Department of Orthopedic Surgery, School of Medicine, Chiba University, Chuo-ku Inohana 1-8-1, Chiba, 260-8670, Japan.
Department of Orthopedic Surgery, School of Medicine, Chiba University, Chuo-ku Inohana 1-8-1, Chiba, 260-8670, Japan.
J Orthop Sci. 2022 Jan;27(1):272-280. doi: 10.1016/j.jos.2020.11.010. Epub 2021 Jan 19.
Conventional topical antimicrobial therapy cannot maintain a constant local concentration, resulting in uncontrolled infection and complications. We propose continuous local antibiotic perfusion (CLAP), which can maintain a constant appropriate local antibiotic concentration for a long time with less invasiveness and complications. CLAP is clearly different from traditional treatment because it uses negative pressure to direct the continuously infused antibiotic solution to the center of infection and excrete it outside the body. This study aimed to demonstrate the effectiveness of CLAP by presenting cases in which even refractory bone and soft-tissue infections caused by the hypervirulent Klebsiella pneumoniae (hvKp) could be cured without significant tissue loss and dysfunction.
This study is a case series in which four patients with limb infection due to hvKp were treated by CLAP. hvKp was defined by a positive string test. The therapy included intra-soft-tissue antibiotic perfusion and intramedullary antibiotic perfusion. Gentamicin (60 mg/50 cc) was infused continuously through dual-lumen tubes and bone marrow needles at low-flow rates (2 mL/h). Negative pressure was used to collect the antimicrobial solution and eliminate the dead space.
The infection was controlled in all four patients after a mean period of 44.3 days. The mean maximum blood concentration of gentamicin was 1.6 μg/dL, and no cases of renal dysfunction or ototoxicity occurred. After CLAP, wound closure was required in two patients and iliac bone grafting was required in one patient. As sequelae, there were one case of osteoarthritis and one case of higher brain dysfunction due to hypoxia.
Our results suggest that intractable hvKp infections can be controlled by CLAP. CLAP may give us the option to directly control local infections with less systemic complications. Therefore, it is considered a valuable treatment for further basic and clinical research, and this research report may be a first step.
传统的局部抗菌治疗无法维持恒定的局部浓度，导致感染失控和并发症。我们提出了持续局部抗生素灌注（CLAP），它可以通过较小的侵入性和更少的并发症，长时间维持恒定的适当局部抗生素浓度。CLAP 与传统治疗明显不同，因为它使用负压将持续输注的抗生素溶液引导到感染中心，并将其排出体外。本研究旨在通过展示即使是由高毒力肺炎克雷伯菌（hvKp）引起的难治性骨和软组织感染也可以治愈，而不会造成明显的组织损失和功能障碍，来证明 CLAP 的有效性。
这是一项病例系列研究，其中 4 例因 hvKp 引起的肢体感染患者接受了 CLAP 治疗。hvKp 通过阳性拉丝试验定义。该治疗包括软组织内抗生素灌注和髓内抗生素灌注。庆大霉素（60mg/50cc）通过双腔管和骨髓针以低流速（2mL/h）持续输注。使用负压收集抗菌溶液并消除死腔。
所有 4 例患者在平均 44.3 天后感染得到控制。庆大霉素的最大血药浓度平均值为 1.6μg/dL，无肾功能不全或耳毒性病例发生。CLAP 后，2 例患者需要伤口闭合，1 例患者需要髂骨移植。作为后遗症，有 1 例出现骨关节炎，1 例因缺氧导致高级脑功能障碍。
我们的结果表明，难治性 hvKp 感染可以通过 CLAP 控制。CLAP 可能为我们提供了一种通过较少的全身并发症直接控制局部感染的选择。因此，它被认为是进一步基础和临床研究的有价值的治疗方法，本研究报告可能是第一步。
