1. Case One
Facilitator version

2. Day 1 65 year-old man Presented to ED at 03.00
Sudden onset pain in left hip at 23.30
Became much worse in subsequent 30 minutes
Unable to weight bear
Sweats and shivers since 00.00
No recent trauma

3. Day 1 Past history Osteoarthritis
Metal on metal resurfacing left hip May 2003
Articular surface replacement right hip November 2003
Right THR 2008
Left TKR 2012
Hiatus hernia
Hyperlipidaemia

4. Day 1 Examination Temp 38.0°C BP 142/82 HR 110 RR 18
O2 sats 98% (on room air) EWS 1
‘irritable’ left hip
Pain on passive movement of left hip
Tenderness left groin
No cellulitis

5. Irish national early warning score

6. Irish national EWS – escalation protocol

7. What would you do next?

8. What would you do next? Routine bloods Blood cultures Imaging CXR
X-ray left hip

9. Day 1 Blood cultures taken WCC 16.1 (diff not reported on call)
Hb 15.9
Plts 280
U&E normal
CRP 4.0 (0-5.0)
Urinalysis - normal
Lactate not done

10. What is wrong with the patient?

11. What is wrong with the patient?
Sepsis = SIRS and infection (suspected or confirmed)
This patient has SIRS and suspected infection
WCC > 12 (16)
HR > 90 (110)
Likely source is left hip
Infected prosthesis
Soft tissue infection

12. What do you do next?

13. What do you do next? Orthopaedic review Imaging – CT pelvis
? antibiotics

14. Day 1 06.30 – orthopaedic registrar review
Likely deep infection left hip - ? abscess
IV fluids
nil by mouth
hold antibiotics
CT scan

15. Day 1 - 15.30 – CT pelvis and left hip

16. CT report
Large 12 x 10 x 3.5 cm fluid collection related to the left hip joint and prosthesis, extending along left iliopsoas muscle
Although not possible to exclude septic arthritis given the history provided, this appearance can be encountered in the setting of metal on metal hip prostheses without superimposed infection

17. What would you advise now?

18. What would you advise now?
Aspiration of collection
Antibiotic therapy

19. Day 1 18.00 – orthopaedic consultant review
CT scan reviewed - ? metal wear ? infection
For ultrasound-guided aspiration
Blood cultures if temperature > 38°C
Not to start antibiotics until discussed with orthopaedic team
18.30 – ultrasound-guided aspiration
30ml dark viscous fluid aspirated
No residual fluid
Micro lab not informed of sample

20. Day 1 23.30 transferred to orthopaedic ward Temp 38.0°C BP 120/70
HR 98
RR 18
O2 sats 95% (on room air)
EWS 0

21. Would you give antibiotics now?

22. Would you give antibiotics now?
Sepsis
Remains febrile
Appropriate samples have been sent

23. Day 2 (Saturday) 02.00 Temp 38.2°C No other obs recorded
Blood cultures taken
11.00
Temp 36.6°C
WCC 22.2 (diff not reported on call)
CRP 399
Blood cultures from day 1 – sterile to date
Left hip aspirate set up
Gram stain - ++ pus ++ GPC in clusters

24. What do you advise?

25. What do you advise?
Source control
Antibiotics
Repeat blood cultures

26. Day 2
11.30
Orthopaedic registrar informed by microbiology registrar, advised start vancomycin and review patient re need for washout
12.00
Vancomycin 1g 12-hourly prescribed
First dose given
Weight 91kg, creatinine 96
Weight 91kg, eGFR 87mL/min; if hospital policy followed, should have had 2g loading dose, then 1.5g 12-hourly with trough before 5th or 6th dose.
Had 4 doses in total. Trough not checked.

