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**Host and Defense > Bone and Joint Infections > Flashcards

Bone and Joint Infections Flashcards

1
Q

What does it mean for a bone infection to be Hematogenous in origin?

A

Bacteria get to the bone through the blood stream

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2
Q

What bacteria can infect the bone from the Hematogenous route?

A
  • Staph Aureus
  • Coagulase negative Staphylococci
  • Gram negative rods
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3
Q

What are 3 sources of a bone infection?

A
  1. Hematogenous
  2. Contiguous spread
  3. Direct Inoculation
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4
Q

T/F Hematogenous infections tend to be monomicrobial

A

TRUE

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5
Q

Where do you most often see Osteomylitis in children?

A

Long bones

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6
Q

Where do you most often see Osteomyelitis in adults?

A

Vertebrae

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7
Q

Define Sequestra

A

Separated dead bone

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8
Q

What are the different classifications of osteomyelitis?

A
  1. Anatomic
  2. Acute
  3. Chronic
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9
Q

What are the 4 stages of Anatomic classification of osteomyelitis?

A
  1. Medullary
  2. Superficial
  3. Localized
  4. Diffuse
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10
Q

Describe The Medullary stage

A

Osteomyelitis confined to the medullary cavity of the bone

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11
Q

Describe the Superficial stage

A

Osteomyelitis involves only the cortical bone

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12
Q

Describe the Localized stage

A

Osteomyelitis usually involves both coritical and medullary bone but does not involve the entire diameter of the bone

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13
Q

Describe the diffuse stage

A

Osteomyelitis involves the entire thickness of the bone with loss of stability

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14
Q

Describe the acute classification of osteomyelitis

A
  • Infection prior to development of sequestra

- Usually less than 2 weeks

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15
Q

Describe the Chronic Classification of Osteomyelitis

A
  • Infection after sequestra have formed

- Other hallmarks include formation of involucrum, bone loss and sinus tract formation

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16
Q

What would the clinical presentation of acute osteomyelitis look like?

A
  1. Gradual onset over several days
  2. Dull pain/local tenderness on exam
  3. Warmth, erythema, swelling, fevers may happen but often absent
  4. Can present as septic arthritis
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17
Q

What would the clinical presentation of Chronic Osteomyelitis look like?

A
  1. Mild pain over several weeks
  2. May have localized swelling or erythema
  3. Draining sinus tract
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18
Q

What is the diagnosis of osteomyelitis based on?

A

Based on culture of bacteria from bone biopsy plus pathology with inflammation and osteonecrosis

**one caveat is positive blood cultures

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19
Q

What would lead you to suspect Chronic Osteomyelitis?

A

Suspected based on:

  1. Clinical presentation +/- bacteremia with typical organisms
  2. Chronic, poorly healing wounds
  3. DM
  4. Vascular disease
  5. Decubitus Ulcers
  6. In the presence of underlying hardware
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20
Q

What type of osteomyelitis is more likely to be detected by a plain radiograph?

A

Chronic, if the infection has been going on for a long time

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21
Q

Lab tests for diagnosis of osteomyelitis are usually _____

A

non-specific

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22
Q

Name 3 things associated with the lab tests for diagnosis of osteomyelitis

A
  1. WBC count
  2. ESR/C-reactive protein
  3. Blood cultures
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23
Q

If you find Gram pos or neg bacteremia clinicallyl what should you suspect?

A

Osteomyelitis

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24
Q

What is the treatment for most osteomyelitis?

A

Antibiotics plus surgery

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25
Q

What is the treatment for Acute osteomyelitis?

A

3-6 weeks antibiotics plus or minus surgery

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26
Q

What is the treatment for Chronic Osteomyelitis?

A

3-6 weeks of antibiotics with surgery

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27
Q

What is the difference between intravenous versus oral antibiotic therapy for osteomyelitis?

A

Not well established

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28
Q

What are some issues to consider when using antibiotics to treat acute osteomyelitis?

A
  • Oral bioavailability

- Bone penetration

29
Q

Odontogenic infections can spread contiguously to the ____

A

Jaw

Caused by Oral aerobes and anaerobes

30
Q

How common is osteomyelits

A

Relatively rare

31
Q

Why is the mandible more susceptible to osteomyelitis of the jaw?

A
  • Thinner cortical plates

- Poor vascular supply

32
Q

What are risk factors for Osteomyelitis of the Jaw?

A
  1. Dental infection
  2. Compound fracture
  3. Malignancy
  4. Irradiation
  5. DM
  6. Steroid Use
33
Q

What areas are at greatest risk for Osteomyelitis of the jaw?

A

Lingual aspect of mandible in region of molar teeth

34
Q

Osteomyelitis of the jaw occurs when the ______ is penetrated with __________ with formation of mucosal or cutaneous ____ and _______

A
  1. Periosteum
  2. Chronic infection
  3. Abscesses
  4. Fistulae
35
Q

List the symptoms of osteomyelitis of the jaw

A
  1. Mandibular pain
  2. Anesthesia or paresthesia on affected side
  3. Lymphadenopathy
  4. Can progress to trismus
36
Q

What is the treatment of osteomyelitis of the jaw?

A

Combination of surgery and antibiotics targeting oral flora

37
Q

Osteomyelitis of the Jaw needs to be differentially diagnosed from what?

A
  1. Medication-related osteonecrosis of the jaw (MRONJ)

2. Antiresorptive (bisphosphonates) and antiangiogenic meds

38
Q

What is trismus?

A

Spasm of the jaw muscles, causing the mouth to remain tightly closed, typically as a symptom of tetanus

39
Q

What is the leading cause of arthroplasty failure?

