Osteomyelitis: An Update for Hospitalists

Abstract

Osteomyelitis is a common and challenging condition for hospitalists to manage. The 3 main types of osteomyelitis that are commonly seen in the hospital setting are 1) contiguous spread from decubitus or diabetic ulcers, 2) hematogenous spread, such as in vertebral or long bone metaphyses, and 3) infections associated with a prosthetic joint. In patients with diabetes, osteomyelitis is the underlying cause of about 20% of foot infections, and greatly increases the chance that the patient will eventually need an amputation and be subject to perioperative risks. Osteomyelitis from hematogenous spread is increasing. The prevalence of vertebral osteomyelitis is also increasing, particularly in intravenous drug users and patients treated with immune-modulating agents. Prosthetic joint infections are perhaps the most challenging type to treat, and require hospitalists, orthopedic surgeons, and infectious disease specialists to work closely together to plan for effective treatment. Due to increasing antibiotic resistance, the microorganisms involved are also proving more difficult to treat. Emerging resistance to the commonly used antibiotics is resulting in changes in treatment choices. Community-acquired methicillin-resistant Staphylococcus aureus is commonly seen, and there is increasing concern about emerging vancomycin resistance. Treatment of osteomyelitis is still based largely on expert opinion rather than evidence from controlled studies.

Distinct cytokine profiles of circulating mononuclear cells stimulated with Staphylococcus aureus enterotoxin A in vitro during early and late episodes of chronic osteomyelitis

“…The manner in which S. aureus interacts with the host tissues may facilitate invasion and enable it to evade the host immune response and release toxins throughout the infection process (Lew & Waldvogel 2004, Howell & Goulston 2011. In patients with osteomyelitis, various cellular and humoral immunological deficits have been demonstrated (Gillespie & Allardyce 1990, Schluter et al 1991, Bansal et al 1992, Sistermann et al 1992, Wagner et al 2003.…”

“…However, these parameters are nonspecific and can increase after a latent phase of days or even weeks (Harle 1989, Lew & Waldvogel 2004, Howell & Goulston 2011. Other parameters to estimate disease activity include measuring inflammatory mediators, such as the polymorphonuclear neutrophil (PMN) elastase level or neopterin level in blood and plasma samples (Peters et al 1991).…”

“…The patients were further sub-grouped based on the time since the last acute recurrence. Considering that chronic osteomyelitis is defined by some authors as when the infection has been present for more than one month (Jevon et al 1999, Brady et al 2008, Howell & Goulston 2011 and by others as an infection lasting longer than six months (Gillespie & Allardyce 1990, Bansal et al 1992, we established two groups of chronic OST patients: early-stage patients (i.e., those in which 1-4 months had elapsed since the most recent acute recurrence) and late-stage patients (i.e., those in which 5-12 months had passed since the last relapse). The median recurrence time in the individuals was four months and both the early stage and late stage groups were composed of 10 OST patients.…”

Ankle Arthrodesis

“…In cases in which the intramedullary nail and space become infected, the nail is removed and an antibiotic spacer is inserted in conjunction with intravenous antibiotic therapy. 40 …”

Epigenetic mechanisms in the pathogenesis of diabetic foot ulcers

“…If left untreated, diabetes can result in numerous complications, including cardiovascular disease such as endothelial dysfunction, atherosclerosis and myocardial infarctions, nephropathy, retinopathy, and the diabetic foot (Bays, Mandarino, & DeFronzo, 2004;Beckman, Creager, & Libby, 2002;Brownlee, 2005). Diabetes can result in numerous complications of the foot, including osteomyelitis, Charcot's neuroarthropathy and diabetic foot ulcers (Blakytny, Spraul, & Jude, 2011;Botek, Anderson, & Taylor, 2011;Howell & Goulston, 2011). Non-healing chronic ulcers can occur in up to 15% of diabetic patients.…”