Extensively drug-resistant pseudomonas aeruginosa sternal osteomyelitis: Suggested reconstructive approach and novel optimization of antimicrobial therapeutics

Abstract

Background Sternal wound infection continues to be the leading complication after median sternotomy. With the growing concern of multidrug-resistant and extensively drug-resistant (XDR) bacterial infections, sternal wound reconstruction is a critical step in successfully healing these patients. The use of a rectus abdominis muscle flap for coverage of the lower one third of sternal wounds as well as objectively optimizing antimicrobial therapy has revolutionized the field of sternal wound reconstruction, yet both practices are not well documented within the literature. Clinical Scenario A 72-year-old man developed an XDR Pseudomonas aeruginosa infection of his sternum after median sternotomy. The sternal wound was successfully reconstructed using a dual flap approach of bilateral pectoralis major myocutaneous flaps and a rectus abdominis muscle flap. Because of the antibiotic susceptibility profile and patient allergy profile, parental tobramycin and high-dose continuous-infusion meropenem were used to treat the osteomyelitis; meropenem serum concentrations were obtained via mass spectroscopy to optimize bactericidal activity. Conclusions Osteomyelitis secondary to XDR P. aeruginosa is exceedingly rare in the literature. Individuals with this type of infection can be successfully treated with aggressive surgical debridement, subsequent reconstruction using bilateral pectoralis major myocutaneous flaps and a rectus abdominis muscle flap for coverage of the sternal wound, and both guided and targeted parental antibiotics. Lastly, the innovative use of antibiotic concentrations was instrumental in targeting the appropriate dose of antimicrobials in this patient.