Osteomyelitis: Difference between revisions
From IDWiki
(ββ) |
m (ββ) Β |
||
(5 intermediate revisions by the same user not shown) | |||
Line 1: | Line 1: | ||
== Background == |
== Background == |
||
+ | *Inflammation of the bone which involves the medullary cavity, in comparison to osteitis (a distinction made on MRI but not clinically relevant) |
||
*Classified by: |
*Classified by: |
||
**[[Acute osteomyelitis]] (1 to 2 weeks) versus [[chronic osteomyelitis]] (3 to 6 months), though this classification is not necessarily helpful |
**[[Acute osteomyelitis]] (1 to 2 weeks) versus [[chronic osteomyelitis]] (3 to 6 months), though this classification is not necessarily helpful |
||
**Etiology and location, including the [[Osteomyelitis with orthopedic hardware|presence of orthopedic hardware]] or [[Prosthetic joint infection|joint prosthesis]] |
**Etiology and location, including the [[Osteomyelitis with orthopedic hardware|presence of orthopedic hardware]] or [[Prosthetic joint infection|joint prosthesis]] |
||
β | **Cierny-Mader classification based on area of bone involvement |
+ | **Cierny-Mader classification based on area of bone involvement<ref>Β |
+ | |||
+ | Cierny G, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clinical Orthopaedics and Related Research. 2003;(414):7β24. doi: [https://doi.org/10.1097/01.blo.0000088564.81746.62 10.1097/01.blo.0000088564.81746.62]</ref> |
||
***Type I: medullary |
***Type I: medullary |
||
***Type II: superficial |
***Type II: superficial |
||
Line 23: | Line 26: | ||
!Foot and Ankle |
!Foot and Ankle |
||
|- |
|- |
||
β | | |
+ | | rowspan="6" |[[Gram-positive bacteria]] |
⚫ | |||
β | | |
||
β | | |
||
β | | |
||
β | | |
||
β | | |
||
β | |- |
||
β | | rowspan="6" | |
||
|[[Staphylococcus aureus]] |
|[[Staphylococcus aureus]] |
||
|10-40% |
|10-40% |
||
Line 80: | Line 75: | ||
| |
| |
||
|- |
|- |
||
β | | |
+ | | rowspan="4" |[[Gram-negative bacteria]] |
+ | |Overall |
||
|5-10% |
|5-10% |
||
|10-40% |
|10-40% |
||
Line 88: | Line 84: | ||
|35-55% |
|35-55% |
||
|- |
|- |
||
β | | rowspan="3" | |
||
|[[Pseudomonas]] species |
|[[Pseudomonas]] species |
||
|<5% |
|<5% |
||
Line 113: | Line 108: | ||
|<5% |
|<5% |
||
|- |
|- |
||
β | | colspan="2" | |
+ | | colspan="2" |Polymicrobial bacteria |
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
β | |- |
||
⚫ | |||
|10-25% |
|10-25% |
||
|15-30% |
|15-30% |
||
Line 128: | Line 115: | ||
|20 |
|20 |
||
|30-80% |
|30-80% |
||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
|} |
|} |
||
Line 272: | Line 267: | ||
|[[amoxicillin]] 500 mg PO bid to tid |
|[[amoxicillin]] 500 mg PO bid to tid |
||
|- |
|- |
||
β | |[[penicillin]] VK 500 mg PO bid to |
+ | |[[penicillin]] VK 500 mg PO bid to tid |
|} |
|} |
||
β | === OVIVA Trial === |
+ | === [https://www.wikijournalclub.org/wiki/OVIVA OVIVA Trial] === |
β | * Oral therapy non-inferior to intravenous therapy for bone and joint infections requiring 6+ weeks of therapy |
+ | * Oral therapy non-inferior to intravenous therapy for bone and joint infections requiring 6+ weeks of therapy[[CiteRef::li2019or]] |
+ | * Patients were randomized after at least 7 days of appropriate IV antibiotics |
||
β | * Oral regimens included fluoroquinolones (41%), combination with |
