Gram-negative osteomyelitis: clinical and microbiological profile

Introduction: Despite the growing interest in the study of Gram-negative bacilli (GNB) infections, very little information on osteomyelitis caused by GNB is available in the medical literature. Objectives and methods: To assess clinical and microbiological features of 101 cases of osteomyelitis caused by GNB alone, between January 2007 and January 2009, in a reference center for the treatment of high complexity traumas in the city of Sao Paulo. Results: Most patients were men (63%), with median age of 42 years, affected by chronic osteomyelitis (43%) or acute osteomyelitis associated to open fractures (32%), the majority on the lower limbs (71%). The patients were treated with antibiotics as inpatients for 40 days (median) and for 99 days (median) in outpatient settings. After 6 months follow-up, the clinical remission rate was around 60%, relapse 19%, amputation 7%, and death 5%. Nine percent of cases were lost to follow-up. A total of 121 GNB was isolated from 101 clinical samples. The most frequently isolated pathogens were Enterobacter sp. (25%), Acinetobacter baumannii (21%) e Pseudomonas aeruginosa (20%). Susceptibility to carbapenems was about 100% for Enterobacter sp., 75% for Pseudomonas aeruginosa and 60% for Acinetobacter baumannii. Conclusion: Osteomyelitis caused by GNB remains a serious therapeutic challenge, especially when associated to nonfermenting bacteria. We emphasize the need to consider these agents in diagnosed cases of osteomyelitis, so that an ideal antimicrobial treatment can be administered since the very beginning of the therapy. (C) 2012 Elsevier Editora Ltda. All rights reserved.

Predicting the pathogen of diabetic toe osteomyelitis by two consecutive ulcer cultures with bone contact

In this study, we investigate the accuracy of two consecutive ulcer cultures with bone contact compared to bone biopsy for the diagnosis of diabetic toe osteomyelitis. The same nurse and orthopaedic surgeon obtained all samples: sample A-1: bone contact swabbing through the ulcer; sample A-2: a second culture swabbing from the bone surface within 24 h; sample B: surgical bone biopsy in the operating theatre. The kappa statistic measure between samples A-1 and A-2 (bone contact swabs) indicated 82.35% agreement. The sensitivity, specificity, positive and negative predictive values of the two samples A compared to B were 96%, 79%, 92% and 88%, respectively, for the causative pathogen. These results were similar with prior antibiotic treatment, discordant bone surface swabs or with monomicrobial infections. As a conclusion, two consecutive diabetic toe cultures with bone contact accurately predict the pathogen of diabetic toe osteomyelitis in 90% of cases.

Relationship between antibiotic concentration in bone and efficacy of treatment of staphylococcal osteomyelitis in rats: azithromycin compared with clindamycin and rifampin

We examined the effect of azithromycin (CP-62,993), a new oral macrolide-like antibiotic, alone and in combination with rifampin, as treatment for experimental staphylococcal osteomyelitis. Clindamycin was used as a comparison drug. Rats (n = 10 to 15 per group) were infected by direct instillation of Staphylococcus aureus into the tibial medullary cavity. After 10 days, 21-day treatments with azithromycin (50 mg/kg of body weight, once daily, by the oral route), rifampin (20 mg/kg, once daily, subcutaneously), or clindamycin (90 mg/kg, three times daily, by the oral route) were started. The drugs were used singly or in combination (azithromycin plus rifampin or clindamycin plus rifampin). Peak azithromycin concentrations in bone were > 30 times higher than levels in serum, but the drug had little effect on final bacterial titers (5.13 +/- 0.46 log10 CFU/g of bone; for controls, 6.54 +/- 0.28 log10 CFU/g). Clindamycin was more active than azithromycin (3.26 +/- 2.14 log10 CFU/g of bone; 20% of sterilized bones), but rifampin was the most active single drug (1.5 +/- 1.92 log10 CFU/g; 53% of sterilized bones). Therapy with rifampin or clindamycin alone was associated with the emergence of resistance. Rifampin plus azithromycin (0.51 +/- 1.08 log10 CFU/g of bone; 80% of sterilized bones) and rifampin plus clindamycin (0.87 +/- 1.34 log10 CFU/g of bone; 66% of sterilized bones) were the most active regimens. Thus, azithromycin is ineffective as a single drug for the treatment of experimental staphylococcal osteomyelitis, despite high levels in bone that markedly exceeded the MIC, but it may be an attractive partner drug for rifampin.

