Case 23

Patient #23, a 73 year-old male with Type 2 diabetes mellitus, hypertension and severe peripheral vascular disease including a left femoral-popliteal bypass with vascular graft, left superior femoral artery and popliteal atherectom, left femoral profunda endarterectomy with patch angioplasty, left lower superior femoral artery stent and right femoral to left popliteal bypass. In January 2020, his surgical wounds broke down at both right femoral and left popliteal incisions. The wounds were noted to be non-purulent with sinus tracts probing to graft. Culture at both sites grew carbapenem resistant Klebsiella pneumonia and he also had a pseudoaneurysm at the right femoral anastomosis. Blood cultures were negative and there was no fever or leukocytosis. He was treated with multiple antibiotics from 17January to 4March, 2020. Exgraftment of the infected graft was considered with axillary-femoral graft bypass but patient refused this procedure. Even if he had accepted to undergo the procedure, the new graft would have had to be placed into an infected wound bed. Instead, he underwent a right femoral exploration with sartorius muscle flap closure to reduce the risk of spontaneous rupture of the pseudo-aneurysm. In January 2020, he was found to have new cardiomyopathy with severely reduced ejection fraction. The patient was told that the likelihood of cure with antibiotics alone was remote. He was treated with phage therapy (19 doses) starting on 2March, 2020. No adverse events were reported during treatment. In April 2020 he was noted to have left leg gangrene of first and second toe and occlusion of left common iliac artery. Despite these complications, he has reported no fevers or other signs and symptoms of systemic infection. He was also found to have greenish discharge from his left popliteal wound which was open since his initial evaluation in January 2020 and healing of his right groin wound. In May 2020, he had worsening pain in left foot and left calf which has prevented him from walking or sleeping well. At this point, the culture obtained in April showed Pseudomonas aeruginosa and was admitted for IV antibiotics and clearance for surgery. Cefepime was initiated from admission and continued to date. Due to his cardiac risks, he was transferred to another hospital for cardiac optimization before proceeding with the left above-knee-amputation. During this admission, he remained afebrile, without leukocytosis or other signs and symptoms of systemic infection. He is scheduled for vascular surgery and this case is ongoing.