Transcript BONE AND JOINT INFECTIONS - TOT e

BONE AND JOINT
INFECTIONS
นพ. ยอดปิ ติ ตั้งตรงจิตร
กลุ่มงานศัลยกรรมกระดูก โรงพยาบาลแพร่
3 ตุลาคม 2555
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SEPTIC ARTHRITIS
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Septic Arthritis
• Epidemiology
~2 to 10/100,000 in general population
~30-40/100,000 in RA
~40-68/100,000 in joint prostheses
• 2 age peaks : < 5 years , > 64 years
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• knee 40-50%
• hip 20-25%
• Shoulders, ankles, elbows
10-15%
• wrist 10%
• in infants and very young children, hip is the most
common joint infection.
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Definition
• Acute - < 14days
• Subacute – 2-6 wks
• Chronic - > 6wks
• Monoarthritis – 1 joint
• Oligoarthritis – 2-3 joints
• Polyarhritis - > 4 joints
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Acute Monoarthritis
 Crystal-induced synovitis
 Septic arthtitis
 Acute traumatic and hemorrhagic arthritis
 Acute presentation of systemic rheumatic
diseases eg.RA, SNSA
 Other rheumatic disorders – Adult still’s
disease
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Microorganisms
• Bacteria - the most important
– Neisseria
– Non-neisseria
• Viruses
• Fungi
• Parasites
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Gram-Positive Cocci
Streptococci
• S. pyogenes (beta-hemolyticus group A)
• S. pneumoniae
• Group B and G hemolytic Streptococci.
Staphylococci
• Staph. aureus
• Staphylococcus epidermidis
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Gram Negative Organism
Neisseria
• Neisseria gonorrhoeae
– septic or reactive forms of
arthritis,
• N. meningitidis,
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Gram Negative Organism
Non- Neisseria
• Haemophilus influenzae
• Gram-negative rods
– Enterobacteriaceae
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•
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•
•
•
•
•
E. coli
Shigella
Salmonella
Yersinia
Klebsiella pneumoniae.
Proteus mirabilis
Pasteurellaceae ( Pasteurella multocida)
Campylobacter jejuni
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• Viruses
–
–
–
–
HIV
parvovirus B19
herpes viruses
adenoviruses
• Anaerobes
–
–
–
–
–
Clostridium
Eubacterium
Propionibacterium
Bacteroides
Fusobacterium
Others
•
•
•
•
Mycobacterium
Nocardia.
Spirochetes
Borrelia burgdorferi (
Lyme disease)
• Chlamydias
• Mycoplasmas and
Ureaplasma.
• Fungi, Parasites
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Bacterial isolation
Organism
Percentage of cases
Staphylococcus aureus
40–50
Staphylococcus edidermis
10–15
Streptococcal species
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Gram-negative bacteria
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S. pneumoniae
2
H. influenzae
2
Anaerobes
5
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Microbiology
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Clinical features
• Acute bacterial infection
–
–
–
–
–
–
Fever 60%-80% (< 39°c )
Monarticular : inv. 90%
Limited ROM
Swelling (seen synovial effusion)
Most common : knee > hip
Refusal walk ,limping, Irritability,
failure to thrive, asymmetry of limb position
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Clinical Features
• Systemic symptoms - neonatal period
– High fever
– sepsis
• local signs – children, adult
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–
–
–
Pain
Swelling
Erythema and warm
Limitation of movement
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• Predisposing factors.
1) prosthetic joint.
2) age> 60 yrs.
3) present underlying jt. disease( RA, much less
for OA ).
4) co morbidity( malignancy, DM, alcoholism,
cirrhosis, hemophilia)
5) use of immunosuppressive drug.
6) skin infection.
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Predisposing Factors
Abnormal joint
 RA
 Crystal induced
synovitis
 Prosthetic joint
 Severe OA
 Severe Charcot’s joint
 Severe hemarthrosis
 Intrarticular injection
Abnormal host
 Chronic systemic
disease - DM ,SLE,
CRF, liver disease
 HIV
 IVDU
 Chronic steroid therapy
 Malignancy
 Old age
 New born
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Risk factors for the development of joint sepsis
•
•
•
•
•
•
•
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rheumatoid arthritis (RA) or osteoarthritis
prosthetic joints
low socioeconomic status
intravenous drug abuse
alcoholism
diabetes
previous intra-articular corticosteroid injection
cutaneous ulcers
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Differential diagnosis
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Pathogenesis
• Mechanism
– Hematogenous route.
• Skin, oral cavity, respiratory tract, urinary or
intestinal tract infections, or endocarditis.
– Dissemination from metaphysis or epiphysis.
