Bone and Joint Infections Dr Kamran Afzal Classified Microbiologist
Osteomyelitis <ul><li>Classification:   </li></ul><ul><li>Duration   Acute, Subacute or Chronic </li></ul><ul><li>Route of...
Acute Pyogenic Osteomyelitis <ul><li>Definition: </li></ul><ul><li>AO is usually a bacterial infection of bone involving t...
Acute Pyogenic Osteomyelitis <ul><li>Incidence: </li></ul><ul><li>Age   more in children  </li></ul><ul><li>Sex   boys > g...
Acute Pyogenic Osteomyelitis <ul><li>Causative Organisms: </li></ul><ul><li>Age group Most common organisms </li></ul><ul>...
Acute Pyogenic Osteomyelitis <ul><li>Source of Infection:   </li></ul><ul><li>Hematogenous </li></ul><ul><li>Direct spread...
Acute Pyogenic Osteomyelitis <ul><li>Pathology: </li></ul><ul><li>Primary focus and stage of inflammation </li></ul><ul><l...
Acute Pyogenic Osteomyelitis <ul><li>Age variation </li></ul><ul><li>Neonates: </li></ul><ul><li>Extensive bone necrosis <...
Acute Pyogenic Osteomyelitis <ul><li>Age variation </li></ul><ul><li>Adults: </li></ul><ul><li>Commonly thoracolumbar spin...
Acute Pyogenic Osteomyelitis <ul><li>Clinical Pictures </li></ul><ul><li>Symptoms: </li></ul><ul><li>Severe pain, restless...
Acute Pyogenic Osteomyelitis <ul><li>Clinical Picture </li></ul><ul><li>Signs: </li></ul><ul><li>General </li></ul><ul><li...
Acute Pyogenic Osteomyelitis <ul><li>Radiography </li></ul><ul><li>Plain X-ray (normal in the first (10-14) days) </li></u...
Acute Pyogenic Osteomyelitis <ul><li>Differential Diagnosis </li></ul><ul><li>Acute Septic Arthritis </li></ul><ul><li>Acu...
Acute Pyogenic Osteomyelitis <ul><li>Treatment  </li></ul><ul><li>General: </li></ul><ul><li>Hospitalization </li></ul><ul...
Acute Pyogenic Osteomyelitis <ul><li>Treatment  </li></ul>
Acute Pyogenic Osteomyelitis <ul><li>Treatment  </li></ul><ul><li>Surgical Drainage: </li></ul><ul><ul><ul><li>Indications...
Acute Pyogenic Osteomyelitis <ul><li>Prognosis </li></ul><ul><li>Factors affecting prognosis: </li></ul><ul><li>Organisms ...
Acute Pyogenic Osteomyelitis <ul><li>Complications </li></ul><ul><li>Septicemia and metastatic abscesses </li></ul><ul><li...
Subacute Osteomyelitis <ul><li>Longer history and less virulent organism  </li></ul><ul><li>Insidious onset, mild symptoms...
Subacute Osteomyelitis <ul><li>Abnormal initial radiographs  </li></ul><ul><li>Inconclusive laboratory data  </li></ul><ul...
<ul><li>Brodie’s abscess </li></ul><ul><li>a well defined cavity  </li></ul><ul><li>in cancellous bone </li></ul>
Chronic Osteomyelitis <ul><li>Factors responsible for chronicity </li></ul><ul><li>Local factors:   </li></ul><ul><li>Cavi...
Chronic Osteomyelitis <ul><li>Types </li></ul><ul><li>A complication of Acute Osteomyelitis </li></ul><ul><li>Post traumat...
Chronic Osteomyelitis <ul><li>Organisms </li></ul><ul><li>Usually mixed infection </li></ul><ul><li>Mostly  Staph aureus, ...
Chronic Osteomyelitis <ul><li>Pathology </li></ul><ul><li>Cavities </li></ul><ul><li>Dead bone </li></ul><ul><li>Histologi...
Chronic Osteomyelitis <ul><li>Clinical picture </li></ul><ul><li>Continuous or intermittent suppuration  </li></ul><ul><li...
Chronic Osteomyelitis <ul><li>Investigations </li></ul><ul><li>Lab tests </li></ul><ul><li>Culture and sensitivity </li></...
 
Chronic Osteomyelitis <ul><li>Treatment </li></ul><ul><li>Antibiotics for 6 months </li></ul><ul><li>Surgical treatment  <...
Chronic Osteomyelitis <ul><li>Complications  </li></ul><ul><li>Recurrence and Recurrence and Recurrence </li></ul><ul><li>...
 
