bone and joint infections: osteomyelitis, septic arthritis

MMusculoskeletal Disorders Part 2usculoskeletal Disorders Part 2Bone infectionsBone infections

Maria Carmela L. Domocmat, RN,MSN

Instructor

School of Nursing

Northern Luzon Adventist College

Artacho, Sison, Pangasinan

Overview Overview

� Part 1: Degenerative & Metabolic bone disorders:

� Part 2: Bone infections◦ Osteomyelitis

◦ Septic arthritis ◦ Septic arthritis

� Part 3: Muscular disorders

� Part 4: Disorders of the hand

� Part 5: Spinal column deformities

� Part 6 : Disorders of foot

� Part 7: Sports Injuries

3/5/2012 Maria Carmela L. Domocmat, RN, MSN 2

BONE INFECTIONSBONE INFECTIONS

Osteomyelitis

Septic arthritis


BONE INFECTIONS: BONE INFECTIONS: OSTEOMYELITISOSTEOMYELITISOSTEOMYELITISOSTEOMYELITIS


Osteomyelitis Osteomyelitis


Osteomyelitis is infection in the bones. Often, the original site of infection is elsewhere in the body, and spreads to the bone by the blood. Bacteria or fungus may sometimes be responsible for osteomyelitis.

OsteomyelitisOsteomyelitis

� Infection of the bone, most often of the cortex or medullary portion.

� Is commonly caused by bacteria, fungi, parasites & viruses.parasites & viruses.


� Classified by mode of entry- Contiguous or exogenous is caused by a pathogen from outside the body or the by the spread of infection from adjacent soft spread of infection from adjacent soft tissues.

� The organism is Staph aureus.

� Example- pathogens from open fracture.

� The onset is insidious: initially cellulites progressing to underlying bone.


� Hematogenous- caused by bloodbornepathogens originating from infectious sites within the body.

� Ex: sinus, ear, dental, respiratory & GU infections.infections.

� The infection spreads from the bone to the soft tissues & can eventually break through the skin, becoming a draining fistula.

� Again, Staph aureus is the most common causative organism.

S/s S/s

� Acute Osteomyelitis left untreated or unresolved after 10 days is considered chronic.

� Necrotic bone is the distinguishing feature of chronic osteomyelitis.feature of chronic osteomyelitis.

SymptomsSymptoms

� Bone pain� Fever� General discomfort, uneasiness, or ill-feeling

(malaise)� Local swelling, redness, and warmth� Local swelling, redness, and warmth� Other symptoms that may occur with this

disease:� Chills� Excessive sweating� Low back pain� Swelling of the ankles, feet, and legs


PathophysiologyPathophysiology

� similar to that infectious processes in any other body tissue.

� Bone inflammation is marked by edema, increased vascularity & leukocyte activity.

� fever, malaise, anorexia, & headache. � fever, malaise, anorexia, & headache.

� affected body may be erythematous, tender, & edematous. There may be fistula draining purulent material.

� Blood test- increase WBCs, ESR, & C-protein levels.

Causes, incidence, and risk Causes, incidence, and risk factorsfactors� Bone infection can be caused by bacteria

(more common) or fungi (less common).

� Infection may spread to a bone from infected skin, muscles, or tendons next to infected skin, muscles, or tendons next to the bone, as in osteomyelitis that occurs under a chronic skin ulcer (sore).


Causes, incidence, and risk Causes, incidence, and risk factorsfactors� The infection that causes osteomyelitis

can also start in another part of the body and spread to the bone through the blood.blood.

� A current or past injury may have made the affected bone more likely to develop the infection.


Causes, incidence, and risk Causes, incidence, and risk factorsfactors� A bone infection can also start after bone

surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone.are placed in the bone.

� children -- long bones usually affected.

� Adults -- feet, vertebrae, and pelvis are most commonly affected.


