Chronic osteomyelitis

Bronchiectasis Chronic osteomyelitis Chronic tuberculosis Hepatitis C HIV infection Sprue... 

Compare and contrast the classic signs and symptoms of acute and chronic osteomyelitis. 

O Osteomyelitis, an infection of the bone, can be an acute or chronic process. 

The treatment goals for acute and chronic osteomyelitis are to eradicate the infection and prevent recurrence. Higher cure rates are seen with acute compared to chronic osteomyelitis. 

Therefore, in chronic osteomyelitis, a common treatment goal for many patients is to prevent complications such as amputation. 

Treatment of osteomyelitis is dependent on the extent of bone necrosis. For acute osteomyelitis with minimal bone destruction, an extended course of antimicrobial therapy should effectively treat the infection however, in chronic osteomyelitis surgical intervention is also typically required. 

O Osteomyelitis is an infection of the bone that is associated with high morbidity and increased health care costs. The inflammatory response associated with acute osteomyelitis can lead to bone necrosis and subsequently chronic infections. Bacterial pathogens, particularly Staphylococcus aureus, are the most common microorganisms implicated in these infections. Diagnosis and treatment are often difficult due to the heterogeneous... 

Historically, osteomyelitis has been classified as acute or chronic based on duration of disease (Fig. 78-2).2,4 However, there are no established definitions for acute and chronic infections.2-4 Acute infection has been defined as first episode or recent onset of symptoms (less than 1 week).2,3 Chronic osteomyelitis is generally defined as relapse of the disease or symptoms persisting beyond 4 weeks.2,3 Others describe chronic osteomyelitis as the presence of necrotic bone.3 ... 

An alternative classification, the Cierny-Mader staging system, is based on anatomic site and physiologic status of the patient.1 This classification scheme was developed for chronic osteomyelitis involving long bones and has limited application for small bones and digits. The detailed stratification has the greatest utility in clinical trials since it would permit comparison of treatment regimens in patients with diverse comorbidities and infection sites. 

The clinical presentation of osteomyelitis may vary depending on route and duration of infection, as well as patient-specific factors such as infection site, age, and comorbidities. In hematogenous osteomyelitis, the patient typically experiences systemic and localized signs and symptoms.3 4 7 12 13 In comparison, patients with chronic infection typically present with only localized signs and symptoms.4 6 A cardinal sign of chronic osteomyelitis is the formation of sinus tracts with purulent drainage.2,3,6... 

Antimicrobial therapy alone is the mainstay of treatment for acute osteomyelitis.7 12 In comparison, treatment for chronic osteomyelitis typically requires a combination of antimicrobial therapy and surgical intervention.3 6 14 15 If the patient is not a candidate for surgical intervention, prolonged antimicrobial therapy is generally necessary.6,10,16... 

The duration of treatment is typically 4 to 6 weeks for acute osteomyelitis,15 Chronic osteomyelitis also requires 4 to 6 weeks of therapy however, the total length of therapy should be counted after the date of the last major surgical intervention.8 15 Longer courses may be necessary for certain populations such as patients with vascular insufficiency.3,6,10,16... 

Ciampolini J, Harding KG. Pathophysiology of chronic bacterial osteomyelitis. Why do antibiotics fail so often Postgrad Med J 2000 76 479M83. 

Mader JT, Shirtliff ME, Bergquist SC, Calhoun J. Antibiotic treatment of chronic osteomyelitis. Clin Orthop Relat Res 1999 360 47-65. 

Suggested Alternatives for Differential Diagnosis Influenza, infectious mononucleosis, hepatitis, leptospirosis, infective endocarditis, malaria, tuberculosis, typhoid fever, cryptococcosis, histoplasmosis, ankylosing spondylitis and undifferentiated spondyloarthropathy, collagen vascular disease, chronic fatigue syndrome, malignancy, and osteomyelitis. 

Clinical improvement, especially the disappearance of fever or defervescence, is the best parameter to judge the response to therapy. However, clinical improvement can be difficult to monitor objectively in critically ill patients with multi-system disease. Also, clinical improvement can be very slow for certain infections, e.g. tuberculosis. The peripheral blood leukocyte count including the presence of early stages in leucocyte differention and the level of serum C-Reactive Protein (CRP, an acute phase protein) are parameters that can be sequentially determined to monitor improvement. For monitoring the effect of treatment of chronic infections such as endocarditis or osteomyelitis, weekly determination of the erythrocyte sedimentation rate has been proven useful. 

Breaches in the integrity of the skin (eczema, trauma or burns) are predisposing factors for infection. Lymphoedema represents a risk for erysipelas. Open complicated fractures are often complicated by chronic osteomyelitis. Patients with diabetes mel-lims have more frequent as well as more severe infections of the skin, soft tissue and of bone. Sickle cell disease predisposes to osteomyelitis. 

