CHRONIC OSTEOMYELITIS

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Whatever the cause is, it may give
Prolonged morbidity
Economic loss
Sometimes permanent disability
psychosocial

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Management

Antibiotic
Surgery (radical debridement) + AB
Immobilisation

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Antibiotics

Empiric
Culture sensitivity test

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Radical debridement

Evacuation of pus
To achieve
Excision of dead tissues +foreign bodies
Viable environment
Not conductive to bacterial growth
L. Pasteur : it is not the bacteria, but the terrain where it
grows

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Immobilisation

Splint
External fixation

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Antibiotics

Knowledge :
When to use
How to use : local irrigation, beads,
parenteral, oral
How much to give appropriate, effective, side effects
How long to give

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Fracture stable : reduce wound sepsis & promote healing
Fracture unstable : promote wound sepsis & non union

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Fracture stable + sepsis

present of implant
is it necessary to be removed?

If - healing can proceed

- under controle (+antibiotic)
stability is maintained

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Fracture unstable + sepsis

present of implant
Implant should be removed
debridement
antibiotic (s)
external fixation
bone graft +

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To reduce wound sepsis

sterile operating environment

personal attire and movement
antibiotic prophylactic

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Hypothesis of Gristina
Glycocalix :
exopolysaccharide slime produced by bacteria or tissue cells
pivotal factors responsible for the behavior of biomaterial
centered infections
this biofilm is the major factor in the persistence of many chronic
orthopaedic infections
the biofilm protects the bacteria from phagocytosis, antibodies,
antibiotics

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The Race for the Surface

Between Cells and Bacteria

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Biofilm

Shortly after attachment

and adhesion (3-4) hrs
growth & propagation
In optimal condition
produces polysaccharides
polymers adhesion to
surface
aggregation consortia
formation of cells of other
species

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Biofilm is formed by :

Aggregated accummulation of polysaccharida

Bacteria
Bacteria microcolonies/of different species
Host products/environmental products

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Bacterial analysis :

joint fluids, wound exudates, swab of infected

sites
Often yielded growth only one specimen
frequently (2/3) polymicrobial population
Antibiotic chosen may be not effective

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Bacteria in Biomaterial sepsis

Most common :
S. epidermidis
S. aureus
Additional
coli
P. auriginosa
P. mirabilis
streptococci
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Polymicrobial Infection (Cierny & Mader Hospital)

Most common 75% :

S. aureus
Pseudomonas
Enterococcus
S. epidermidis
Bacillus
Proteus

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Tx. Chronic osteomyelitis :
debridement
Antibiotic
+ immobilization

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Factors that make unsuccessful Tx
inadequate AB lives of the site of infection
anaerobic environment
Stationary growth phase of bacteria
Cell-wall-deficient variants
Intracellular bacteria
Biofilm (glycocalyx)

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Antibiotic given
high dosis
Intravenous
Prolonged period

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Empiric Antibiotic Treatment in Osteomyelitis

Clinical condition Usual organisms Prefered i.v./p.o. regimens Penicillin-allergic

patient
Initial i.v. Terminal p.o Initial i.v. Terminal p.o
therapy x 14 days therapy x 14 days therapy x 14 days therapy x 14 days
Acute osteomyelitis Staphylococcus Cefonicid 2g Cephalexin 1g Vancomycin 1g Clindamycin 300 mg
Normal hots Aureus q24hh q.i.d slowly over 30-60 q.i.d
If MRSA significant (or) TMP-SMX 10mg/ min, q12h TMP-SMX 10mg/
hospital problem Cefazolin 1g, q8h kg/day in 4 doses Vancomycin 1g kg/day in 4 doses
Vancomycin 1g q.i.d slowly over 30-60 q.i.d
slowly over 30-60 (plus) min, q12h (plus)
min, q12h Rifampin 300 mg Rifampin 300 mg
b.i.d b.i.d
(or)
Ciprofloxacin 750
mg. b.i.d
I.V. drug abusers Staphylococcus Ceftazidime 2g, Imipenem 1 g Ciprofloxacin 750
Aureus q8h slowly, q6h mg. b.i.d
Serratia marcescens (plus) (or)
Pseudomonas Vancomycin 1g Clindamycin 600 mg
aeruginosa slowly over 30-60 q8h
min, q12h (plus)
(plus) Amikacin 15mg/kg/
Amikacin 15mg/kg/ day in 2 doses, q12h
day in 2 doses, q12h (or)
(or) Aztreonam 2g, q8h
Aztreonam 2g, q8h
(or)
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 Empiric Antibiotic Treatment in Osteomyelitis
Clinical condition Usual organisms Prefered i.v./p.o. regimens Penicillin-allergic
patient
Initial i.v. Terminal p.o Initial i.v. Terminal p.o
therapy x 14 days therapy x 14 days therapy x 14 days therapy x 14 days
Cefoperazone 2g Ciprofloxacin 750
q12hh mg. b.i.d
(plus)
Amikacin 15mg/kg/
day in 2 doses,
q12h, or
Aztreonam 2g, q8h
(or)
Ciprofloxacin 300
mg, q12h

