Dr Savita Gossain Heart of England NHS Foundation Trust Educational Workshops 2013 Bone and Joint Infections An oozy wound Dr Savita Gossain Heart of England NHS Foundation Trust

Case History 77Y F with background of Type II diabetes; Hypertension; Previous SVT & Osteoporosis March 2008: Fractured Left NOF, Dynamic hip screw Oct 2009: Pain in Left hip; at rest & on walking Nov 2009: DHS revised to gamma nail, satisfactory recovery 12 Dec 2009: Left total hip replacement following failed gamma nail; post-operative anaemia, otherwise uneventful recovery. [ASA 2/3, BMI ~ 35 ]

Day 15 post-op THR 27 Dec 2009: Readmission Pain & erythema hip wound Wound oozing serous fluid Systemically well WCC 7.5; CRP 16 X-ray hip : NAD

WHAT WOULD YOU ADVISE?

1 Jan 2010: Discharged home 4/7 later on oral Flucloxacillin 7days (No micro/ID consult) 4 Jan 2010: T&O clinic review (D23 post-op) Wound erythematous & indurated with mucky discharge Temp 380C but otherwise well CRP 91

WHAT WOULD YOU ADVISE NOW?

Commenced on IV Benzylpenicillin +Flucloxacillin 5 Jan 2010 (Day 24): Open washout 30-40ml purulent fluid oozed from joint Samples sent for micro (fluid & tissue) Wound packed – layers not closed as plan to take back to theatre in 48hrs

7 Jan 2010 (Day 26) E.coli grown from fluid samples x2 Tissue not received (!) Changed to iv ciprofloxacin + stat gentamicin in theatre (Microbiology advice) Back to theatre “most tissues appeared healthy & viable. Three tissue samples taken (superficial, deep & capsule). Further debridement to healthy tissue. Washout of hip joint, 6 litres saline with pulsed lavage”

9 Jan 2010: All tissue samples from 7/1/10 grew E 9 Jan 2010: All tissue samples from 7/1/10 grew E.coli as previously, ciprofloxacin continued. E.coli = fully sensitive (Ampicillin, Gentamicin, Ciprofloxacin, Cefuroxime, Meropenem..)

What would you advise for further management ?

Antibiotic treatment Picc line inserted 11/1/10 & Ceftriaxone 2g od commenced by ID Consultant. Plan for 4-6/52 iv to be continued as OPAT and then prolonged oral course of antibiotics (Ciprofloxacin) to eradicate the infection.

Liver function tests 7 Dec 2009 6 Jan 2010 12 Jan 2010 ALT (0 – 33) 11 211 Alk Phos (40 -185) 76 83 627 Bilirubin (0 – 17) 5 3 4

Cause of deranged LFTs? What would you advise?

It was thought that rise may be related to ciprofloxacin as raised 12 hours after switch to ceftriaxone. However liver SEs much more common with ceftriaxone so planned to closely watch LFTs over next few days....

Liver function tests 7 Dec 2009 6 Jan 2010 12 Jan 2010 14 Jan 16 Jan ALT (0 – 33) 11 10 211 106 52 16 14 Alk Phos (40 -185) 76 83 627 507 369 210 172 Bilirubin (0 – 17) 5 3 4

Further progress Following debridement & washout – wound oozing serous fluid for few days. Clips were removed 20/1/10 (Day 13 post debridement) 22/1/10: temperature spike and ?rigors. Septic screen and paired BC advised & to remove line if further spike temperature. Wound ooze settling.

Cultures: W/S mixed skin flora MSU : 13 WBC, 15 RBC, culture not indicated BC x 2: Negative CRP 15 However, continuing ooze from wound (serous)and few spikes of temperature over next few days (still on ceftriaxone)

WHAT WOULD YOU ADVISE?

ID consult Wound not settled post debridement although inflammatory markers down Wound not cellulitic. Continued ooze suggests sinus tract Consider USS to see if superficial collection If joint secure – further w/o & debridement, excision sinus tract & and replacement of any exchangeable components If joint loose – 2 stage revision Alternative of long term suppression with antibiotics less useful with E.coli as more resistant strains may emerge during treatment

USS on 4/2/10 (D28 post debridement): No collection, no effusion in joint. Temperature settling, mobilising, pain better T & O consultant: “as improving and CRP coming down and no collection on USS, does not want to do 2 stage revision at this time” Wound continued to ooze : no cellulitis, small discharging sinus middle wound

WHAT ARE THE OPTIONS?

19/2/10 Completed 6/52 IV Ceftriaxone ?Unsuccessful attempt at cure by DAIR Discharging chronic sinus No plan for revision Discharged home on po Amoxycillin 500mg qds & review in 1 month whether to continue If deterioration hip function , may require revision Discharged home 1/3/10 (D53 post debridement)

April 2010: Clinic Review Systemically well No cellulitis over wound Sinus over the wound healed Normal WCC & CRP 10 Continued Amoxicillin 500mg tds, suppressive treatment Patient made aware of CDI risk, chronicity of infection.

July 2011 & July 2012: No problems with the hip. Xray hip: NAD Wound healed. Continuing suppressive Amoxycillin

SUMMARY Case of early infection THR (<30d post surgery) Delayed wound healing/ ooze may represent early infection +/- systemic symptoms Managed as DAIR initially – IDSA guidelines (A-II recommendation for early infection, well fixed prosthesis) ?Failed DAIR – sinus developed , but no further surgery planned Suppressive antibiotics continuing