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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
Prosthetic Joint infections (PJI) Classifications (after surgery) : early onset
<3 mo joint pain, warmth, erythema wound drainage or dehiscence, hematoma, F
26
Prosthetic Joint infections (PJI) Classifications (after surgery) : delayed onset
>3 mo - 2 yrs persistent joint pain joint loosening? sinus tract? F?
27
Prosthetic Joint infections (PJI) Classifications (after surgery) : Late onset
>2 years Hematogenous seeding from somewhere else Acute pres. similar to early Less inflamm. as early Pain
28
Prosthetic Joint infections (PJI) Pathogenesis
Direct inoculation at time of surg Hematogenous seeding Contiguous spread adj tissue Pathogens
29
Prosthetic Joint infections (PJI) Early microbial diffential
S aureus Aerobic GNB Polymicrobial Anaerobic
30
Prosthetic Joint infections (PJI) Delayed microbiologic diff.
less virulent coagulase - staph Enterococcus Cutibacterium
31
Prosthetic Joint infections (PJI) Late onset microbiologic diff.
S aureus beta- Hemolytic strep GNB
32
Prosthetic Joint infections (PJI) DX
CRP or D-Dimer CBC Syn. fluid aspiration for cell counts/culture (neutrophils) X-ray
33
Prosthetic Joint infections (PJI) TX
depends on ortho determination debridement and retention of prosthesis One-stage implant exhange 2-stage implant exchange Amputation
34
Disseminated Gonococcal Infxn (DGI) usually occurs in who?
otherwise healthy from untreated gonorrhea
35
Disseminated Gonococcal Infxn (DGI) MC in who?
women>men MC in menses and pregnancy MSM <40 complement deficiences
36
Disseminated Gonococcal Infxn (DGI) pathophys cause
menses - less adherent to neutrophils tissue trauma
37
Disseminated Gonococcal Infxn (DGI) Presentation (clin form 1)
Tenosynovitis Dermatitis Polyarthritis w/o purulent arthritis
38
Disseminated Gonococcal Infxn (DGI) Pres. (clin form 2)
Purulent monoarthritis Assoc. F/C, malaise may be present usually w/i 2-3 wks GU infxn More common
39
Disseminated Gonococcal Infxn (DGI) history - what else to ask
thorough sex hx family hx exposures
40
Disseminated Gonococcal Infxn (DGI) PE
careful skin exam good joint exam Heart/lungs
41
Disseminated Gonococcal Infxn (DGI) DDX
Septic arthritis (non gonococcal) Reactive arthritis (Reiter's syndrome) Lyme dz involving knee Infective endocarditis w/ septic arthritis Gout or pseudogout Rheumatic fever
42
Disseminated Gonococcal Infxn (DGI) Lab test
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)
43
Disseminated Gonococcal Infxn (DGI) Tx
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
44
Disseminated Gonococcal Infxn (DGI) prognosis
complete recovery is rule responds dramatically to abx refer if dx in doubt reportable to HD tx partners
45
Viral Arthritis frank arthritis uncommon w/ 2 exceptions
Parvovirus B19 - polyarticular arthritis (adult pts) Chikungunya fever - arthalgias adn polyarthritis
46
Hep B may produce ..
polyarthritis before jaundice appears
47
Viral arthritis/arthalgias typically..
self-limited and short duration
48
Viral Arthritis mainstay or tx is?
NSAIDs
49
if any doubt viral infxn could be septic - need to do what?