Risk factors Risk factors

� Diabetes

� Hemodialysis

� Injected drug use

� Poor blood supply� Poor blood supply

� Recent trauma

� People who have had their spleen removed are also at higher risk for osteomyelitis



� Osteomyelitis of diabetic foot

� Osteomyelitis of T10 secondary to streptococcal disease.



� Osteomyelitis of the great toe

� Osteomyelitis of index finger metacarpal head secondary to clenched fist injuryclenched fist injury



� Osteomyelitis of index finger metacarpal head secondary to clenched fist injury.

� Osteomyelitis of the elbow.

clenched fist injury.


DxDx teststests

� A physical examination shows bone tenderness and possibly swelling and redness.

� Tests may include:◦ Blood cultures◦ Bone biopsy (which is then cultured)◦ Bone scan◦ Bone scan◦ Bone x-ray◦ Complete blood count (CBC)◦ C-reactive protein (CRP)◦ Erythrocyte sedimentation rate (ESR)◦ MRI of the bone◦ Needle aspiration of the area around affected bones


DxDx teststests

� Diagnosis requires 2 of the 4 following criteria:

◦ Purulent material on aspiration of affected bonebone

◦ Positive findings of bone tissue or blood culture

◦ Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema

◦ Positive radiological imaging study


http://emedicine.medscape.com/article/785020-treatment

Emergency Department CareEmergency Department Care

� Select the appropriate antibiotics using direct culture results in samples from the infected site, whenever possible.

� Further surgical management may involve removal of the nidus of infection, implantation removal of the nidus of infection, implantation of antibiotic beads or pumps, hyperbaric oxygen therapy,or other modalities.


http://emedicine.medscape.com/article/785020-treatment

Nidus: a nest; A central point or focus of bacterial growth in a living organism. the point of origin or focus of a disease process.

TreatmentTreatment

� Treatment is difficult & costly.

� Goal of treatment

◦ complete removal of necrotic bone & affected soft tissuesoft tissue

◦ control of infection & elimination of dead space (after removal of necrotic bone).

TreatmentTreatment

� The primary treatment for osteomyelitis

◦ parenteral (IV) antibiotics that penetrate bone and joint cavities for at least 4-6 weeks.

◦ After intravenous antibiotics are initiated on an inpatient basis, therapy may be continued After intravenous antibiotics are initiated on an inpatient basis, therapy may be continued with intravenous or oral antibiotics, depending on the type and location of the infection, on an outpatient basis.


AntibioticsAntibiotics

� Nafcillin (Nafcil, Unipen)

� Ceftriaxone (Rocephin)

� Cefazolin (Ancef)

� Ciprofloxacin (Cipro)� Ciprofloxacin (Cipro)

� Ceftazidime (Fortaz, Ceptaz)

� Clindamycin (Cleocin)

� Vancomycin (Vancocin)

� Linezolid (Zyvox)


TreatmentTreatment

� Surgery

◦ to remove dead bone tissue if have an infection that does not go away.

◦ If there are metal plates near the infection, they may need to be removed. If there are metal plates near the infection, they may need to be removed.

◦ The open space left by the removed bone tissue may be filled with bone graft or packing material that promotes the growth of new bone tissue.


TreatmentTreatment

� Infection of an orthopedic prosthesis, such as an artificial joint, may need surgery to remove the prosthesis and infected tissue around the area. infected tissue around the area.

� If have diabetes- need to be well controlled.

� If problems with blood supply to the infected area, such as the foot, surgery to improve blood flow may be needed.


Nursing managementNursing management

� use of aseptic technique during dressing changes.

� Observed for S/S of systemic infection, &

� administered antibiotic on time.� administered antibiotic on time.

� ROM exercises are encouraged to prevent contractures & flexion deformities & participation in ADL to the fullest extent is encouraged.

Expectations (prognosis)Expectations (prognosis)

� markedly improved with timely diagnosis and aggressive therapeutic intervention.

� The outlook is worse for those with long-term (chronic) osteomyelitis, even with term (chronic) osteomyelitis, even with surgery.

