Salvaging lives in carbapenem resistant Gram negative osteoarticular infections: early compromises save lives says study

Vikas M. Agashe et al treated carbapenem resistant Gram negative osteoarticular and soft tissue infections with a modifed approach and found that - the "risk to life" cases can be successfully treated by lowering the aims and expectations from "excellent function to salvage of life and infection remission".

A retrospective study included 26 patients with osteoarticular and soft tissue infections with carbapenem-resistant Gram-negative bacilli (CR GNB) treated between 2001 and 2017 with at least two year follow-up after stopping antibiotics.

Some salient aspects of the procedure followed:

• Debridement beyond infection.

• Suitable stabilization, negative pressure wound therapy (NPWT) and appropriate local antibiotics were used when indicated for source control as indicated.

• Early soft tissue cover.

• Antibiotics protocol — preferred to operate with "antibiotic-free" interval of two weeks unless the general condition of patient did not permit it. Post-operative empirical (before culture reports) followed by targeted antibiotics based on final antimicrobial susceptibility pattern (AMSP) were selected by the ID specialist in collaboration with the microbiologist and histopathologist. A central line/peripheral intravenous catheter was established in cases which needed prolonged intravenous antibiotics.

• Contact isolation — of patients to avoid nosocomial infection as decided by ID consultant.

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.

The results of the study were -

 25/26 patients had prior history of antibiotic consumption, and most were on empirical therapy for variable periods.

 Commonest organism cultured was Pseudomonas aeruginosa (n=18).

 There were five amputations, two excision arthroplasty of hip, many minor but acceptable malunions and shortening.

 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 24 patients.

The authors concluded that - the primary objective of achieving good functional outcome must be weighed against the risks involved in managing infections caused by CR GNB. The objectives must be revised /modified on a regular basis, considering the clinical profile, physiology and anti-microbial resistant pattern. Limb salvage must be weighed against the higher risk mortality with multiple staged procedures. Fulminant infections with CR GNB have forced us to look at the goals from a different perspective, putting Life before Limb before Function.

Further reading:

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

Vikas M. Agashe, Rajeev Soman, Camilla Rodrigues et al

International Orthopaedics (2022) 46:963–970

https://doi.org/10.1007/s00264-022-05342-z