Infection image: cystic pneumocystis jirovecii pneumonia - forgotten?

A 43-year-old male patient presented to the emergency department with progressive dyspnea. CT scan showed pronounced cystic lesions and ground glass opacitiy in both lungs and diagnosis of HIV infection was established. Bronchoscopy confirmed diagnosis of pneumocystis jirovecii pneumonia (PCP). The radiological presentation with perihilar large cysts is typical for PCP in HIV-infected patients, but rarely encountered today.

Predictors for prolonged and escalated perioperative antibiotic therapy after microvascular head and neck reconstruction: a comprehensive analysis of 446 cases.

Literature suggests that intravenous prophylaxis exceeding 48 h offers no additional benefit in preventing surgical site infections (SSI) in patients with microvascular head and neck reconstruction. However, protocols for antibiotic therapy duration post-reconstruction are not standardized. This study identifies factors predicting prolonged intravenous antibiotic use and antibiotic escalation in patients receiving free flap head neck reconstruction. A retrospective analysis of 446 patients receiving free flap reconstruction was conducted, examining predictors for antibiotic therapy > 10 days and postoperative escalation. 111 patients (24.8%) experienced escalation, while 159 patients (35.6%) received prolonged therapy. Multivariate regression analysis revealed predictors for escalation: microvascular bone reconstruction (p = 0.008, OR = 2.0), clinically suspected SSI (p < 0.001, OR = 5.4), culture-positive SSI (p = 0.03, OR = 2.9), extended ICU stay (p = 0.01, OR = 1.1) and hospital-acquired pneumonia (p = 0.01, OR = 5.9). Prolonged therapy was associated with bone reconstruction (p = 0.06, OR = 2.0), preoperative irradiation (p = 0.001, OR = 1.9) and culture-positive SSI (p < 0.001, OR = 3.5). The study concludes that SSIs are a primary factor driving the escalation of perioperative antibiotic use. Clinical suspicion of infection often necessitates escalation, even in the absence of confirmed microbiological evidence. Microvascular bone reconstruction was a significant predictor for both the escalation and extension of antibiotic therapy beyond 10 days. Furthermore, preoperative radiation therapy, hospital-acquired pneumonia, and prolonged ICU stay were associated with an increased likelihood of escalation, resulting in significantly extended antibiotic administration during hospitalization. Antibiotic stewardship programmes must be implemented to reduce postoperative antibiotic administration time.Trial registration The study was registered approved by the local Ethics Committee (Nr: 18-1131-104).

Clinical Characterization of Pathogens, Risk Factors and Quality of Life in an Observational Study of Native vs. Prosthetic Aortic Valve Endocarditis Surgery.

Background: Native (NVE) and prosthetic (PVE) aortic valve endocarditis (AVE) remain a surgical challenge with an ongoing trend towards more complex surgical procedures. Methods: First-time NVE was compared with PVE, focusing on pathogens, risk factors, perioperative course, postoperative follow-up, including recurrent infection, as well as health-related quality of life (HRQOL). Results: From 2007 to 2022, surgical intervention for AVE was necessary in 231 patients with 233 episodes of infective aortic valve endocarditis, i.e., there were only two cases of reinfection (NVE group). The study group consisted of 130 cases with NVE and 103 with PVE. Overall, a median of 40.3% of survivors were in NYHA class I or II. In-hospital mortality was higher in the PVE group with 13.3%. The most common pathogen was Staphylococcus aureus, with 24.9% across both groups. EuroSCORE II was higher in the PVE group (19.0 ± 14.3% total, NVE 11.1 ± 8.1%, PVE 27.8 ± 14.6%; p < 0.05), reflecting an older, more co-morbid patient cohort. Abscess formation was also more common in the PVE group, while vegetations were more common in the NVE group. The 5-year and 10-year survival rates did not differ significantly between NVE and PVE and were 74.4% and 52.2% for the NVE group, respectively, and 67.4% and 52.9% for the PVE group, respectively. The HRQOL as assessed by the Minnesota Living with HF Questionnaire (MLHFQ) demonstrated no significant difference between both groups. Conclusions: Long-term survival and QoL after surgical treatment of infective aortic valve endocarditis are excellent and do not depend on the type of replacement.