Oral anti-staphylococcal penicillins or cotrimox-azole are effective against most skin pathogens. Five days of therapy (or 3 days after local signs are resolved) is usually sufficient. For arthritis 2 or 3 weeks of therapy are required. In chronic osteomyelitis, resection of dead tissue should be followed by at least six weeks to 3 months of antibiotics until the ESR returns to normal. Oral quinolones are useful for gram-negative osteomyelitis while clindamycin is effective in gram-positive and anaerobic infections. 

Chronic tuberculous arthritis is not at all rare in developing countries. Mycobacterial tuberculosis can directly or indirectly affect the musculoskeletal system. Most commonly there is a direct musculoskeletal involvement of M. tuberculosis which may lead to spondylitis, osteomyelitis, septic arthritis and tenosynovitis. M. tuberculosis has become an important pathogen in rheumatic diseases since the use of anti-TNF-a biopharmaceuticals was introduced. 

Lymphatic tuberculosis, tubercular joint disease, chronic osteomyelitis, rheumatoid arthritis, aseptic suppuration, cancer. 

Webster DA, Spadaro JA, Becker RO, et al. 1981. Silver anode treatment of chronic osteomyelitis. Clinical Orthopedics and Related Research 161 105-114. 

A 34-year-old woman who had taken intranasal metamfetamine weekly for 15 years developed osteomyelitis of the frontal bone and a subperiosteal abscess. The authors proposed that this was due to chronic abuse of metamfetamine (80). 

A 43-year-old woman with a past history of chronic heavy cocaine use and osteomyelitis of the hard palate and nasal cavity 10 years before had required continuous follow-up for recurrent ethmoid and sphenoid sinusitis (116). Endoscopy showed an absent nasal septum, middle turbinates, anterior two-thirds of the inferior turbinates, and lateral nasal wall. 

Gupta A, Hawrych A, Wilson WR. Cocaine-induced sinona-sal destruction. Otolaryngol Head Neck Surg 2001 124(4) 480. Noskin GA, Kalish SB. Pott s puffy tumor a complication of intranasal cocaine abuse. Rev Infect Dis 1991 13(4) 606-8. Smith JC, Kacker A, Anand VK. Midline nasal and hard palate destruction in cocaine abusers and cocaine s role in rhinologic practice. Ear Nose Throat J 2002 81(3) 172-7. Talbott JF, Gorti GK, Koch RJ. Midfacial osteomyelitis in a chronic cocaine abuser a case report. Ear Nose Throat J 2001 80(10) 738-43. 

Mateev G, Kantjardjiev T, Vassileva S, Tsankov N Chronic mucocutaneous candidosis with osteomyelitis of the frontal bone. Int J Dermatol 1993 32 888-889. 

R. Ascherl, A. Stemberger, F. Lechner, L. Paumann, G. Rupp, K. Maschka, W. Erhardt, K. H. Sorg, G. Blimel, Treatment of chronic osteomyelitis with a collagen-antibiotica compound—preliminary information. Acc/deo/ 12 125 (1986). 

Linezolid is licensed in the UK for skin, soft tissue and respiratory tract infections, and it is usually restricted on grounds of cost to those caused by multiply resistant pathogens. The oral formulation may prove useful for follow-on therapy of severe and chronic infections caused by bacteria resistant to other agents, e.g. MRSA osteomyelitis. 

Osteomyelitis may be acute or chronic and the causative bacteria arrive in the bloodstream or are implanted directly (through a compound fracture, chronic local infection of local tissue, or surgical operation). Staphylococcus aureus is the commonest isolate in all patient groups but Haemophilus influenzae is frequently seen in children (much reduced now by the Hib vaccine), and Salmonella species in the tropics. Chronic osteomyelitis of the lower limbs (especially when underlying chronic skin infection in the elderly) frequently involves obligate anaerobes (such as Bacteroides species) and coliforms. 

Strenuous efforts should be made to obtain bone for culture because superficial and sinus cultures are poorly predictive of the underlying flora, and prolonged therapy is required for chronic osteomyelitis (usually 6-8 weeks, sometimes longer). The outcome of chronic osteomyelitis is improved if dead bone can be removed surgically. 

Jones RO, Cross G 3rd. Suspected chronic osteomyelitis secondary to acupuncture treatment a case report. J Am Podiatry Assoc 1980 70(3) 149-51. 

During long-term use of roxithromycin 300 mg/day for 2-66 months in nine patients with chronic diffuse sclerosing osteomyelitis of the mandible, diarrhea and stomach discomfort occurred in one case and liver dysfunction in another (7). 

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