– Vicinity of the joint
– Iatrogenic or penetrating trauma
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Source of infection
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Hematogenous spread
Systemic bacteremia
Invade synovial cartilaginous junction
Synovial infected
Increase inflammatory cell
Destruction of the articular cartilage
Joint dislocation, subluxation,
osteomyelitis
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1. Hematogenous route.
4. Vicinity of the joint
2,3 Dissemination from bone
5. Iatrogenic or penetrating trauma
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Bacteria
Synovium
Inflammation
Synovial cell proliferation
Leukocytes migration
Blood flow
Erythema
Exudation
Swelling
Tenderness
Irreversible destruction
Enzymes
Destruction
Pannus
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Investigations
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•
•
•
•
CBC,ESR,CRP
Blood culture
Synovium fluid
Plain radiographs ( 2-3 weeks or more)
Scintigraphy
– 99mTc phosphate (three-phase bone scan)
– 99mTc nanocolloid scanning
– Indium 111-labeled leukocytes
• Computed tomography (CT)
• Magnetic resonance imaging (MRI)
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Laboratory
• CBC
- often normal.
- predominance of segmented neutrophil.
• ESR ( erytrocyte sedimentation rate)
- elevation, but not specific for infections.
- present for less than 48 hr, return to
normal ~3 weeks.
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level
CRP
xx
ESR
3-5days
24
48
72
time
Subside 31
Laboratory
• CRP ( C- reactive protein).
- elevation.
- inc. within 6 hr, return to normal 1 week after
treatment began.
- better way to follow the response to ATB.
• Blood culture
- positive~ 50%-70%.
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Laboratory
• Synovial fluid analysis
- should be aspirated immidiately if there is
suspicious.
- recommended: crystals examination.
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Diagnosis
Joint aspiration
disease
WBC
% PMN
normal
<200
<25
traumatic
<5,000+rbc
<25
Toxic synovitis
5,000-15,000
<25
Acute rheumatic
10,000-15,000
50
JRA
15,000-80,000
75
Septic arthritis
>80,000
>75
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Synovial fluid
Percent
Method
Gram
positive
Gram
negative
N.
gonorrhea
Gram strain
80
50
25
Synovial C/S
80-90
60-70
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Streptococci
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Neisseria gonorrhoeae
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Radiologic Evaluation
 Initial plain x-ray
 baseline assessment
 exclude osteomyelitis
 Definitive changes usually take a
number of weeks
 Rapidity depends on virulence of
organism
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Radiologic Evaluation
Earliest : joint effusion with
displacement of fat pad
During first week
– periarticular osteoporosis
 Within 7-14 days
- joint space narrowing & erosions
>20days: bone destruction
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Radiologic Evaluation
periarticular osteoporosis
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Radiologic Evaluation
joint space narrowing & erosions
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Radiologic Evaluation
CT / MRI
Difficulty to evaluate clinically
Complex anatomical structure
( hip, shoulder, SC jt, SI jt )
 Early bony erosions, soft tissue extension
Bone scan
Axial joints infections
sensitivity
Cannot differentiate septic from aseptic Jt.
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Laboratory
• CT scan
– good definition of contiguous bone
lesions and ability to guide needle
aspiration
• MRI
– better defines soft tissue (distended joint
space and extension to periarticular
structures)
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Laboratory
• Radionuclide
- physiologic picture.
- reflect inflammatory change/ reaction of
bone to infection.
- 3 most common use
1) Technitium 99m phosphate.
2) gallium 67 citrate.
3) indium 111-labled leukocytes.
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Bone scan
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Polyarticular Septic Arthritis
 15%
 50% RA
 systemic illness/IVDU
 Most common
S.aureus
Group G streptococcus
H.influenza
S. Pneumoniae
Polymicrobial
 30% died!!
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Treatment
Principle in the management of acute septic arthritic
(Nade )
1. Joint must be adequately drained
2. Antibiotic must be given to diminish the systemic
effects of sepsis
3. Joint must be rested in a stable position
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Treatment.
1. synovial analysis and blood cultures before IV
antibiotic treatment
2. rapid administration of IV antibiotics IV
oxacillin in combination with IV ceftriaxone,
cefotaxime, or ceftizoxime.
3. drainage of the septic joint
4. evaluation
5. Arthroscopic drainage or arthrotomy
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Treatment & Outcome
 ATB should be started as soon as
 ATB selected on the basis of gram
stain and clinical picture
 Adjust ATB on the basis of sensitivity,
toxicity and cost
 Most iv ATB at least 2 weeks ,followed
by 1-2 weeks of oral ATB
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Organism
ATB of choice
Alternative
S. Aureus
MRSA
Cloxacillin
Vancomycin
Cefazilin,clindamycin
Streptococcus
Group A
non group A
pneumococci
Penicillin
PG + aminoglycoside
Penicillin
Cefazolin
Cefazolin + aminoglycoside
vancomycin
N. Gonorrhea
3rd cephalosporin
Ciplofloxacin, olfloxacin
H. Influenza
Amox. + calvulanate
3rd cephalosporin,
Ciplofloxacin
Enterobacteria
3rd cephalosporin
Imipenem
Ps. Aeruginosa
Antipseudomonas
Imipenem
Anaerobe
Metronidazole,
doxycycline
Clindamycin
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Treatment
•
1)
2)
3)
Recommendation for arthrotomy/ arthroscope
Hip joint.
