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8/8/2019 Bone and Joint Infection MD2009
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Bone and joint infection
Matthew Dryden
RHCH
WinchesterMatthew DrydenRoyal Hampshire County Hospital
Winchester
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Objectives
1. Understand the causes of bone and
joint infections
2. Recognize the clinical presentation3. Develop an approach to the diagnosis
of bone and joint infections
4. Discuss antimicrobial management
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Complications of an RTA
Mr BA, retired barrister
Serious RTA, 3/12 ago, head on collision
Chest injury; 4 fractured ri
bs
Head; subdural haematoma, CSF leak
Abdomen; lacerated liver/spleen
Lower limbs; compound fracture of Rfemur
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5 weeks in ITU
Ventilated because of ARDS and hospitalacquired pneumonia
3 weeks in orthopaedic ward:intramedullary nail
Wound infection. Esch. coli isolated
His wife died in the accident and he hastrouble coping since.
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At orthopaedic clinic, Mr BA is apyrexial
Discharge of pus from leg wound
Dull acheWound swab Staph. aureus
What should we do with him?
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The issues
Rehabilitation
Bereavement
SplenectomyLeg infection
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Leg infection
What is the significance of S.aureus in thewound
It is reported as resistant to pen, flucloxacillin,erythromycin, ciprofloxacin. Is this unusual?
X ray of femur; shows sclerosis of the bone &periosteum, soft tissue swelling
BA taken to theatre, bone debrided, S.aureusgrown from bone
Diagnosis?
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Osteomyelitis and septic arthritis
Primary
acute,
haematogenous,
systemic illness
Secondary
Contiguous spread
from ulcer, trauma Vascular problems of
limb eg elderly,
diabetic
S.aureus 90%
Hib, Strep pyogenes
Rare -Brucella,salmonella, gram neg
Polymicrobial,
S.aureus, gram neg,
Pseudomonas,anaerobes
Coagulase negative
staphylococci esp in
prosthetic joint
infection
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Osteomyelitis
Microbes invade bone
Inflammation and pus tracksthrough Haversian andVolkmanns canals
Ischaemia and necrosis
Periosteal elevation Osteoblasts generate newbone
Old dead bone calledsequestrum; surrounding livebone called involucrum
No blood supply tosequestrum, therefore infectionmay persist
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Source of infection
1. Haematogenousspread
2. Extension frombone to joint
3. Spread from
adjacent softtissue infection
4. Diagnostic,surgicalinterventions
5. Trauma
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Clinical features native joint SA
Monoarticular (90%)
Mostly acute onset
Fevermild (60 - 80% of cases)
>39oC (third of cases)
Movement limitation
Swelling (effusion)
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Chronic osteomyelitis
Acute OM can progress to chronicAcute OM can progress to chronic
OMOM
Bone loss and persistent drainageBone loss and persistent drainagethrough sinus.through sinus.
Squamous cell carcinoma andSquamous cell carcinoma and
amyloidosis are rareamyloidosis are rarecomplicationscomplications
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Tuberculous osteomyelitis
Potts disease
Potts disease: T and L spine bone destruction,
deformity, and paraplegia.
MRI of a 31-year-old man
with tuberculosis of the
spine. Images show the
thoracic spine before and
after an infusion ofintravenous gadolinium
contrast. The abscess and
subsequent destruction of
the T11-T12 disc
interspace is marked with
arrowheads. Vertebralbody alignment is normal.
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Osteomyelitis
DiagnosisXray, CT, MRI
Microbiology; bone, pus, blood
ManagementAntibiotics; combination, prolonged
Surgical washout; debridement, drainage
Removal of metalwork, prosthetic jointMonitor inflammatory markers; ESR, CRP
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Antibiotic treatment
Be guided by microbiology
Flucloxacillin 1-2gms qds IV plus oral fusidicacid 500 tds
Penicillin allergic consider clindamycin orceftriaxone
Child under5 consider ceftriaxone to cover Hib
For MRSA: Vancomycin or teicoplanin plus
fusidic acid (or Linezolid)
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Antibiotic treatment
Oral treatment can start after 10-14 days
and needs to continue for 6-12 weeks.
Monitor CRP + ESR
Combinations include
Flucloxacillin + fusidic acid
Rifampicin plus doxycycline or fusidic acid
Ciprofloxacin plus clindamycin
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Septic arthritis
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Septic arthritis
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Joint pus
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Osteomyelitis anddiabetes
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Prosthetic-device septic arthritis or
osteomyelitis
Incidence should be under 1% of joint
replacements
Presents with swollen, hot joint, sinus,pain, loosening
Prosthetic joint usually requires removal
Culture of tissue and molecular diagnosis Bacterial 16s ribosomal DNA
Two stage replacement
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Treatment of PJI
Antibiotic treatment
with surgical
debridement/ removal
Monitor WBC andCRP
Antibiotic cement
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Vertebralosteomyelitis/discitis
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