Impact of Selective Reporting of Antibiotic Susceptibility Test Results on Antibiotic Use in Patients with Bloodstream Infection with Streptococcus pneumoniae.

Introduction: Invasive pneumococcal disease is a major cause of morbidity and mortality in infectious diseases. Selective reporting of antibiotic susceptibility test results might lead to a tailored antibiotic therapy and could therefore be an important antibiotic stewardship program intervention. The aim of this study was to analyse whether a switch to selective reporting of antibiotic test results leads to a more focused antibiotic therapy in patients with a bloodstream infection with Streptococcus pneumoniae. Methods: This study was performed as a retrospective cohort study at the University Hospital Regensburg, Germany. All blood cultures positive for Streptococcus pneumoniae between 2006 and 2021 were analysed. In 2014, a switch to selective reporting of antibiotic susceptibility test results omitting sensitivity results for agents not recommended was introduced. Results: Twenty-four hours after final antibiotic susceptibility test results were available, 20.9% before (BI) versus 15.4% after implementation (AI) of selective reporting of antibiotic test results received a narrow-spectrum penicillin, while only 2.3% BI versus 5.8% AI received a narrow-spectrum penicillin from the beginning. Conclusion: Selective reporting of antibiotic susceptibility test results without further antimicrobial stewardship interventions did not lead to a higher use of a narrow-spectrum penicillin in this study.

Hepatitis E virus infection in immunosuppressed patients and its clinical manifestations.

BACKGROUND & AIMS: Hepatitis E virus (HEV) is a main cause of acute hepatitis globally. However, immunosuppressed patients regularly develop chronic courses. The aim of this study was to analyse the current status of HEV diagnostics, characterize clinical manifestations and identify risk factors for complicated HEV infections. METHODS: In this retrospective study at two large hospitals, 512 patients with borderline and positive anti-HEV-IgM and 94 patients with positive HEV-PCR between January 1999 and May 2023 were included. RESULTS: Detection by anti-HEV-IgM-ELISA led to a positive HEV-PCR in only 17.9 %. Amongst patients with positive HEV-PCR, 61 had underlying immunosuppression and 23 were patients after solid organ transplantation (SOT). All 13 patients with chronic HEV infections were immunosuppressed. Generally, immunosuppression led to higher HEV-RNA concentrations and a higher probability of receiving immediate treatment. However, all fulminant courses with liver failure happened in patients without immunosuppression. Immunocompetent patients showed symptoms more frequently and primarily had higher bilirubin levels indicating more severe liver damage. A risk factor for delayed or failed viral clearance after SOT was the administration of mTOR inhibitors. CONCLUSIONS: Fulminant HEV infections happen primarily in immunocompetent patients. Nevertheless, immunosuppressed patients bear the risk of undetected, prolonged HEV infections, reflected by the rare occurrence of symptoms.

Negative impact of face masks in patients with interstitial lung disease: A prospective study.

INTRODUCTION: Face masks increase airway resistance, data on the actual extent of this effect are scarce. The aim of this study was to assess the effect of different mask types on clinical parameters during moderate exercise in healthy non-smokers, active smokers and patients with interstitial lung disease (ILD) without the need of oxygen therapy. METHODS: In a prospective observational pilot study participants performed a six-minute walk test without mask, with a surgical mask, a well-fitted FFP2 mask and with a valved FFP3 mask. Respiratory rate, blood pressure, heart rate, blood gas analysis parameters, dyspnoea and six-minute walk distance were measured. Data were analysed in an ANOVA model. RESULTS: 21 healthy participants, 17 active smokers without known pulmonary disease and 15 patients with interstitial lung disease were included. Participants with ILD had a significant lower walking distance, a higher respiratory rate and a lower pO2 when using FFP2 masks, but not with valved FFP3 masks or surgical masks compared to not wearing a mask. CONCLUSION: For patients with ILD without the need of oxygen therapy wearing an FFP2 mask had a negative impact on pO2, respiratory rate and walking distance in the six-minute walk test. This effect was not seen with valved FFP3 masks or surgical masks.

Case report: Local bacteriophage therapy for fracture-related infection with polymicrobial multi-resistant bacteria: hydrogel application and postoperative phage analysis through metagenomic sequencing.

