Bacteriophage therapy cures a recurrent Enterococcus faecalis infected total hip arthroplasty? A case report

A 76-year-old male patient presented with osteoarthritis of the left hip. He had no relevant medical history and had been professionally active in agriculture. Cemented total hip arthroplasty (THA), performed in September 2015, was complicated by an extensive hematoma and wound leakage on the second postoperative day. Wound leakage persisted for another 8 days, and debridement was performed. All 6 tissue samples showed the presence of Enterococcus faecalis, and the patient was treated with intravenous teicoplanin 600 mg twice a day for 3 months. After this treatment, the infection recurred, and a 2-stage septic revision was scheduled. The prosthesis and all surrounding cement were removed in February 2016. All samples taken showed growth of E. faecalis. After susceptibility testing, teicoplanin was restarted and continued for 6 weeks. Reimplantation followed in May 2016 after an antibiotic-free period of more than 6 weeks. Tissue samples obtained at that time showed no bacterial growth. In December 2016, the patient complained of pain and discomfort. 2 separate joint aspirations showed no bacterial growth, but serial radiological images showed loosening of the femoral stem. The patient was planned for revision surgery in January 2017. In 5 out of 7 samples, E. faecalis was cultured. After susceptibility testing, teicoplanin was restarted for another 3 months at the same dose. In June 2017, an aspiration, performed due to persistent pain, turned out to be positive for E. faecalis again. Extraction of the hip prosthesis followed and teicoplanin was restarted for another 6 weeks. After an antibiotic-free period of 2 weeks, open biopsies were taken. They all showed no bacterial growth. 4 weeks later, the hip was reimplanted (Figure 1). At the time of reimplantation, E. faecalis was cultured in 4 out of 7 samples. Due to kidney failure during the last period of teicoplanin therapy, this antibiotic regime could not be restarted. Postoperatively, oral amoxicillin 1,000 mg was administered 4 times a day for 3 months. In the summer of 2018, a new sample was obtained because of pain. The known E. faecalis was again cultured. A Girdlestone procedure was not accepted by the patient, who opted for suppressive therapy with doxycycline 200 mg once a day. Due to gastrointestinal side effects, the doxycycline dose was reduced to 100 mg once a day in September 2018. Nausea, vomiting, and loss of appetite lasted until shortly after the antibiotics were stopped in December 2019.