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ICM Unit 4 MSK > Infectious Diseases of Bones and Joints > Flashcards

Infectious Diseases of Bones and Joints Flashcards

1
Q

What is Septic Arthritis?

A

bacteria enter JOINT and deposit w/i synovial lining -> moves into fluid due to absence of basement mem

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2
Q

How does one get Septic Arthritis?

5 ways

A

1) hematogenous route
2) dissemination from osteomyelitis
3) spread from adj soft tissue infxn
4) diagnostic or therapeutic measures
5) penetrating damage (puncture or trauma)

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3
Q

Septic arthritis

A

acute onset INFLAMMATORY MONO-ARTICULAR ARTHRITIS

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4
Q

Septic arthritis usually in what joints and usually spread by how?

A

large weight bearing joints and wrists

hematogenous SEEDING (one site to another)

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5
Q

Septic arthritis key risk factors

A

persistent bacteremia (injection drug use)
damaged joints (RA)
compromised (DM, renal failure, alcoholism. etc)
Loss of skin integrity (psoriasis)
Procedures
Indwelling catheters
Advanced age

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6
Q

Septic Arthritis Organisms - MC

A

STAPH AUREUS MC CAUSE (both MRSA and MSSA)

usually monomicrobial

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7
Q

Septic arthritis other organisms

A

Group A strep
G- in IV drug users, GI infxns, immunocomp. (pseudo, E. coli)

N. Meningitides

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8
Q

Septic Arthritis

HX

A

F/C
Sudden onset pain, swelling, warmth USUALLY THE KNEE

unusual sites in IV drug users (sternoclavicular or sacroiliac joint)

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9
Q

Septic Arthritis

PE

A

erthematous, swollen, warm joint

large effusion typically

pain w/ limited AROM and PROM

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10
Q

Septic Arthritis DDX

infectious causes

A

Septic bursitis
Lyme dz
Viral arthritis
Synovitis
TB arthritis

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11
Q

Septic Arthritis DDX

inflammatory causes

A

Traumatic arthritis
Gout/Pseudogout
Reactive arthritis
RA

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12
Q

Septic Arthritis

DX

A

x-rays not helpful but done
US to find fluid if not obvi
MRI/CT for diff. to xamine joints like hips

CBC w/ ESR/CRP (inflam. markers)

Blood cultures

ASPIRATION OF SYN. FLUID - usually turbid
- usually > 20,000
- syn. fluid cultures gen. + if aspiration done prior to admin. of abx

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13
Q

Septic Arthritis

Treatment

A

EARLY ORTHO REFERRAL - arthroscopic lavage (IRRIGATE)

MEDS =
prompt systemic broad abx therapy w/ coverage against
Staphylococcus (GM+ cocci);
Streptoccocus;
G- (pseudo/E.coli))

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14
Q

Septic Arthritis : Gram + cocci
start tx w?

A

G+ = VANC
(MSSA - nafcillin, oxacillin, or cephazolin)

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15
Q

Septic Arthritis : Gram - bacilli

tx with?

A

G - bacilli = 3rd or 4th gen Cephalosporin
(ceftazidime, cefepime, ceftriaxone OR Pip-tazo)

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16
Q

Septic Arthritis : PSEUDO isolated

IVDA or severely immunocomp

A

2 anti-pseudo agents

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17
Q

Septic arthritis tx pneumonic

A

Solution to Pollution is Dilution

abx tx

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18
Q

If unsure what organism (waiting for results) causing septic arthritis tx w?

A

vanc + ceftriaxone

until results come back

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19
Q

After obtaining culture results (septic arthritis), do what?

Time to treat sep. arth.?

A

adj coverage of abx

time to tx 2-4 wks

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20
Q

Septic Arthritis complications

A

articular destruction
complications of sepsis

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21
Q

Septic Arthritis prognosis

A

PROMPT abx tx and no serious underlying dz - func. recovery good

mortality <5% from sepsis

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22
Q

Prosthetic Joint infections (PJI)

form what?
how can it infect?

