Case 41

Patient 41 is a 25 year-old male with no significant past medical history who sustained an extensive electrical injury on Oct2020 resulting in 22% total body surface area burns. Burn wounds were complicated by a cranial osteomyelitis with associated complicated soft tissue infection. The patient underwent extensive debridement of the scalp and skull throughout his hospital course, and ultimately underwent full thickness craniectomy with muscle flap and skin grafting in Dec2020 for definitive closure. Operative cultures from the soft tissues of the scalp and cranium grew a MDR Pseudomonas aeruginosa. The Pseudomonal isolates had increasing resistance throughout patient’s hospital course. He had previously been treated with cefepime, then imipenem-relebactam, followed by ceftazidime-avibactam. The final available Pseudomonal isolates from scalp tissue were only susceptible to Cefiderocol which the patient was started on in Dec2020 after definitive closure of the scalp wound. Since the patient was on last line antimicrobial therapy, he was started on adjunctive therapy with Pseudomonas aeruginosa-specific bacteriophage on 6Jan2021. He ultimately received Cefiderocol for 6 weeks and adjunctive bacteriophage therapy for 4 Weeks. The patient tolerated bacteriophage therapy well with no significant adverse events noted. Repeat head CT at the end of therapy showed stable post-surgical changes with no soft tissue collections or new osseous erosive changes to suggest a progressive infectious/inflammatory process. The overlying muscle flap and skin graft healed well and there was good venous and arterial signals on doppler. He was discharged to a spinal cord injury rehabilitation center in Feb2021.