work-up
50
Osteomyelitis mechanism of infxn
HEMATOGENOUS- "seeded" NON-HEMATOGENOUS (direct inoculation; spread from soft tissue and nearby infxn - contiguous)
51
Osteomyelitis duration of infxn: acute vs chronic
acute - days to weeks chronic - mths to yrs
52
Stages of biofilm development
1) planktonic bacteria attachment 2) microcolony formation and matrix production 3) prolif. and mature biofilm formation 4) bacteria detachment and film dispersal
53
Acute Hematogenous Osteomyelitis Organisms
MSSA MRSA Coagulase neg Staph (epidermis, haemolyticus, hominis) GN (pseudo, E. coli)
54
Osteomyelitis Acute tx
abx - need to ID organism (blood culture, bx) days to few weeks
55
Osteomyelitis Chronic tx
months-years before tx initiated Staph common; less common - enterococcus, enterobacteriaceae, Pseudo Abx + debridement surg
56
Stages of Osteomyelitis
initial infxn First stage - blood supply blocked (infxn moving to weakest area) Second stage - pus escape, new bone formation, dead bone
57
Hematogenous Osteomyelitis MC in ..
children adults >50
58
Hematogenous Osteomyelitis in adults most often affects..
vertebrae
59
Hematogenous Osteomyelitis risk factors
endocarditis IVDA indwelling cath ortho devices immunocomp.
60
Acute Hematogenous Osteomyelitis Pres
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
Acute Hematogenous Osteomyelitis diagnostics
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
Acute Hematogenous Osteomyelitis early - symp
soft tissue swelling loss tissue planes periarticular demineralization
63
Acute Hematogenous Osteomyelitis 2 wks - symp
erosion of bone alteration of bone -> periostitis
64
Acute Hematogenous Osteomyelitis after 2-6 wks
lytic changes when 50-70% density lost
65
Acute Hematogenous Osteomyelitis tx
debride NECROTIC bone parenteral ABX
66
Acute Hematogenous Osteomyelitis prognosis
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
Acute Osteomyelitis in older pts pathophy
HEMATOGENOUS - infxn spread from introduced indwelling cath, IV caths, etc. PRESENTATION TENDS TO BE MORE SUBTLE -
68
Acute Osteomyelitis in older pts MC sites
lumbar and thoracic vertebrae
69
Osteomyelitis due to Sickle cell dz (hematogenous) pathophys
sickling - episodic vascular occlusion in small vessels in bone marrow and bony matrix = bone infarction (OSTEONECROSIS)
70
Osteomyelitis due to Sickle cell dz (hematogenous) MC location for this
femur and humerus
71
Osteomyelitis due to Sickle cell dz (hematogenous) SCD pts more prone to..(organism)
encapsulated bacteria (Strep pneumo. ; H. flu; N. meningitides)
72
Osteomyelitis due to Sickle cell dz (hematogenous) Predominant bacterial species
SALMONELLA E.COLI species
73
Acute Hematogenous Osteomyelitis site and bacterial sp. dependent on co-existing factors such as?
Hemoglobinpathies (sickle cell dz) Injectable drug users DM older pts
74
Osteomyelitis in injectable drug users (hematogenous) pathphy
injections into vascular sys intro. bacterial sp. into blood stream
75
Osteomyelitis in injectable drug users (hematogenous) most likely site of infxn?
SPINE also may be in STERNUM and EXTREMITIES
76
Osteomyelitis in injectable drug users (hematogenous) MC bacterial sp
MRSA AND MSSA
77
Osteomyelitis in injectable drug users (hematogenous) rapid progression to ..
epidural abscess not uncommon - back pain, F/ sensory and motor loss
78
Osteomyelitis in injectable drug users (hematogenous) tx
typical strategies + urgent neurosurgical drainage of epidural abscess and decompress spinal cord ?
79
Mycotic infxns of Bones and Joints (hematogenous)
usually secondary to primary infxn of another organ
80
Mycotic infxns of Bones and Joints (hematogenous) infxn caused by
Candida sp.