Imaging of chronic recurrent multifocal osteomyelitis of childhood first presenting with isolated primary spinal involvement

OBJECTIVE: Initial presentation with primary spinal involvement in chronic recurrent multifocal osteomyelitis of childhood (CRMO) is rare. Our objective was to review the imaging appearances of three patients who had CRMO who initially presented with isolated primary spinal involvement. DESIGN AND PATIENTS: The imaging, clinical, laboratory and histology findings of the three patients were retrospectively reviewed. Imaging included seven spinal MR imaging scans, one computed tomography scan, nine bone scans, two tomograms and 16 radiographs. These were reviewed by two musculoskeletal radiologists and a consensus view is reported. All three patients presented with atraumatic spinal pain and had extensive bone spinal pathology. The patients were aged 11, 13 and 12 years. There were two females and one male. RESULTS AND CONCLUSIONS: The initial patient had thoracic T6 and T8 vertebra plana. Bone scan showed additional vertebral body involvement. Follow-up was available over a 3 year period. The second patient had partial collapse of T9 and, 2 years later, of C6. Subsequently extensive multifocal disease ensued and follow-up was available over 8 years. The third patient initially had L3 inferior partial collapse and 1 year later T8 involvement with multifocal disease. Follow-up was available over 3 years. The imaging findings of the three patients include partial and complete vertebra plana with a subchondral line adjacent to endplates associated with bone marrow MR signal alterations. Awareness of the imaging appearances may help the radiologist to include this entity in the differential diagnosis in children who present with spinal pathology and no history of trauma. Histopathological examination excludes tumor and infection but with typical imaging findings may not always be necessary.

Silent chronic osteomyelitis lasting for 30 years before outburst of symptoms

A 56-year-old male patient presented with left knee and thigh pain after suffering a knee contusion. History revealed a complex fracture of the distal femur 30 years prior to presentation. Initial blood tests upon admission showed elevated C reactive protein values. Subsequent imaging and biopsies showed a correlate to osteomyelitis, upon which the diagnosis of a late onset osteomyelitis as an outburst of silent chronic osteomyelitis was made. The patient was successfully treated surgically by means of aggressive debridement and discharged after confirmation of negative biopsies.

Septic osteitis and osteomyelitis in foals - are antimicrobials alone enough?

The case report by Lawrence and Fraser (2012) describes the successful management of 2 weanlings with septic osteitis of the proximal sesamoid bones, using prolonged (6 weeks) antimicrobial therapy alone. Doxycycline, an antimicrobial with excellent bone penetration properties, was deemed essential to treatment success. In contrast to the poor outcome in previously reported cases of septic sesamoid bone osteitis, the authors were able to show the value of a conservative approach over surgical debridement. The question is to what extent are we able to extrapolate this to the general treatment of septic osteitis and osteomyelitis in young horses?

Pressure Ulcer-Related Pelvic Osteomyelitis: A Neglected Disease?

Background. Decubitus ulcers can become complicated by pelvic osteomyelitis. Little is known about the epidemiology of pressure ulcer-related pelvic osteomyelitis. Methods. We performed a retrospective cohort study of adult patients with pressure ulcer and pelvic osteomyelitis admitted to an academic center from 2006 to 2011. Data on clinical presentation, diagnostic evaluation, and treatment during the index admission were collected. Outcome measures included length of hospital stay and number of readmissions in the subsequent year. Results. Two hundred twenty patients were included: 163 (74%) were para/quadriplegic and 148 (67%) were male (148; 67%). Mean age was 50 (±18) years. Pelvic osteomyelitis was the primary admission diagnosis for 117 (53%). Fifty-six (26%) patients had concurrent febrile urinary tract infection. Wound cultures collected for 113 patients (51%) were notable for methicillin-resistant Staphylococcus aureus (37; 33%), Streptococci (19; 17%), and Pseudomonas spp (20; 18%). Plain films were obtained in 89 (40%) patients, computed tomography scans were obtained for 81 (37%) patients, and magnetic resonance images were obtained for 40 (18%) patients. Most patients received osteomyelitis-directed antibiotics (153; 70%), 134 of 153 (88%) of which were scheduled to receive ≥6 weeks of treatment. Fifty-five (25%) patients underwent surgery during the index admission; 48 (22%) patients received a combined medical-surgical approach. One third of patients had ≥2 readmissions during the subsequent year. Patients treated with a combined approach were less likely to be readmitted than those who received antibiotics alone (0 [range, 0-4] vs 1 [0-7] readmissions; P = .04). Conclusions. This is one of the largest cohort studies of pressure ulcer-related pelvic osteomyelitis to date. Significant variations existed in diagnostic approach. Most patients received antibiotics; those treated with a combined medical-surgical approach had fewer hospital readmissions.

Über embolie der Lungencapillaren mit flüssigem feitt bei Osteomyelitis : Inagural-Dissertation zur Erlangung der Doctorwürde ... /

Tesis doctoral Univ. Heildelberg.

