Case 25

Patient #25, a 61 year-old male who had a primary left total hip arthroplasty in 1985 which required revisions in 1991, 2000, and 2004 complicated by infection with staphylococcus. He failed debridement, antibiotics and implant retention (DAIR) and required a two-stage exchange in 2004-2005 for Enterococcus cloacae, followed by further surgical interventions in 2008 (staphylococcus epidermidis), 2010 (staphylococcus epidermidis), 2013 with exchange of modular head due to a MSSA infection, and in 2014 with exchange of acetabular liner and modular head with insertion of antibiotic-impregnated cement due to a Enterobacter cloacae. infection. In 2016, he developed a Candida albicans infection while on chronic suppression with both minocycline and levofloxacin and had a second DAIR and on antibiotic suppressive treatment including fluconazole. In 2019, he developed a left lateral thigh fluid collection which was aspirated and grew minocycline-susceptible coagulase-negative staphylococci. He underwent a third DAIR in June 2019 and was maintained on chronic suppressive antimicrobial therapy. Despite this, the patient developed re-accumulation of fluid. Because of insufficient femoral bone stock, the only remaining surgical options were total femoral replacement done in stages which is highly morbid and unlikely to successfully eradicate the infection versus hip disarticulation. Since he had exhausted reasonable surgical and medical interventions, he was evaluated for phage therapy and the collection was aspirated (1 liter of bloody fluid) in April, 2020 which yielded a positive culture for oxacillin-resistant Staphylococcus epidermidis. Phage therapy was started intra-articularly (single dose) and daily intravenous doses x 10 days. He was maintained on levofloxacin, minocycline, and fluconazole. He did well clinically with minimal pain (this is baseline). A repeat aspiration is planned and the case is ongoing.