Immunocompromised host
Joint that are difficult to access: sacroiliac,
sternoclavicular jt.
4) Difficult to completely drain: shoulder, wrist.
5) Close needle aspiration> 7 days.
6) P.aeruginosa or gram negative bacteria.
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Treatment
•
Recommendation for arthrotomy/ arthroscope
7) Sepsis
8) Extension into soft tissue or secondary
osteomyelytis
9) Fungal infection
10) Prosthetic or FB
11) Unresponse to ATB
12) Superimpose on joint disease - RA
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 Closed needle aspiration should be the
initial Rx of choice
 Serial synovial fluid c/s & wbc count
 Acute,suppurative phase
: sling/splint/cast should be used to maintain
the joint in optimal position
: muscle-tightening exercises
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Poor prognosis factors
–
–
–
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–
–
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Immunodeficiency
RA
prematurity
osteomyelitis,
hip
prosthetic infections
+ blood cultures,
symptoms >1 week,
>4 joints,
+ cultures after aspiration after 7 days of abx tx
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Complication
– arthritis stiffness
– Dislocation or subluxation
– AVN
– local growth distrubance
– Osteomyelitis
– postinfection synovitis
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 Postinfectious arthritis
 recurrent inflammatory when begin
ambulate, but sterile effusion
 DDx - incompletely treated infection
 NSAIDs
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Outcome
Results of Rx
 10-15% mortality
 25-50% chronic joint damage & disability
Poor outcome
 Persist/ Recurrent infection
 Marked decrease ROM/ankylosis
 Persistent pain
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Factors associated to poor outcome
 Duration of infection
 Virulense of bacteria
 The infected joints
 Host defences
 Age of patient
 Comorbidity
 Effective therapy
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OSTEOMYELIS
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Osteomyelitis
• Inflammation of the bone by organism.
– single portion.
– surrounding regions ; marrow , cortex
& periosteum
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Classification
1.
2.
3.
4.
Acute , subacute , chronic
Exogenous , hematogenous
Pyogenic , nonpyogenic
Neonate , children , adult
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Source of infection
• Blood circulation :
– infection in Oral, Throat, Ear, Gastrointestinal tract, Urinary
tract, Skin and soft tissue
• Trauma (30-50%)
– หกล้ม กระแทก
– Minor trauma
Caution : in infant < 18 month มักเกิด septic arthritis ร่ วมกับ
Osteomyelitis
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Acute Hematogenous Osteomyelitis
• Most common usually seen in
children.
• Infection involve the metaphyses of
rapidly growing long bones
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Natural history and Pathogenesis of Acute
hematogenous osteomyelitis
• Almost at “metaphysis”
– lower extremities > upper extremities 5 เท่า โดย
เฉพาะที่ distal femur และ proximal tibia
– metaphysis (no phagocytosis cell) ≠ diaphysis
(diaphysis = reticuloendothelial tissue +
phagocytosis cells)
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Why organism seeding the metaphyses ?
• nutrient capillaries form sharp
loops to establishment of infection
• metaphysis has relatively fewer
phagocytetic cell than the physis
or diaphysis.
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Pathogenesis
Source of Infection
Blood stream
Metaphysis
Venous stasis
Bacterial colonization
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Inflammation: acute osteomyelitis
• First 24 hours
• Vascular congestion
• Polymorphonuclear leukocyte
infiltration
• Exudation
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Inflammation: acute osteomyelitis
• 2-3 day No treat with antibiotic
•  Intraosseus pressure  intense pain
 intravascular thrombosis  ischemia
เด็กจะร้ องปวดมาก
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Suppuration
 4-5 days
 Pus formation
 Subperiosteal abscess
via Volkmann canals
 Pus spreading




epiphysis
joint
medullary cavity
soft tissue
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Necrosis
• Bone death by the end of a
week
• Bone destruction ← toxin
← ischemia
• Epiphyseal plate injury
• Sequestrum formation
– small  removed by
macrophage,osteoclast.
– large  remained
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New bone formation
• By the end of 2nd week
(10 – 14 days)
• Involucrum (new bone
formation from deep layer of
periosteum ) surround
infected tissue.
• If infection persist- pus
discharge through sinus to
skin surface Chronic
osteomyelitis
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Primary osteomyelitis
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Primary osteomyelitis
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• Children < 2 yr. blood vessel cross
the physis & spread infection into
epiphysis.
