TREATMENT OF MULTIDRUG-RESISTANT

ACINETOBACTER BAUMANII OSTEOMYELITIS WITH

ADJUNCTIVE CONTINUOUS COLISTIN IRRIGATION

LT Christina Jamros, DO (Associate)

CDR Ryan Maves, MD (Fellow)
CAPT Mary Bavaro, MD (Fellow)
Department of Internal Medicine
Naval Medical Center, San Diego, CA
 Disclosure
I have no relevant financial relationships with any
commercial supporters.
 The case
26-year-old man was
transferred to the
intensive care unit after
a private plane crash.
bilateral closed femur
and open tibia fractures
above the knee
amputations and
implanted hardware
 Presentation
Physical exam was concerning for soft tissue
and bone infections at the surgical sites.
debridement
started cefazolin and gentamicin
Fevers persisted and he developed
pneumonia.
broadened to vancomycin, piperacillin-
tazobactam, and ciprofloxacin
 Introducing
Cultures from bronchoalveolar
lavage and wound
debridement grew multidrug-
resistant Acinetobacter
baumanii complex.
initially susceptible to only
colistin
IV colistin, meropenem, and
minocycline
persistent fever and purulent
drainage from the surgical sites
multiple surgical debridements
and washouts
application of wound vacuum-
assisted closure (VAC)

Source: Public Health Image Library

 Progress
Initiated trial of continuous irrigation of
colistin via his wound VAC .
wounds improved
normalization of inflammatory markers

Subsequent testing revealed colistin/rifampin

synergy.
 Outcome
Finally discharged on meropenem, colistin, and
rifampin for 4 additional weeks.

Transitioned to amoxicillin and doxycycline

chronic suppression of multidrug-resistant organism
osteomyelitis due to retained hardware

Seven years of follow-up

living independently with bilateral lower extremity
prostheses
 Discussion
Multidrug-resistant organisms cause a variety
of infections and are an economic burden.

Associated with
increased length of hospitalization
healthcare costs
$20 million a year
additional costs $35 billion a year
mortality
Threat Report 2013
 Bad bugs, need drugs
New antibacterial agents approved by the US Food and Drug Administration
1983 - 2012

Boucher H W et al. Clin Infect Dis. 2013;cid.cit152

 Then and now

Challenge for newer uses of older drugs

Devices for VAC instillation therapy

 Colistin: The last resort

Introduced in 1952 for the treatment of

infections caused by Gram-negative bacilli
including multidrug-resistant Acinetobacter baumannii

Replaced in the 1970s with other antibiotics

owing to its nephrotoxicity and neurotoxicity
Mechanism of action

RIFAMPIN
 Phoenix rising
Citations in the PubMed from 1960 to 2011 using either the term
'colistin' or 'colistin resistance'.
 Negative pressure
wound therapy
Since 1990s, advances
in wound management

VAC or negative
pressure wound
therapy combined with
local antiseptic wound
cleansing
KCI V.A.C. Instill Therapy Unit
Instillation Therapy Combined
with Negative Pressure Wound
Therapy
 How it works

Application of sub-atmospheric pressure to the local wound environment

Back DA, et al. Int Wound J 2013; 10 (suppl. 1):3242.

 A clinical example

Wound VAC placement for a case of necrotizing fasciitis

Back DA, et al. Int Wound J 2013; 10 (suppl. 1):3242.

 MEDLINE literature searches
negative pressure wound and instillation therapy from
1990 to 2013 (36 peer-reviewed citations)
randomized controlled trials from 2005 to 2012
wound care with bone involvement (27 publications) or
soft-tissue wounds without bone participation (11
publications)
 The future
use of VAC instillation is not yet widespread
and literature is limited
there is a need for further studies
benefit using antiseptics (polyhexanide , acetic
acid, povidone-iodine)
role for prophylactic use in contaminated wounds
that cannot be closed primarily with surgical
means
 Navy medicine
Acinetobacter baumanii complex infections were
notorious during Operation Iraqi
Freedom/Operation Enduring Freedom
hospital acquired
resistance deployed > nondeployed
Hawley JS et al. noted isolates developed resistance to
colistin during testing
increasing cause of infection in personnel returning
from overseas conflicts after care in deployed military
hospitals
 Military physicians face similar
challenges

More attention to unique

treatment and preventive
measures
Camp Bastion 2009
Approved for training use by UK MOD
 Lessons from the case
In colistin-resistant infections, high minimum
inhibitory concentrations may potentially be
overcome through the direct application of
high drug concentrations to the affected site.

Synergy testing
expand the antibiotic spectrum
prevent the emergence of resistance
 Thank you!

Questions? Comments
 References
Back DA, Scheuermann-Poley C, Willy C. Recommendations on negative pressure wound therapy
with instillation and antimicrobial solutions when, where and how to use: what does the evidence
show? Int Wound J 2013; 10 (suppl. 1):3242.
Bassetti M. New treatment options against gram-negative organisms. Crit Care. 2011; 15(2): 215.
Biswas, S et al. Colistin: An Update on the Antibiotic of the 21st Century. Expert Rev Anti Infect
Ther. 2012; 10(8): 917-934.
Boucher, HW et al. Clin Infect Dis. 2013; 152.
Calhoun, JH et al. Multidrug-resistant Organisms in Military Wounds from Iraq and Afghanistan. Clin
Orthop Relat Res (2008) 466:13561362.
Centers for Disease Control and Prevention (CDC). Antibiotic Resistance Threats in the United
States. Atlanta: CDC, 2013.
Centers for Disease Control and Prevention (CDC). Healthcare-associated infections. Atlanta: CDC,
2014.
Conly JM, Johnston BL. Colistin: The Phoenix Arises. Can J Infect Dis Med Microbiol. 2006 Sep-Oct;
17(5): 267269.
Saiman L. Clinical utility of synergy testing for multidrug-resistant Pseudomonas aeruginosa isolated
from patients with cystic fibrosis: the motion for. Paed Resp Rev. 2007; 8: 249255.