Fracture-related infections can be challenging, particularly with concomitant severe bone defects and multi-resistant microorganisms. We present a case of a 42-year-old patient with a fracture-related infection following a war injury from a gunshot, resulting in a 12-cm subtrochanteric segmental bone defect and the detection of four different multi-resistant Gram-negative bacteria. Due to antibiotic drug resistance, treatment with bacteriophages was considered. Phage susceptibility testing revealed the activity of a commercially available bacteriophage cocktail (Intesti bacteriophage, Eliava Institute, Tbilisi, Georgia). This phage cocktail was included in a modified two-stage Masquelet technique. During the first intervention, the bone was debrided and samples for microbiological and phage testing were harvested. The indwelling intramedullary rod was removed, and the bone defect was filled with a PMMA spacer loaded with colistin and the bone stabilized with a plate. During the second procedure, the PMMA spacer was removed and a silver-coated angular stable plate was implanted. The bone defect was filled with a fibular autograft and allograft cancellous bone chips. At the end of the procedure, the Intesti bacteriophage cocktail was injected into a DAC hydrogel and this bacteriophage hydrogel composite was then put onto the angular stable plate. Postoperatively the wound fluid was collected over 72 h, and high-throughput metagenomic sequencing was performed. This showed a time-dependent release of the bacteriophages in the wound fluid, with a relatively high concentration after 12 h, decreasing to DNA copies of 0 after 72 h. Furthermore, we have assessed the release of phages from DAC gel and the effect of DAC gel on the phages in vitro. The results showed a stable and rapid release of phages from the DAC gel (~1×103 PFU/mL). The clinical course of the patient showed no relapse of the infection with good bone consolidation of the bone defect after 1 year without the need for any surgical revision. To the best of our knowledge, this is the first case that shows the detection of bacteriophage DNA copies by high-throughput metagenomics sequencing in a patient with a complex fracture-related infection. Successful treatment of this case encourages further investigation of bacteriophage therapy in patients with complex bone and joint infections.

Refractory circulatory failure in COVID-19 patients treated with veno-arterial ECMO a retrospective single-center experience.

OBJECTIVE: In this retrospective case series, survival rates in different indications for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and differential diagnoses of COVID-19 associated refractory circulatory failure are investigated. METHODS: Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO. All VA-ECMO's were cannulated peripherally, using a femoro-femoral cannulation. RESULTS: At VA-ECMO initiation, median age was 57 years (IQR: 51-62), SOFA score 16 (IQR: 13-17) and norepinephrine dosing 0.53µg/kg/min (IQR: 0.35-0.87). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Indications for VA-ECMO support were pulmonary embolism (PE) (n = 5, survival 80%), right heart failure due to secondary pulmonary hypertension (n = 5, survival 20%), cardiac arrest (n = 4, survival 25%), acute heart failure (AHF) (n = 10, survival 40%) and refractory vasoplegia (n = 4, survival 0%). Among the patients with AHF, 4 patients suffered from COVID-19 associated heart failure (CovHF) (survival 100%) and 6 patients from sepsis associated heart failure (SHF) (survival 0%). Main Complications were acute kidney injury (AKI) 93%, renal replacement therapy was needed in 79%, intracranial hemorrhage occurred in 18%. Overall survival to hospital discharge was 39%. CONCLUSION: Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decision making. A subgroup of patients suffers from acute heart failure due to inflammation, which has to be differentiated into septic or COVID-19 associated. Novel biomarkers are required to ensure reliable differentiation between these entities; a candidate might be soluble interleukin 2 receptor.

SARS-CoV2 evokes structural brain changes resulting in declined executive function.

BACKGROUND: Several research has underlined the multi-system character of COVID-19. Though effects on the Central Nervous System are mainly discussed as disease-specific affections due to the virus' neurotropism, no comprehensive disease model of COVID-19 exists on a neurofunctional base by now. We aimed to investigate neuroplastic grey- and white matter changes related to COVID-19 and to link these changes to neurocognitive testings leading towards a multi-dimensional disease model. METHODS: Groups of acutely ill COVID-19 patients (n = 16), recovered COVID-19 patients (n = 21) and healthy controls (n = 13) were prospectively included into this study. MR-imaging included T1-weighted sequences for analysis of grey matter using voxel-based morphometry and diffusion-weighted sequences to investigate white matter tracts using probabilistic tractography. Comprehensive neurocognitive testing for verbal and non-verbal domains was performed. RESULTS: Alterations strongly focused on grey matter of the frontal-basal ganglia-thalamus network and temporal areas, as well as fiber tracts connecting these areas. In acute COVID-19 patients, a decline of grey matter volume was found with an accompanying diminution of white matter tracts. A decline in executive function and especially verbal fluency was found in acute patients, partially persisting in recovered. CONCLUSION: Changes in gray matter volume and white matter tracts included mainly areas involved in networks of executive control and language. Deeper understanding of these alterations is necessary especially with respect to long-term impairments, often referred to as 'Post-COVID'.