Chronic osteomyelitis Staphylococcus Surgical, Ciprofloxacin 750 Surgical,

Normal/abnormal Aureus debridement mg. b.i.d debridement
hosts Gram-negative bacilli (plus) Ciprofloxacin 750 Imipenem 1 g
Ceptizoxime 2g, q8h mg. b.i.d slowly, q6h
(plus) (or)
Ciprofloxacin 300 Chloramphenicol
mg, q12h 500 mg, q6h
(or)
TMP-SMX 10mg/
kg/day in 4 doses
q6h
(or)
Ciprofloxacin 300 Ciprofloxacin 750
mg. q12h mg. b.i.d
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 Specific Antibiotic Treatment for Osteomyelitis

Organism Prefered i.v./p.o. regimens Penicillin-allergic patient

Initial i.v. Terminal p.o Initial i.v. Terminal p.o
therapy x 14 days therapy x 14 days therapy x 14 days therapy x 14 days
Staphylococcus aureus Cefonicid 2g q24h Cephalexin 1g Vancomycin 1g slowly over Clindamycin 300 mg q.i.d
MRSA q.i.d 30-60 min, q12h TMP-SMX 10mg/ kg/day in
Vancomycin 1g slowly over TMP-SMX 10mg/ kg/day in Vancomycin 1g slowly over 4 doses q.i.d
1.min, q12h 4 doses q6h 30-60 min, q12h (plus)
(plus) Rifampin 300 mg b.i.d
Rifampin 300 mg b.i.d
Group A Cefonicid 2g q24h Cephalexin 1g, q.i.d Vancomycin 1g slowly over Clindamycin 300 mg, q.i.d
streptococci 30-60 min, q12h Erythromycin 500 mg, q.i.d
Group D Ampicillin 2g,q4h Amoxicillin 1g, t.i.d Vancomycin 1g slowly over Ciprofloxacin 750 mg b.i.d
streptococci (or) 30-60 min, q12h
Enterococci Bacampicillin 400 mg (plus)
b.i.d Gentamicin 5mg/kg/day in 3
doses, q8h
(or)
Imipenem 1 g slowly, q6h
(or)
Chloramphenicol 1 g slowly
, q6h
Haemophilus TMP-SMX 10mg/ kg/day in TMP-SMX 10mg/ kg/day in Imipenem 1 g slowly, q6h
influenzae 4 doses q6h 4 doses q6h (or)
Chloramphenicol 1 g slowly Doxycycline 100 mg, b.i.d
, q6h TMP-SMX 10mg/ kg/day in
(or) 4 doses q.i.d
TMP-SMX 10mg/ kg/day in
4 doses q6h
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Specific Antibiotic Treatment for Osteomyelitis

