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One proposal for this is that nearly half of all patients with VRE infections have at least one comorbidity, including obesity, diabetes mellitus, coronary artery disease, or chronic kidney failure ( 2, 12). Morbidity and mortality of these infections are higher than with other organisms. However, when the prosthesis is infected with a resistant organism, these rates increase up to 4-fold ( 8, 9).Īn estimated 3% to 10% of PJI by Gram-positive bacteria are caused by Enterococcus spp. After an initial infection, average failure rate of arthroplasty ranges from 10% to 20%, depending on the pathogen ( 2, 10, 11). In addition to surgical intervention, intravenous antibiotics should be administered for approximately six weeks ( 6, 8, 9). Current options for treating PJI include open debridement and reimplantation in either one or two stages ( 8- 10). Overall lifetime infection rates of prosthetic joints are up to 3% ( 1- 3).
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Follow-up four months later revealed normalization of the ESR and CRP with no evidence of persistence of the infection.
Four weeks into treatment, ESR and CRP were 24 mm/h and 2.3 mg/dL, respectively.
Ithenticate ttu serial#
Serial cultures from the Hickman of the synovial fluid did not show regrowth of the VRE. A Hickman catheter was placed in the joint, and the patient was administered 100 mg daptomycin daily in 2 cc saline intraarticularly as well as 4 mg/kg/day intravenously. The knee was swollen, tender, and drained serosanguineous fluid. Her temperature was 101.1F, blood pressure 98/78 mmhg, and pulse 102 bpm. At this time, she was clinically ill-looking. Despite the prolonged course of antibiotics, she continued to have pain and persistent elevation of her ESR (68 mm/h) and CRP (4.4 mg/dL).Įight months after the incision and drainage, she was taken back to surgery for a two-stage revision of the knee, upon which synovial fluid cultures showed heavy growth of VRE. She was taken to surgery and underwent an incision and drainage with a change of the polymer and subsequent treatment with ceftriaxone 2 g daily for 6 weeks. Cultures of the aspirated fluid were negative. Laboratory findings were significant for an erythrocyte sedimentation rate (ESR) of 56 mm/h and C-reactive protein (CRP) of 5.6 mg/dL.Īrthrocentesis of the affected joint revealed turbid synovial fluid with a leukocyte count of 34.202 cells/mm 3 and red blood cell count of 124 cells/mm 3. The remaining physical examination was unremarkable. There was also evidence of a synovial effusion. Pertinent findings on exam included an ill-appearing woman with an edematous knee and significant tenderness to the joint.
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At the time of her examination, her temperature was 100.2F, blood pressure was 124/76 mm Hg and pulse was 96 bpm. We present a case of VRE affecting a total knee arthroplasty (TKA) that was treated with a two-stage revision along with intravenous and intraarticular daptomycin for a 6-week period with a good outcome.Ī 72-year-old female with a history of diabetes mellitus, hypertension, and osteoarthritis who underwent a right TKA 3 years prior to presentation was seen by her physician for pain, swelling, and tenderness to the knee. While substantial literature exists describing prosthetic joint infections (PJI) caused by MRSA, less has been written covering VRE ( 7, 9). Failure rates of arthroplasty in cases of MDR bacteria range from 24% to 82% ( 5- 8). Risk of failure increases substantially if the infection is caused by a multidrug-resistant (MDR) organism, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Within the veterans health administration, 43% of readmissions in the year post hip or knee arthroplasty are caused by infection ( 4). Infection, however, poses one of the greatest risks of failure, found in 0.5% to 3% of patients ( 1- 3). From 2000 to 2009, rates of knee replacement in the United States nearly doubled, increasing from about 120 to 215 per 100,000 people ( 1). Total joint arthroplasty is becoming a commonly used surgery in the ageing population, providing for pain relief and increased mobility.