0206 to decrease biofilm and planktonic bacteria on ex vivo infected prosthesis following removal from patients with chronic PJI.MethodsDe-identified infected prosthetics were removed from nine patients with PJI, despite chronic suppressive oral antibiotics, during a 2-stage revision procedure. Removed prosthetics were then submersed ex vivo to an expected clinical exposure of PLG0206, 1 mg/mL, for ~15 minutes. Upon completion of the 15-minute exposure, the treated explant was placed into buffer and sonicated. The sonication solution was then plated for bacterial analysis including colony forming unit (CFU) enumeration. Remaining explanted implants from the same patient served as a control and was processed similarly but without exposure to PLG0206.ResultsAs shown in the Table, both Gram-positive and Gram-negative bacteria were identified from removed prosthetics during a 2-stage revision procedure of chronic PJI. Eight of ten infected prosthetics treated ex vivo to PLG0206 1 mg/mL were sterilized (No. 1-5, 8-10). Of the two infected prosthetics that were not sterilized (No. 6 and 7), one was polymicrobial (No. 6) and the other was monomicrobial (No. 7). Collectively, infected prosthetics exposed to PLG0206 demonstrated a mean 4log10 reduction (range 2 to 7).Summary of culture and CFU log reduction among infected prosthetics exposed and not exposed to PLG0206 Table: Summary of culture and CFU log reduction among infected prosthetics exposed and not exposed to PLG0206ConclusionOverall, these findings support the ongoing development of PLG0206 as a local irrigation solution at 1 mg/mL concentration in the wound cavity for 15 minutes in patients undergoing treatment of a PJI occurring after total knee arthroplasty.Disclosures David Huang, MD, PhD, Peptilogics (Employee) Nicholas Pachuda, DPM, Peptilogics (Employee) Despina Dobbins, BS, Peptilogics (Employee) Jonathan Steckbeck, PhD, Peptilogics (Employee) Kenneth Urish, MD, PhD, Peptilogics (Grant/Research Support)

Congenital Hepatic Fibrosis as a Cause of Recurrent Cholangitis: A Case Report and Review of the Literature

Rare liver diseases caused by ductal plate malformation, such as congenital hepatic fibrosis (CHF), Caroli syndrome, and polycystic liver disease, can have clinical manifestations such as recurrent cholangitis—frequently involving multidrug-resistant microorganisms—leading to difficulties in selecting the optimal antimicrobial treatment. Without prompt recognition, these infections severely hamper the patient’s quality of life and can develop into life-threatening complications. We report here the case of a 50-year-old woman with a history of recurring cholangitis with occasional systemic involvement leading to bloodstream infection, who ultimately received a diagnosis of CHF and was put on chronic suppressive antibiotic therapy while on the waiting list for a liver transplant. We also reviewed the literature collecting cases of recurrent infections occurring in patients with ductal plate malformation.

The role of chronic suppressive antibiotics therapy in superficial drive line infection relapse of left ventricular assist devices: A retrospective cohort from a tertiary care center.

Drive line infections (DLIs) are common complications of left ventricular assist devices (LVADs). Data on use of suppression antibiotic therapy are limited. We performed a retrospective review of 451 patients who underwent LVAD placement from January 2009 to May 2015. First superficial DLIs were included for analysis. We examined factors associated with the use of chronic suppressive antibiotics (CSAs) therapy. Cox proportional hazards models were performed to identify factors associated with DLI relapse with the same organism as the initial DLI. A total of 69 patients developed a superficial DLI within a median of 195 (interquartile range [IQR] 98-348) days of LVAD insertion. The median age was 57years, 87% were males, and 74% were White. Gram positive bacteria caused 61% of infections, with Staphylococcus aureus being the most common (35%). Forty-three (62%) patients received suppressive antibiotic therapy. Relapse DLI occurred in 29 (42%) patients. Independent risk factors for relapse infection in multivariable analysis were sepsis (aHR 5.94 [CI 1.42-24.92]), and MRSA DLI (aHR 4.19 [CI 1.37-12.79]). There was no difference in the proportion of patients with relapse among those who were treated with antibiotic suppression therapy versus not (44%vs. 38%, p=0.64), although relapse occurred at a later time in those who received suppression (185vs. 69 days, p<0.01). CSA therapy was associated with delayed time to DLI relapse but no significant difference in the proportion of patients with relapse. A prospective study is needed to examine the effect of suppression on relapse rates.