+ | * Oral regimens included [[fluoroquinolones]] (41%), combination with [[ciprofloxacin]]/[[clindamycin]] or [[ciprofloxacin]]/[[doxycycline]] (14%), [[Beta lactam antibiotics|beta lactams]] (15%), [[macrolides]] or [[lincosamides]] (11%), [[tetracyclines]] (9%), and other antibiotics (9%) |
[[Category:Bone and joint infections]] |
[[Category:Bone and joint infections]] |
Latest revision as of 13:29, 3 March 2023
Background
- Inflammation of the bone which involves the medullary cavity, in comparison to osteitis (a distinction made on MRI but not clinically relevant)
- Classified by:
- Acute osteomyelitis (1 to 2 weeks) versus chronic osteomyelitis (3 to 6 months), though this classification is not necessarily helpful
- Etiology and location, including the presence of orthopedic hardware or joint prosthesis
- Cierny-Mader classification based on area of bone involvement[1]
- Type I: medullary
- Type II: superficial
- Type III: localized
- Type IV: diffuse
- Immune status and frailty of host
Microbiology
- Based on 1
Species | Upper Extremity | Vertebral | Lower Extremity PJI | Trauma of Fracture | Hematogenous | Foot and Ankle | |
---|---|---|---|---|---|---|---|
Gram-positive bacteria | Staphylococcus aureus | 10-40% | 15-60% | 20-30% | 20-40% | 40% | 45-55% |
Coagulase-negative staphylococci | 10-20% | 5-40% | 25-35% | 10-40% | <5% | <5% | |
Streptococcus species | 5-10% | 5-10% | <5% | 5-10% | 5-10% | 5-20% | |
Enterococcus species | <5% | 5-15% | <5% | 5% | <5% | 5% | |
Diphtheroids | <5% | 5% | <5% | 5% | <5% | <5% | |
Cutibacterium acnes | 30-50% in shoulder | 10-15% spinal fusion | |||||
Gram-negative bacteria | Overall | 5-10% | 10-40% | 5-10% | 20% | 10-15% | 35-55% |
Pseudomonas species | <5% | 5-10% | <5% | 5-10% | 5-10% | 10-20% | |
Enterobacteriaceae | <5% | 10-20% | <5% | 5-20% | 5% | 10-15% | |
HACEK group | <5% | <5% | <5% | <5% | <5% | <5% | |
Polymicrobial bacteria | 10-25% | 15-30% | 10-20% | 20-30% | 20 | 30-80% | |
Fungi | <5% | <5% | <5% | <5% | <5% | <5% |
- Polymicrobial infections are more common in trauma-related OM, PJI, and diabetic foot infections
- Poorer outcomes
- Commonly involves Staphylococcus aureus iwht a mix of other bacteria
Diagnosis
- Bone biopsy for histology and culture is the gold standard
- However, diagnosis is usually made based on a combination of physical exam, lab tests, and imaging
- Physical exam findings: fever, constitutional symptoms, sinus tract, joint pain and swelling, cellulitis at the site
- Blood tests: elevated WBC or CRP, positive blood cultures
- Novel tests: alpha-defensin, D-dimer, synolvial IL-6, and synovial CRP
- Imaging: MRI is the most sensitive; can also use bone scan and labelled WBC scan, or plain film x-ray or CT (if more chronic)
Management
- No clinically meaningful differences in bone penetration between classes of antibiotics exist2
- Bioavailability likely still important
- Empiric antimicrobials should generally cover MRSA, susceptible Gram-positives, and common Gram-negatives
- For example, vancomycin plus ceftriaxone
Parenteral Antimicrobials
Organism | Antimicrobial Options |
---|---|
MSSA | nafcillin 2 g IV q4h |
oxacillin 2 g IV q4h | |
cefazolin 2 g IV q8h | |
flucloxacillin 2 g IV q6h | |
ceftriaxone 2 g IV q24h | |