Acute Septic Arthritis <ul><li>Septic arthritis is usually a bacterial infection of the joint, as viral arthritis is usual...
Acute Septic Arthritis <ul><li>Organisms </li></ul><ul><li>Staphylococus aureus </li></ul><ul><li>Streptococcus  pyogenes ...
Acute Septic Arthritis <ul><li>Route of Infection </li></ul><ul><li>Direct invasion  penetrating wound </li></ul><ul><li>i...
Acute Septic Arthritis <ul><li>Pathology </li></ul><ul><li>Acute synovitis with purulent joint effusion </li></ul><ul><li>...
Acute Septic Arthritis <ul><li>Clinical Picture </li></ul><ul><li>General manifestations: </li></ul><ul><li>Constitutional...
Acute Septic Arthritis <ul><li>Investigations </li></ul><ul><li>Lab tests/ cultures  </li></ul><ul><li>Aspiration:   </li>...
Acute Septic Arthritis <ul><li>Differential Diagnosis </li></ul><ul><li>Acute osteomyelitis </li></ul><ul><li>Transient sy...
Acute Septic Arthritis <ul><li>Treatment </li></ul><ul><li>Aspiration  </li></ul><ul><li>Antibiotics  </li></ul><ul><li>Sp...
 
Tuberculosis - Clinical Features <ul><li>Contact with TB patient </li></ul><ul><li>Pain, swelling, loss of weight </li></u...
Tuberculosis - Pathology <ul><li>Primary complex (in the lung or the gut) </li></ul><ul><li>Secondary spread </li></ul><ul...
Tuberculosis - Diagnosis <ul><li>Long history </li></ul><ul><li>Involvement of single joint </li></ul><ul><li>Marked thick...
Tuberculosis - Investigations <ul><li>FBC, ESR </li></ul><ul><li>Mantoux  </li></ul><ul><li>Xray soft tissue swelling  </l...
Tuberculosis - Differential diagnosis <ul><li>Transient synovitis </li></ul><ul><li>Monoarticular </li></ul><ul><li>Haemor...
Tuberculosis - Treatment <ul><li>Chemotherapy </li></ul><ul><li>rifampicin  </li></ul><ul><li>isoniazid  8 weeks </li></ul...
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Bone+joint infections

