Salvaging lives in carbapenem-resistant Gram-negative osteoarticular and soft tissue infections: early compromises save lives

• Published in: International orthopaedics Vol. 46; no. 5; pp. 963 - 970
• Main Authors: Agashe, Vikas M., Soman, Rajeev, Rodrigues, Camilla, Shetty, Anjali, Sunavala, Ayesha, Raghuvanshi, Sagar, Menon, Aditya
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-05-2022
• Subjects: Anti-Bacterial Agents - therapeutic use; Carbapenems - pharmacology; Carbapenems - therapeutic use; Gram-Negative Bacteria; Humans; Medicine; Medicine & Public Health; Original Paper; Orthopedics; Retrospective Studies; Soft Tissue Infections - drug therapy; Soft Tissue Infections - epidemiology; Osteomyelitis; Gram-negative bacilli; Carbapenem-resistant; Soft tissue infection; Carbapenemase-producing organism; Multidrug-resistant bacteria
• ISSN: 0341-2695; 1432-5195
• DOI: 10.1007/s00264-022-05342-z

Purpose
Incidence of carbapenem-resistant Gram-negative infections has risen alarmingly all across the globe, both in developed and developing countries alike. The purpose of this study was to assess whether challenges of life-threatening infections with very high resistance pattern can be successfully addressed by a modified approach.
Methods
This is a retrospective study of 26 patients with osteoarticular and soft tissue infections with carbapenem-resistant Gram-negative bacilli treated between 2001 and 2017 with at least two year follow-up after stopping antibiotics. All were treated by a multispecialty team approach with primary aim of “source control at the earliest and avoiding recurrence at all cost”. The protocol involved opting for early compromises especially in at “risk individuals”, such as resorting to early amputations, especially if salvage meant multiple bony and soft tissue reconstructive procedures, explanation of prosthesis than staged revision, avoiding internal fixations, opting for shortest possible time in external fixators with reshaping and telescoping bone ends to get bony stability and increase surface area even if it meant compromising length.
Results
There were five amputations, two excision arthroplasty of hip, many minor but acceptable malunions and shortening. However, lives of 24/26 patients could be salvaged, much better than most of the published data. The two patients who died had peri-prosthetic joint infection after total hip arthroplasty and presented very late in sepsis and died within days of explantation. Infection remission could be achieved in remaining patients.
Conclusion
These “risk to life” cases can be successfully treated by lowering the aims and expectations from “excellent function to salvage of life and infection remission”. Therein lies the “success” in these complex high-risk cases.