Osteomyelitis & Septic Arthritis - Calgary Em

Osteomyelitis & Septic Arthritis - Calgary Em

Osteomyelitis & Septic Arthritis Jay Green November 23, 2006 Outline Both Risk factors, mechanism of infection, pathogens Osteomyelitis Septic Arthritis

Case 61y.o. M, R leg pain, fever, H/A, fatigue PMH: DMII, CAD, smoker, COPD Recent # R tibia ORIF Post-op exacerbation of COPD still tx Question What are some risk factors for bone/joint infections?

Who gets bone/joint infections? Risk Factors IV drug users AIDS Post-sx prosthetic implants Iatrogenic immune suppression

Sickle cell anemia Diabetes Alcoholism Pre-existing joint disease Bone/Joint Infection Fast Facts Bimodal age distribution Occur in healthy kids or adults with RF Mortality (OM)

<20 y.o. and >50 y.o. Pre-antibiotic era 20% Today <5% 1% incidence in inpatients Anatomy Review - FYI Case

51y.o. M, swollen, tender R knee Seen in ED 2 weeks ago fluid taken off Last 2 weeks pain/redness/swelling knee Using ice, ibuprofen with some relief Now fever, fatigue, nausea, myalgias Question By what mechanisms can a bone/joint become infected? Mechanism of Infection

Hematogenous spread Contiguous spread Direct inoculation Penetrating trauma Joint aspiration Predisposed sites Long bone metaphysis, vertebral body What bug?

12F from Angola 23M sexually active Pasteurella 21M bouncer bitten by drunk on elbow

S. aureus, Anaerobes, enterobacteriaceae 12F bit by her cat N. gonorrhea 68M with DMII and foot ulcer TB Eikenella

51M stepped on nail Pseudomonas Pathogens *Bacterial* Viral Fungal Parasitic Depends on host/environmental factors

Pathogens Key Points S. aureus = #1 (except neonates GBS) H. influenzae B gone N. gonorrhea <30y.o. Gram ve in elderly Polymicrobial DM, post-trauma, chronic Pathogens Key Points

Pseudomonas puncture wound to foot, prosthetic implants, IV drug users Pasteurella multocida animal bites Fungal increasingly common Case

9F ing pain R tibia x 4 days Malaise, H/A, fatigue, anorexia No fever at home, no trauma O/E: Vitals: 375, 98/75, 88, 18 Gen: looks well R leg: erythema, swelling, ++tender, warm ?Osteomyelitis? Question

What would you like to order? Labs? Imaging? Osteomyelitis - History 5 cardinal signs of inflammation Pain, erythema, swelling, warmth, function

Fever Systemic symptoms H/A, fatigue, malaise, anorexia Osteomyelitis Physical Exam General Inspection

Not ill Erythema, swelling Palpation Point tenderness, warmth involucrum, sequestrum Involucrum New periosteal growth due to subperiosteal abscess Sequestrum

Disengaged ischemic segments of bone Return to case WBC 12,000 ESR 80mm/hr Plain x-ray N (confirmed by radiology) What do you think of her ESR?

Investigations Labs typically unhelpful WBC (N 15,000) ESR more sensitive Mean ESR = 70 <8% have ESR < 15 Imaging

Start with plain films May miss acute presentation <1/3 have abN x-ray if <10d of symptoms Lucent areas 30-50% bone mineral lost Features? Lytic lesions, periosteal reaction, sequestra, involucrum Soft tissue deep swelling, distorted fascial planes,

altered fat interfaces Question WBC 12,000, ESR 80, plain film normal What would you like to do now? Bone scan Imaging Nuclear Medicine Bone scan

Can detect OM within 48-72h 99mTc MDP 3-phase scan Flow within 60sec Pool 5-15min Delayed 2-4hrs Imaging 99mTc MDP Flow Pool Delay

Diagnosis - - - Not OM - - + Degenerative disease

+ + - Inflammation + + + OM, false + Imaging 99mTc MDP

SN > 90% FP rate ~65% Trauma, surgery, tumor, chronic soft tissue infection, healing fracture Other radionuclides Ga citrate 111In oxine 99Tc hexamethylpropyleneamine oxime

?Useful in ED 67 All have 24-48h wait time CT Scan May miss acute presentation

Better for: Sternum, vertebrae, pelvic bones, calcaneus Useful post-bone scan, guides sx/bx MRI Comparable SN to bone scan Better resolution IV gadolinium