MRSA | vancomycin 20 mg/kg load followed by 15-20 mg IV q8-12h |
daptomycin 6 to 10 mg/kg IV daily | |
teicoplanin 12 mg/kg IV q12h for 3 to 5 doses followed by q24h | |
Adjunctive staphylococcal agent | rifampin 300 to 450 mg PO bid |
fusidic acid 500 mg PO tid | |
Gram-negative bacteria | ciprofloxacin 750 mg PO big to 400 mg IV q12h |
levofloxacin 750 mg PO/IV daily | |
ceftriaxone 2 g IV q24h | |
ceftazidime 2 g IV q8h | |
cefepime 2 g IV q8-12h | |
ertapenem 1 g IV q24h | |
meropenem 1 g IV q8h | |
Pseudomonas aeruginosa | ciprofloxacin 400 mg IV q8h |
Enterococcus | ampicillin 12 g continuous IV q24h |
ampicillin 2 g IV q4h | |
penicillin G 20 to 24 million units continuous IV q24h | |
penicillin G 3-4 million units IV q4h | |
vancomycin 20 mg/kg IV load followed by 15 mg/kg IV q12h (max 2 g per dose) | |
daptomycin 6 to 10 mg/kg IV daily | |
teicoplanin 12 mg/kg IV q12h for 3 to 5 doses, followed by q24h | |
ampicillin as above, PLUS ceftriaxone 2 g IV q12-24h | |
penicillin-susceptible streptococci | ampicillin 12 g continuous IV q24h |
ampicillin 2 g IV q4h | |
penicillin G 20 to 24 million units continuous IV q24h | |
penicillin G 3-4 million units IV q4h | |
ceftriaxone 2 g IV q24h | |
vancomycin 20 mg/kg IV load followed by 15 mg/kg IV q12h (max 2 g per dose) | |
Cutibacterium acnes | penicillin G 20 to 24 million units continuous IV q24h |
penicillin G 3-4 million units IV q4h | |
ceftriaxone 2 g IV q24h |
Oral Antimicrobials
Organism | Antibiotic Options |
---|---|
MSSA | cefadroxil 500 to 1000 mg PO bid |
cephalexin 500 mg PO tid to qid, or 1000 mg PO bid to tid | |
dicloxacillin 500 mg PO tid to qid | |
flucloxaxillin 500 mg PO tid to qid | |
MRSA | TMP-SMX DS 1 tablet PO bid |
doxycycline 100 mg PO bid | |
minocycline 100 mg PO bid | |
clindamycin 600 mg PO tid | |
Gram-negative bacteria | TMP-SMX DS 1 tablet PO bid |
ciprofloxacin 500 mg PO bid | |
levofloxacin 500 mg PO daily | |
penicillin-susceptible streptococci and enterococci | amoxicillin 500 mg PO bid to tid |
penicillin VK 500 mg PO bid to tid | |
Cutibacterium acnes | amoxicillin 500 mg PO bid to tid |
penicillin VK 500 mg PO bid to tid |
OVIVA Trial
- Oral therapy non-inferior to intravenous therapy for bone and joint infections requiring 6+ weeks of therapy3
- Patients were randomized after at least 7 days of appropriate IV antibiotics
- Oral regimens included fluoroquinolones (41%), combination with ciprofloxacin/clindamycin or ciprofloxacin/doxycycline (14%), beta lactams (15%), macrolides or lincosamides (11%), tetracyclines (9%), and other antibiotics (9%)
- β Cierny G, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clinical Orthopaedics and Related Research. 2003;(414):7β24. doi: 10.1097/01.blo.0000088564.81746.62
References
- ^ Elysia A. Masters, Benjamin F. Ricciardi, Karen L. de Mesy Bentley, T. Fintan Moriarty, Edward M. Schwarz, Gowrishankar Muthukrishnan. Skeletal infections: microbial pathogenesis, immunity and clinical management. Nature Reviews Microbiology. 2022. doi:10.1038/s41579-022-00686-0.
- ^ Cornelia B. Landersdorfer, JΓΌrgen B. Bulitta, Martina Kinzig, Ulrike Holzgrabe, Fritz SΓΆrgel. Penetration of Antibacterials into Bone. Clinical Pharmacokinetics. 2009;48(2):89-124. doi:10.2165/00003088-200948020-00002.