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Bone and joint infections: Osteomyelitis, Septic Arthritis

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Musculoskeletal Disorders Part 2 …

Musculoskeletal Disorders Part 2
Bone and joint infections: Osteomyelitis, Septic Arthritis

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  • 1. Musculoskeletal Disorders Part 2Bone infectionsMaria Carmela L. Domocmat, RN,MSNInstructorSchool of NursingNorthern Luzon Adventist CollegeArtacho, Sison, Pangasinan
  • 2. Overview Part 1: Degenerative & Metabolic bone disorders: Part 2: Bone infections ◦ Osteomyelitis ◦ Septic arthritis Part 3: Muscular disorders Part 4: Disorders of the hand Part 5: Spinal column deformities Part 6 : Disorders of foot Part 7: Sports Injuries 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 2
  • 3. Osteomyelitis Septic arthritisBONE INFECTIONS 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 3
  • 4. BONE INFECTIONS:OSTEOMYELITIS 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 4
  • 5. OsteomyelitisOsteomyelitis is infection in the bones. Often, the original site ofinfection is elsewhere in the body, and spreads to the bone by theblood. Bacteria or fungus may sometimes be responsible forosteomyelitis. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 5
  • 6. Osteomyelitis Infection of the bone, most often of the cortex or medullary portion. Is commonly caused by bacteria, fungi, parasites & viruses.
  • 7. Osteomyelitis Classified by mode of entry- Contiguous or exogenous is caused by a pathogen from outside the body or the by the spread of infection from adjacent soft tissues. The organism is Staph aureus. Example- pathogens from open fracture. The onset is insidious: initially cellulites progressing to underlying bone.
  • 8. Osteomyelitis Hematogenous- caused by bloodborne pathogens originating from infectious sites within the body. Ex: sinus, ear, dental, respiratory & GU infections. The infection spreads from the bone to the soft tissues & can eventually break through the skin, becoming a draining fistula. Again, Staph aureus is the most common causative organism.
  • 9. S/s Acute Osteomyelitis left untreated or unresolved after 10 days is considered chronic. Necrotic bone is the distinguishing feature of chronic osteomyelitis.
  • 10. Symptoms Bone pain Fever General discomfort, uneasiness, or ill-feeling (malaise) Local swelling, redness, and warmth Other symptoms that may occur with this disease: Chills Excessive sweating Low back pain Swelling of the ankles, feet, and legs 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 10
  • 11. Pathophysiology similar to that infectious processes in any other body tissue. Bone inflammation is marked by edema, increased vascularity & leukocyte activity. fever, malaise, anorexia, & headache. affected body may be erythematous, tender, & edematous. There may be fistula draining purulent material. Blood test- increase WBCs, ESR, & C-protein levels.
  • 12. Causes, incidence, and riskfactors Bone infection can be caused by bacteria (more common) or fungi (less common). Infection may spread to a bone from infected skin, muscles, or tendons next to the bone, as in osteomyelitis that occurs under a chronic skin ulcer (sore). 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 12
  • 13. Causes, incidence, and riskfactors The infection that causes osteomyelitis can also start in another part of the body and spread to the bone through the blood. A current or past injury may have made the affected bone more likely to develop the infection. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 13
  • 14. Causes, incidence, and riskfactors A bone infection can also start after bone surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone. children -- long bones usually affected. Adults -- feet, vertebrae, and pelvis are most commonly affected. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 14
  • 15. Risk factors Diabetes Hemodialysis Injected drug use Poor blood supply Recent trauma People who have had their spleen removed are also at higher risk for osteomyelitis 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 15
  • 16. Osteomyelitis Osteomyelitis of Osteomyelitis of T10 diabetic foot secondary to streptococcal disease. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 16
  • 17. Osteomyelitis Osteomyelitis of the Osteomyelitis of great toe index finger metacarpal head secondary to clenched fist injury 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 17
  • 18. Osteomyelitis Osteomyelitis of Osteomyelitis of the index finger elbow. metacarpal head secondary to clenched fist injury. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 18
  • 19. Dx tests A physical examination shows bone tenderness and possibly swelling and redness. Tests may include: ◦ Blood cultures ◦ Bone biopsy (which is then cultured) ◦ Bone scan ◦ Bone x-ray ◦ Complete blood count (CBC) ◦ C-reactive protein (CRP) ◦ Erythrocyte sedimentation rate (ESR) ◦ MRI of the bone ◦ Needle aspiration of the area around affected bones 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 19
  • 20. Dx tests Diagnosis requires 2 of the 4 following criteria: ◦ Purulent material on aspiration of affected bone ◦ Positive findings of bone tissue or blood culture ◦ Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema ◦ Positive radiological imaging studyhttp://emedicine.medscape.com/article/785020-treatment 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 20
  • 21. Emergency Department Care Select the appropriate antibiotics using direct culture results in samples from the infected site, whenever possible. Further surgical management may involve removal of the nidus of infection, implantation of antibiotic beads or pumps, hyperbaric oxygen therapy,or other modalities.Nidus: a nest; A central point or focus of bacterial growth in a living organism.the point of origin or focus of a disease process.http://emedicine.medscape.com/article/785020-treatment 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 21
  • 22. Treatment Treatment is difficult & costly. Goal of treatment ◦ complete removal of necrotic bone & affected soft tissue ◦ control of infection & elimination of dead space (after removal of necrotic bone).