Pathogens and their resistance behavior in necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis (NF) is a rare but life-threatening condition in which extensive soft tissue destruction can occur very quickly if left untreated. Therefore, timely broad-spectrum antibiotic administration is of prognostic importance in addition to radical surgical debridement. AIM: This study evaluates the cases of NF in our hospital during the last ten years retrospectively with respect to the pathogens involved and their antimicrobial resistance. This approach aims to provide guidance regarding the most targeted initial antibiotic therapy. METHODS: We performed a retrospective microbiological study evaluating pathogen detection and resistance patterns including susceptibility testing of 42 patients with NF. RESULTS: Type 1 NF (polymicrobial infection) occurred in 45% of the patients; 31% presented type 2 NF (monomicrobial infection). The most common pathogens detected were E. coli, staphylococci such as Staphylococcus aureus and Staphylococcus epidermidis, Proteus mirabilis, enterococci, and streptococci such as Streptococcus pyogenes. Twelve percent presented an additional fungus infection (type 4). Ten percent showed no cultivation. Two percent (one patient) presented cocci without specification. CONCLUSION: Most pathogens were sensitive to antibiotics recommended by guidelines. This confirms the targeting accuracy of the guidelines. Further studies are necessary to identify risk factors associated with multidrug resistant infections requiring early vancomycin/meropenem administration.

Fracture-Related Infection-Epidemiology, Etiology, Diagnosis, Prevention, and Treatment.

BACKGROUND: Fracture-related infection (FRI) is a challenge to physicians and other workers in health care. In 2018, there were 7253 listed cases of FRI in Germany, corresponding to an incidence of 10.7 cases per 100 000 persons per year. METHODS: This review is based on pertinent publications retrieved from a search in PubMed with the search terms "fracture," "infection," "guideline," and "consensus." Aside from the primary literature, international guidelines and consensus recommendations were evaluated as well. RESULTS: FRI arise mainly from bacterial contamination of the fracture site. Staphylococcus aureus is the most commonly detected pathogen. The treatment is based on surgery and antibiotics and should be agreed upon by an interdisciplinary team; it is often difficult because of biofilm formation. Treatment options include implant-preserving procedures and single-stage, two-stage, or multi-stage implant replacement. Treatment failure occurs in 10.3% to 21.4% of cases. The available evidence on the efficacy of various treatment approaches is derived mainly from retrospective cohort studies (level III evidence). Therefore, periprosthetic joint infections and FRI are often discussed together. CONCLUSION: FRI presents an increasing challenge. Preventive measures should be optimized, and the treatment should always be decided upon by an interdisciplinary team. Only low-level evidence is available to date to guide diagnostic and treatment decisions. High-quality studies are therefore needed to help us meet this challenge more effectively.

Postpartum cryptococcosis in an HIV-negative patient.

PURPOSE AND METHODS: We present an unusual case of an HIV-negative patient with postpartum pulmonary cryptococcosis and cryptococcemia. RESULTS: The diagnostic methods and treatment of cryptococcosis in a postpartum patient are presented in this case report. Due to anaphylaxis to liposomal amphotericin B, desensitisation to the drug was performed. CONCLUSION: We would like to raise awareness about rare infections such as cryptococcosis in pregnancy and the postpartum period. In addition, we were able to document a successful desensitisation to liposomal amphotericin B.

18F-FDG PET/CT-derived total lesion glycolysis predicts abscess formation in patients with surgically confirmed infective endocarditis: Results of a retrospective study at a tertiary center.