◦ Amputation may be needed, especially in those with diabetes or poor blood circulation.


Expectations (prognosis)Expectations (prognosis)

� The outlook for those with an infection of an orthopedic prosthesis depends, in part, on:

◦ The patient's health◦ The patient's health

◦ The type of infection

◦ Whether the infected prosthesis can be safely removed


ComplicationsComplications

� Bone abscess

� Paravertebral/epidural abscess

� Bacteremia

� Fracture� Fracture

� Loosening of the prosthetic implant

� Overlying soft-tissue cellulitis

� Draining soft-tissue sinus tracts


ComplicationsComplications

� When the bone is infected, pus is produced in the bone, which may result in an abscess.

� The abscess steals the bone's blood supply. The lost blood supply can result in a complication called chronic osteomyelitis. The lost blood supply can result in a complication called chronic osteomyelitis.

� Other complications include:

◦ Need for amputation

◦ Reduced limb or joint function

◦ Spread of infection to surrounding tissues or the bloodstream


PreventionPrevention

� Prompt and complete treatment of infections is helpful. People who are at high risk or who have a compromised immune system should see a health care immune system should see a health care provider promptly if they have signs of an infection anywhere in the body.


Deterrence/PreventionDeterrence/Prevention

� Acute hematogenous osteomyelitis

◦ can potentially be avoided by preventing bacterial seeding of bone from a remote site.

◦ This involves the appropriate diagnosis and treatment of primary bacterial infections.This involves the appropriate diagnosis and treatment of primary bacterial infections.


Deterrence/PreventionDeterrence/Prevention

� Direct inoculation osteomyelitis

◦ can best be prevented with appropriate wound management and consideration of prophylactic antibiotic use at the time of injury.injury.


SEPTIC ARTHRITIS SEPTIC ARTHRITIS


Septic arthritisSeptic arthritis

� Septic arthritis is inflammation of a joint due to a bacterial or fungal infection.

� AKA:

◦ infectious arthritis◦ infectious arthritis

◦ Bacterial arthritis

◦ Non-gonococcal bacterial arthritis


CausesCauses

� Septic arthritis develops when bacteria or other tiny disease-causing organisms (microorganisms) spread through the bloodstream to a joint. It may also occur bloodstream to a joint. It may also occur when the joint is directly infected with a microorganism from an injury or during surgery.


CausesCauses

� most common sites - knee and hip.

� acute septic arthritis

◦ bacteria such as staphylococcus or streptococcus.streptococcus.

� chronic septic arthritis –

◦ less common

◦ caused by organisms such as Mycobacterium tuberculosisand Candida albicans.



� Artificial joint implants� Bacterial infection somewhere else in your

body� Chronic illness or disease (such as

diabetes, rheumatoid arthritis, and sickle cell disease)diabetes, rheumatoid arthritis, and sickle cell disease)

� Intravenous (IV) or injection drug use� Medications that suppress your immune

system� Recent joint injury� Recent joint arthroscopy or other surgery



� seen at any age.

� Children◦ occurs most often in those younger than 3

years.

◦ The hip is often the site of infection in infants.◦ The hip is often the site of infection in infants.

� uncommon from age 3 to adolescence.

� Children - more likely than adults infected with Group B streptococcus or Haemophilus influenza, if they have not been vaccinated.


SymptomsSymptoms

� Symptoms usually come on quickly.

� Fever

� joint swelling - usually just one joint.

� intense joint pain- gets worse with � intense joint pain- gets worse with movement.


Symptoms in newborns or infants:Symptoms in newborns or infants:

� Cries when infected joint is moved (example: diaper change causes crying if hip joint is infected)

� Fever� Fever

� Inability to move the limb with the infected joint (pseudoparalysis)

� Irritability


Symptoms in children and adults:Symptoms in children and adults:

� Inability to move the limb with the infected joint (pseudoparalysis)

� Intense joint pain

� Joint swelling� Joint swelling

� Joint redness

� Low fever

� Chills may occur, but are uncommon


Exams and TestsExams and Tests

� Aspiration of joint fluid for cell count, examination of crystals under the microscope, gram stain, and culture

� Blood culture� Blood culture

� X-ray of affected joint


TreatmentTreatment

� Antibiotics are used to treat the infection.

