Paper of the week: Salvage Debridement, Antibiotics and Implant Retention (“DAIR”) With Local Injection of a Selected Cocktail of Bacteriophages: Is It an Option for an Elderly Patient With Relapsing Staphylococcus aureus Prosthetic-Joint Infection? Tristan Ferry, Gilles Leboucher, Cindy Fevre, Yannick Herry, Anne Conrad, Jérôme Josse, Cécile Batailler, Christian Chidiac, Mathieu Medina, S Lustig, Frédéric Laurent, and Lyon BJI Study Group. Open Forum Infect Dis. 2018 Nov; 5(11): ofy269. Published online 2018 Oct 24. doi: 10.1093/ofid/ofy269

Summary and editorial by Sreeram Penna

This publication is about the use of bacteriophage treatment in a patient with relapsing poly microbial periprosthetic joint infection. The study case is an 80-year-old patient with a known history of type 2 diabetes and mild chronic renal failure. The patient had multiple procedures for PJI and grew methicillin-susceptible Staphylococcus aureus (MSSA), fluoroquinolone-resistant Escherichia coli (E. coli) and multi-drug resistant Pseudomonas aeruginosa. During her DAIR procedure, she had a cocktail of four bacteriophages targeting Pseudomonas and MSSA, which was grown preop. Operative specimens grew MSSA and E. coli and Staphylococcus lugdunensis. The patient had a course of Daptomycin and amoxicillin post op. The patient required further DAIR procedure for Citrobacter koseri infection eight months later. Eighteen months post-procedure with bacteriophage treatment patient was without signs of infection but was on long-term amoxicillin.

Bacteriophages are natural viruses that target bacteria. Bacteriophages were used in the past in treatment of osteomyelitis where they were injected through the fistula.[1] Bacteriophages are particularly interesting because they act synergistically with antibiotics. [2] In addition bacteriophages amplify during treatment due to their replication in bacteria.[3] Phages are being used in multidrug-resistant life-threatening infections with authorization from Food and Drug Administration (FDA) to administer the cocktails as an emergency investigational new drug (eIND) as seen in case of a patient with multidrug-resistant Acinetobacter baumannii infection.[4] The phase treatment thus shows promise as a viable treatment in multidrug-resistant PJIs.

References

[1] Kutateladze M, Adamia R. Bacteriophages as potential new therapeutics to replace or supplement antibiotics. Trends in Biotechnology 2010;28:591–595. doi:10.1016/j.tibtech.2010.08.001.

[2] Oechslin F, Piccardi P, Mancini S, Gabard J, Moreillon P, Entenza JM, et al. Synergistic Interaction Between Phage Therapy and Antibiotics Clears Pseudomonas Aeruginosa Infection in Endocarditis and Reduces Virulence. The Journal of Infectious Diseases 2017;215:703–712. doi:10.1093/infdis/jiw632.

[3] Clokie MR, Millard AD, Letarov AV, Heaphy S. Phages in nature. Bacteriophage 2011;1:31–45. doi:10.4161/bact.1.1.14942.

[4] Schooley RT, Biswas B, Gill JJ, Hernandez-Morales A, Lancaster J, Lessor L, et al. Development and Use of Personalized Bacteriophage-Based Therapeutic Cocktails To Treat a Patient with a Disseminated Resistant Acinetobacter baumannii Infection. Antimicrob Agents Chemother 2017;61. doi:10.1128/AAC.00954-17.