Systems biology evaluation of refractory Clostridioides difficile infection including multiple failures of fecal microbiota transplantation

BackgroundFecal microbiota transplantation (FMT) aims to cure Clostridioides difficile infection (CDI) through reestablishing a healthy microbiome and restoring colonization resistance. Although often effective after one infusion, patients with continued microbiome disruptions may require multiple FMTs. In this N-of-1 study, we use a systems biology approach to evaluate CDI in a patient receiving chronic suppressive antibiotics with four failed FMTs over two years. MethodsSeven stool samples were obtained between 2016-18 while the patient underwent five FMTs. Stool samples were cultured for C. difficile and underwent microbial characterization and functional gene analysis using shotgun metagenomics. C. difficile isolates were characterized through ribotyping, whole genome sequencing, metabolic pathway analysis, and minimum inhibitory concentration (MIC) determinations. ResultsGrowing ten strains from each sample, the index and first four recurrent cultures were single strain ribotype F078-126, the fifth was a mixed culture of ribotypes F002 and F054, and the final culture was ribotype F002. One single nucleotide polymorphism (SNP) variant was identified in the RNA polymerase (RNAP) β-subunit RpoB in the final isolated F078-126 strain when compared to previous F078-126 isolates. This SNV was associated with metabolic shifts but phenotypic differences in fidaxomicin MIC were not observed. Microbiome differences were observed over time during vancomycin therapy and after failed FMTs. ConclusionThis study highlights the importance of antimicrobial stewardship in patients receiving FMT. Continued antibiotics play a destructive role on a transplanted microbiome and applies selection pressure for resistance to the few antibiotics available to treat CDI.

Pseudomonas aeruginosa Infection Predicts Need for Surgical Incision and Drainage in LVAD Patients with Driveline Infection

<h3>Purpose</h3> Driveline infection (DLI) is a frequent cause of morbidity and mortality in LVAD pts. Infections caused by <i>Pseudomonas (P) aeruginosa</i>, an organism that is widespread in water, are difficult to treat due to limited antibiotic susceptibility and tendency to form biofilms. Surgical incision and drainage (I&D) is required for deeper infections. We aimed to investigate survival after I&D as well as predictors of initial and recurrent I&D or death in this population. <h3>Methods</h3> DLI incidence, microbiology and management were evaluated in LVAD pts implanted between 2/09 and 5/19. Endpoints were predictors of: i) initial I&D; and ii) recurrent I&D or death. Cox proportional hazard models were fit with the following variables: age, sex, BMI, DM, organism and bacteremia. <h3>Results</h3> 591 pts (56±14 y; 81% M; 63% HMII, 27% HM3, 10% other) were studied. DLI occurred in 87 (15%) pts. Baseline characteristics were similar in pts with and without DLI. 116 organisms were cultured from the 87 pts. The most common were <i>Staphylococcus aureus</i> (MSSA 27%, MRSA 9%) and <i>P. aeruginosa</i> (19%). Median [IQR] time to initiation of antibiotics was 0[3]d. Initial antibiotic strategy was oral in 51 (58.6%) pts and intravenous in 36 (41.4%) pts. 59 (68%) pts were placed on chronic suppressive antibiotics. 31 (36%) pts required I&D at a median of 77[380]d after DLI diagnosis. Survival after DLI diagnosis was 87% at 1 year and 61.2% at 2 years, whereas survival after I&D was 73.0% at 1 year and 63.8% at 2 years. In multivariable analyses, infection with <i>P. aeruginosa</i> was the only independent predictor of initial I&D (HR 4.35, CI 1.55-12.19, p<0.01; Table 1a). A positive association was also found between <i>P. aeruginosa</i> and bacteremia with need for recurrent I&D or death (Table 1b). <h3>Conclusion</h3> Need for I&D is associated with poor survival. <i>P. aeruginosa</i> independently predicts need for initial I&D. Reinforcement of strict no showering/bathing policy may help decrease the risk of <i>P. aeruginosa</i> DLI and improve outcomes in this population.