Bone vs. soft tissue infection Normal vs. devitalized bone Availability limited ?Replace bone scan altogether? Question How do we find the bug? In ED

Blood culture + in 50% always if chronic Not in ED NOT cultures from fistulae/sinus Biopsy needle, resection

Find bug in 80-90% Question WBC 12, ESR 80, x-ray N, bone scan + What would you like to do doctor? Management IV antibiotics

Typically empiric to begin 4-6 weeks Surgery Debridement often necessary Can avoid in kids with acute hematogenous OM Empiric Abx - Adults Osteomyelitis Pathogen Therapy Hematogenous

S. aureus Cloxacillin or Cefazolin +/Gentamicin IVDU S. aureus P. aeruginosa Cloxacillin or Cefazolin + Gentamicin Contiguous: vascular insufficiency, diabetic foot Polymicrobial

Clinda + Cipro or Ancef + Metronidazole Severe: imipenem or pip-tazo Nail-puncture of foot P. aeruginosa Prophylaxis: cipro Treatment:pip-tazo + tobramycin Post-op prosthetic joint S. aureus S. epidermidis Vancomycin +

Gentamicin Empiric Abx - Kids Osteomyelitis Pathogen Therapy Neonates GBS, S. aureus, Enterobacteriaceae Cloxacillin + Cefotaxime Children

S. aureus, Strep, H. flu Cloxacillin Sickle cell S. aureus, Salmonella sp. Cloxacillin + Cefotaxime Post-op S.aureus, GAS, Enterobacteriaceae Cefazolin +/- Gentamicin Post-op spinal rods or

sternotomy S. aureus, CNS, GAS, Enterobacteriaceae, Pseudomonas Vancomycin + Gentamicin Nail puncture of foot Pseudomonas aeruginosa Piperacillin+Tobra or Ceftazidime + Tobra Case

77M DMII, ankle ulcer x 1 yr Draining pus, occasionally pain/redness Several courses of abx over past year Question Are imaging or cultures of the pus useful in chronic osteomyelitis? Will IV/PO antibiotics be sufficient? Chronic Osteomyelitis

Usually complication of post-traumatic OM, surgery, diabetic foot infection Recurrent course Sequestra Chronic draining sinus/fistulae Polymicrobial, commonly anaerobes Chronic OM - Investigations

Bone scan limited use Cultures of tracts not reliable Need bone bx Chronic OM - Management Surgery Antibiotic-containing beads Bone grafts HBO

Seems to be effective in case-series and nonrandomized studies for DM foot osteomyelitis Case 28 y.o. M Ped-MVC while biking to work Spinal precautions Tachycardic, BP 90/65 GCS = 11 Multiple abrasions, open # R tibia

Question How can we prevent OM in his R leg? OM Prophylaxis In Open # Cut away surrounding clothing Pour sterile NS/water over bone Cover with moist sterile gauze Surface cultures?

Manipulate? Not predictive of future pathogens Only if severe vascular compromise Early Abx Ancef G- coverage Case

4y.o. M, R hip pain x 2d, refusing to walk No trauma Cough, runny nose, sore throat last week O/E: Vitals normal (T = 37.5C) Refusing to walk, knee/ankle normal R leg in flexion, slight abd, slight ER Pain at end range of IR Question

What would you like to order doctor? Investigations Labs WBC 11.2, ESR 14 Imaging Plain films

?R hip effusion, suggest U/S U/S effusion present Ideas? Transient Synovitis

Diagnosis of exclusion Most common cause of hip pain in kids Typically ages 3-6yrs Usually affects hip>knee Pain can be referred to knee/thigh U/S effusion present in 60-70% Taylor GR, Clark NM. Management of the irritable hip: A review of hospital admission policy. Arch Dis Child 71:59, 1994. Septic arthritis Synovitis 1) 2) 3) 4) Severe hip pain/spasm

Tenderness on palpation T >= 38C ESR >= 20mm/hr 62% 86% 81% 90% 12% 17% 8% 11% Any 2 SN 95%, SP 91% for septic arthritis Question

Youre convinced this is TS How would you like to treat this child? Transient Synovitis - Management Outpatient F/U exam in 12-24hrs 2wks Rest

Initial non-weight bearing Gradual return to activity NSAIDs Transient Synovitis - Outcome 75% - 2 weeks 88% - 4 weeks 12% - persistent pain x 8 weeks

These should have U/S for ?persistent effusion Long-term Relapse, asymptomatic coxa magna, mild cystic changes of femoral neck, LCP disease Case 51y.o. M, swollen, tender R knee Seen in ED 2 weeks ago fluid taken off

Last 2 weeks pain/redness/swelling knee Using ice, ibuprofen with some relief Now fever, fatigue, nausea, myalgias Question What would you like to do? Labs? Imaging? Tap joint? ?Septic Arthritis?