81
Mycotic infxns of Bones and Joints (hematogenous) Treatment
Fluconazole 400mg daily for susceptible sp. (6-12 mos)
82
Mycotic infxns of Bones and Joints (hematogenous) common pts who get infected/ risk factors
Debilitated, malnourished, immunocomp. IV drug users Infected central line/ IV cath Prosthetic joints
83
Treatment summary by organisms Empiric
Vancomycin
84
Treatment summary by organisms Staph, methicillin resistant
vancomycin
85
Treatment summary by organisms Staph, methicillin sensitive
nafcillin, oxacillin, ceftriaxone
86
Treatment summary by organisms GN organsims
Cipro, Levofloxacin (FQs) Cefepime
87
Treatment summary by organisms mycoctic
fluconazole or other fungal agents (months of treatment)
88
Treatment summary by organisms typical duration
10-14 days
89
Treatment summary by organisms if pt needs to retain hardware and cannot be removed
6 weeks
90
Vertebral Osteomyelitis clin pres
BACK PAIN +/- F/C Malaise/myalgias Local tenderness Good MS/Neuro exam
91
Vertebral Osteomyelitis Dx
CBC CRP/ESR/urine Blood cultures x2 (aerobic and anaerobic) MRI *** Bx - CT or fluoroscopy guided)
92
Vertebral Osteomyelitis Treatment
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
Vertebral Osteomyelitis prog
mortality up to 11% depression chronic pain
94
Vertebral Osteomyelitis remember most are..
hematogenous
95
Vertebral Osteomyelitis Caused from Tuberculosis (AKA Pott's dz) Clin considerations (who gets it, how does it spread, where does it affect)
mostly in pts from countries endemic to TB and immunocomp. hematogenous spread from primary lung infxn to spine effects thoracic and lumbar MC
96
Vertebral Osteomyelitis Caused from Tuberculosis (AKA Pott's dz) clin manifestations
chronic and prog. back pain often present for months sm assoc. radicular symp. and LE weakness test for Active TB dz
97
Vertebral Osteomyelitis Caused from Tuberculosis (AKA Pott's dz) DX
collapse of anterior segment of vertebral body "GIBBUS" deformity MRI most vertebral bx pos most pts have + PPD or interferon gold test
98
Vertebral Osteomyelitis Caused from Tuberculosis (AKA Pott's dz) Treatment
typical TB regimen neurosurgical intervention - spinal instability or neuro compromise
99
Contiguous Osteomyelitis pathophys
spread of infxn to bone from adj area soft tissue direct inoculation of bone primarily adults
100
Contiguous Osteomyelitis risk factors
Prosthetic joints replacement / external devices Pressure ulcers Vascular insuff. Neurosurg Trauma (penetrating injuries)
101
Contiguous Osteomyelitis clin features
more subtle than acute hemat. osteo. signs inflamm. may be present - no high fever or toxicity dx requires high index suspicion
102
Contiguous Osteomyelitis where does this occur?
can happen anywhere
103
Contiguous Osteomyelitis causative organisms
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
Contiguous Osteomyelitis dx/ tx
similar to hemat. osteo. EXCEPT implantable devices and prostheses may be removed
105
Contiguous Osteomyelitis Vascular insufficiency - usually diabetics causative organisms
S. aureus Strep anaerobes/GNB (bacteriodes, pseudo)
106
Contiguous Osteomyelitis Vascular insufficiency - usually diabetics dx/tx
suspect if bone palpable w sterile probe "PROBE TO BONE" osteomyelitis until proven otherwise
107
Contiguous Osteomyelitis Vascular insufficiency - usually diabetics mc site
FOOT
108
Contiguous Osteomyelitis Vascular insufficiency - usually diabetics infxn typically from ..
ulcer or break in skin of foot or ankle
109
Contiguous Osteomyelitis Vascular insufficiency - usually diabetics nearly always involves..
small bones of feet of adults w diabetes wide variety organisms causative
110
Contiguous Osteomyelitis Vascular insufficiency - usually diabetics symptoms?
bone pain typically ABSENT or muted by neuropathy
111
Chronic Osteomyelitis
severe, progressive, recurrent often
112
Chronic Osteomyelitis what is common?
sinus tracts b/w bone and skin common and can be severe and may have foul smelling discharge
113
Chronic Osteomyelitis risk factors of getting
contiguous- focus FB increases risk (pros. joints) poor healing of fx may involve into
114
Chronic Osteomyelitis tx
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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