Bone and Joint Infections

1
Bone and Joint Infections

• 5/10/04

2
Risk Factors

• Corticosteroids-33
• Existing arthritis-24
• Infection elsewhere-22
• DM-13
• Trauma-12
• None-8

3
Frequency of Joints

• Knee-48
• Hip-24
• Ankle-7
• Elbow-11
• Wrist-7
• Shoulder-15
• Sternoclavicular-8

4
Pathology

• High vascularity
• S. aureus collagen-binding adhesin associated
  with osteomyelitis but not septic joint
• Disruption of normal joint by pre-existing joint
  disease
• Proteolytic enzymes released

5
Signs and Symptoms

• Joint pain, swelling, warmth, and decreased range
  of motion
• Joint tenderness to pressure or movement
• Tendon tenderness
• Fever
• May resemble acute crystal dz. or hemothrosis

6
Organisms Associated

• Neisseria-1-12
• Non-gonorrhea-S. aureus-37-56,
  Streptococcal-10-28, GNR-4-19, coagulase
  negative staph-5, anaerobic-2, PMB-less than
  10
• Am Rheum Disease-2002, 61267

7
Septic Arthritis-odd organisms

• Lyme, Mycoplasma
• Listeria, enterococcus, chlamydia
• M. tuberculosis, atypical Tb
• Candida,sporothrix, blastomycosis/coccidiomycosis
• Rubella, hep b and c, EBV, parvovirus, mumps

8
Synovial Effusion

• Normal-clear, viscous, colorless-lt200 wbc (lt25
  pmns)
• Noninflammatory-clear, viscous, yellow 200-2000
  wbc-lt25 pmns
• Inflammatory-cloudy, watery, yellow-2000-50,000
  cells (gt50 polys)

9
Synovial Effusion, continued

• Infected-purulent-gt50,000 cells (gt75 pmns)
• Great overlap at times

10
Gonococcal vs. non gc Arthritis

• Gc-sexually active adults, migratory
  polyarthralgias, tenosynovitis, dermatitis
  common, gt50 polyarthritis, BC positive lt10,
  joint fluid positive 25

11
GC vs. non GC

• Non GC-very young or elderly, polyarthralgias,
  tenosynovitis rare, dermatitis rare, gt85
  monoarthritis, BC positive 50, joint fluid
  positive 85-90
• NEJM-1985, 312764-771

12
Outcome of Bacterial Arthritis

• 154, 121 adults-half had joint disease
• 29 of joints contained synthetic material
• Poor outcome in 21 of patients-10 mortality
• Poor joint outcome in nearly 50 of patients

13
Outcome continued

• Risk factors for poor outcome include-older age,
  existing joint disease, synthetic joint
• Arthritis and Rheumatism
• 1997, 40884.

14
Factors Associated with Poor Prognosis

• Age gt60 years
• Pre-existing rheumatoid arthritis or hip or
  shoulder infection
• gt1 week of infection
• gt4 joints involved
• Positive cultures after 7 days of appropriate
  treatment

15
Management

• Antimicrobials do achieve adequate levels in
  joint fluid
• Joint effusion drainage necessary but best method
  to drain is uncertain

16
Prosthetic Hip Infxns, Organisms

• Gram positive-CNSEgtS. aureusgtstreptococcusgtenteroc
  c
• Gram negative-Entericgtpseudomonas
• Anaerobes-least common
• J Bone Jt. Surg-1996, 78512

17
Results of Rx of Infxns-Prosthetic Hip

• Positive intraoperative-28/31 good outcome (90)
  3.5 year followup
• Early Postoperative 25/35 (71 good outcome) 3.3
  yrs followup
• Late chronic-29/34 (85) good outcome-4.2 years
  followup

18
Results of Treatment continued

• Acute hematogenous-3/6 (50) good outcome-2.6
  years followup
• Journal Bone and Joint Surgery 1996, 78512

19
Prosthetic Joint Infection

• Positive intraoperative cx-6 weeks iv with no
  surgical Rx
• Early (one month)-surgical, remove liner, leave
  bone components, 4 weeks iv antibiotics