A

infxn due to implantable device

covered w/ host proteins - makes easier to allow adherence of bacteria and form biofilm to resist breakdown

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23
Q

Prosthetic Joint infections (PJI)

risks

A

Chronic dz (DM, CA, RA, COPD)
Obesity
Prednisone
Long surgery
Prev joint replacements

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24
Q

Prosthetic Joint infections (PJI)

risks highest when and by what organism?

A

first 2 years

Staph

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25
Q

Prosthetic Joint infections (PJI)

Classifications (after surgery) : early onset

A

<3 mo

joint pain, warmth, erythema

wound drainage or dehiscence, hematoma, F

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26
Q

Prosthetic Joint infections (PJI)

Classifications (after surgery) : delayed onset

A

> 3 mo - 2 yrs

persistent joint pain
joint loosening?
sinus tract?
F?

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27
Q

Prosthetic Joint infections (PJI)

Classifications (after surgery) : Late onset

A

> 2 years

Hematogenous seeding from somewhere else
Acute pres. similar to early
Less inflamm. as early
Pain

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28
Q

Prosthetic Joint infections (PJI)

Pathogenesis

A

Direct inoculation at time of surg
Hematogenous seeding
Contiguous spread adj tissue
Pathogens

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29
Q

Prosthetic Joint infections (PJI)

Early microbial diffential

A

S aureus
Aerobic GNB
Polymicrobial
Anaerobic

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30
Q

Prosthetic Joint infections (PJI)

Delayed microbiologic diff.

A

less virulent

coagulase - staph

Enterococcus

Cutibacterium

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31
Q

Prosthetic Joint infections (PJI)

Late onset microbiologic diff.

A

S aureus
beta- Hemolytic strep
GNB

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32
Q

Prosthetic Joint infections (PJI)

DX

A

CRP or D-Dimer

CBC

Syn. fluid aspiration for cell counts/culture (neutrophils)

X-ray

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33
Q

Prosthetic Joint infections (PJI)

TX

A

depends on ortho determination

debridement and retention of prosthesis
One-stage implant exhange
2-stage implant exchange
Amputation

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34
Q

Disseminated Gonococcal Infxn (DGI)

usually occurs in who?

A

otherwise healthy from untreated gonorrhea

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35
Q

Disseminated Gonococcal Infxn (DGI)

MC in who?

A

women>men

MC in menses and pregnancy

MSM

<40

complement deficiences

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36
Q

Disseminated Gonococcal Infxn (DGI)

pathophys cause

A

menses - less adherent to neutrophils
tissue trauma

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37
Q

Disseminated Gonococcal Infxn (DGI)

Presentation (clin form 1)

A

Tenosynovitis
Dermatitis
Polyarthritis w/o purulent arthritis

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38
Q

Disseminated Gonococcal Infxn (DGI)

Pres. (clin form 2)

A

Purulent monoarthritis
Assoc. F/C, malaise may be present
usually w/i 2-3 wks GU infxn

More common

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39
Q

Disseminated Gonococcal Infxn (DGI)

history - what else to ask

A

thorough sex hx
family hx
exposures

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40
Q

Disseminated Gonococcal Infxn (DGI)

PE

A

careful skin exam
good joint exam
Heart/lungs

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41
Q

Disseminated Gonococcal Infxn (DGI)

DDX

A

Septic arthritis (non gonococcal)
Reactive arthritis (Reiter’s syndrome)
Lyme dz involving knee
Infective endocarditis w/ septic arthritis
Gout or pseudogout
Rheumatic fever

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42
Q

Disseminated Gonococcal Infxn (DGI)

Lab test

A

Syn. fluid (cell count, diff, gram stain and cult)
WBC >20,000

Blood cultures (at least 2 sets)
Urethral, throat, rectal cultures for gonorrhea
Test for other STI (HIV, CLAP, HEP B, syph)

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43
Q

Disseminated Gonococcal Infxn (DGI)