S1413 Caroli's Syndrome: A Common Presentation of a Not-So-Common Disease

INTRODUCTION: Caroli's syndrome is a congenital disorder associated with autosomal recessive polycystic kidney disease characterized by intrahepatic bile duct dilatation and congenital hepatic fibrosis. While uncommon, it should be considered in the differential diagnosis of those with right upper quadrant pain and jaundice as it can lead to recurrent cholangitis and cholangiocarcinoma. CASE DESCRIPTION/METHODS: A 25 year old male with end stage renal disease secondary to autosomal recessive polycystic kidney disease presented with right sided abdominal pain and fevers of two months duration. Labs were remarkable for liver injury, coagulopathy, elevated inflammatory markers, and hyponatremia. Extensive autoimmune, rheumatologic, and infectious workup were negative. Imaging was remarkable for cystic dilation of intrahepatic bile ducts, common bile duct dilatation, and hepatomegaly with sequela of portal hypertension. Liver biopsy revealed congenital hepatic fibrosis. Patient was diagnosed with Caroli's syndrome with smoldering/subacute cholangitis. He completed a seven day course of antibiotics and was discharged with Gastroenterology follow up to determine if he would be continued on chronic antibiotics or undergo endoscopic evaluation. DISCUSSION: Caroli's syndrome (CS) is a rare congenital disorder characterized by multifocal segmental non-obstructive saccular or fusiform dilatation of the intrahepatic bile ducts. The incidence of CS has been found to be low, at just 1 in 1,000,000. There are two types of Caroli’s: type 1 (Caroli's disease), which consists of cystic dilatations of the intrahepatic bile ducts and type 2 (Caroli's syndrome), which is associated with congenital hepatic fibrosis on biopsy. CS can be difficult to diagnose as it has no distinguishing signs or symptoms. The most common initial symptoms include right upper quadrant pain, fever, anorexia, fatigue, and jaundice. With worsening disease, patients can have complications of hepatic fibrosis or cirrhosis, portal hypertension, recurrent cholangitis, intrahepatic calculi, biliary abscess, and cholangiocarcinoma. Although definitive diagnosis is made with liver biopsy, many patients can be diagnosed based on imaging studies such as computerized tomography and magnetic resonance cholangiopancreatography. Treatment is dependent on clinical features and location of abnormalities. Treatment options include endoscopic therapy, chronic suppressive antibiotic therapy, internal biliary bypass, hemi-hepatectomy, and liver transplantation.

Long-Term Results of Revision Total Hip Arthroplasty Using a Modern Extensively Porous-Coated Femoral Stem

BackgroundThe use of an extensively porous-coated uncemented cobalt-chrome monoblock femoral stem for revision total hip arthroplasty (THA) is well established with excellent mid-term results. The aim of this study is to report the long-term survivorship of these implants in femoral stem revisions. MethodsThis is a long-term retrospective review of prospectively collected data of 55 femoral stem revisions in 55 patients using a contemporary, cementless extensively porous-coated cobalt-chrome monoblock stem. All patients between 2001 and 2006 who underwent first time femoral stem revision with a contemporary, cementless extensively porous-coated cobalt-chrome monoblock stem were included. Harris Hip Score, Western Ontario and McMaster Universities Index, and University of California Los Angeles activity scores were recorded preoperatively and at latest follow-up. Radiographs were analyzed for evidence of loosening, subsidence, osteolysis, and bony union. This study included 55 patients, comprising of 36 females (66%) and 19 males (34%) with a mean age of 66.4 ± 9.3 years at the time of surgery. The mean time interval from index procedure was 9.8 ± 2.9 years. Mean time from revision THA to final follow-up was 13.2 ± 2.17 years with a minimum of 10 years of follow-up. ResultsIndications for revision included aseptic loosening (33), prosthetic joint infection (13), and periprosthetic fracture (10). Significant improvement in Harris Hip Score (85.1 ± 1.77 vs 51.8 ± 2.3, P < .001), Western Ontario and McMaster Universities Index (17.6 ± 0.77 vs 33.3 ± 0.8, P < .001), and University of California Los Angeles (5.25 ± 0.2 vs 2.7 ± 0.36, P < .001) scores were found at latest follow-up compared to preoperative. Fifty-four patients (98%) achieved stable bony ingrowth on radiographic analysis. All 10 patients treated for periprosthetic fractures achieved bony union of their fractures. Two patients suffered intraoperative periprosthetic fractures and were treated with a cable-plating system. There were no mechanical failures and no femoral stem re-revisions. One patient was diagnosed with a deep infection and was treated with chronic suppressive antibiotic therapy due to significant medical comorbidities. ConclusionRevision of the femoral component with a contemporary extensively porous-coated cobalt-chrome femoral stem has excellent functional outcomes, radiographic outcomes, and long-term survivorship with minimal complications.