27. What do you think of the antibiotic choice?

28. What do you think of the antibiotic choice?
Prosthetic hip infection
ID and susceptibilties of staphylococcus awaited
Hospital admission 7/12 previously for TKR
Vancomycin
No loading dose
Suboptimal dose
Load with 2g, then 1.5g 12-hourly

29. Day 3 (Sunday) 12.00 Left hip aspirate (from day 1) – Staph. aureus
Blood cultures (from day 2) – GPC in clusters on Gram stain of aerobic bottle
Temp 38.5°C
WCC 20.4, CRP 466
SIOC informed, advised to continue vancomycin

30. Day 3 23.45 Temp 40.5°C with rigors BP 98/52 HR 136 RR 22
O2 sats 87% on room air
EWS 10
WCC 17.9, CRP 423

31. Day 3-4
Temperature
Heart rate
RR and oxygen sats
Blood pressure

32. What do you do now?

33. What do you do now? Urgent review by senior doctor
Sepsis 6 within 1 hour
Cultures
Lactate
Urine monitoring
Oxygen
Fluid challenge
Antibiotic therapy

34. Day 4 00.00 – orthopaedic registrar review Unwell, rigors
Discussed with orthopaedic consultant on call
Sepsis 6?
Flucloxacillin 2g IV 6-hourly added
IV fluids – 1L over one hour
Oxygen

35. What else should be done?

36. What else should be done?
Source control

37. Day 4 00.45 – theatre BP 117/65 Frank pus ++
Thorough soft tissue and capsular debridement
6L washout
Pus, tissue sent for C&S

38. Day 4 04.15 – back from theatre Temp 38.1°C BP 127/81 HR 118 RR 18
O2 sats 96% on 60% O2
EWS 6

39. Day 4 11.00 – microbiology review on ward
Aspirate left hip – MSSA (resistant penicillin, fusidic acid)
Blood cultures day 2 – MSSA
Temp 38.3°C
BP 126/69, HR 112, RR 16, O2 sats 96% on 60% O2
EWS 6
WCC 17.9, CRP 388
Vancomycin stopped
Flucloxacillin increased to 2g IV 4-hourly
Repeat blood cultures

40. Day 5 09.30 – microbiology review on ward Temp 39.5°C
BP 105/62, HR 84, RR 18, O2 sats 94% on 4L O2
EWS 6
WCC 11.8, CRP 390
Pus and tissue left hip day 3 - Staph. aureus
Blood cultures (day 4) - GPC in clusters on Gram stain of aerobic bottle

41. What next?

42. What next? Ongoing sepsis Persistent positive blood cultures
Source control
Repeat blood cultures

43. Day 5 11.00 – theatre Washout left hip – looked clean Swabs x 5 – MSSA
Blood cultures not sent

44. Days 6-7 Remained febrile Normotensive, HR 80-90
Intermittent supplemental oxygen (2L)
EWS 0-4
Pain ++ in hip

45. What are you thinking?

46. What are you thinking?
Ongoing infection – need for further source control?
Possibility of additional focus of infection?
Imaging
CT/MRI
Bone scan
Echo
Blood cultures

47. Day 7 Blood cultures taken MRI lumbar spine and pelvis
? Evidence of discitis
? Evidence of psoas abscess

48. Day 7 – MRI lumbar spine and pelvis
No discitis or epidural abscess
New left iliacus muscle abscess (5 x 2 x 6 cm)

49. Day 8 – bone scan Increased uptake in upper left tibia
Indicates active inflammation
Suspicious for infection at left prosthetic knee joint
Team felt changes likely post-surgical

50. Day 9
Temp 38.3°C
WCC 22.8, CRP 120
Blood culture (day 7) – sterile to date
Returned to theatre
Left hip macroscopically clean, washed out
Drainage left iliacus abscess – pus evacuated from iliac fossa, debridement
Tissue x 1 – MSSA
Swab x 1 – MSSA

51. Day 11 Temp 38.3°C WCC 20.2, CRP 190 Transthoracic echo Normal valves
No vegetations seen

52. Day 12 Temp 36.2°C WCC 18.9, CRP 144 1st stage revision
Vancomycin spacer
Plan
6 weeks antibiotics
2 weeks break
2nd stage

53. Further progress Remained afebrile
Discharged on day 26 on OPAT (cefazolin)
WCC 7.3, CRP 7
Successful second stage
Dislocation of THR on 2 occasions

54. Key points Recognition EWS Resuscitation Sepsis 6 Source control
Identify
Control – may need repeated interventions
Consider additional sources

55. CONTROL