  • 23. Treatment The primary treatment for osteomyelitis ◦ parenteral (IV) antibiotics that penetrate bone and joint cavities for at least 4-6 weeks. ◦ After intravenous antibiotics are initiated on an inpatient basis, therapy may be continued with intravenous or oral antibiotics, depending on the type and location of the infection, on an outpatient basis. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 23
  • 24. Antibiotics Nafcillin (Nafcil, Unipen) Ceftriaxone (Rocephin) Cefazolin (Ancef) Ciprofloxacin (Cipro) Ceftazidime (Fortaz, Ceptaz) Clindamycin (Cleocin) Vancomycin (Vancocin) Linezolid (Zyvox) 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 24
  • 25. Treatment Surgery ◦ to remove dead bone tissue if have an infection that does not go away. ◦ If there are metal plates near the infection, they may need to be removed. ◦ The open space left by the removed bone tissue may be filled with bone graft or packing material that promotes the growth of new bone tissue. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 25
  • 26. Treatment Infection of an orthopedic prosthesis, such as an artificial joint, may need surgery to remove the prosthesis and infected tissue around the area. If have diabetes- need to be well controlled. If problems with blood supply to the infected area, such as the foot, surgery to improve blood flow may be needed. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 26
  • 27. Nursing managementuse of aseptic technique during dressingchanges.Observed for S/S of systemic infection, &administered antibiotic on time.ROM exercises are encouraged toprevent contractures & flexiondeformities & participation in ADL to thefullest extent is encouraged.
  • 28. Expectations (prognosis) markedly improved with timely diagnosis and aggressive therapeutic intervention. The outlook is worse for those with long- term (chronic) osteomyelitis, even with surgery. ◦ Amputation may be needed, especially in those with diabetes or poor blood circulation. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 28
  • 29. Expectations (prognosis) The outlook for those with an infection of an orthopedic prosthesis depends, in part, on: ◦ The patients health ◦ The type of infection ◦ Whether the infected prosthesis can be safely removed 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 29
  • 30. Complications Bone abscess Paravertebral/epidural abscess Bacteremia Fracture Loosening of the prosthetic implant Overlying soft-tissue cellulitis Draining soft-tissue sinus tracts 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 30
  • 31. Complications When the bone is infected, pus is produced in the bone, which may result in an abscess. The abscess steals the bones blood supply. The lost blood supply can result in a complication called chronic osteomyelitis. Other complications include: ◦ Need for amputation ◦ Reduced limb or joint function ◦ Spread of infection to surrounding tissues or the bloodstream 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 31
  • 32. Prevention Prompt and complete treatment of infections is helpful. People who are at high risk or who have a compromised immune system should see a health care provider promptly if they have signs of an infection anywhere in the body. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 32
  • 33. Deterrence/Prevention Acute hematogenous osteomyelitis ◦ can potentially be avoided by preventing bacterial seeding of bone from a remote site. ◦ This involves the appropriate diagnosis and treatment of primary bacterial infections. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 33
  • 34. Deterrence/Prevention Direct inoculation osteomyelitis ◦ can best be prevented with appropriate wound management and consideration of prophylactic antibiotic use at the time of injury. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 34
  • 35. SEPTIC ARTHRITIS 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 35
  • 36. Septic arthritis Septic arthritis is inflammation of a joint due to a bacterial or fungal infection. AKA: ◦ infectious arthritis ◦ Bacterial arthritis ◦ Non-gonococcal bacterial arthritis 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 36
  • 37. Causes Septic arthritis develops when bacteria or other tiny disease-causing organisms (microorganisms) spread through the bloodstream to a joint. It may also occur when the joint is directly infected with a microorganism from an injury or during surgery. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 37
  • 38. Causes most common sites - knee and hip. acute septic arthritis ◦ bacteria such as staphylococcus or streptococcus. chronic septic arthritis – ◦ less common ◦ caused by organisms such as Mycobacterium tuberculosisand Candida albicans. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 38