Osteomyelitis complicating secondarily infected atopic eczema: two case reports and a narrative literature review

BackgroundAtopic eczema is a relapsing, itchy chronic cutaneous inflammatory disease that commonly affects children. The disease is often complicated by cutaneous infections such as eczema herpeticum, eczema vaccinatum and a varied number of bacterial infections – impetigo, cellulitis and erysipelas. However, rare case reports of infective endocarditis, otitis media and osteo-articular infections have been associated with atopic eczema. These associations possibly represent the extracutaneous infectious complications of atopic eczema.Case presentationHere we present two cases of osteomyelitis in HIV negative children with habitual scratching of poorly managed and/or uncontrolled atopic eczema respectively. Both cases presented to the orthopaedic surgeons and were admitted as acute phalangeal osteomyelitis and acute – on – chronic tibial osteomyelitis respectively. The first case was an 8 year old girl who had moderate-severe poorly-controlled atopic eczema and contiguously spread phalangeal osteomyelitis. The second case was an 11 year old pre-pubertal boy who had untreated atopic eczema and tibial osteomyelitis possibly from haematogenously spread Staphylococcus aureus infection. Both were successfully discharged from hospital and currently have well controlled eczema. The 11 year old patient is also being reviewed monthly by the orthopaedic surgeons and is chronic suppressive antibiotics. He may require sequestrectomy, should it be needed.ConclusionsInvasive staphylococcal and streptococcal osteo-articular (OA) infection can arise as an extra-cutaneous infectious complication of poorly controlled atopic eczema. It is more common in the 3 to 15 year age group and especially in boys with a septic arthritis to osteomyelitis ratio of around 29:5. Clinicians should maintain a high index of suspicion in patients with moderate-severe atopic eczema and they ought to promptly manage these OA infections with intravenous antibiotics to avoid further complications.

380. Characterizing Host Factors, Treatment Strategy, and Clinical Outcomes of Group A Streptococcus Orthopedic Infections