� Joint Immobilization and Physical Therapy

◦ Resting, keeping the joint still, raising the joint, and using cool compresses may help relieve and using cool compresses may help relieve pain.

◦ Exercising the affected joint helps the recovery process.


TreatmentTreatment

� Arthrocentesis

◦ If synovial fluid builds up quickly due to the infection, a needle may be inserted into the joint often to aspirate the fluid.

Severe cases may need surgery to drain � Severe cases may need surgery to drain the infected joint fluid.


TreatmentTreatment

� Medical management of infective arthritis focuses

◦ adequate and timely drainage of the infected synovial fluid, synovial fluid,

◦ administration of appropriate antimicrobial therapy

◦ immobilization of the joint to control pain.


Antibiotic TherapyAntibiotic Therapy� In native joint infections, parenteral antibiotics - at least 2

weeks.

� Infection with either methicillin-resistant S aureus (MRSA) or methicillin-susceptible S aureus (MSSA) - at least 4 full weeks IV antibiotic therapy.

� Orally administered antimicrobial agents are almost never indicated in the treatment of S aureus infections.indicated in the treatment of S aureus infections.

� Gram-negative native joint infections with a pathogen that is sensitive to quinolones can be treated with oral ciprofloxacin for the final 1-2 weeks of treatment.

� As a rule, a 2-week course of intravenous antibiotics is sufficient to treat gonococcal arthritis.



� linezolid with or without rifampin - for staphylococcal prosthetic joint infection (PJI).

� Ceftriaxone (Rocephin)

◦ drug of choice (DOC) against N gonorrhoeae. drug of choice (DOC) against N gonorrhoeae.

◦ This agent is effective against gram-negative enteric rods.

◦ Monitor sensitivity data.

� Ciprofloxacin (Cipro)

◦ alternative antibiotic to ceftriaxone to treat N gonorrhoeae and gram-negative enteric rods.



� Cefixime (Suprax)

◦ a third-generation oral cephalosporin with broad activity against gram-negative bacteria.

◦ Oral cefixime is used as a follow-up to intravenous (IV) ceftriaxone to treat N Oral cefixime is used as a follow-up to intravenous (IV) ceftriaxone to treat N gonorrhoeae.

� Oxacillin

◦ useful against methicillin-sensitive S aureus(MSSA).



� Vancomycin (Vancocin)◦ anti-infective agent used against methicillin-

sensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients ampicillin-resistant enterococci in patients allergic to penicillin.

� Linezolid (Zyvox)◦ an alternative antibiotic that is used in

patients allergic to vancomycin and for the treatment of vancomycin-resistant enterococci.


http://emedicine.medscape.com/article/236299-medication#showall

Joint Immobilization and Joint Immobilization and Physical TherapyPhysical Therapy� Usually, immobilization of the infected

joint to control pain is not necessary after the first few days.

� If the patient's condition responds adequately after 5 days of treatment, adequately after 5 days of treatment, begin gentle mobilization of the infected joint.

� Most patients require aggressive physical therapy to allow maximum postinfectionfunctioning of the joint.


Joint Immobilization and Joint Immobilization and Physical TherapyPhysical Therapy� Initial physical therapy consists of

maintaining the joint in its functional position and providing passive ROM exercises.

� The joint should bear no weight until the � The joint should bear no weight until the clinical signs and symptoms of synovitishave resolved.

� Aggressive physical therapy is often required to achieve maximum therapy benefit.


Synovial Fluid DrainageSynovial Fluid Drainage

� The choice of the type of drainage, whether percutaneous or surgical, has not been resolved completely.

� In general, use a needle aspirate initially, repeating joint taps frequently enough to prevent significant reaccumulation of fluid. repeating joint taps frequently enough to prevent significant reaccumulation of fluid.

