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Risk Factors

Risk Factors. Corticosteroids Existing arthritis Articular infection Infection elsewhere DM Trauma None. Frequency of Joints. Knee Hip Ankle Elbow Wrist Shoulder Sternoclavicular. Pathology. High vascularity

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Risk Factors

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  1. Risk Factors • Corticosteroids • Existing arthritis • Articular infection • Infection elsewhere • DM • Trauma • None

  2. Frequency of Joints • Knee • Hip • Ankle • Elbow • Wrist • Shoulder • Sternoclavicular

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

  4. 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

  5. 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, 61:267

  6. Septic Arthritis-odd organisms • Lyme, Mycoplasma • Listeria, enterococcus, chlmydia • M. tuberculosis, atypical Tb • Candida, sporothrix, blastomycosis, coccidiom\ • Rubella, hep b and c, EBV, parvovirus, mumps

  7. Synovial Effusion • Normal-clear, viscous, colorless-<200 wbc (<25% pmns) • Noninflammatory-clear, viscous, yellow 200-2000 wbc-<25% pmns • Inflammatory-cloudy, watery, yellow-2000-50,000 cells (>50% polys)

  8. Synovial Effusion, continued • Infected-purulent->50,000 cells (>75% pmns) • Great overlap at times

  9. Gonococcal vs. non gc Arthritis • Gc-sexually active adults, migratory polyarthralgias, tenosynovitis, dermatitis common, >50% polyarthritis, BC positive <10%, joint fluid positive 25%

  10. GC vs. non GC • Non GC-very young or elderly, polyarthralgias, tenosynovitis rare, dermatitis rare, >85% monoarthritis, BC positive 50%, joint fluid positive 85-90% • NEJM-1985, 312:764-771

  11. Outcome of Bacterial Arthritis • 154, 121 adults-half had joint disease • 29% of joints contained synthetic material • Poor outcome in 21% of patients • Poor joint outcome in nearly 50% of patients

  12. Outcome continued • Risk factors for poor outcome include-older age, existing joint disease, synthetic joint • Arthritis and Rheumatism • 1997, 40:884.

  13. Factors Associated with Poor Prognosis • Age >60 years • Pre-existing rheumatoid arthritis or hip or shoulder infection • >1 week of infection • >4 joints involved • Positive cultures after 7 days of appropriate treatment

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

  15. Prosthetic Hip Infxns, Organisms • Gram positive-CNSE>S. aureus>streptococcus>enterocc • Gram negative-Enteric>pseudomonas • Anaerobes least common • J Bone Jt. Surg-1996, 78:512

  16. 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-2.6 years followup

  17. Results of Treatment continued • Acute hematogenous-3/6 (50%) good outcome-2.6 years followup • Journal Bone and Joint Surgery 1996, 78:512

  18. Prosthetic Joint Infection • Positive intraoperative cx-6 weeks iv with no surgical Rx • Early (one month)-surgical, remove lines, leave bone components, 4 weeks iv antibiotics

  19. 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

  20. 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

  21. Rifampin Containing Regimens • 12/12 cured with cipro+rifampin • 7/12 cured with cipro plus placebo • JAMA-1998, 279, 1537 • Lancet 2001, 1:175.

  22. 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

  23. Suppression-continued • Conclusion-benefits are limited • Orthopaedics-1991, 14:841.

  24. Osteomyelitis classification • Cierny and Mader-Orthopaedic Review-1987, 16:259 • I-medullary, II-superficial, III-localized, IV-diffuse • Host factors-A-normal, B-compromised, C-prohibitive • Waldvogel-NEJM-1970, 282:198 • Hematogenous, continguous

  25. Osteomyelitis diagnosis • Staging studies-MRI, CT, nuclear scans, ESR, CRP, bone biopsies and cultures

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

  27. 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

  28. 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. 273:721

  29. 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).

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