Subcutaneous suppressive antibiotic therapy for bone and joint infections: safety and outcome in a cohort of 10 patients
Authors: Pouderoux Cécile , Becker Agathe , Goutelle Sylvain , Lustig Sébastien , Triffault-Fillit Claire , Daoud Fatiha , Fessy Michel Henry , Cohen Sabine , Laurent Frédéric , Chidiac Christian , Valour Florent , Ferry Tristan ,   Lyon Bone and Joint Infection Study Group, Ferry Tristan , Valour Florent , Perpoint Thomas , Miailhes Patrick , Ader Florence , Becker Agathe , Roux Sandrine , Triffault-Fillit Claire , Conrad Anne , Perry Marielle , Pouderoux Cécile , Daoud Fatiha , Lippman Johanna , Braun Evelyne , Chidiac Christian , Lustig Sébastien , Batailler Elvire Servien Cécile , Gaillard Romain , Gunst Stanislas , Roger Julien , Fiquet Charles , Fessy Michel-Henry , Viste Anthony , Chaudier Philippe , Besse Jean-Luc , Louboutin Lucie , Gaudin Gaël , Ledru Tanguy , Van Haecke Andrien , Ode Quentin , Mercier Marcelle , Alech-Tournier Florie , Martres Sébastien , Trouillet Franck , Barrey Cédric , Jouanneau Emmanuel , Jacquesson Timothée , Gerenton Brice , Mojallal Ali , Boucher Fabien , Shipkov Hristo , Céruse Philippe , Fuchsmann Carine , Gleizal Arnaud , Aubrun Frédéric , Dziadzko Mikhail , Macabéo Caroline , Laurent Frederic , Beraut Laetitia , Dupieux Céline , Kolenda Camille , Josse Jérôme , Gustave Claude-Alexandre , Craighero Fabien , Boussel Loic , Pialat Jean-Baptiste , Morelec Isabelle , Tod Michel , Gagnieu Marie-Claude , Goutelle Sylvain , Mabrut Eugénie 
Published: March 2019

Abstract

Background
Optimal treatment of prosthetic joint infection and chronic osteomyelitis consists of surgical removal of biofilm-embedded bacteria, followed by a 6–12 week course of antimicrobial therapy. However, when optimal surgery is not feasible, oral prolonged suppressive antibiotic therapy (PSAT) is recommended to prevent prosthesis loosening and/or relapse of infection. Since 2010, we have used infection salvage therapy using off-label subcutaneous (sc) injection of a β-lactam as PSAT for patients in whom oral PSAT is not possible.

Methods
A single-centre prospective cohort study (2010–18) reporting treatment modalities, efficacy and safety in all patients receiving sc PSAT. NCT03403608.

Results
The 10 included patients (median age 79 years) had polymicrobial (n = 5) or MDR bacterial (n = 4) prosthetic joint infection (knee, n = 4; hip, n = 3) or chronic osteomyelitis (n = 3). After initial intensive therapy, seven patients received ertapenem, three patients received ceftriaxone and one patient received ceftazidime by sc injection (one patient received 8 days of ceftriaxone before receiving ertapenem). In one patient, sc PSAT failed with recurrent signs of infection under treatment. In three patients, sc PSAT had to be discontinued due to side effects; in only one of these was the sc route implicated (skin necrosis following direct sc injection and not gravity infusion). Median treatment duration was 433 days. In six patients, sc PSAT was successful with favourable outcome at the time of writing. Interestingly, three patients with MDR bacterial carriage at baseline lost this under PSAT during follow-up.

Conclusions
As salvage therapy, sc PSAT delivered by gravity infusion is a safe and interesting alternative when an optimal surgical strategy is not feasible and no oral treatment is available.