Tx

A

CO TREAT GONORRHEA AND CHLAMYDIA

3rd gen ceph = Ceftriaxone (1gm qd IM)
+
DOXY 100mg BID 7 days

improvement - 24-48hrs, pt discharged and receive rochepin 500mg-1gm IM qd AT LEAST 7 DAYS

purulent arthritis and pt ill - hospital IV access 7-14 days

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44
Q

Disseminated Gonococcal Infxn (DGI)

prognosis

A

complete recovery is rule

responds dramatically to abx

refer if dx in doubt

reportable to HD

tx partners

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45
Q

Viral Arthritis

frank arthritis uncommon w/ 2 exceptions

A

Parvovirus B19 - polyarticular arthritis (adult pts)
Chikungunya fever - arthalgias adn polyarthritis

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46
Q

Hep B may produce ..

A

polyarthritis before jaundice appears

47
Q

Viral arthritis/arthalgias typically..

A

self-limited and short duration

48
Q

Viral Arthritis

mainstay or tx is?

A

NSAIDs

49
Q

if any doubt viral infxn could be septic - need to do what?

A

work-up

50
Q

Osteomyelitis

mechanism of infxn

A

HEMATOGENOUS- “seeded”

NON-HEMATOGENOUS
(direct inoculation; spread from soft tissue and nearby infxn - contiguous)

51
Q

Osteomyelitis

duration of infxn: acute vs chronic

A

acute - days to weeks

chronic - mths to yrs

52
Q

Stages of biofilm development

A

1) planktonic bacteria attachment
2) microcolony formation and matrix production
3) prolif. and mature biofilm formation
4) bacteria detachment and film dispersal

53
Q

Acute Hematogenous Osteomyelitis

Organisms

A

MSSA
MRSA
Coagulase neg Staph (epidermis, haemolyticus, hominis)
GN (pseudo, E. coli)

54
Q

Osteomyelitis
Acute tx

A

abx - need to ID organism (blood culture, bx)

days to few weeks

55
Q

Osteomyelitis
Chronic tx

A

months-years before tx initiated

Staph common; less common - enterococcus, enterobacteriaceae, Pseudo

Abx + debridement surg

56
Q

Stages of Osteomyelitis

A

initial infxn

First stage - blood supply blocked (infxn moving to weakest area)

Second stage - pus escape, new bone formation, dead bone

57
Q

Hematogenous Osteomyelitis

MC in ..

A

children
adults >50

58
Q

Hematogenous Osteomyelitis

in adults most often affects..

A

vertebrae

59
Q

Hematogenous Osteomyelitis

risk factors

A

endocarditis
IVDA
indwelling cath
ortho devices
immunocomp.

60
Q

Acute Hematogenous Osteomyelitis

Pres

A

acute -subacute onset PAIN and TENDERNESS
warmth around bone

Fatigue, malaise, myalgias

F/C

symp present w/i a few days development of bacteremia

61
Q

Acute Hematogenous Osteomyelitis

diagnostics

A

plain films often neg until at least 14 days after infxn
MRI, CT, Nuclear bone scan - early findings

Blood cultures
Bx suspected locus infxn ***
ESR and CRP - high
CBC elev. WBC count

62
Q

Acute Hematogenous Osteomyelitis

early - symp

A

soft tissue swelling

loss tissue planes

periarticular demineralization

63
Q

Acute Hematogenous Osteomyelitis

2 wks - symp

A

erosion of bone

alteration of bone -> periostitis

64
Q

Acute Hematogenous Osteomyelitis

after 2-6 wks

A

lytic changes when 50-70% density lost

65
Q

Acute Hematogenous Osteomyelitis

tx

A

debride NECROTIC bone

parenteral ABX

66
Q

Acute Hematogenous Osteomyelitis

prognosis

A

if isolation of organism w/i 2-4 days = good result (unless immune sys comp.)

development of chronic osteomyelitis - LE and in DM pts

67
Q

Acute Osteomyelitis in older pts

pathophy

A

HEMATOGENOUS - infxn spread from introduced indwelling cath, IV caths, etc.

