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Successful treatment of Pseudomonas aeruginosaosteomyelitis with limited duration of antibiotic
monotherapy
Nadir Laghmouche1, Fabrice Compain2,3, Anne-Sophie Jannot5, Pierre Guigui1,2, Jean-Luc Mainardi2,3,4, Guillaume Lonjon1,2, Benjamin Bouyer1,2 and Marie-Paule Fernandez-Gerlinger2,3,4
1 service de Service de chirurgie orthopédique et de traumatologie, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
2Université Paris Descartes, Paris, France
3Service de Microbiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
4Unité Mobile de Microbiologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
5Service d'informatique médicale, de biostatistique et de Santé Publique, Assistance Publique-Hôpitaux de Paris, Hôpital européen Georges Pompidou, Paris, France.
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Background
Osteomyelitis : a major therapeuticchallenge
Gilbert et al. Am J Med 1987; Lucht et al. Infection 1994
Relapse or failure ? prolonged antibiotherapy
Prolonged antibiotherapy ? selection of resistance (MDR), adverse effects, etc…
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• P. aeruginosa : Gram negative aerobicbacteria
• Under-reported pathogen in osteomyelitis
• Particular concern: natural antibioticresistance and ability to developresistance and biofilm
• Recurrences, difficult to treat
antibiotic combination
What about Pseudomonas aeruginosa?
Spellberg et al. CID 2012; Titécat et al. Orthop Traumatol Surg Res OTSR 2013; Ketterl et al. JAC 1988; Tice Alan JAC 2003; Legout et al. Clin Microbiol Infect Off Publ Eur Soc Clin MicrobiolInfect Dis
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Objective: What about Hôpital européen Georges Pompidou experience?
Is antibiotic combination necessary?
Is long course of antibiotic necessary?
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Patients and methods
• Retrospective monocentric study
• 15 years
• All bone biopsies positive to P. aeruginosa(mono or polymicrobial)
• Exclusion criteria: • < 18 yo,
• pregnancy,
• uncertain diagnosis of persistent osteomyelitis after surgical excision,
• files without sufficient clinical information,
• absence of antibiotic treatment and follow-up less than 6 months.
• Treatment failure was defined as:
• the persistence or recurrence of osteomyelitis with the initial P. aeruginosa strain,
• or the reinfection with another pathogen,
• or a re-operation for any cause,
• or the necessity to introduce a new antibiotic therapy for a local
recurrence.
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Results: flowchart
Non-repetitive bone
biopsies positive for P.
aeruginosa (n=292)
Files without sufficient clinical data (n=137)
Patient transferred to another institution (n=5)
Insufficient follow-up (<6-month) (n=22 including 15
deaths)
Incomplete clinical files (n=110)
Complete clinical files
available for analysis
(n=155)
Patients who did not receive any antibiotics (n=88)
Surgical treatment only (n=59)
P. aeruginosa was considered a culture contaminant (n=5)
P. aeruginosa osteomyelitis was not retained as the final
diagnosis (n=24)
Patients included in this
study (n=67)
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Results
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Results: success and failures
• Treatment failure:
14 patients
4/14 due to persistance of P. aeruginosa (2 out of the 4 received a
combination therapy from the start).
• Treatment success = 79.1%
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Results
Antibiotic duration? 82% of patients received antibiotherapy for 6 weeks or less : no difference
Mono or bitherapy against P. aeruginosa ? 94% of patients received monotherapy : no difference
Maintening surgical devices ? 14 out of 26 patients : no difference
Mono or polymicrobial : poorer outcome? No: failures rates were similar : no difference
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Discussion
• P. aeruginosa osteomylitis : rare
• Success rate (79.1%): not inferior to the literature.
• No European guidelines covering bone and joint infections:
Quid of antibiotic duration with or without implant removal?Quid of combination therapy?
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Limitations
Monocentric
Retrospective design
Lack of power to conclude
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Conclusion
• We advocate antibiotic monotherapy over the full course of the treatment
• Treatment duration should not exceed six weeks.