BACKGROUND: Abnormal activity of 18F-FDG PET/CT is a major Duke criterion in the diagnostic work-up of infective prosthetic valve endocarditis (IE). We hypothesized that quantitative lesion assessment by 18F-FDG PET/CT-derived standard maximum uptake ratio (SURmax), metabolic volume (MV), and total lesion glycolysis (TLG) might be useful in distinct subgroups of IE patients (e.g. IE-related abscess formation). METHODS: All patients (n = 27) hospitalized in our tertiary IE referral medical center from January 2014 to October 2018 with preoperatively performed 18F-FDG PET/CT and surgically confirmed IE were included into this retrospective analysis. RESULTS: Patients with surgically confirmed abscess formation (n = 10) had significantly increased MV (by ~ fivefold) and TLG (by ~ sevenfold) as compared to patients without abscess (n = 17). Receiver operation characteristics (ROC) analyses demonstrated that TLG (calculated as MV × SURmean, i.e. TLG (SUR)) had the most favorable area under the ROC curve (0.841 [CI 0.659 to 1.000]) in predicting IE-related abscess formation. This resulted in a sensitivity of 80% and a specificity of 88% at a cut-off value of 14.14 mL for TLG (SUR). CONCLUSION: We suggest that 18F-FDG PET/CT-derived quantitative assessment of TLG (SUR) may provide a novel diagnostic tool in predicting endocarditis-associated abscess formation.

[Rare cause of necrotizing pneumonia : A case report]. / Seltene Ursache einer einschmelzenden Pneumonie : Ein Fallbericht.

A 29-year-old Indian patient was admitted to the authors' pulmonary clinic with cough and fever. Community-acquired pneumonia was initially suspected. Various antibiotic therapies were administered, which did not lead to any clinical improvement. Despite detailed diagnostics, no pathogen was found. Computed tomography showed rapidly progressive pneumonia in the left upper lobe. Since the infection could not be managed conservatively, upper lobe resection was performed. Histologically, an amoebic abscess was found to be the cause of the infection. Since cerebral and hepatic abscesses were also found, hematogenous dissemination may be assumed.

Short report: impact of selective reporting of antibiotic susceptibility testing on antibiotic use in patients with bloodstream infection with Enterococcus faecalis.

INTRODUCTION: Bloodstream infections with Enterococcus faecalis are associated with relevant morbidity and mortality. Targeted antimicrobial therapy is essential. The choice of an adequate treatment may be challenging when susceptibility testing offers different options. Selective reporting of antibiotic susceptibility test results might lead to a more tailored antibiotic therapy and could therefore be an important antimicrobial stewardship program intervention. The aim of this study was to analyse whether the introduction of selective reporting of antibiotic test results leads to a more targeted antibiotic therapy in patients with bloodstream infection with Enterococcus faecalis. METHODS: This study was performed as a retrospective cohort study at the University Hospital Regensburg, Germany. All patients with blood cultures positive for Enterococcus faecalis between March 2003 and March 2022 were analysed. In February 2014 selective reporting of antibiotic susceptibility test results omitting sensitivity results for agents not recommended was introduced. RESULTS: 263 patients with blood cultures positive for Enterococcus faecalis were included. After introduction of selective reporting of antibiotic tests (AI) significantly more patients received ampicillin than before introduction of selective reporting (BI) (9.6% BI vs. 34.6% AI, p < 0.001). CONCLUSION: Selective reporting of antibiotic susceptibility test results led to a significantly higher use of ampicillin.

Multidisciplinary Treatment of Fracture-Related Infection Has a Positive Impact on Clinical Outcome-A Retrospective Case Control Study at a Tertiary Referral Center.

