1. EDUCATIONAL WORKSHOPS 2009 CASE PRESENTATION TWO Orthopaedic graft infection Author: Savita Gossain, Heart of England Foundation Trust

2. Sponsored through an unrestricted educational grant from Novartis Pharmaceutical Ltd to help support the cost of developing and hosting this educational workshop series

3. Background 83 yr old Female Past medical history: Hypertension, Gout, TIA Severe osteoarthritis both hips; Left > Right October 2006 Left THR Prophylaxis: Cefuroxime x 3 doses Uneventful postoperative recovery Discharged home 1 week later, wound healed Author: Savita Gossain, Heart of England Foundation Trust

4. February 2007 Admitted with sepsis, Temp 40 Cellulitis & collection over Left THR wound CRP 179, WCC 11.3 Empirical iv vancomycin & ciprofloxacin Wound aspirate: Group G Streptococcus Changed to iv Benzylpenicillin Author: Savita Gossain, Heart of England Foundation Trust

5. February 2007 3 weeks later – no clinical improvement Washout of hip Postoperative bleeding ++ Iv Benzylpenicillin continuing Author: Savita Gossain, Heart of England Foundation Trust

6. March 2007 Received 4 weeks iv Benzylpenicillin - changed to oral Antibiotics (Penicillin V) Rash 3 days later, so changed to oral Erythromycin Author: Savita Gossain, Heart of England Foundation Trust

7. March 2007 1 week after change to oral Erythromycin: Further debridement & washout infected Left THR required, raised CRP 2 x swabs and 3 x tissue grew Enterococcus faecalis (Amp, Vanc sensitive) IV Vancomycin commenced Author: Savita Gossain, Heart of England Foundation Trust

8. March & April 2007 Clinical improvement post-operatively although wound discharge for 10 days. Immunology Opinion: RAST test: IgE abs negative for Penicillin G and Penicillin V. “Rash may have resulted from interaction between oral Pen V and Allopurinol”. Author: Savita Gossain, Heart of England Foundation Trust

9. April 2007 Clinically improved, keen for home Received IV vancomycin for 3/52, discussion with Microbiology re: cautious trial oral Amoxycillin to continue treatment Discharged home 13 April 2007 on po amoxycillin Author: Savita Gossain, Heart of England Foundation Trust

10. End April 2007 Readmission with severe diarrhoea & vomiting, abdominal pain CDT positive WCC 65 CRP 349 Surgical Review -> Conservative Management Rx: Oral Vancomycin + iv Metronidazole then po Vancomycin total 4/52. Author: Savita Gossain, Heart of England Foundation Trust

11. June 2007 Diarrhoea settled with antibiotic treatment of CDI and rehydration etc Orthopaedic Review. No hip pain. Wound healed. Mobilising, Discharged home 30/6/07. QUESTION: Should Amoxycillin have been stopped? (Had received 3/52 iv vancomycin and 2/52 oral amoxycillin after last debridement and washout) Author: Savita Gossain, Heart of England Foundation Trust

12. Nov 2007 – Dec 2008 Orthopaedic Outpatient Reviews. Pain in L hip and thigh. August 2008: CRP 84 Xray: loosening acetabular cup in all 3 zones Dec 2008: Xray: Loose femoral and acetabular component Agreed for 2 Stage revision L THR Author: Savita Gossain, Heart of England Foundation Trust

14. January 2009 Admission with pain in L THR and draining sinus CRP 105, WCC 7.1, ESR 117 1 week later: First stage of Revision L THR 3/5 Tissue samples growing Enterococcus faecalis (Amp, Vanc Sensitive) IV Teicoplanin commenced 400mg. Low serum level. Changed to 600mg Author: Savita Gossain, Heart of England Foundation Trust

15. March 2009 Received 4 weeks of iv teicoplanin Wound discharge and CRP still raised (83) Superficial W/S grew Mixed coliforms Debridement & washout performed and cement spacer removed Tissue/fluid growing Proteus sp. (fully sens) Trimethoprim added to Teicoplanin Author: Savita Gossain, Heart of England Foundation Trust

16. April 2009 Initial improvement but 4 weeks after starting trimethoprim, CRP 65. Further debridement & washout of hip Tissue/Fluid samples: Proteus species as previously Ertapenem commenced and Teicoplanin continued Author: Savita Gossain, Heart of England Foundation Trust

17. June 2009 6/52 iv antibiotics, then 2/52 off antibiotics 2 nd stage procedure with insertion new prosthesis All tissue samples : No growth iv Ertapenem + teicoplanin Plan: 6/52 iv Abx (OPAT) and CRP monitoring Author: Savita Gossain, Heart of England Foundation Trust

18. 4 August 2009 Clinically well Mobilising with support CRP 14 IV antibiotics (OPAT) stopped after 8 weeks Xrays of L Hip : next 2 slides Author: Savita Gossain, Heart of England Foundation Trust