Continuous-infusion vancomycin therapy for patients with severe bone and joint infections due to multi-drug resistant staphylococcal strains

31 patients with severe bone and joint infections due to multi-drug resistant staphylococcal strains (S. aureus = 21 patients, S. epidermidis = 10 patients) received continuous-infusion vancomycin (CIV) therapy in combination with one or two Other antibiotics after debridement and removal of all foreign material (osteosynthesis = 8 patients, total joint arthroplasty = 15 patients). Vancomycin and teicoplanin MICs were 2-4 mu g/ml et 4-16 mu g/ml respectively. The mean duration of CIV was 62 days (range 42-78d) for 28 patients and 3 patients had longer CIV (8, 10 and 14 months) because of duration and severity of infections. CIV therapy consisted of 40 to 100 mg/Kg/d infused over 24 h to obtain serum vancomycin concentrations reaching 40 mu g/ml. In 20 patients, vancomycin levels in infected bone and tissues ranged between 30 to 80 mu g/g at initiation of therapy; they increased to 50-130 mu g/g after 1 month of treatment. 30 out of 31 patients were apparently cured (follow-up at least 2 years) and 13 out of 15 patients underwent total joint replacement. Tolerance of 4 to 6 g per day of CIV was excellent. Neither hematological or cutaneous toxicity nor hearing loss were reported in these carefully monitored patients. Transient renal insufficiency was reported in 2 patients treated with furosemide. CIV was well tolerated and easy to monitor. Its efficiency depends on the quality of the excisional surgery.