This document discusses the microbiology, diagnosis, and treatment of osteomyelitis and septic arthritis. It notes that osteomyelitis is most commonly caused by pyogenic bacteria and mycobacteria. Staphylococcus aureus is the most frequent pathogen in both hematogenous osteomyelitis and contiguous osteomyelitis. Treatment involves obtaining cultures, administering high doses of bactericidal antibiotics parenterally based on culture results, and considering surgical drainage. Antibiotic therapy typically involves IV administration for 5-10 days followed by oral antibiotics.
This document discusses the microbiology, diagnosis, and treatment of osteomyelitis and septic arthritis. It notes that osteomyelitis is most commonly caused by pyogenic bacteria and mycobacteria. Staphylococcus aureus is the most frequent pathogen in both hematogenous osteomyelitis and contiguous osteomyelitis. Treatment involves obtaining cultures, administering high doses of bactericidal antibiotics parenterally based on culture results, and considering surgical drainage. Antibiotic therapy typically involves IV administration for 5-10 days followed by oral antibiotics.
This document discusses the microbiology, diagnosis, and treatment of osteomyelitis and septic arthritis. It notes that osteomyelitis is most commonly caused by pyogenic bacteria and mycobacteria. Staphylococcus aureus is the most frequent pathogen in both hematogenous osteomyelitis and contiguous osteomyelitis. Treatment involves obtaining cultures, administering high doses of bactericidal antibiotics parenterally based on culture results, and considering surgical drainage. Antibiotic therapy typically involves IV administration for 5-10 days followed by oral antibiotics.
osteomyelitis An infection of bone most commonly caused by pyogenic bacteria and mcyobacteria. Types 1. Hematogenous osteomyelitis 2. Osteomyelitis secondary to contiguous focus of infection 3. Chronic osteomyelitis
Microbiology of hematogenous osteomyelitis Majority of cases occur in children 95% of cases of hematogenous osteomyelitis are caused by a single organism. Staph.aures accounts for 50% of cases. Other common pathogens are group A streptococci in children, group B streptococci and E.coli in neonates. Microbiology of hematogenous osteomyelitis In adults, hematogenous osteomyelitis occurs most commonly in vertebrae. The organisms are staph.aureus, pseudomonas, serratia and candida. The most common risk factor is iv drug abuse Hemoglobionopathy patients have osteomyelitis of long bones caused by salmonella and staph.aureus. Microbiology of hematogenous osteomyelitis Immunocompromised persons may develop osteomyelitis due to atypical mycobacteria, bartonella and fungi.
Microbiology of contiguous focus osteomyelitis Staph.aureus accounts for >50% cases. However, these infections are mostly polymicrobial and involve anaerobes and gram negative bacteria. Staph.aureus most common cause of post operative osteomyelitis. Coagulase negative staph are common pathogens after implantation of orthopaedic appliances. Microbiology of contiguous focus osteomyelitis Mycoplasma can cause sternal osteomyelitis after cardiac surgery. Pseudomonas can cause osteomyelitis after puncture wounds of foot. Pasteurella.multocida osteomyelitis follows cat bite. Principles of Antibiotic therapy in osteomyelitis Antibiotics should be administered only after appropriate specimens have been obtained for culture. use of bactericidal antibiotics is recommended. Antibiotics should be given in high dose parentrally. Principles of Antibiotic therapy in osteomyelitis Guidelines for empirical therapy: It should be chosen based on findings on gram staining of a specimen from a bone or abscess. Or it can be chosen to cover the most likely pathogens.(staph.aureus) Empirical antibiotic therapy should also include against anaerobes in the setting of decubitis ulcer and diabetic foot.
