Tibial Osteomyelitis Caused by Carbapenem-Resistant Enterobacter cloacae

A 31-year-old man presented with a symptomatic tibial non-union following an open tibia fracture sustained in India. The open fracture was persistently draining for 8 months following the initial injury. The decision was made to revise his tibia fracture to promote union. Intraoperative cultures of the non-union site during the revision procedure revealed osteomyelitis caused by carbapenemase-producing Enterobacter cloacae which was multi-drug resistant to all antibiotics except for tigecycline. The patient was treated successfully with a tigecycline-impregnated antibiotic spacer and intravenous tigecycline with repeat bone cultures demonstrating eradication of the infection. Eight weeks into treatment (1 year from initial injury), the patient developed new pain and swelling in the adjacent proximal fibula of the limb treated for osteomyelitis. MRI and biopsy revealed Ewing sarcoma. The patient underwent transfemoral amputation. This report describes a management protocol of carbapenemase-resistant post-traumatic osteomyelitis with no evidence of infection recurrence.