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Osteomyelitis attributable to vancomycin-resistant enterococci
Paul D Holtom1, David Zamorano, Michael J Patzakis
1Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA.
Abstract:
Vancomycin-resistant enterococcus first was described in 1988, and has become a major problem in nosocomial infections. This is a retrospective review of 10 patients, seen at the authors' hospital during a 2-year period, with confirmed vancomycin-resistant enterococcal osteomyelitis: four patients had total joint arthroplasty infections, one patient had an infected tibial nail, three patients had infections associated with external fixators, and two patients had osteomyelitis of the femur. Four of the 10 patients had underlying medical illnesses (diabetes mellitus, systemic lupus erythematosus, human immunodeficiency virus infection); four of the 10 patients were intravenous drug users. Two patients had vancomycin-resistant enterococci on admission, and the other eight patients were admitted to the hospital for a mean of 21.3 days (range, 3-73 days) before vancomycin-resistant enterococci were identified in the bone. Eight of the 10 patients had monomicrobial infections with vancomycin-resistant enterococci. Patients were treated by surgical debridement, removal of hardware, and antibiotics (chloramphenicol in eight patients, quinupristin and dalfopristin (Synercid) in two patients). All patients initially improved with therapy, but one patient had a recurrence of vancomycin-resistant enterococcal osteomyelitis and died of bacteremia. Bone infections with vancomycin-resistant enterococcus still may be uncommon, but with time and selective antibiotic pressures, vancomycin-resistant enterococci may become a more prominent entity in orthopaedic infections.
Insights
Vancomycin-resistant enterococcus (VRE) osteomyelitis is a growing concern in healthcare settings. This review highlights treatment outcomes for 10 patients, emphasizing surgical intervention and targeted antibiotics for VRE bone infections.
Area of Science:
- Orthopaedic Surgery
- Infectious Diseases
- Microbiology
Background:
- Vancomycin-resistant enterococcus (VRE) emerged in 1988 and is a significant cause of nosocomial infections.
- VRE osteomyelitis presents a therapeutic challenge, particularly in patients with orthopaedic hardware or underlying conditions.
- This study reviews cases of VRE osteomyelitis to understand its clinical presentation and treatment outcomes.
Purpose of the Study:
- To retrospectively analyze 10 cases of vancomycin-resistant enterococcal osteomyelitis.
- To evaluate treatment strategies, including surgical debridement and antibiotic regimens.
- To assess patient outcomes and identify risk factors associated with VRE bone infections.
Main Methods:
- Retrospective review of 10 patients diagnosed with vancomycin-resistant enterococcal osteomyelitis over a 2-year period.
- Analysis of patient demographics, underlying medical conditions, and previous hospitalizations.
- Review of treatment protocols, including surgical interventions and antibiotic choices (chloramphenicol, quinupristin/dalfopristin).
Main Results:
- The 10 patients presented with diverse orthopaedic infections, including joint arthroplasty, tibial nail, external fixator, and femur osteomyelitis.
- Eight patients had monomicrobial VRE infections; four had underlying illnesses, and four were intravenous drug users.
- All patients initially responded to treatment (surgery and antibiotics), but one experienced recurrence and died from bacteremia.
Conclusions:
- Vancomycin-resistant enterococcal osteomyelitis, though potentially uncommon, requires aggressive management involving surgical debridement and appropriate antibiotics.
- The increasing prevalence of VRE suggests it may become a more significant pathogen in orthopaedic infections.
- Early identification and comprehensive treatment are crucial for improving outcomes in VRE osteomyelitis.