Three cases of Q fever osteomyelitis in children and a review of the literature

Q fever is a common zoonosis worldwide. Awareness of the disease and newer diagnostic modalities have resulted in increasing recognition of unusual manifestations. We report 3 cases of Q fever osteomyelitis in children and review the literature on 11 other reported cases. The cases demonstrate that Coxiella burnetii can cause granulomatous osteomyelitis that presents without systemic symptoms and frequently results in a chronic, relapsing, multifocal clinical course. Optimal selection and duration of antimicrobial therapy and methods of monitoring therapy are currently uncertain.

Osteomyelitis of the maxilla in a patient with Malignant Infantile Osteopetrosis

Osteopetrosis is characterized by a considerable increase in bone density resulting in defective remodeling, caused by failure in the normal function of osteoclasts, and varies in severity. It is usually subdivided into three types: benign autosomal dominant osteopetrosis; intermediate autosomal recessive osteopetrosis; and malignant autosomal recessive infantile osteopetrosis, considered the most serious type. The authors describe a case of chronic osteomyelitis in the maxilla of a 6-year-old patient with Malignant Infantile Osteopetrosis. The treatment plan included pre-maxilla sequestrectomy and extraction of erupted upper teeth. No surgical procedure was shown to be the best to prevent the progression of oral infection. Taking into account the patient's general condition, if the patient develops severe symptomatic and refractory osteomyelitis surgery should be considered. The patient and his family are aware of the risks and benefits of surgery and its possible complications.

Continuous infusion of ticarcillin-clavulanate for home treatment of serious infections : clinical efficacy, safety, pharmacokinetics and pharmacodynamics

Continuous infusion (CI) ticarcillin–clavulanate is a potential therapeutic improvement over conventional intermittent dosing because the major pharmacodynamic (PD) predictor of efficacy of β-lactams is the time that free drug levels exceed the MIC. This study incorporated a 6-year retrospective arm evaluating efficacy and safety of CI ticarcillin–clavulanate in the home treatment of serious infections and a prospective arm additionally evaluating pharmacokinetics (PK) and PD. In the prospective arm, steady-state serum ticarcillin and clavulanate levels and MIC testing of significant pathogens were performed. One hundred and twelve patients (median age, 56 years) were treated with a CI dose of 9.3–12.4 g/day and mean CI duration of 18.0 days. Infections treated included osteomyelitis (50 patients), septic arthritis (6), cellulitis (17), pulmonary infections (12), febrile neutropenia (7), vascular infections (7), intra-abdominal infections (2), and Gram-negative endocarditis (2); 91/112 (81%) of patients were cured, 14 (13%) had partial response and 7 (6%) failed therapy. Nine patients had PICC line complications and five patients had drug adverse events. Eighteen patients had prospective PK/PD assessment although only four patients had sufficient data for a full PK/PD evaluation (both serum steady-state drug levels and ticarcillin and clavulanate MICs from a bacteriological isolate), as this was difficult to obtain in home-based patients, particularly as serum clavulanate levels were found to deteriorate rapidly on storage. Three of four patients with matched PK/PD assessment had free drug levels exceeding the MIC of the pathogen. Home CI of ticarcillin–clavulanate is a safe, effective, convenient and practical therapy and is a therapeutic advance over traditional intermittent dosing when used in the home setting.

Queensland diabetic foot hospitalisations (2005-10) : in what state is our foot hospital problem?

Background Diabetes foot complications are a leading cause of overall avoidable hospital admissions. Since 2006, the Queensland Diabetes Clinical Network has implemented programs aimed at reducing diabetes-related hospitalisation. The aim of this retrospective observational study was to determine the incidence of diabetes foot-related hospital admissions in Queensland from 2005 to 2010. Methods Data on all primary diabetes foot-related admissions in Queensland from 2005-2010 was obtained using diabetes foot-related ICD-10-AM (hospital discharge) codes. Queensland diabetes foot-related admission incidences were calculated using general population data from the Australian Bureau of Statistics. Furthermore, diabetes foot-related sub-group admissions were analysed. Chi-squared tests were used to assess changes in admissions over time. Results Overall, 24,917 diabetes foot-related admissions occurred, resulting in the use of 260,085 bed days or 1.4% of all available Queensland hospital bed days (18,352,152). The primary reasons for these admissions were foot ulcers (49.8%), cellulitis (20.7%), peripheral vascular disease (17.8%) and osteomyelitis (3.8%). The diabetes foot-related admission incidence among the general population (per 100,000) reduced by 22% (103.0 in 2005, to 80.7 in 2010, p < 0.001); bed days decreased by 18% (1,099 to 904, p < 0.001). Conclusion Diabetes foot complications appear to be the primary reason for 1.4 out of every 100 hospital beds used in Queensland. There has been a significant reduction in the incidence of diabetes foot-related admissions in Queensland between 2005 and 2010. This decrease has coincided with a corresponding decrease in amputations and the implementation of several diabetes foot clinical programs throughout Queensland.