Case 26

Patient #26, a 60-year-old man with multiple medical comorbidities including a thoracic aortic aneurysm, atrial fibrillation status post ablation, gastric bypass surgery 2014 complicated by postop gastric sleeve strictures requiring stenting, history of DVT, and multiple joint arthroplasties including bilateral total knee arthroplasty, total hip arthroplasty (THA) and total shoulder arthroplasty. He underwent primary left total hip arthroplasty on May 27, 2014 which was complicated by methicillin resistant Staphylococcus aureus (MRSA) bacteremia and prosthetic joint infection (PJI) in 2015 and treated with debridement, antibiotics, and implant retention (DAIR) followed by chronic antibiotic suppression, which he had significant difficulty tolerating. He had a subsequent left THA revision in 2018 due to a fracture after a fall and this was complicated by recurrent infection with cultures positive for MRSA and group B strep and he underwent a repeat revision. He had continued difficulty tolerating both IV abx (daptomycin) as well as bactrim/penicillin for chronic suppression. He developed loosening of the components in late 2018. Discussions were had about possibly performing a girdlestone procedure but due to significant anticipated loss of function, this was delayed. A repeat left THA aspiration in Feb 2020 cultured MRSA. Since then he had been having intermittent fevers despite suppression with Bactrim and penicillin VK. He had two hospital admissions in February 2020 and March 2020 with drainage, erythema, fevers, and rigors, and chest pain and was wheelchair bound. The patient had multiple medical complications and did poorly with 9 or 10 out of 10 pain, intermittent fevers and chills, inability to bear weight on left leg and copious and constant brown drainage. In April, 2020 he had a DAIR procedure and received 1 dose of phage intraoperatively. His (pre-phage) intra-operative cultures were positive for MRSA and was placed on vancomycin and rifampin. He received a double dose of IA phage the next day and received ten daily (single dose) IV doses over 14 days. He did well clinically, and all drainage stopped. Re-aspiration of the joint is planned and the case is ongoing.