BackgroundThe annual incidence of invasive β-hemolytic group A streptococcus (GAS) infections in the United States is approximately 3.8 cases per 100,000 patients with 10–30% mortality. But data in GAS orthopedic infections is limited. We sought to characterize patient factors, medical and surgical management, and clinical outcomes from GAS orthopedic infections at our medical center.MethodsA total of 12 patients with GAS orthopedic infections (necrotizing fasciitis, osteomyelitis, prosthetic joint infection, septic arthritis, or tenosynovitis) from July 2017 and March 2019 were included. Medical records were reviewed for site of positive GAS culture (blood, wound, joint fluid, or tissue cultures), demographics, comorbidities, surgical management, and antibiotic regimen and duration. The primary outcome was cure at 90 days defined as clinical improvement without recurrent or new infection, or further surgical or medical management at 90 days after treatment completion. The secondary outcome was erythrocyte sedimentation rates (ESR) before and after treatment.ResultsThe median age of the 12 patients was 56 years (range 3–75); 58% were female and 58% had a body mass index ≥30 kg/m2. The median Charlson comorbidity index score was 3 (range 0–7) with 58% having diabetes mellitus. Two patients had either rheumatoid arthritis or monoclonal gammopathy (Table 1). Most patients had severe infections; 33% with necrotizing fasciitis and 25% with orthopedic implants. All patients had an elevated initial ESR, including 75% with ESR >40 mm/h. 92% required surgery, including 42% amputations and 17% prosthesis removals. Patients were mostly treated with β-lactams and vancomycin (92%); only 50% received clindamycin or linezolid. Most patients (75%) required at least 2 weeks of antibiotics. Five patients (42%) were not cured at 90 days, and 1 died of infectious complications (Table 2).ConclusionSevere GAS orthopedic infections necessitate both surgical management and prolonged antibiotics. 42% of our patients were not cured at 90 days and most eventually required amputation. Toxin mediators, clindamycin and linezolid, were underutilized. Chronic suppressive antibiotics should be considered for patients with orthopedic implants, especially those with durable immune suppression. Disclosures All authors: No reported disclosures.

Knee arthrodesis as a salvage method for septic TKA failure

Abstract Periprosthetic joint infection is the most common reason for a failed TKA, with a septic TKA reported rate of 1 to 4% of primary TKA patients. Septic TKA has a various number of treatment options which include chronic-suppressive antibiotics, irrigation and debridement, single or staged revision arthroplasty. The goal is to eradicate the periprosthetic joint infection and reimplant a sterile and fully functional total knee prosthesis. In case the infection becomes uncontrollable, there is only one option to eradicate the infection: knee arthrodesis or above-knee amputation. We report the case of a 63-year-old patient who in 2009 underwent TKA, the 1 year follow-up showed periprosthetic infection. At first stage, the prosthetic implants were removed and a solid cement spacer was shaped to occupy the remaining space. In 2011, after achieving complete clinical and biological remission of the infection, the cement spacer was removed and LCCK revision prosthesis was inserted. In 2013 reinfection occurred leading to removal of the prosthetic implants and reinsertion of an antibiotic impregnated cement spacer. Since the patient suffered significant bone loss and the local conditions were unfavorable, being prone to infection, there were 2 options to evaluate: knee arthrodesis or above knee amputation. We chose knee arthrodesis using Ilizarov external fixation technique. Many surgical techniques are available to achieve knee arthrodesis: internal fixation with plates or intramedullary nails and external fixation. The Ilizarov method is a very effective technique that could be taken into consideration when knee arthrodesis is required.

Palliation and Nonextraction Approaches.

Although definitive therapy for infected cardiac implantable electronic device systems requires removal of all hardware in the infected areas with extraction of intravascular components as well, there are situations where extraction is not available or appropriate. Palliative procedures and chronic suppressive antibiotics may be used in these cases. There are also options that may in some cases result in long-term freedom from infection.

