Eradication of Acinetobacter baumannii/Enterobacter cloacae complex in an open proximal tibial fracture and closed drop foot correction with a multidisciplinary approach using the Taylor Spatial Frame®: a case report

Compassionate use of cefiderocol in a complex case of extensively drug-resistant Acinetobacter baumannii fracture-related infection: a comprehensive approach and multidisciplinary management

PURPOSE

Fracture-related infections (FRI) pose a difficult management problem, as they require numerous surgical interventions and extended antibiotic treatments, especially when a multidrug-resistant organism is involved, with a paucity of available literature that provides guidance.

RESULTS

A 42 year-old male presents an open diaphyseal tibia and fibula fracture, complicated by soft tissue necrosis and infections caused by extensively drug-resistant Acinetobacter baumannii (XDR-Ab). Initially treated with a damage control external fixator, the patient underwent multiple surgical procedures, including radical debridement, negative pressure wound therapy, external fixator revisions and reconstructive surgery using a latissimus dorsi free flap. The emergence of colistin resistance in the Acinetobacter baumannii strain led to the compassionate use of cefiderocol, finally achieving clinical cure.

CONCLUSIONS

This case report is one of the firsts that highlights the potential efficacy of cefiderocol in treating challenging bone and joint infections sustained by XDR-Ab. The successful outcome also emphasizes the importance of a comprehensive, multidisciplinary approach in achieving favorable results in complex FRI.

The Use of the Taylor Spatial Frame in Treating Tibial Osteomyelitis Following Traumatic Tibial Fracture

Introduction

Tibial osteomyelitis can follow open fractures with bacteria colonising the wound and persisting through biofilm and sequestrum formation. The treatment is complex, requiring eradication through debridement before limb reconstruction, for which the Taylor spatial frame (TSF) is one option. This study evaluates patient outcomes after reconstruction and identifies factors associated with post-operative complications.

Materials and methods

Fifty-one cases of tibial osteomyelitis were treated by the Ilizarov technique from 2015 to 2021 at a major trauma centre. Bacterial samples and treatment factors were assessed. Patient outcomes were complication rates and time to bony union. Complications were expressed as odds-ratios (OR) with 95% confidence intervals. Linear regression was used to assess factors associated with time to union.

Results

The mean follow-up was 24.1 months with the mean time to radiological union being 11 months. Post-operative complications were noted in 76.5% of patients with pin-site infections most common (52.9%), followed by fracture malunion (29.4%). Smoking was associated with increased fracture malunion (OR = 4.148, 95% confidence Interval [1.13-15.18], p = 0.031). The time to union was positively associated with complications, age and time to full weight-bearing (FWB). All other measured factors were found not significant.

Conclusion

Tibial osteomyelitis is treated reliably by debridement and reconstruction using the Ilizarov technique using a TSF application. The most common complication was pin-site infection. Optimising patients through cessation of smoking and encouraging post-operative weight-bearing can reduce the complication rate and improve time to union.

Clinical significance

The Ilizarov technique using a TSF can treat significant deformities that result from the management of tibial osteomyelitis.

How to cite this article

Geetala R, Zhang J, Maghsoudi D, et al. The Use of the Taylor Spatial Frame in Treating Tibial Osteomyelitis Following Traumatic Tibial Fracture. Strategies Trauma Limb Reconstr 2024;19(1):32-35.

Osteosynthesis-associated infection of the lower limbs by multidrug-resistant and extensively drug-resistant Gram-negative bacteria: a multicentre cohort study

Purpose: The purpose of this study was the clinical and therapeutic assessment of lower-limb osteosynthesis-associated infection (OAI) by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria (GNB), which have been poorly studied to date. Methods: A prospective multicentre observational study was conducted on behalf of ESGIAI (the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group on Implant-Associated Infections). Factors associated with remission of the infection were evaluated by multivariate and Cox regression analysis for a 24-month follow-up period. Results: Patients ( n = 57 ) had a history of trauma (87.7 %), tumour resection (7 %) and other bone lesions (5.3 %). Pathogens included Escherichia coli ( n = 16 ), Pseudomonas aeruginosa ( n = 14 ; XDR 50 %), Klebsiella spp. ( n = 7 ), Enterobacter spp. ( n = 9 ), Acinetobacter spp. ( n = 5 ), Proteus mirabilis ( n = 3 ), Serratia marcescens ( n = 2 ) and Stenotrophomonas maltophilia ( n = 1 ). The prevalence of ESBL (extended-spectrum β -lactamase), fluoroquinolone and carbapenem resistance were 71.9 %, 59.6 % and 17.5 % respectively. Most patients ( n = 37 ; 64.9 %) were treated with a combination including carbapenems ( n = 32 ) and colistin ( n = 11 ) for a mean of 63.3 d. Implant retention with debridement occurred in early OAI (66.7 %), whereas the infected device was removed in late OAI (70.4 %) ( p = 0.008 ). OAI remission was achieved in 29 cases (50.9 %). The type of surgery, antimicrobial resistance and duration of treatment did not significantly influence the outcome. Independent predictors of the failure to eradicate OAI were age > 60  years (hazard ratio, HR, of 3.875; 95 % confidence interval, CI95 %, of 1.540-9.752; p = 0.004 ) and multiple surgeries for OAI (HR of 2.822; CI95 % of 1.144-6.963; p = 0.024 ). Conclusions: Only half of the MDR/XDR GNB OAI cases treated by antimicrobials and surgery had a successful outcome. Advanced age and multiple surgeries hampered the eradication of OAI. Optimal therapeutic options remain a challenge.

