title: Complex prosthetic joint infections due to carbapenemase-producing Klebsiella pneumoniae: a unique challenge in the era of untreatable infections.
abstract: OBJECTIVE
  Limited clinical experience exists regarding the management of prosthetic joint infection (PJI) due to multidrug-resistant (MDR) Gram-negative organisms. We review three cases of carbapenem-resistant Klebsiella pneumoniae (CRKP) complicating PJI.
  
  
  METHODS
  This was a retrospective study of all patients at a tertiary care institution with CRKP complicating PJI between January 2007 and December 2010. Demographic data, procedures, organisms involved, length of stay, antibiotic treatments, and outcomes were collected. Antimicrobial susceptibility testing was performed on CRKP isolates, and the mechanism of resistance was ascertained by PCR.
  
  
  RESULTS
  This analysis demonstrated that: (1) the CRKP possessed blaKPC and were difficult to eradicate (persistent) in PJI; (2) multiple surgeries and antibiotic courses were undertaken and patients required a prolonged length of stay; (3) resistance to colistin and amikacin emerged on therapy; (4) the same strain of CRKP may be responsible for relapse of infection; (5) significant morbidity and mortality resulted.
  
  
  CONCLUSIONS
  These cases highlight the opportunistic and chronic nature of CRKP in PJIs and the need for aggressive medical and surgical treatment. Further investigations of the management of CRKP PJI and new drug therapies for infections due to MDR Gram-negative organisms are urgently needed.
authors.affiliation: Division of Infectious Disease, Spectrum Health Medical Group, 230 Michigan Ave, NE, Grand Rapids, MI 49503, USA; Section of Bone and Joint Infections, Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Division of Infectious Diseases, UNC School of Medicine, Chapel Hill, North Carolina, USA. Electronic address: Jorgelina.deSanctis@spectrumhealth.org.
authors.forename: Jorgelina
authors.initials: J
authors.lastname: de Sanctis
authors.affiliation: Division of Infectious Disease, Spectrum Health Medical Group, 230 Michigan Ave, NE, Grand Rapids, MI 49503, USA; Section of Bone and Joint Infections, Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Division of Infectious Diseases, UNC School of Medicine, Chapel Hill, North Carolina, USA.
authors.forename: Lucileia
authors.initials: L
authors.lastname: Teixeira
authors.affiliation: Division of Infectious Disease, Spectrum Health Medical Group, 230 Michigan Ave, NE, Grand Rapids, MI 49503, USA; Section of Bone and Joint Infections, Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Division of Infectious Diseases, UNC School of Medicine, Chapel Hill, North Carolina, USA.
authors.forename: David
authors.initials: D
authors.lastname: van Duin
authors.affiliation: Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Camila
authors.initials: C
authors.lastname: Odio
authors.affiliation: Division of Infectious Disease, Spectrum Health Medical Group, 230 Michigan Ave, NE, Grand Rapids, MI 49503, USA; Section of Bone and Joint Infections, Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Division of Infectious Diseases, UNC School of Medicine, Chapel Hill, North Carolina, USA.
authors.forename: Geraldine
authors.initials: G
authors.lastname: Hall
authors.affiliation: Division of Infectious Disease, Spectrum Health Medical Group, 230 Michigan Ave, NE, Grand Rapids, MI 49503, USA; Section of Bone and Joint Infections, Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Division of Infectious Diseases, UNC School of Medicine, Chapel Hill, North Carolina, USA.
authors.forename: J Walton
authors.initials: JW
authors.lastname: Tomford
authors.affiliation: Research Services, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA; Medicine Services, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA; Department of Medicine, Case Western Reserve School of Medicine, Cleveland, Ohio, USA.
authors.forename: Federico
authors.initials: F
authors.lastname: Perez
authors.affiliation: Research Services, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA.
authors.forename: Susan D
authors.initials: SD
authors.lastname: Rudin
authors.affiliation: Research Services, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA; Medicine Services, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA; Department of Medicine, Case Western Reserve School of Medicine, Cleveland, Ohio, USA; Department of Pharmacology, Case Western Reserve School of Medicine, Cleveland, Ohio, USA; Department of Molecular Biology and Microbiology, Case Western Reserve School of Medicine, Cleveland, Ohio, USA.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Bonomo
authors.affiliation: Department of Orthopedic Surgery and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Wael K
authors.initials: WK
authors.lastname: Barsoum
authors.affiliation: Department of Orthopedic Surgery and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Joyce
authors.affiliation: Department of Orthopedic Surgery and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Viktor
authors.initials: V
authors.lastname: Krebs
authors.affiliation: Division of Infectious Disease, Spectrum Health Medical Group, 230 Michigan Ave, NE, Grand Rapids, MI 49503, USA; Section of Bone and Joint Infections, Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Division of Infectious Diseases, UNC School of Medicine, Chapel Hill, North Carolina, USA.
authors.forename: Steven
authors.initials: S
authors.lastname: Schmitt
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use; D001426:Bacterial Proteins / Q000096:biosynthesis / Q000235:genetics*; D003428:Cross Infection; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007595:Joint Prosthesis / Q000009:adverse effects*; D007710:Klebsiella Infections / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D007711:Klebsiella pneumoniae / Q000145:classification / Q000187:drug effects / Q000235:genetics*; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D058889:Molecular Typing; D009820:Ohio; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology*; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D016896:Treatment Outcome; D018440:beta-Lactam Resistance; D065093:beta-Lactamase Inhibitors / Q000494:pharmacology / Q000627:therapeutic use; D001618:beta-Lactamases / Q000096:biosynthesis / Q000235:genetics*
chemical_list: D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins; D065093:beta-Lactamase Inhibitors; D001618:beta-Lactamases; C063912:carbapenemase
keywords: Carbapenem-resistant Enterobacteriaceae; Carbapenem-resistant Klebsiella pneumoniae; Colistin; K. pneumoniae carbapenemase (KPC); Multidrug-resistant organisms; Prosthetic joint infection