  • 39. Risk factors Artificial joint implants Bacterial infection somewhere else in your body Chronic illness or disease (such as diabetes, rheumatoid arthritis, and sickle cell disease) Intravenous (IV) or injection drug use Medications that suppress your immune system Recent joint injury Recent joint arthroscopy or other surgery 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 39
  • 40. Risk factors seen at any age. Children ◦ occurs most often in those younger than 3 years. ◦ The hip is often the site of infection in infants. uncommon from age 3 to adolescence. Children - more likely than adults infected with Group B streptococcus or Haemophilus influenza, if they have not been vaccinated. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 40
  • 41. Symptoms Symptoms usually come on quickly. Fever joint swelling - usually just one joint. intense joint pain- gets worse with movement. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 41
  • 42. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 42
  • 43. Symptoms in newborns or infants: Cries when infected joint is moved (example: diaper change causes crying if hip joint is infected) Fever Inability to move the limb with the infected joint (pseudoparalysis) Irritability 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 43
  • 44. Symptoms in children and adults: Inability to move the limb with the infected joint (pseudoparalysis) Intense joint pain Joint swelling Joint redness Low fever Chills may occur, but are uncommon 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 44
  • 45. Exams and Tests Aspiration of joint fluid for cell count, examination of crystals under the microscope, gram stain, and culture Blood culture X-ray of affected joint 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 45
  • 46. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 46
  • 47. Treatment Antibiotics are used to treat the infection. Joint Immobilization and Physical Therapy ◦ Resting, keeping the joint still, raising the joint, and using cool compresses may help relieve pain. ◦ Exercising the affected joint helps the recovery process. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 47
  • 48. Treatment Arthrocentesis ◦ If synovial fluid builds up quickly due to the infection, a needle may be inserted into the joint often to aspirate the fluid. Severe cases may need surgery to drain the infected joint fluid. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 48
  • 49. Treatment Medical management of infective arthritis focuses ◦ adequate and timely drainage of the infected synovial fluid, ◦ administration of appropriate antimicrobial therapy ◦ immobilization of the joint to control pain. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 49
  • 50. Antibiotic Therapy In native joint infections, parenteral antibiotics - at least 2 weeks. Infection with either methicillin-resistant S aureus (MRSA) or methicillin-susceptible S aureus (MSSA) - at least 4 full weeks IV antibiotic therapy. Orally administered antimicrobial agents are almost never indicated in the treatment of S aureus infections. Gram-negative native joint infections with a pathogen that is sensitive to quinolones can be treated with oral ciprofloxacin for the final 1-2 weeks of treatment. As a rule, a 2-week course of intravenous antibiotics is sufficient to treat gonococcal arthritis. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 50
  • 51. Antibiotics linezolid with or without rifampin - for staphylococcal prosthetic joint infection (PJI). Ceftriaxone (Rocephin) ◦ drug of choice (DOC) against N gonorrhoeae. ◦ This agent is effective against gram-negative enteric rods. ◦ Monitor sensitivity data. Ciprofloxacin (Cipro) ◦ alternative antibiotic to ceftriaxone to treat N gonorrhoeae and gram-negative enteric rods. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 51
  • 52. Antibiotics Cefixime (Suprax) ◦ a third-generation oral cephalosporin with broad activity against gram-negative bacteria. ◦ Oral cefixime is used as a follow-up to intravenous (IV) ceftriaxone to treat N gonorrhoeae. Oxacillin ◦ useful against methicillin-sensitive S aureus (MSSA). 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 52
  • 53. Antibiotics Vancomycin (Vancocin) ◦ anti-infective agent used against methicillin- sensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients allergic to penicillin. Linezolid (Zyvox) ◦ an alternative antibiotic that is used in patients allergic to vancomycin and for the treatment of vancomycin-resistant enterococci.http://emedicine.medscape.com/article/236299-medication#showall 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 53
  • 54. Joint Immobilization andPhysical Therapy Usually, immobilization of the infected joint to control pain is not necessary after the first few days. If the patients condition responds adequately after 5 days of treatment, begin gentle mobilization of the infected joint. Most patients require aggressive physical therapy to allow maximum postinfection functioning of the joint. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 54