A

Prosthetic joint infections

40
Q

Prosthetic joint infections can lead to what?

A
  • More surgery
  • Prolonged antimicrobials
  • More rehab
  • Excess costs
41
Q

What is the failure rate of PJIs?

A

10-20%

42
Q

What are some risk factors for PJI?

A

There’s a lot:

  1. Surgical site infection not involving joint prosthesis**
  2. Prior surgery at site of prosthesis
  3. Prior native joint infection
  4. Extended operative time (>2.5 hrs)
  5. Arthroplasty for management of fracture
  6. Obesity
  7. DM
  8. Rheumatoid arthritis
  9. Immunosuppression
  10. Use of DMARDs
  11. Poor nutritional status
  12. Advanced age
  13. Malignancy
  14. Colonization With Staph aureus
43
Q

What are the gram + cocci that can cause PJIs?

A
  1. Coagulate-negative Staphylococci
  2. Staph. Aureus
  3. Strep. Spp.
  4. Enterococcus Spp.
44
Q

What is the pathogenesis of PJIs?

A
  1. Skin organisms are inoculated at the time of implantation
  2. Hematogenous seeding occurs later
  3. Small numbers of organisms adhere to implant
  4. Form protective biofilm evading antimicrobials and immunity
45
Q

Define an Early PJI

A
  1. Occurs within 1-3 months
  2. Acquired during prosthesis implantation
  3. Virulent organisms (S. aureus, Gram negative)
46
Q

Define delayed PJI

A
  1. Occurs within 3 months to 2 years
  2. Acquired during prosthesis implantation
  3. Less virulent organisms (CoNS, P. Ances)
47
Q

Define Late PJI

A
  1. Occurs beyond 1-2 years

2. Hematogenous seeding or late manifestation of surgical infection

48
Q

What are clinical presentations of Early PJI?

A
  1. Local erythema
  2. Swelling
  3. Pain
  4. Drainage
  5. Delayed wound healing
  6. May also have a fever
49
Q

What are the clinical presentations of Delayed PJI?

A

Chronic pain and draining sinus

50
Q

What are the clinical presentations of Late PJI?

A
  1. Chronic pain

2. Draining sinus or acute septic arthritis with sudden pain (hematogenous)

51
Q

How do you treat PJIs?

A

Surgery + Antibiotics

52
Q

What are the surgical management options for PJIs?

A
  1. Debridement and retention
  2. Two stage exchange
  3. One stage exchange
  4. Resection arthroplasty with arthrodesis
  5. Amputation
53
Q

What are the antibiotic options accompanying Debridement and Retention?

A

This pertains to a staphylococcal infection:

  1. 2-6 weeks of IV therapy + rifampin
  2. Followed by oral therapy + rifampin
    • Ciprofloxacin, Levofloxacin, TMP/SMX, tetracycline, dicloxacillin
  3. Duration (IV + Oral): THA-3 months, TKA: 6 months
  • *THA: Total hip arthroplasty
  • *TKA: Total Knee arthroplasty
54
Q

What are the antibiotic options accompanying a 1 stage exchange?

A

Same as debridement and retention except the duration is 3 months (IV + oral)

55
Q

What are the antibiotic options accompanying a 2 stage exchange?

A
  1. 4-6 weeks IV therapy or highly bioavailable oral therapy
  2. Rifampin not recommended because prosthetic material removed
  3. Antibiotic impregnated cement spacer used to maintain limb length. May decrease infection recurrence
  4. Re-implantation (Stage 2) 6 weeks-3 months
56
Q

T/F Generally speaking, for patients with prosthetic joint implants, prophylactic antibiotics are recommended prior to dental procedures to prevent prosthetic joint infections

A

FALSE

57
Q

What are the reasons for not doing prophylactic antibiotics for dental procedures in patients with prosthetic joint implants?

A
  1. Evidence suggests that dental procedures are not associated with prosthetic joint implant infections
  2. Evidence shows that antibiotics provided before oral care do not prevent prosthetic joint implant infections
  3. Potential harms of antibiotics including risk for: anaphylaxis, antibiotic resistance, opportunistic infections (C. Diff)
  4. Benefits may not exceed the harm for most patients
  5. Individual patient circumstances should be considered
58
Q

Osteomyelitis is classified based on ______ and whether it is _________ or _______

A
  1. Chronicity
  2. Hematogenous
  3. Contiguous
59
Q

T/F For Acute osteomeyelitis the difference between intravenous versus oral antibiotic therapy is significant

A

FALSE, this difference is not well established

60
Q

Oral bioavailability and bone penetration are two issue to consider when treating _______ with antibiotics

A

Acute osteomyelitis

61
Q

Why would surgery play a greater role in chronic osteomyelitis?

A

Due to necrotic bone and lack of antibiotic penetration to devascularized bone

62
Q

What percentage of PJIs are caused by Gram + cocci?

A

65%

63
Q

What percentage of PJIs are caused by Aerobic gram negative bacilli?

A

6%

64
Q

What percent of PJIs are caused by anaerobes?

A

4%

65
Q

What percent of PJIs are polymicrobial?

A

20%

66
Q

What percent of PJIs are culture negative?

A

7%

67
Q

What percent of PJIs are caused by fungi?

A

Around 1%

68
Q

What are the aerobic Gram negative bacilli that could cause a PJI?

A
  1. Enterobacteriaceae

2. Pseudo. Aeruginosa

69
Q

What are the Anaerobes that could cause PJI?

A
  1. Propionibacterium species (think shoulder arthroplasty)
  2. Peptosptreptococcus species
  3. Finegoldia magna

**Host and Defense (31 decks)

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