PRESENTATION TENDS TO BE MORE SUBTLE -

68
Q

Acute Osteomyelitis in older pts

MC sites

A

lumbar and thoracic vertebrae

69
Q

Osteomyelitis due to Sickle cell dz
(hematogenous)

pathophys

A

sickling - episodic vascular occlusion in small vessels in bone marrow and bony matrix = bone infarction (OSTEONECROSIS)

70
Q

Osteomyelitis due to Sickle cell dz
(hematogenous)

MC location for this

A

femur and humerus

71
Q

Osteomyelitis due to Sickle cell dz
(hematogenous)

SCD pts more prone to..(organism)

A

encapsulated bacteria (Strep pneumo. ; H. flu; N. meningitides)

72
Q

Osteomyelitis due to Sickle cell dz
(hematogenous)

Predominant bacterial species

A

SALMONELLA

E.COLI species

73
Q

Acute Hematogenous Osteomyelitis

site and bacterial sp. dependent on co-existing factors such as?

A

Hemoglobinpathies (sickle cell dz)
Injectable drug users
DM
older pts

74
Q

Osteomyelitis in injectable drug users (hematogenous)

pathphy

A

injections into vascular sys intro. bacterial sp. into blood stream

75
Q

Osteomyelitis in injectable drug users (hematogenous)

most likely site of infxn?

A

SPINE

also may be in STERNUM and EXTREMITIES

76
Q

Osteomyelitis in injectable drug users (hematogenous)

MC bacterial sp

A

MRSA AND MSSA

77
Q

Osteomyelitis in injectable drug users (hematogenous)

rapid progression to ..

A

epidural abscess not uncommon
- back pain, F/ sensory and motor loss

78
Q

Osteomyelitis in injectable drug users (hematogenous)

tx

A

typical strategies
+
urgent neurosurgical drainage of epidural abscess and decompress spinal cord ?

79
Q

Mycotic infxns of Bones and Joints (hematogenous)

A

usually secondary to primary infxn of another organ

80
Q

Mycotic infxns of Bones and Joints (hematogenous)

infxn caused by

A

Candida sp.

81
Q

Mycotic infxns of Bones and Joints (hematogenous)

Treatment

A

Fluconazole 400mg daily for susceptible sp. (6-12 mos)

82
Q

Mycotic infxns of Bones and Joints (hematogenous)

common pts who get infected/ risk factors

A

Debilitated, malnourished, immunocomp.
IV drug users
Infected central line/ IV cath
Prosthetic joints

83
Q

Treatment summary by organisms

Empiric

A

Vancomycin

84
Q

Treatment summary by organisms

Staph, methicillin resistant

A

vancomycin

85
Q

Treatment summary by organisms

Staph, methicillin sensitive

A

nafcillin, oxacillin, ceftriaxone

86
Q

Treatment summary by organisms

GN organsims

A

Cipro, Levofloxacin (FQs)
Cefepime

87
Q

Treatment summary by organisms

mycoctic

A

fluconazole or other fungal agents
(months of treatment)

88
Q

Treatment summary by organisms

typical duration

A

10-14 days

89
Q

Treatment summary by organisms

if pt needs to retain hardware and cannot be removed

A

6 weeks

90
Q

Vertebral Osteomyelitis

clin pres

A

BACK PAIN
+/- F/C
Malaise/myalgias
Local tenderness
Good MS/Neuro exam

91
Q

Vertebral Osteomyelitis

Dx

A

CBC
CRP/ESR/urine
Blood cultures x2 (aerobic and anaerobic)
MRI
*** Bx - CT or fluoroscopy guided)

92
Q

Vertebral Osteomyelitis

Treatment

A

septic = empiric abx (tailor when results come back)

NOT septic /neg blood cultures or NO neuro findings = CT guided BX of affected vertebrae after blood cultures

6 weeks

93
Q

Vertebral Osteomyelitis

prog

A

mortality up to 11%

depression

chronic pain

94
Q

Vertebral Osteomyelitis

remember most are..