• Children > 2 yr. , the physis
effectively barrier to spread.
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• In adult , after the physes closed ,
acute osteomyelitis is less common ;
; infection extend directly metaphysis
to epiphysis to joint & hematogenous
seeding in compromised host
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• Spread to joint in children < 2 yr. ,
most commonly is hip joint .
( proximal humerous , radius neck ,
distal fibular are intraarticular , can
lead to septic arthritis. )
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Diagnosis
• History , Physical exam.
• Clinical : fever , malaise ,
fatigue , irritability , pain , local
tenderness , swelling ,
restriction of movement
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• Investigation : X- Ray , WBC ,
ESR , CRP , Bone scan ,
MRI , Blood culture ,
Bone aspiration for gram strain
, culture & sensitivities.
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X-ray soft tissue swelling ,
periosteal reaction , bony
destruction , 10–12 day after onset.
WBC often normal
ESR elevated
CRP elevated
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• Bone scan can confirm
diagnosis 24-48 hr. after onset.
• MRI show early inflamation
changes in bone marrow and
soft tissue
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Treatment acute osteomyelitis
• Sequestered abscesses drainage.
• Simple inflammation without abscess ;
antibiotic based on Gram strain
• Gram strain not found ; empirical
antibiotics for most likely organism.
• CRP every 2-3 days
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Two main indications for surgery
•
abscess requiring
drainage.
•
failure iv antibiotic
treatment. ( no clinical
response 24-48 hr. )
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Nade proposed five principles for treatment
1. appropriate antibiotic will be
effective before pus formation.
2. avascular tissues or abscesss
require surgical remove.
3. if such removal is effective ,
antibiotics should prevent their
reformation & primary wound
closure should be safe.
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4. surgery should not further
damage already ischemic
bone & soft tissue.
5. antibiotics should be
continuous after surgery.
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Organism
Patient Type
Neonate
Propable Organism
Grp. B Strep , S. aureus ,
Gram-neg. rod
(H. influenza)
Infants & children S. aureus
Sickle cell disease S. aureus , Sallmonella
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Antibiotic
• Appropriate ; infection type , organisms ,
sensitivity , host , antibiotic
• Iv 4 – 6 wk. , switch iv 1 wk. + oral 6 wk.
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Subacute osteomyelitis
• insidious onset & lacks the severity of
symptom
• diagnosis delayed for more than 2 wks.
• systemic signs & symptoms are minimal.
• WBC normal
• ESR elevation ( 50% )
• blood culture ; usually negative.
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• bone aspirate or biopsy ; 60%
pathogen identified
• x-ray & bone scan ; positive.
• course ; increased host resistance ,
decreased bacterial virulence ,
antibiotic before the onset of
symptom.
• differentiation lesion from a primary
bone tumor.
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Classification of subacute osteomyelitis
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Differential
Type
I
Langerhans’cell histiocytosis , Brodie abscess
II
Eosinophilic granuloma , Osteogenic sarcoma
III
Osteoid osteoma
IV
Ewing sarcoma
V
Chondroblastoma
VI
Tuberculosis ; osteogenic sarcoma
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Treatment subacute osteomyelitis
• Ross & Cole recommended biopsy &
currettage aggressive lesions and
antibiotics.
• biopsy not recommended in simple
abscess lesion
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Chronic osteomyelitis
• Systemic symptom subside ; bone
contain purulant material , infection
tissue
• Intermittant acute exacerbation ;
respond antibiotic & rest
• Multiple organism ; culture &
biopsy
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Cierny & Mader Staging System for Chronic Osteomyelitis
Anatomical type
I
II
III
IV
Physiological class
A host
B host
C host
Medullary
Superficial
Localized
Diffuse
Normal
Compromised
Prohibitive
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Diagnosis
•
•
•
•
•
Gold standard ; biopsy , microbiological
PE. skin , soft tissue , neurovascular
ESR & CRP ; elevation
WBC ; normal
X-ray ; cortical destruction , periosteal
reaction
• Bone scan
• MRI
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Treatment
• Sequestrectomy , resection scar &
infection bone
• Antibiotics 6 wk. ( 1 wk. for iv , 6 wk.
for oral form)
• Reconstruction of bone & soft tissue
( bone graft , bone transfer , myoplasty , flap )
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Fracture management
•Active infection ; sequestrectomy ,
debridement , antibiotics ( > 6 m.) &
immobilization
•Active infection without involucrum ;
debridement , bone graft , antibiotics &
immobilization
•Inactive infection & no involucrum ;
immobilization & bone graft.
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Amputation for osteomyelitis
• malignant change
• arterial insufficiency , major
nerve paralysis , joint
stiffness
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