� Aspirating the joint 2-3 times a day may be necessary during the first few days.

� If frequent drainage is necessary, surgical drainage becomes more attractive.

� Gonococcal-infected joints rarely require surgical drainage.


Synovial Fluid DrainageSynovial Fluid Drainage

� Surgical drainage is indicated when one or more of the following occur:◦ The appropriate choice of antibiotic and vigorous

percutaneous drainage fails to clear the infection after 5-7 days

◦ The infected joints are difficult to aspirate (eg, hip)◦ The infected joints are difficult to aspirate (eg, hip)

◦ Adjacent soft tissue is infected

◦ Routine arthroscopic lavage is rarely indicated. However, drainage through the arthroscope is replacing open surgical drainage. With arthroscopic drainage, the operator can visualize the interior of the joint and can drain pus, debride, and lyse adhesions.


Surgical Intervention in Surgical Intervention in Prosthetic Joint InfectionProsthetic Joint Infection� In cases of prosthetic joint infection (PJI) that require

surgery for cure, successful treatment requires appropriate antibiotic therapy combined with removal of the hardware.

� Despite appropriate antibiotic use, the success rate has been only about 20% if the prosthesis is left in place. place.

� In recent years, evidence has shown that debridement alone could yield a cure rate of 74.5% of patients with a prosthetic joint infection and a C-reactive protein (CRP) level of 15 mg/dL or less who are treated with a fluoroquinolone.

� For the time being, a 2-stage approach should be regarded as the most effective technique.


Surgical Intervention in Surgical Intervention in Prosthetic Joint InfectionProsthetic Joint Infection� First, remove the prosthesis and follow with

6 weeks of antibiotic therapy.

� Then, place the new joint, impregnating the methylmethacrylate cement with an anti-infective agent (ie, gentamicin, tobramycin). infective agent (ie, gentamicin, tobramycin).

� Antibiotic diffusion into the surrounding tissues is the goal.

� The success rate for this approach is approximately 95% for both hip and knee joints.


Surgical Intervention in Surgical Intervention in Prosthetic Joint InfectionProsthetic Joint Infection� An intermediate method is to exchange

the new joint for the infected joint in a 1-stage surgical procedure with concomitant antibiotic therapy. concomitant antibiotic therapy.

� This method, with concurrent use of antibiotic cement, succeeds in 70-90% of cases.


Outlook (Prognosis)Outlook (Prognosis)

� Recovery is good with prompt antibiotic treatment. If treatment is delayed, permanent joint damage may result.


Possible ComplicationsPossible Complications

� Joint degeneration (arthritis)



� Strictly adhere to sterile procedures whenever the joint space is invaded (eg, in aspiration or arthroscopic procedures).

� Antibiotic prophylaxis ◦ with an antistaphylococcal antibiotic has been ◦ with an antistaphylococcal antibiotic has been

demonstrated to reduce wound infections in joint replacement surgery.

◦ Polymethylmethacrylate cement impregnated with antibiotics may decrease perioperative infections.



� Treat any infection promptly to lessen the chance of bloodstream invasion.

� decreasing the incidence of underlying infections best prevents reactive arthritisinfections best prevents reactive arthritis


ReferencesReferences

� Espinoza LR. Infections of bursae, joints, and bones. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 290.

� Ohl CA. Infectious arthritis of native joints. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. 7th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 102.

� http://www.nlm.nih.gov/medlineplus/ency/article/000430.htm

� http://emedicine.medscape.com/article/236299-medication#showall


REACTIVE ARTHRITISREACTIVE ARTHRITIS


Reactive arthritisReactive arthritis

� AKA: Reiter syndrome; Post-infectious arthritis

� a sterile inflammatory process that usually results from an extra-articular infectious results from an extra-articular infectious process.

� Bacteria are the most significant pathogens because of their rapidly destructive nature.


bone and joint infections: osteomyelitis, septic arthritis

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