  • 55. Joint Immobilization andPhysical Therapy Initial physical therapy consists of maintaining the joint in its functional position and providing passive ROM exercises. The joint should bear no weight until the clinical signs and symptoms of synovitis have resolved. Aggressive physical therapy is often required to achieve maximum therapy benefit. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 55
  • 56. Synovial Fluid Drainage The choice of the type of drainage, whether percutaneous or surgical, has not been resolved completely. In general, use a needle aspirate initially, repeating joint taps frequently enough to prevent significant reaccumulation of fluid. Aspirating the joint 2-3 times a day may be necessary during the first few days. If frequent drainage is necessary, surgical drainage becomes more attractive. Gonococcal-infected joints rarely require surgical drainage. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 56
  • 57. Synovial Fluid Drainage Surgical drainage is indicated when one or more of the following occur: ◦ The appropriate choice of antibiotic and vigorous percutaneous drainage fails to clear the infection after 5-7 days ◦ The infected joints are difficult to aspirate (eg, hip) ◦ Adjacent soft tissue is infected ◦ Routine arthroscopic lavage is rarely indicated. However, drainage through the arthroscope is replacing open surgical drainage. With arthroscopic drainage, the operator can visualize the interior of the joint and can drain pus, debride, and lyse adhesions. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 57
  • 58. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 58
  • 59. Surgical Intervention inProsthetic Joint Infection In cases of prosthetic joint infection (PJI) that require surgery for cure, successful treatment requires appropriate antibiotic therapy combined with removal of the hardware. Despite appropriate antibiotic use, the success rate has been only about 20% if the prosthesis is left in place. In recent years, evidence has shown that debridement alone could yield a cure rate of 74.5% of patients with a prosthetic joint infection and a C-reactive protein (CRP) level of 15 mg/dL or less who are treated with a fluoroquinolone. For the time being, a 2-stage approach should be regarded as the most effective technique. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 59
  • 60. Surgical Intervention inProsthetic Joint Infection First, remove the prosthesis and follow with 6 weeks of antibiotic therapy. Then, place the new joint, impregnating the methylmethacrylate cement with an anti- infective agent (ie, gentamicin, tobramycin). Antibiotic diffusion into the surrounding tissues is the goal. The success rate for this approach is approximately 95% for both hip and knee joints. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 60
  • 61. Surgical Intervention inProsthetic Joint Infection An intermediate method is to exchange the new joint for the infected joint in a 1- stage surgical procedure with concomitant antibiotic therapy. This method, with concurrent use of antibiotic cement, succeeds in 70-90% of cases. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 61
  • 62. Outlook (Prognosis) Recovery is good with prompt antibiotic treatment. If treatment is delayed, permanent joint damage may result. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 62
  • 63. Possible Complications Joint degeneration (arthritis) 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 63
  • 64. Prevention Strictly adhere to sterile procedures whenever the joint space is invaded (eg, in aspiration or arthroscopic procedures). Antibiotic prophylaxis ◦ with an antistaphylococcal antibiotic has been demonstrated to reduce wound infections in joint replacement surgery. ◦ Polymethylmethacrylate cement impregnated with antibiotics may decrease perioperative infections. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 64
  • 65. Prevention Treat any infection promptly to lessen the chance of bloodstream invasion. decreasing the incidence of underlying infections best prevents reactive arthritis 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 65
  • 66. References Espinoza LR. Infections of bursae, joints, and bones. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 290. Ohl CA. Infectious arthritis of native joints. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennetts Principles and Practice of Infectious Disease. 7th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 102. http://www.nlm.nih.gov/medlineplus/ency/article/0 00430.htm http://emedicine.medscape.com/article/236299- medication#showall 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 66
  • 67. REACTIVE ARTHRITIS 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 67
  • 68. Reactive arthritis AKA: Reiter syndrome; Post-infectious arthritis a sterile inflammatory process that usually results from an extra-articular infectious process. Bacteria are the most significant pathogens because of their rapidly destructive nature. 3/5/2012 Maria Carmela L. Domocmat, RN, MSN 68