Organism Prefered i.v./p.o. regimens Penicillin-allergic patient

Initial i.v. Terminal p.o Initial i.v. Terminal p.o
therapy x 14 days therapy x 14 days therapy x 14 days therapy x 14 days
Klebsiella Cefonicid 2g q24h Cephalexin 1g q.i.d Imipenem 1 g slowly, q6h Ciprofloxacin 750 mg, b.i.d
pneumoniae (or )
Chloramphenicol 1 g , q6h
Proteus mirabilis Cefonicid 2g q24h Cephalexin 1g q.i.d TMP-SMX 10mg/ kg/day in TMP-SMX 10mg/ kg/day in
(indonel negative) 4 doses q.i.d 4 doses q.i.d
Proteus Ceftizoxime 2g, q8h TMP-SMX 10mg/ kg/day in Imipenem 1 g slowly, q6h TMP-SMX 10mg/ kg/day in
(indole positive) 4 doses q6h (or) 4 doses q.i.d
TMP-SMX 10mg/ kg/day in
4 doses, q6h
Serratia marcescens Ceftizoxime 2g, q8h TMP-SMX 10mg/ kg/day in Imipenem 1 g slowly, q6h TMP-SMX 10mg/ kg/day in
4 doses q6h (or) 4 doses q.i.d
TMP-SMX 10mg/ kg/day in (or)
4 doses q6h Ciprofloxacin 750 mg, b.i.d
Pseudomonas Cefoperazone 2g, q12h Ciprofloxacin 750 mg, b.i.d Amikacin 15mg/kg/day in 2 Ciprofloxacin 750 mg, b.i.d
aeruginosa (plus) doses, q12h
Amikacin 15 mg/kg/day in (or)
2 doses, q12h Aztreonam 2g, q8h
(or) (or)
Aztreonam 2g, q8h Polymyxin B 70 mg (i.m),
(or) q6h
Ciprofloxacin 300 mg, (or)
q12h Ciprofloxacin 300 mg,
q12h
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Specific Antibiotic Treatment for Osteomyelitis

Organism Prefered i.v./p.o. regimens Penicillin-allergic patient

Initial i.v. Terminal p.o Initial i.v. Terminal p.o

therapy x 14 days therapy x 14 days therapy x 14 days therapy x 14 days

Bacteroides species Clindamycin 600 mg q8h Clindamycin 300 mg Clindamycin 900 mg q8h Clindamycin 300 mg q.i.d
(or) q.i.d (or)
Metronidazole 15mg/kg/day Metronidazole
in 3 doses q8h 15mg/kg/day in 3
(or) doses q8h
Imipenem 1 g slowly, q6h (or)
(or) Imipenem 1 g slowly, q6h
Sulbactam/Ampicillin 1,5 g,
q6h

Fusobacterium Metronidazole 15mg/kg/day Metronidazole Chloramphenicol 1 g, q6h Metronidazole

in 3 doses q8h 15mg/kg/day in 3 (or) 15mg/kg/day in 3
(or) doses t.i.d. Imipenem 1 g slowly, q6h doses t.i.d
Imipenem 1 g slowly, q6h

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Ciprofloxacin

The first orally administered agent available

for the Tx of G.N.B osteomyelitis including P.
aeruginosa [Eron et al, 1985]

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Ciprofloxacin

Side effects :
hypersensitive : rare
gastro intestinal :+
Liver :-
Kidney :-
CNS : rare
perif. N.S. :-
Hematopoesis coag : (-)
Skin : rare
Bone & joint : rare
Good for penicillin-allergic patient.

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Contraindication

Pregnancy, lactation period, growth (child),

epilepsy

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PROGRESSIVE TB-PROCESS

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Mr. A : 20 yrs old
1996 : Admitted to hospital (typhoid?)
1997 : - muscle ache, joints pain & stiff
routinely take herb : jamu pegel linu
contains : dexamethazone
to rheumatologic dept. : pyroxicam + kenacort
to neurologist : + depomedrol
1998 : Rheumatologist : kenacort
1999 : Internal med + hematologist : admitted to hospital :
+ ultralan

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 2000 Orthopaed :
Full moon face
No t able to walk
Gibbus + pain
Shoulder (L&R) stiff, sinusis
Axilla (L&R) sinusis
Hip (L&R) stiff + sinusis
Knee : swelling, stiff (L&R)
Inguinal : scars

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Tx : 3 drugs : Rif/INH/Etham 18 months
no pain, no sinus, BW, apetite
general condition improve, descrepancy 5.5 cm

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