LAUSR

A 78-year-old man who underwent aortic graft repair for an abdominal aortic aneurysm at the age of 60 years, presented to our institution with fever and low back pain. Laboratory investigations, computed tomography (CT), magnetic resonance imaging (MRI), and blood cultures confirmed a diagnosis of septic shock and pyogenic spondylitis. He began antibiotic therapy when his blood culture indicated Staphylococcus aureus. The patient was treated with intravenous cefazolin 3 g/day for three weeks, intravenous ceftriaxone 2 g/day for five weeks, oral levofloxacin 500 mg/day, and minocycline 200 mg/day thereafter. His symptoms improved, and he was discharged from the hospital three months later. He continued treatment with oral antibiotics and was followed up in the outpatient clinic. After seven months, he presented again with high fever and low back pain. A recurrence of purulent spondylitis was suspected. We diagnosed septic shock, pyogenic spondylitis at L4/5, and an epidural abscess (Fig. 1). The patient underwent laminectomy and drainage with intravenous antibiotic therapy (cefazolin 3 g/day for 4 weeks and ceftriaxone 2 g/ day for four weeks). The patient’s low back pain resolved, but he re-presented after nine months with a recurrence of high fever and septic shock. Blood culture revealed methicillin-resistant S. aureus and Serratia sp. Therefore, we changed the intravenous antibiotic therapy to vancomycin 2 g/day and meropenem 3 g/ day for eight weeks. After confirming that the antibiotic treatment controlled the purulent spondylitis, we performed pedicle screw fixation using a percutaneous screw at ten months, and we changed the antibiotic regimen to trimethoprim/sulfamethoxazole 4 g/day and rifampicin 450 mg/day. After that, the infection appeared to resolve. Laboratory tests, CT, MRI, and echocardiographic examinations were repeated but did not identify another source of infection. At 12 months, the patient re-presented with a recurrence of high fever. A contrast-enhanced CT examination at that time showed perigraft air, which raised suspicion for an infected vascular graft (Fig. 2). We consulted the vascular surgeons who advised, that the likelihood of graft infection was low, so we continued antibiotic therapy. At 14 months, he presented again with high fever, and a blood culture identified Candida parapsilosis and Escherichia coli. We changed the antibiotic regimen to intravenous ceftriaxone 2 g/day, fosfluconazole 200 mg/day for eight weeks, and oral fluconazole 100 mg/day. The purulent spondylitis responded to this treatment, and the patient was discharged at 16 months. At 17 months, the patient was returned to our hospital with a further recurrence of high fever. A blood culture detected Enterococcus faecalis and methicillin-resistant S. aureus. We diagnosed recurrent pyogenic spondylitis and sepsis. The patient started appropriate antibiotic therapy (intravenous sulbactam/ampicillin 6 g/day for two weeks, imipenem/cilastatin 2 g/day for four weeks, and oral levofloxacin 500 mg/day for two weeks) and antifungal therapy (intravenous micafungin 150 mg/day for three weeks and fosfluconazole 200 mg/day for five weeks). We sus-