title: Tolerability and efficacy of long-term treatment with daptomycin, ceftazidime and colistin in a patient with a polymicrobial, multidrug-resistant prosthetic joint reinfection: a case report.
abstract: BACKGROUND
  Prosthetic joint infections are severe complications of joint implants. Further complications arise when polymicrobial and/or multidrug-resistant microorganisms are involved. Currently, there are limited data on the management of these infections and on the tolerability of long-term treatment with daptomycin, ceftazidime and colistin.
  
  
  METHODS
  A 55-year-old Caucasian woman who had a right hip prosthesis removed 1 year prior because of infection was admitted for prosthesis reimplantation. On admission at our hospital, anamnesis regarding etiology and management of prosthesis infection was not available. On clinical, laboratory findings and imaging studies infection was not suspected. A hip prosthesis was reimplanted. At surgery, histopathological and microbiological investigations were not taken. Three weeks after reimplantation, surgical site infection due to Enterobacter cloacae was diagnosed and oral ciprofloxacin was prescribed. Four days later, a periprosthesis fluid collection was evidenced and a percutaneous needle aspirate grew Staphylococcus epidermidis and S. haemolyticus. Enterobacter genome was also detected from the same sample. Teicoplanin and meropenem were added to ciprofloxacin without clinical improvement. Moreover, acetabular cup dislocation was documented. She underwent prosthesis explantation, debridement, and positioning of an antimicrobial mixed spacer. From the intraoperatory cultures S. epidermidis and Acinetobacter baumannii were grown. Daptomycin, ceftazidime, colistin and rifampin were administered. Four days later, rifampin was stopped due to a suspected liver toxicity. While undergoing therapy she presented recurrent episodes of wound dehiscence and on the 22nd week of treatment a further surgical debridement was performed, upon which the spacer was removed. At this time, intraoperative cultures resulted negative. Three months later, after a total of 8 months, antimicrobials were interrupted. Subsequently, a femoral transcondylar traction was positioned, and 3 weeks later a new prosthesis was reimplanted. At over 1 year after reimplantation she is well.
  
  
  CONCLUSIONS
  Our findings suggest that microbiologic investigations are mandatory even when prosthetic joint infection is not suspected. Molecular methods for identification of microorganisms can be used in addition to conventional cultures especially when patients are under antibiotic treatment. Daptomycin, ceftazidime and colistin can be administered for several months without side effects. Guidelines specifically addressing the diagnosis and the management of polymicrobial, multidrug-resistant prosthetic joint infections need to be developed.
authors.affiliation: Infectious Disease Section, Department of Experimental Medicine and Biochemical Sciences, University of Perugia, 06100 Perugia, Italy. mariabruna.pasticci@unipg.it.
authors.forename: Maria Bruna
authors.initials: MB
authors.lastname: Pasticci
authors.forename: Paolo
authors.initials: P
authors.lastname: Di Filippo
authors.forename: Leonella
authors.initials: L
authors.lastname: Pasqualini
authors.forename: Antonella
authors.initials: A
authors.lastname: Mencacci
authors.forename: Carlo
authors.initials: C
authors.lastname: Pallotto
authors.forename: Lisa
authors.initials: L
authors.lastname: Malincarne
authors.forename: Franco
authors.initials: F
authors.lastname: Baldelli
mesh_terms: D000151:Acinetobacter Infections / Q000188:drug therapy*; D040981:Acinetobacter baumannii; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002442:Ceftazidime / Q000627:therapeutic use*; D060085:Coinfection / Q000188:drug therapy; D003091:Colistin / Q000627:therapeutic use*; D017576:Daptomycin / Q000627:therapeutic use*; D024901:Drug Resistance, Multiple, Bacterial; D004359:Drug Therapy, Combination; D016972:Enterobacter cloacae; D004756:Enterobacteriaceae Infections / Q000188:drug therapy*; D005260:Female; D006622:Hip Prosthesis; D006801:Humans; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000188:drug therapy*; D012008:Recurrence; D012086:Reoperation; D013203:Staphylococcal Infections / Q000188:drug therapy*; D013212:Staphylococcus epidermidis; D041162:Staphylococcus haemolyticus; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D002442:Ceftazidime; D017576:Daptomycin; D003091:Colistin