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Open Access Case report

Evidence of MRSE on a gentamicin and vancomycin impregnated polymethyl-methacrylate (PMMA) bone cement spacer after two-stage exchange arthroplasty due to periprosthetic joint infection of the knee

Jan Schmolders1, Gunnar TR Hischebeth2, Max J Friedrich1, Thomas M Randau1, Matthias D Wimmer1, Hendrik Kohlhof1, Ernst Molitor2 and Sascha Gravius1*

Author Affiliations

1 Department for Orthopaedic and Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany

2 Institute for Medical Microbiology, Immunology, and Parasitology, Rheinische-Friedrich-Wilhelms Universität Bonn, Bonn, Germany

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BMC Infectious Diseases 2014, 14:144  doi:10.1186/1471-2334-14-144

Published: 18 March 2014

Abstract

Background

Periprosthetic joint infections (PJI) are often treated by two stage exchange with the use of an antibiotic impregnated spacer. Most of the two-stage exchange algorithms recommend the implantation of an antibiotic-impregnated spacer during the first stage for a period of 2–24 weeks before reimplantation of the new prosthesis. For the spacer to have a therapeutic effect, the local antibiotic concentration must be greater than the minimal inhibition concentration (MIC) against the pathogens causing the PJI. It must remain so for the entire spacer period, otherwise recurrence of infection or resistances might occur. The question as to whether a sufficient concentration of antibiotics in vivo is reached for the entire spacer period has not been answered satisfactorily.

Case presentation

We here present a case of a histologically confirmed chronic PJI 20 month after primary arthroplasty. The primary knee arthroplasty was performed due to osteoarthritis of the joint. Initial assessment did not detect a causative pathogen, and two stage exchange with a vancomycin-gentamycin impregnated spacer was performed. At the time of reimplantation, sonication of the explanted spacer revealed a multi-resistant strain of staphylococcus epidermidis on the device and in the joint. Adaption of the therapy and prolonged treatment successfully eradicated the infection.

Conclusion

According to the authors’ knowledge, the case presented here confirms for the first time the surface contamination (proven through sonication) of a vancomycin-/gentamicin- impregnated Vancogenx®-spacer with a MRSE after ten weeks of implantation.

This case study demonstrates the difficulties still associated with the diagnostics of PJI and the published different two stage treatment regimes with the use of antibiotic impregnated spacers.