20
Prosthetic Joint Infection

• Late chronic infection-debridement, remove
  components and cement, 6 weeks iv antibiotics
• Acute hematogenous-treatment same as early
  postoperative, replace components if loose
• J Bone Jt Surg 1995, 77 1576

21
Rifampin Containing Regimens

• Proven S. aureus or coagulase negative staph
  infxns.
• Stable joint with sms less than 21 days
• Initial debridement and 2 weeks of antistaph
  followed by oral for 3 months if hip or 6 months
  if hip

22
Rifampin Containing Regimens

• 12/12 cured with ciprorifampin
• 7/12 cured with cipro plus placebo
• JAMA-1998, 279, 1537
• Lancet 2001, 1175.

23
Suppression with oral

• In one study of patients who were high risk/poor
  function if joint removed-treatment mean was 37.6
  months
• 10/13 patients required prothesis removal for
  recurrent infections (mean 21.6 months

24
Suppression-continued

• Conclusion-benefits are limited
• Orthopaedics-1991, 14841.

25
Osteomyelitis classification

• Cierny and Mader-Orthopaedic Review-1987, 16259
• I-medullary, II-superficial, III-localized,
  IV-diffuse
• Host factors-A-normal, B-compromised,
  C-prohibitive
• Waldvogel-NEJM-1970, 282198
• Hematogenous, continguous

26
Types of Host Compromise

• Local-lymphedema, venous stasis, vessel disease,
  arteritis, scarring, xrt, neuropathy, tobacco
• Systemic-malnutrition, liver/renal, dm,
  malignancy, immunosuppresion, age extremes,
  chronic hypoxemia

27
Osteomyelitis diagnosis

• Staging studies-MRI, CT, nuclear scans, ESR, CRP,
  bone biopsies and cultures

28
Osteomyelitis treatment

• Surgery and antibiotics
• Controversies in length of treatment, etc.

29
Diabetic Foot

• MRI-99 sensitive, 83 specific
• Plain x-ray-60 sensitive, 66 specific
• Tc99m bone scan-86 sensitive, 45 specific
• In111 WBC-89 sensitive, 78 specific, CID 1997
  25 1318

30
Probing to Bone

• Technique to determine bone infection
• Sterile, steel probe used
• positive test if bone can be touched with probe
• Sensitivity-89, specificity-85 JAMA-1995.
  273721

31
Diabetic Foot

• 254 isolates from 96 patients
• S. aureus-38 isolates, Enterococcus-31,
  peptostreptococcus-31, CNSE-27, streptococcus
  sp-27, proteus-10, klebsiella-10
• CID-1995, 20 (supplement 2).

32
Treatment

• Surgical debridement
• Avoid weight bearing
• Antibiotics-4-6 weeks iv/oral combination
• Surgical bone resection may shorten antibiotic
  course

33
Prognosis

• Risk factors for amputation were highest in the
  group with severe neuropathy-12.9 odds ratio and
  no diabetes education-16.3 odds ratio vs low O2
  tension and PVD-odds ratio of 1.1

34
Vertebral

• 123 patients
• Back and neck pain-96
• Fever-43
• Increased WBC-34
• ESR-84

35
Organisms

• S. aureus-68
• Enterobacteriae-28
• Streptococcus-8
• CNSE-3
• P. aeruginosa-lt1, candida-lt1

36
Organisms continued

• Unusual causes include-bartonella henselae in
  association with cat scratch
• Aspergillosis-41 cases in literature with 34 no
  predisposing factors

37
Vertebral-epidemiology

• Mean age-59 years with sms for 48 days
• Blood cultures positive up to 78
• Paraspinal or epidural extension in 74-did not
  correlate with neurologic deficits in 28

38
Vertebral

• 58/101 hematogenous vertebral osteomyelitis cases
  who had surgery with less back pain in follow-up
• Only 18 with epidural abscess and 23 with
  paralysis fully recovered after surg decompression

39
Continued

• 100 of patients with paraparesis recovered
  completely following decompression surgery