Principles of Antibiotic therapy in osteomyelitis Specific therapy: Its ultimately based on in-vitro susceptibility testing of organisms isolated from bone or blood. The decision to give outpatient parenteral antimicrobial therapy is suitable for medically stable and motivated patients. Parenteral therapy should be given for 5-10 days and then oral antibiotics should be used. SUGGESTED REGIMENS For Staph aureus Penicillin resistant, methicillin sensitive : Nafcillin / Oxacillin 2gm IV q4h Penicillin sensitive : Penicillin 3-4 million U IV q4h Methicillin resistant : Vancomycin 15mg/kg IV Q12h + Rifampicin 300mg PO q12h Penicillin allergic patients : Clindamycin 900mg IV q8h / Cefazolin 1g IV q8h. SUGGESTED REGIMENS Streptococci : d.o.c Penicillin. Alternatives: cefazolin, clindamycin. Gram negative bacilli : E.coli : d.o.c : Ampicillin 2g IV q4h , alternative : Ceftriaxone Pseudomonas : d.o.c : Piperacillin 3-4g IV / Ceftazidime 2g IV plus Tobramycin 5-7mg/kg Mixed infections : Ampicillin+sulbactam, Piperacillin+tazobactamalternative : Carbapenem+ Clindamycin. Septic arthritis Microbiology Every bacterial pathogen is capable of causing septic arthritis In infants : group B Streptococci, gram negative bacilli and staph aureus. Adolescents and young adults : neisseria gonorrhea is most common Staph aureus most common non gonoccocal cause Septic arthritis Microbiology Infections after surgical procedures and penetrating injuries are caused by staph aureus Human bites near joints and extension of decubitus ulcers cause septic arthritis due to anaerobes Bites and scratches from cats introduce pasteurella into joints. Septic arthritis Rx Prompt administration of systemic antibiotics and drainage of involved joint is needed. Emperical antibiotics should be started once samples of blood and synovial fluid have been obtained for culture. Emperical antibiotics are given based on bacteria visualised on smears Septic arthritis Initial therapy should consist of iv adminsitration of bactericidal agents Direct administration of antibiotics into joints is not necessary D.o.c: iv cefotaxime or ceftriaxone if smears show no organisms Is smears show gram positive cocci : oxacillin or naficillin is used If MRSA : Vancomycin Septic arthritis Definitive therapy is based on identity and antibiotic susceptibilty of bacteria isolated in culture For staph : oxacillin/ naficillin or vancomycin For pneumococcal and strepto :2 weeks of penicillin For H. Influenzae : cefotaxime Enteric gram negative infections : ceftriaxone or fluroquinolone for 3-4 weeks Gonococcal arthritis Initial treatment iv ceftriaxone 1gm Once local and systemic signs resolve 7 day course of ciprofloaxcin can be given Infections in prosthetic joints Rx High dose parenteral antibiotics for 4-6 weeks because bone is involved. A high cure rate with retention of prosthesis has been reported with the combination of oral rifampicin and ciprofloxacin for 3-6 months Role of antibiotics in gas gangrene Previously the antibiotic of choice has been PenicillinG , 20 MILLION UNITS per day. But due to increasing resistance to this drug, antibiotics inhibiting toxin synthesis appear to be favourable. Clindamycin treatment enhanced survival than penicillin treatment Dose of clindamycin : 600mg every 6h. Anti TB drugs First line essential drugs 1. Rifampicin : most important and most potent 2. Isoniazid : 2 nd best anti TB drug available 3. ethambutol : least potent amongst first line drugs 4. Pyrazinamide : important in short course therapy Anti TB drugs First line supplemental drugs 1. streptomycin : available for iv/ im administration only 2. rifabutin : recommended in HIV positive individuals in place of rifampicin Anti TB drugs Second line drugs 1. Quinolones : Levofloxacin and Moxifloxacin 2. Capreomycin 3. Amikacin 4. Ethionamide 5. Para-aminosalicylic acid 6. Cycloserine Newer anti TB drugs LINEZOLID : can be used in drug resistant TB cases Can be used iv or orally Anti TB drug regimens Category I includes : spinal disease with neurological complications. The treatment in Category I consists of an intensive phase of isoniazid (H), rifampicin (R), Pyraziamide (Z) and ethambutol (E) administered under a direct supervision thrice weekly on alternate days for 2 months (24 dosages), followed by a continuation phase of H and R thrice weekly on alternate days for 4 months (18 weeks, 54dosages). The first dose of each week given directly supervised and the patient self-administering next two doses of the week, at home.
Anti TB drug regimens Category III: includes sputum negative musculo-skeletal TB Category III treatment is similar to that of Category I, but is executed without an inclusion of ethambutol.
Anti TB drug regimens Category II : Relapsed and treatment failure (smear-positive) cases Treatment after substantial interruption. These patients are at risk of developing multidrug resistant tuberculosis (MDR-TB) In category II intensive phase consists streptomycin (S), H, R, Z and E for 2 months followed by 1 month of H, R, Z and E (total 36 dosages), is administered in the same supervised manner as Category I and is followed by an appropriately supervised continuation phase consisting of 5 months (22 weeks, 66 dosages) of H, R and E.
Side effects of anti TB drugs Rifampicin : GI upset, hepatitis, rash, flu like syndrome and red orange urine. Isoniazid : hepatitis, peripheral neuropathy and seizures. Pyrazinamide : hepatitis, hyperuricemia and arthralgia Ethambutol : optic neuritis Streptomycin, amikacin and capreomycin : ototoxicity and nephrotoxicity Side effects of other antibiotics Beta lactams : allergies in 1-4 % patients, diarrhea, non allergic skin reactions. Vancomycin : red man syndrome, nephrotoxicity and ototoxicity Aminoglycosides : nephrotoxicity (reversible) ,ototoxicity (irreversible) Clindamycin : diarrhea due to colitis Fluoroquinolones : tendon ruptures Side effects of other antibiotics Metronidazole : metallic taste Linezolid : thrombocytopenia and peripheral neuropathy. --------The end---------------