OBJECTIVES: Fracture-related infection (FRI) is a major complication in orthopedic and trauma surgery. The management and choice of treatment can be difficult depending on multiple factors. Therefore, we implemented a weekly multidisciplinary team discussion to determine diagnostic and treatment strategies in FRI patients and aimed to analyze its effect on clinical outcomes. METHODS: Clinical outcomes of FRI patients treated before and after implementation of a structured multidisciplinary treatment (MDT) approach with a weekly case discussion were compared at a follow-up of 12 months. RESULTS: In total, n = 117 were eligible for enrolment, whereby n = 58 patients (72.4% male, mean age 56.7 ± 16.8 years) constituted the MDT group and n = 59 patients (72.9% male, mean age 55.0 ± 16.5 years) the control group. In the MDT group more cases were treated with local antibiotics (67.2% vs. 27.1%, p < 0.001) and significant less amputations (3.4% vs. 6.8%, p = 0.014), as well as less revision surgeries (1.5 ± 1.2 (0-5) vs. 2.2 ± 1.2 (0-7), p = 0.048) were performed. A trend towards less debridement, antibiotics and implant retention (DAIR) procedures, lower rates of recurrence of infection and less treatment failures in the MDT group was observable, even though not statistically significant. CONCLUSION: An MDT approach providing a patient tailored treatment concept in the treatment of FRI patients appears to be beneficial for the affected patients. Quality and efficacy of implemented MDT meetings should further be evaluated to provide sufficient evidence to further implement this valuable tool in clinical practice and decision making.

Antibiotic Prophylaxis and Empirical Antibiotic Therapy in Primary Arthroplasty and Periprosthetic Joint Infections: Current Practice and Need for Therapy Optimization. / Antibiotikaprophylaxe und empirische Antibiotikatherapie bei Primärendoprothetik und periprothetischen Gelenkinfektionen: Aktuelle Praxis und Bedarf an Therapieoptimierung.

The aim of the present work was to survey the situation of healthcare regarding the use of prophylactic and empirical antibiotics in primary arthroplasty and treatment of periprosthetic joint infections (PJI). For this purpose, a survey was conducted at German university and occupational accident hospitals. Survey data was compared to previously published data on the antimicrobial regimes of PJI (n=81) patients (n=81) treated in our department between 2017 and 2020. A homogeneous picture emerged for the prophylactic administration of antibiotics in the context of primary arthroplasty. In 93.2% (elective) and 88.6% (fracture treatment) of the hospitals, first or second generation cephalosporins were administered perioperatively for infection prophylaxis in primary hip arthroplasty. The empirical antibiotic treatment of PJIs showed a clearly inhomogeneous therapeutic picture. Monotherapy with an aminopenicillin plus a beta-lactamase inhibitor is used most frequently (38.7%); first and second generation cephalosporins are used second most frequently as monotherapy (18.2%). In light of the global problem of antibiotic multi-resistance, clinical use of antibiotics has to be reasonable and effective. The present results highlight the further need to improve awareness and following existing guidelines in the administration of empirical antibiotic therapy in PJI.

[Antibiotic use for prophylaxis and empirical therapy of fracture-related infections in Germany : A survey of 44 hospitals]. / Antibiotikaeinsatz zu Prophylaxe und empirischer Therapie von frakturassoziierten Infektionen in Deutschland : Eine Umfrage an 44 Kliniken.

BACKGROUND: Antibiotics play an important role in the prophylaxis and treatment of infections in orthopedic trauma surgery; however, there seems to be remarkable differences in the clinical antibiotic practice between hospitals, particularly for open fractures and for the empirical therapy of fracture-related infections (FRI). METHODS: Therefore, we intended to evaluate the current clinical praxis in university and workers' compensation hospitals in Germany with a questionnaire on prophylaxis and empirical treatment of FRI. The results were compared with the resistance profile of 86 FRI patients in order to analyze the hypothetical effectiveness of the empirical treatment. RESULTS: A total of 44 hospitals (62.0%) responded. A homogeneous antibiotic prophylaxis (95.5% of all hospitals) with cephalosporins was reported for perioperative prophylaxis of internal fixation of closed fractures. For open fractures, eight different monotherapy and combination treatment concepts were reported. In empirical treatment of FRI, 12 different therapeutic concepts were reported, including aminopenicillins/beta lactamase inhibitors (BLI) (31.8%), cephalosporins (31.8%), and ampicillin/sulbactam + vancomycin (9.1%). In terms of the hypothetical effectiveness of these antibiotic regimes, low sensitivity rates of 65.1% and 74.4% for cephalosporins and aminopenicillins/BLI, respectively, were found. For the combination vancomycin + meropenem, the highest hypothetical sensitivity (91.9%) was detected. DISCUSSION: Based on the existing, institution-specific pathogen spectrum, the combination therapy including meropenem and vancomycin seems to be of value but should be restricted to patients with multiple revision procedures or a septic course of infection in order to prevent the selection of highly resistant pathogens.