A

hematogenous

95
Q

Vertebral Osteomyelitis
Caused from Tuberculosis (AKA Pott’s dz)

Clin considerations (who gets it, how does it spread, where does it affect)

A

mostly in pts from countries endemic to TB and immunocomp.

hematogenous spread from primary lung infxn to spine

effects thoracic and lumbar MC

96
Q

Vertebral Osteomyelitis
Caused from Tuberculosis (AKA Pott’s dz)

clin manifestations

A

chronic and prog. back pain

often present for months

sm assoc. radicular symp. and LE weakness

test for Active TB dz

97
Q

Vertebral Osteomyelitis
Caused from Tuberculosis (AKA Pott’s dz)

DX

A

collapse of anterior segment of vertebral body
“GIBBUS” deformity

MRI
most vertebral bx pos

most pts have + PPD or interferon gold test

98
Q

Vertebral Osteomyelitis
Caused from Tuberculosis (AKA Pott’s dz)

Treatment

A

typical TB regimen

neurosurgical intervention - spinal instability or neuro compromise

99
Q

Contiguous Osteomyelitis

pathophys

A

spread of infxn to bone from adj area soft tissue

direct inoculation of bone

primarily adults

100
Q

Contiguous Osteomyelitis

risk factors

A

Prosthetic joints replacement / external devices
Pressure ulcers
Vascular insuff.
Neurosurg
Trauma (penetrating injuries)

101
Q

Contiguous Osteomyelitis

clin features

A

more subtle than acute hemat. osteo.

signs inflamm. may be present - no high fever or toxicity

dx requires high index suspicion

102
Q

Contiguous Osteomyelitis

where does this occur?

A

can happen anywhere

103
Q

Contiguous Osteomyelitis

causative organisms

A

can be monomicrobial or poly

S. AUREUS (mrsa and coag neg staph CoNS)

S. aureus - MC postop infxn
P. Aeruginosa = puncture wounds of foot

104
Q

Contiguous Osteomyelitis

dx/ tx

A

similar to hemat. osteo.

EXCEPT implantable devices and prostheses may be removed

105
Q

Contiguous Osteomyelitis

Vascular insufficiency - usually diabetics

causative organisms

A

S. aureus
Strep
anaerobes/GNB (bacteriodes, pseudo)

106
Q

Contiguous Osteomyelitis

Vascular insufficiency - usually diabetics

dx/tx

A

suspect if bone palpable w sterile probe

“PROBE TO BONE”
osteomyelitis until proven otherwise

107
Q

Contiguous Osteomyelitis
Vascular insufficiency - usually diabetics

mc site

A

FOOT

108
Q

Contiguous Osteomyelitis
Vascular insufficiency - usually diabetics

infxn typically from ..

A

ulcer or break in skin of foot or ankle

109
Q

Contiguous Osteomyelitis

Vascular insufficiency - usually diabetics

nearly always involves..

A

small bones of feet of adults w diabetes

wide variety organisms causative

110
Q

Contiguous Osteomyelitis
Vascular insufficiency - usually diabetics

symptoms?

A

bone pain typically ABSENT or muted by neuropathy

111
Q

Chronic Osteomyelitis

A

severe, progressive, recurrent often

112
Q

Chronic Osteomyelitis

what is common?

A

sinus tracts b/w bone and skin common and can be severe and may have foul smelling discharge

113
Q

Chronic Osteomyelitis

risk factors of getting

A

contiguous- focus

FB increases risk (pros. joints)

poor healing of fx may involve into

114
Q

Chronic Osteomyelitis

tx

A

optimize nutritional and metabolic status

abx several days b4 surg (if organism known)

surg debridement all necrotic bone

post op abx 6-8 wks; prolonged course if hardware to be maintained

ICM Unit 4 MSK (5 decks)

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