Sequential Multi-organism Periprosthetic Joint Infection after Total Hip Arthroplasty: A Case Report

Periprosthetic joint infection after total hip arthroplasty is uncommon but morbid. Reports usually focus on a single organism or a persistent recurrent infection. This case is important because it describes sequential infections with four distinct and therapeutically challenging organisms in the same arthroplasty, illustrating how management must be repeatedly re-evaluated rather than anchored to the initial culture result.

A 62-year-old woman with hypertension, chronic anemia, and a history of methicillin-resistant Staphylococcus aureus infection underwent robotic-assisted left total hip arthroplasty. Her ethnic background was not available in the deidentified record. Over 16 months, she developed four culture-confirmed periprosthetic joint infections caused by Pseudomonas aeruginosa, Candida glabrata, methicillin-resistant S. aureus, and Serratia marcescens. Each episode was managed with repeat culture acquisition before antimicrobial therapy, surgical debridement with spacer exchange when indicated, and organism-directed antimicrobial or antifungal treatment. Definitive reimplantation was delayed until the wound was healed, inflammatory markers had normalized, and repeat aspiration after an antimicrobial-free interval was negative. At 9 months after reimplantation, she remained free of recurrent infection and was improving with physical therapy. The patient did not have diabetes mellitus, and her serology status was negative. No patient-specific clinical wound photographs or intraoperative photographs were available for publication. The available operative descriptions note debridement through the prior incision with removal of infected tissue and placement or exchange of a temporary antibiotic-loaded cement hip spacer. Available susceptibility reports showed that the P. aeruginosa isolate was susceptible to all tested antipseudomonal agents, the methicillin-resistant S. aureus isolate was susceptible to vancomycin, and the S. marcescens isolate was reported as multidrug-resistant and carbapenem-resistant but remained susceptible to cefepime. The C. glabrata report confirmed organism growth, but an antifungal susceptibility panel was not available in the provided report.

This case emphasizes that recurrent hip periprosthetic joint infection during staged management should be treated as a new diagnostic event until proven otherwise. Repeated cultures, multidisciplinary antimicrobial selection, and individualized timing of reimplantation may improve decision-making in complex sequential infections and may be useful to orthopedic surgeons managing difficult revision arthroplasty cases.