Chronic osteomyelitis: is it time for a paradigm shift in our delivery of care?

Dr Tony Berendt Consultant Physician Bone Infection Unit

Nuffield Orthopaedic Centre Oxford University Hospitals NHS Trust

22nd ECCMID, London, 2012

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Declaration of interests

• No commercial interests • I am a medical manager as well as a practising

clinician • I have worked on a multi-disciplinary unit for the

management of bone and joint infection for over 15 years

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Bone Infection Unit, NOC, OUH

3rd Oxford Bone Infection Conference, Oxford, March 2013

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The challenge • 44 yr old male • History of paraplegia, illicit drug dependency in past • Previous pressure sores treated and reconstructed • Recurrent ulceration and episodes of sepsis including

proven E coli bacteremia • Readmitted with sepsis; massive pressure sores with

pelvic osteomyelitis • Low albumin, BMI low, malnourished • Diazepam dependency • “Difficult” patient

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PATIENT DIAGNOSIS

5 47 female Osteomyelitis of coccyx & sacrum & multiple intra-abdominal collections + wound/drain site dehiscence.

PMH: Ulcerative colitis, badly controlled Type 1 diabetic, Diabetic neuropathy, depression. L foot charcot joint. Sub-total colectomy- ileostomy. Parastomal hernia. Grade 4 sacral pressure sore.

6 73 male Failed 2 stage elsewhere and 3 repeat first stage debridements, referred on 3 months iv. Rx

7 64 male Recurrent E coli bacteraemias, R native hip now Girdlestone, persistent bacteraemias, ? ongoing pelvic or L hip involvement

8 69 male Multiple revised R TKR elsewhere, further 2 stage in progress, confusion, fractured and revised spacer, wound still leaking

9 25 female

Infected spinal metalware on suppression, breakthrough infection now Stenotrophomonas, previous ESBL E coli

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10 67 male Infected R Girdlestone (done elsewhere), CVA, schizophrenia, asthma, risk of falls. Benign essential tremor. VRE, recurrent seromas

11 38 male Pedicle flap to chronic sacral ulcer 18.1.12 transferred to ITU with respiratory failure.

PMH: RTA, tetraplegic, asthma, PE 2008, C6 cord transaction. Bilateral girdlestones.

12 68 female L5 Discitis, has leg ulcers on L leg and R heel has dry sore

PMH: Chronic ETOH, Leg ulcers both legs, lymphodoema, PVD, cirrhosis and varices

13 67 female Native R knee joint MSSA septic arthritis and bacteraemia, recurrent bacteraemia post treatment and aggressive destruction of L hip now Girdlestone

15 36 female Excision osteomyelitis left tibia. PMH: Type 1DM, hiatus hernis CKD, asthma,

hyperthyroidism (previous thyroidectomy for Graves)

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16 52 male RO infected plate L knee and gastroc flap (20/2/12) 16

17 61 male L total femoral replacement for sarcoma, 2 stage revision for infection, breakthrough infection after 2 years suppression, history of on table cardiac arrest and hypoxic brain injury. Sinuses at each end of femur

18 47 male Excision of Infected Bone L Femur + Local Flap 22/2/12. Ex IVDU still on Methadone

19 71 male Infected bilateral Girdlestones of hips. Pericarditis PMH-bilateral lymphadenectomy 2002, iliac abscess 2009,

septic arthritis hips, Ca penis

20 39 male Infected grade 4 pressure sore. For 3 day assessment from Exeter

PMH: paraplegia secondary to RTA 1991, OM R femur and R hip, anaemia, Prev alcohol addiction.

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21 67 male MRSA Spinal abscess not for surgery, : NIDDM, Schizophrenia,

21

23 46 male Osteomyelitis Pelvis-for assessment 1 grade 4 and 1 grade 2 pressure sore right buttock, BKA

(1999) following burst femoral artery, T12 paraplegia following fall, 2 metal rods spine 1988, L hip joint removal 1998,

Allergy to penicillin

24 47 female Excision Osteomyelitis Lt calcaneum + free flap 27/2/12, peri-op ITU transfer due to bronchial plugging

Allergic to penicillin

25 73 female 2 stage revision L TKR, lymphoedema of leg, bowel Ca – in remission, coronary stent. VRE

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“My sins sicken me like pus in my

bones Help me Jesus, Lamb of God, for I am

sinking in deepest slime”

J.S. Bach, Cantata 179 1723

Osteomyelitis: a historical disease

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The self-fulfilling prophecy of osteomyelitis

Poor outcomes

Ineffective treatment

Therapeutic nihilism

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Clinical manifestations

• Diabetic foot • Other decubiti, mainly pelvic or femoral • Long bone • Vertebral • Sternal post sternotomy • Skull base • Osteochondritis of foot • Mandible • Osteitis pubis

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What we know

• Pathogenesis • Pathophysiology of the chronic osteomyelitic lesion • Diagnosis and treatment can be difficult • Good outcomes are possible…..