Septic Arthritis The Bad, The Ugly Infection effusion decreased nutrients into jt dormant m/o resistance to abx PMN enzymes degrade cartilage Hyaline cartilage cannot re-grow Other structures at risk

Bursae, tendons, bone Septic Arthritis - History Joint pain, refusal to use limb Fever 40% adults, 80% kids Constitutional symptoms

Minimal in immunocomp/steroids Weakness, malaise, anorexia, nausea, myalgias Risk factors Septic Arthritis Physical Exam General

Inspection Fever, other vitals N Focus (skin, nose, ears, pharynx) Referred pain Motionless limb, slight flexion Swelling, erythema Palpation

Warmth Tenderness Joint movement ++painful Investigations Labs Not consistently helpful WBC in 50% ESR in 90%

+BC in 25-50% Culture of focus Question What are you looking for on the x-ray? Imaging Plain films Effusion Bone erosions

Synovial attachment, subchondral Concurrent OM Air Imaging Bone scan

U/S Only if diagnostic uncertainty May risk further damage Effusion, help with aspiration CT/MRI Better anatomy, ?used in ED Joint Aspiration - Technique

Anteromedial Approach Position: knee in full extension or 20 flexion with towel under knee 18-ga needle, 60cc syringe Middle/superior portion of the medial patella 1 cm medial to the anteromedial patellar edge Direct needle posteriorly elevate patella Can milk suprapatellar pouch Investigations

Joint aspiration Definitive test culture Gram stain, smear Cell count/diff WBC > 50,000 (90% have S.A.), PMNs

Fasting fluid/serum glucose < 1:2 (or fluid glu) WBC < 10,000 and glucose N S.A. unlikely Priority culture, smear, Gram stain, cell count, glucose Question Your labs and joint aspiration results point you towards septic arthritis What would you like to do doctor? Management

Early IV antibiotics Admission Medical vs. surgical decompression No RCTs Animal evidence surgical > medical Definitely surgery in: Septic hip (esp. kids), shoulder Infected prosthesis

Septic Arthritis Abx - Adults Septic Arthritis Pathogen Antibiotics Adults (native joint +/penetrating trauma) S. aureus, P. aeruginosa Cloxacillin or cefazolin +/- gentamicin Gonococcal N. gonorrhoeae

Cefotaxime Rheumatoid arthritis S. aureus, Strep sp, Enterobacteriaceae Cefazolin +/gentamicin Prosthetic joint S. aureus, S. epidermidis, others Vancomycin + gentamicin

IVDU S. aureus, P. aeruginosa Cloxacillin or cefazolin +/- gentamicin Septic Arthritis Abx - Kids Septic Arthritis Pathogen Antibiotics Neonates GBS, S. aureus,

Enterbacteriaceae Cloxacillin + Cefotaxime Children S. aureus, Strep sp., rarely H. flu <5yrs: cefuroxime >5yrs:Cloxacillin or cefazolin Sexually active N. gonorrhoeae

Cefotaxime Case 8y.o. F Your dx: R shoulder septic arthritis Pt being admitted, on IV abx Mom asks:

Is this going to lead to any short or long term problems doctor? Complications Local Epiphyseal damage Tissue damage

Impaired growth, length discrepancy Bursae, tendons, ligaments, muscles Ankylosis Systemic Sepsis elderly, immunocompromised Question Mom says:

Wow, you seem so smart, can you tell me what my childs chance of a full recovery is? Prognosis Complete recovery 66% Tx initiated within 1 week of onset Long-term complications

33% mobility, ankylosis, pain, chronic infection, sepsis, death Delay in dx/tx, RA, polyarticular, +BC Question Any questions? References Le Saux et al. Shorter courses of parenteral antibiotic therapy do not appear to influence response rates for children with acute

hematogenous ostermyelitis: a systematic review. BMC Inf Disease. 2:16, 2002. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed., Copyright 2006 Mosby, Inc. Roberts: Clinical Procedures in Emergency Medicine, 4th ed., Copyright 2004 Saunders, An Imprint of Elsevier Taylor GR, Clark NM. Management of the irritable hip: A review of hospital admission policy. Arch Dis Child 71:59, 1994.

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