Antibacterial Designs for Implantable Medical Devices: Evolutions and Challenges

The uses of implantable medical devices are safer and more common since sterilization methods and techniques were established a century ago; however, device-associated infections (DAIs) are still frequent and becoming a leading complication as the number of medical device implantations keeps increasing. This urges the world to develop instructive prevention and treatment strategies for DAIs, boosting the studies on the design of antibacterial surfaces. Every year, studies associated with DAIs yield thousands of publications, which here are categorized into four groups, i.e., antibacterial surfaces with long-term efficacy, cell-selective capability, tailored responsiveness, and immune-instructive actions. These innovations are promising in advancing the solution to DAIs; whereas most of these are normally quite preliminary “proof of concept” studies lacking exact clinical scopes. To help identify the flaws of our current antibacterial designs, clinical features of DAIs are highlighted. These include unpredictable onset, site-specific incidence, and possibly involving multiple and resistant pathogenic strains. The key point we delivered is antibacterial designs should meet the specific requirements of the primary functions defined by the “intended use” of an implantable medical device. This review intends to help comprehend the complex relationship between the device, pathogens, and the host, and figure out future directions for improving the quality of antibacterial designs and promoting clinical translations.

Heteroleptic pincer palladium(II) complex coated orthopedic implants impede the AbaI/AbaR quorum sensing system and biofilm development by Acinetobacter baumannii

Implant-associated infections mediated by Acinetobacter baumannii biofilms have become a major concern in the healthcare sector. As biofilm formation by this important pathogen is mediated by quorum sensing, quorum sensing inhibitors (QSI) have gained much attention. The present study confirms that novel thiazolinyl-picolinamide based palladium(II) complexes had good biofilm disruptive and QSI properties against A. baumannii. Key QS-mediated virulence factors like pili mediated surface motility and polysaccharide production were inhibited by the best Pd(II) complex (E). This also showed potent inhibitory activity against both the standard and clinical strains of A. baumannii. Molecular docking analysis also proved the potent binding affinity of Pd(II)-E with the virulence targets. The Pd(II) complex also disrupted preformed biofilms and down-regulated the expression of QS mediated virulence genes in the biofilms established on implant material (titanium plates). As a whole, the present study showed that the novel thiazolinyl-picolinamide based Pd(II) complexes offer a promising anti-infective strategy to combat biofilm-mediated implant infections.

Tigecycline Versus Colistin in the Treatment of Carbapenem-resistant Acinetobacter baumannii Complex Osteomyelitis

Background: Acinetobacter baumannii complex is an increasingly important cause of osteomyelitis. It is considered a difficult to treat agent, due to increasing antimicrobial resistance and few available therapeutic options. Objective: To compare effectiveness and tolerability of tigecycline and colistin in patients with osteomyelitis caused by carbapenem-resistant A. baumannii complex (CRABC). Methods: This retrospective review included all patients admitted to a 150-bed tertiary hospital from 2007 to 2015 with microbiologically confirmed CRABC osteomyelitis for which they received tigecycline or colistin. Data on demographic and clinical characteristics, adverse events, and outcomes 12 months after the end of antimicrobial treatment were analysed and stratified according to the antimicrobial used. Results: 65 patients were included, 34 treated with colistin and 31 with tigecycline. There were significantly more men (P = 0.028) in the colistin group, and more smokers (P = 0.021) and greater occurrence of chronic osteomyelitis (P = 0.036) in the tigecycline treatment group. Median duration of therapy was 42.5 days for colistin and 42 days for tigecycline, with no significant difference. Overall incidence of adverse events was higher in the colistin group (P = 0.047). In particular, incidence of renal impairment was also higher in this group (P = 0.003). Nausea and vomiting were more frequent with tigecycline (P = 0.046). There were no significant differences between groups in relapse, amputation, or death. Conclusions: Tigecycline had a better safety profile than colistin in the treatment of osteomyelitis due to CRABC, with no significant difference in outcomes after 12 months of follow-up.

Tibial Osteomyelitis Caused by Carbapenem-Resistant Enterobacter cloacae

A 31-year-old man presented with a symptomatic tibial non-union following an open tibia fracture sustained in India. The open fracture was persistently draining for 8 months following the initial injury. The decision was made to revise his tibia fracture to promote union. Intraoperative cultures of the non-union site during the revision procedure revealed osteomyelitis caused by carbapenemase-producing Enterobacter cloacae which was multi-drug resistant to all antibiotics except for tigecycline. The patient was treated successfully with a tigecycline-impregnated antibiotic spacer and intravenous tigecycline with repeat bone cultures demonstrating eradication of the infection. Eight weeks into treatment (1 year from initial injury), the patient developed new pain and swelling in the adjacent proximal fibula of the limb treated for osteomyelitis. MRI and biopsy revealed Ewing sarcoma. The patient underwent transfemoral amputation. This report describes a management protocol of carbapenemase-resistant post-traumatic osteomyelitis with no evidence of infection recurrence.