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Pathogenesis • Access of pathogen

• Haematogenous • Contiguous focus

• Contiguous infection as site of entry to bone • Chronic soft tissue loss as cause

• Pathogen factors • Adhesins • Toxins • Agents leading to bone resorption

• Host response • Inflammation • Bone resorption • Bone death

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Pathogenesis (Host factors) • Trauma • Surgery • Injecting drug users • Dialysis or transplant patients • Immunocompromised

• Immunosuppression • HIV • Sickle

• Cancer • Chemotherapy • Radiotherapy

• Elderly and debilitated • Paraplegic and neuropathic

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Pathophysiology of the chronic osteomyelitic lesion (1) • Chronic infection

• Biofilm formation • Chronic inflammation • Pus

• Bony compromise • Lysis

• Fracture • Cavities and surgical dead spaces

• Bone death • Sequestrum

• New bone formation • Sclerosis • Involucrum

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Pathophysiology of the chronic osteomyelitic lesion (2)

• Soft tissue compromise • Chronic wounds • Sinus formation • Abnormal tissue planes and adhesions • Scarring • Local hypoxia

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Diagnosis

• Lack of criterion standards • Use tests according to evidence • Experience valuable in grey areas • Regular interaction between clinicians and those who

provide diagnostic tests for learning

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Diagnosis • Blood tests

• Inflammatory markers • Bone related markers

• Laboratory • Culture • Molecular

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Colonisers

Pathogens

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Diagnosis • Blood tests

• Inflammatory markers • Bone related markers

• Laboratory • Culture • Molecular

• Imaging • Ultrasound • Plain film • Isotope scans • Cross sectional

• CT • MRI • PET/SPECT

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Treatment is often challenging • Antibiotic selection, route and duration

• Wide variety of pathogens (Sheehy et al, 2010, J. Infect 60:338) • Staphylococci (32% of all Staph aureus) • Enterobacteriaceae • Pseudomonas • Anaerobes • Salmonella • TB • NTM • Brucella • fungi • Others

• Culture negative (28%) • MDROs • Allergies and intolerances • OPAT, iv vs oral, locally-delivered

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Treatment is often challenging • Surgical expertise

• Orthopaedic • Plastic • Vascular

• Medical optimisation • Physiological optimisation (nutrition, organ failure) • Revascularisation • Offloading • HBO

• Psychological support • Rehabilitation

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Joint (and bone) destruction

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What do we offer, and patients get?

“Isolated islands of excellence in a sea of indifference,

nihilism and fragmented care”

Berendt, ECCMID, 2012

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Modern healthcare’s “perfect storm”

• Demographics (patient and workforce) • Patient and societal expectations • Economic downturn and inflating costs • New commissioning relationships and structures

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High quality care • Safety – At all points in the pathway • Effectiveness

• Evidence based care • Outcomes

• Technical • Patient-reported

• Cost effective • Patient experience

• Staff beliefs, attitudes, knowledge and skills • Access to services • Environment and facilities • Partnership and empowerment

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How will we get there? Vision • Multi-disciplinary model of care • Patient involvement and empowerment • Evidence based care • Clinical networks and specialist centres • Consensus definitions and multi-centre studies • Strong attention to outcomes and governance

Acute Recurrent Relapsed Chronic

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How will we get there? Strategy • Start now • Set clinical standards and audit them • Consider power of networks including ESCMID • Influencing

• Commissioners • Colleagues • Patients and public

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Is it possible?

• Yes • Examples

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It is well recognised that patients require special support when affected by xxx. Because of the rarity of xxx, most patients and non-specialist clinicians will have no background knowledge of the condition. This can lead to a sense of frustration and isolation for the patient. The problem is not helped by fragmented information and few reliable information sources. There are also specific long-term healthcare support issues that must be addressed. xxx surgery is frequently disabling or disfiguring, and although fewer patients face amputation than in the past they require lifetime access to support services with specific expertise. Some centres have established key workers, usually clinical nurse specialists, and patient support groups.

What’s the diagnosis?

Improving outcomes for people with sarcoma, NICE 2006, http://www.nice.org.uk/nicemedia/live/10903/28934/28934.p

df

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Features of this disease • Usually progressive without treatment • Serious, with risk of death • May be painful • Systemic illness, weight loss • Major psychological issues • Needs complex treatment including medical and

surgical and a range of other treatments exist • Imperfect evidence base • Prospect that treatment may fail, tendency to relapse

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NICE on MDTs • Sarcoma: “All patients with a confirmed diagnosis of

bone or soft tissue sarcoma (except children with certain soft tissue sarcomas) should have their care supervised by or in conjunction with a sarcoma multidisciplinary team (MDT)”.

• Breast cancer: “People who develop local recurrence, regional recurrence and/or distant metastatic disease have their treatment and care discussed by the multidisciplinary team”

• Chronic heart failure: “People with chronic heart failure are cared for by a multidisciplinary heart failure team led by a specialist and consisting of professionals with appropriate competencies from primary and secondary care, and are given a single point of contact for the team”

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NICE on MDTs • Colorectal cancer: “Discuss the risk of local

recurrence, short-term and long-term morbidity and late effects with the patient after discussion in the multidisciplinary team”

• Diabetes: “People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours”

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Benefits of teams

• Dividing and covering the work • Spreading the load • Improving communication • Accessing necessary skills • Reducing risks of making human factors errors • Offering challenge and support • Improving safety (Michael West)

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Problems with teams

• They are made up of people…..

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Human factors • Attention • Memory constraints • Automaticity • Situation awareness • Heuristics (ways of thinking and learning)

• Pattern matching not careful reasoning • Do what has worked before • Confirmation bias • Availability • Selectivity • Frequency gambling

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Building high performing teams • Aware, distributed leadership • Healthy conflict • Commitment to common goal and to

continuous work to achieve and maintain it

• Accountability • Delivery (attention to results) • Empathy • Respect • Value and support team members • Serious thought and reflection

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In conclusion

• MDTs widely used to improve quality and governance • BJI needs to adopt not just the concept but the rigour

• Composition and attendance • Documentation • Standards • Outcome measures • Team building and team functioning

• Treating a difficult condition with a challenging prognosis is no excuse for lack of discipline

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Conclusions (2)

• Establishment of a network with centres of excellence and extended MDTs, supporting the general hospitals

• Clear definitions of treatment and referral thresholds and standards

• Consensus definitions allowing better classification, aggregation of data and comparision between methods and centres

• “We are the change we seek”…

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