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Osteomyelitis Attributable to Vancomycin-Resistant Enterococci

Vancomycin-resistant enterococcus first was described in 1988, and has become a major problem in nosocomial infections. This is a retrospective review of 10 patients, seen at the authors’ hospital during a 2-year period, with confirmed vancomycin-resistant enterococcal osteomyelitis: four patients had total joint arthroplasty infections, one patient had an infected tibial nail, three patients had infections associated with external fixators, and two patients had osteomyelitis of the femur. Four of the 10 patients had underlying medical illnesses (diabetes mellitus, systemic lupus erythematosus, human immunodeficiency virus infection); four of the 10 patients were intravenous drug users. Two patients had vancomycin-resistant enterococci on admission, and the other eight patients were admitted to the hospital for a mean of 21.3 days (range, 3–73 days) before vancomycin-resistant enterococci were identified in the bone. Eight of the 10 patients had monomicrobial infections with vancomycin-resistant enterococci. Patients were treated by surgical debridement, removal of hardware, and antibiotics (chloramphenicol in eight patients, quinupristin and dalfopristin (Synercid) in two patients). All patients initially improved with therapy, but one patient had a recurrence of vancomycin-resistant enterococcal osteomyelitis and died of bacteremia. Bone infections with vancomycin-resistant enterococcus still may be uncommon, but with time and selective antibiotic pressures, vancomycin-resistant enterococci may become a more prominent entity in orthopaedic infections.