A Rare Case of Endotipsitis with Multiorgan Involvement

Transjugular intrahepatic portosystemic shunt (TIPS) is commonly used in the setting of portal hypertension and associated symptoms such as variceal bleeding. Infection of the TIPS, or Endotipsitis, is a condition being increasingly recognized. Endotipsitis has an estimated incidence of 1.5% and carries a very high mortality rate. However, there are no guidelines to manage this condition. Here we describe a case of endotipsitis with multiple causative organisms and complications involving several organs. A 41 yo male with history of autoimmune pancreatitis, biliary strictures, and portal hypertension with gastroesophageal varices underwent banding and a TIPS procedure complicated by thrombosis which required revision. He subsequently developed a polymicrobial bacteremia growing Enterobacter cloacae, Klebsiella pneumonia, and Enterococcus faecalis/faecium. TTE and CT Abdomen/Pelvis were negative. Patient was diagnosed with endotipsitis and discharged on a 6-week course of IV daptomycin and ertapenem. Two weeks later, he presented febrile (102°). He was otherwise asymptomatic. Blood cultures were positive for gram positive cocci. Fluid around TIPS was drained. Both blood cultures and the TIPS fluid cultures were growing Enterococcus faecium and Candida lusitaniae. He was also diagnosed with endocarditis by TTE and fungal chorioretinitis. He was to complete a 6-week course of ampicillin and ceftriaxone, fluconazole, and ciprofloxacin. Exact diagnostic criteria of endotipsitis are still being debated, though persistent bacteremia and fever without clear alternative source of infection following TIPS procedure is highly suggestive. Additionally, TIPS thrombosis, as demonstrated in our patient, is a strong risk factor for endotipsitis. As of mid-2017, approximately 56 cases of endotipsitis have been reported with a 32% mortality rate. A wide range of causative organisms have been documented. However, the most common organisms responsible for early endotipsitis (within 120 days) were gram positive bacteria, including staph and enterococci. Candida infections have been associated with the highest mortality at >60%. While anti-microbial agents are the mainstay of treatment, it is unclear how liver transplantation and chronic suppressive antibiotics fit into the long-term management. Given the increased identification of this condition, clinical practice guidelines for the diagnosis and management for endotipsitis are urgently needed.

The fate of immunocompromised patients in the treatment of chronic periprosthetic joint infection: a single-centre experience

Immunocompromised patients with periprosthetic joint infection (PJI) are rare and currently there are no reliable guidelines according to which these infections can be successfully managed. The purpose of this study was to report the clinical course of different strategies for treatment of PJI in frail patients. A retrospective analysis between 2004 and 2015 included 29 immunocompromised patients (13 hips and 16 knees) with chronic PJI who underwent one-stage revision or debridement, antibiotics and implant retention (DAIR). Patients were stratified according to the Musculoskeletal Infection Society (MSIS) staging system and the clinical course included recurrence of infection and functional outcomes which were extracted from patients' charts. The average follow-up was 68months (range, 26-149months). Sixteen of the 29 patients had recurrent infections. At last follow-up, 13 patients were on chronic suppressive antibiotic therapy, three patients died but not one death was considered to be related to the infection. A recurrent infection was observed in 13 of the 24 medically compromised hosts (MSIS type B). Sixteen of the 24 patients underwent one-stage revision; another eight of them underwent DAIR. The infection recurred in three of the five patients (60%) with the worst host grades (MSIS type C). One-stage revision was performed in one of the five patients and the remaining four patients received DAIR. Our results show that we should compromise our expectation and intemperate treatment for such a population. The goals of PJI treatment in these patients should take into account their preferences and may pay more attention to the concept of disease control rather than cure, especially for patients with severe comorbidities (MSIS C). Therapeutic Level IV.

Left ventricular assist pump pocket infection: conservative treatment strategy for destination therapy candidates.

Heart failure is a major cause of mortality and morbidity, particularly among patients with advanced disease and no access to cardiac transplantation. LVAD implantation is not only a bridge-to-transplantation option for patients awaiting a heart donor, but is often used as bridge-to-destination therapy in patients unsuited for transplantation for various reasons. LVAD infection is considered the second-most common cause of death in patients who survive the initial 6 months on LVAD support. Few reports describe the indications for chronic suppressing antibiotic therapy, device exchange, methods for exchanging infected devices, post-exchange antimicrobial management status, and the outcomes of such patients. This is the case of a 74-year-old male patient with numerous comorbidities who received urgent surgical management for severe heart failure with a HeartMate II. Six months later he developed an LVAD pump infection with methicillin-resistant Staphylococcus epidermidis, which was diagnosed with leucocyte scintigraphy. The patient received an omental graft over the LVAD and a chronic suppressive antibiotic regime. A marked leukocyte scintigraphy showed the infection's regression 6 months after the initiation of antibiotic treatment. We concisely reviewed the driveline infections and the main aspects of the LVAD pump infection. We reviewed options for conservative and nonconservative management and showed that conservative management of the LVAD pump infection is possible. There are no defined recommendations for the management of LVAD pump infection. This case is among the few in the literature showing that conservative treatment of an LVAD pump infection is possible.