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Bone+joint infections

  1. 1. Bone and Joint Infections Dr Kamran Afzal Classified Microbiologist
  2. 2. Osteomyelitis <ul><li>Classification: </li></ul><ul><li>Duration Acute, Subacute or Chronic </li></ul><ul><li>Route of infection Hematogenous or Exogenous </li></ul><ul><li>Host response Pyogenic or Granulomatous </li></ul>
  3. 3. Acute Pyogenic Osteomyelitis <ul><li>Definition: </li></ul><ul><li>AO is usually a bacterial infection of bone involving the periosteum, cortical bone and the medullary cavity </li></ul>Osteomyelitis of the tibia of a young child Numerous abscesses in the bone show as radioluscency
  4. 4. Acute Pyogenic Osteomyelitis <ul><li>Incidence: </li></ul><ul><li>Age more in children </li></ul><ul><li>Sex boys > girls </li></ul><ul><li>Bone affected all bones </li></ul><ul><li>Site of infection metaphysis </li></ul>
  5. 5. Acute Pyogenic Osteomyelitis <ul><li>Causative Organisms: </li></ul><ul><li>Age group Most common organisms </li></ul><ul><li>Newborns (< 4 mo) S. aureus , E. coli , Streptococcus (Gp A and B) </li></ul><ul><li>Children (aged 4 mo to 4 y) S. aureus , Strepto (Gp A and B), H. influenzae , E. coli, Pseudomonas </li></ul><ul><li>Children, adolescents </li></ul><ul><li>(aged 4 y to adult) S. aureus (80%), H. influenzae Strepto (Gp A and B), E. coli </li></ul><ul><li>Adult S. aureus , E. coli , Strepto </li></ul><ul><li>Sickle Cell Anemia Salmonella, S. aureus </li></ul>
  6. 6. Acute Pyogenic Osteomyelitis <ul><li>Source of Infection: </li></ul><ul><li>Hematogenous </li></ul><ul><li>Direct spread </li></ul><ul><li>Exogenous </li></ul>
  7. 7. Acute Pyogenic Osteomyelitis <ul><li>Pathology: </li></ul><ul><li>Primary focus and stage of inflammation </li></ul><ul><li>Spread of infection with pus formation </li></ul><ul><li>Formation of subperiosteal abscess </li></ul><ul><li>Pus tracks toward skin to form a sinus </li></ul><ul><li>Bone infarction (Sequestrum) </li></ul><ul><li>New bone formation (involucrum) </li></ul>
  8. 8. Acute Pyogenic Osteomyelitis <ul><li>Age variation </li></ul><ul><li>Neonates: </li></ul><ul><li>Extensive bone necrosis </li></ul><ul><li>Increased ability to absorb large sequestrum </li></ul><ul><li>Increased ability to remodel </li></ul><ul><li>Epiphysio-metaphyseal vascular connection leading to secondary septic arthritis </li></ul>
  9. 9. Acute Pyogenic Osteomyelitis <ul><li>Age variation </li></ul><ul><li>Adults: </li></ul><ul><li>Commonly thoracolumbar spine </li></ul><ul><li>Fever, backache </li></ul><ul><li>History of UTI or urological procedure </li></ul><ul><li>Old, diabetic, immunocompromised </li></ul><ul><li>No subperiosteal abscess due to adherent periosteum </li></ul><ul><li>Soft tissue abscess </li></ul><ul><li>Vascular connection with the joint leading to secondary septic arthritis </li></ul>
  10. 10. Acute Pyogenic Osteomyelitis <ul><li>Clinical Pictures </li></ul><ul><li>Symptoms: </li></ul><ul><li>Severe pain, restlessness </li></ul><ul><li>Malaise and fever </li></ul><ul><li>Toxemia </li></ul><ul><li>The limb is held still, reluctant to move </li></ul><ul><li>(pseudo paralysis) </li></ul>
  11. 11. Acute Pyogenic Osteomyelitis <ul><li>Clinical Picture </li></ul><ul><li>Signs: </li></ul><ul><li>General </li></ul><ul><li>Local </li></ul><ul><li>Laboratory Tests: </li></ul><ul><ul><li>CBC </li></ul></ul><ul><ul><li>ESR+CRP </li></ul></ul><ul><ul><li>Blood culture (+ve in 50-70%) </li></ul></ul><ul><ul><li>Aspiration </li></ul></ul><ul><ul><li>(Gram stain, culture and sensitivity) </li></ul></ul>
  12. 12. Acute Pyogenic Osteomyelitis <ul><li>Radiography </li></ul><ul><li>Plain X-ray (normal in the first (10-14) days) </li></ul><ul><li>Ultrasound </li></ul><ul><li>Bone, Technicium Tc99 and Gallium scan </li></ul><ul><li>(Sensitive but not specific) </li></ul><ul><li>CT scan </li></ul><ul><li>MRI </li></ul>
  13. 13. Acute Pyogenic Osteomyelitis <ul><li>Differential Diagnosis </li></ul><ul><li>Acute Septic Arthritis </li></ul><ul><li>Acute monoarticular rheumatoid arthritis </li></ul><ul><li>Sickle cell crisis </li></ul><ul><li>Cellulitis </li></ul><ul><li>Ewing’s Sarcoma </li></ul>
  14. 14. Acute Pyogenic Osteomyelitis <ul><li>Treatment </li></ul><ul><li>General: </li></ul><ul><li>Hospitalization </li></ul><ul><ul><li>Hydration </li></ul></ul><ul><ul><li>Electrolyte replacement </li></ul></ul><ul><ul><li>Analgesia </li></ul></ul><ul><ul><li>Immobilization </li></ul></ul><ul><ul><li>Splintage </li></ul></ul>
  15. 15. Acute Pyogenic Osteomyelitis <ul><li>Treatment </li></ul>
  16. 16. Acute Pyogenic Osteomyelitis <ul><li>Treatment </li></ul><ul><li>Surgical Drainage: </li></ul><ul><ul><ul><li>Indications? </li></ul></ul></ul><ul><ul><ul><li>Procedure? </li></ul></ul></ul><ul><ul><ul><li>Drilling? </li></ul></ul></ul><ul><ul><ul><li>Antibiotics: </li></ul></ul></ul><ul><ul><ul><li>Type? </li></ul></ul></ul><ul><ul><ul><li>Route? </li></ul></ul></ul><ul><ul><ul><li>When to start? </li></ul></ul></ul><ul><ul><ul><li>When to stop </li></ul></ul></ul><ul><ul><ul><li>Monitoring? </li></ul></ul></ul>
  17. 17. Acute Pyogenic Osteomyelitis <ul><li>Prognosis </li></ul><ul><li>Factors affecting prognosis: </li></ul><ul><li>Organisms </li></ul><ul><li>Infected Bone </li></ul><ul><li>Age of the Patient </li></ul><ul><li>Treatment </li></ul>
  18. 18. Acute Pyogenic Osteomyelitis <ul><li>Complications </li></ul><ul><li>Septicemia and metastatic abscesses </li></ul><ul><li>Septic arthritis </li></ul><ul><li>Growth disturbance (children) </li></ul><ul><li>Pathological fracture </li></ul><ul><li>Chronic osteomyelitis </li></ul>
  19. 19. Subacute Osteomyelitis <ul><li>Longer history and less virulent organism </li></ul><ul><li>Insidious onset, mild symptoms </li></ul><ul><li>Pain is the most consistent symptom </li></ul><ul><li>Usually no constitutional symptoms </li></ul>
  20. 20. Subacute Osteomyelitis <ul><li>Abnormal initial radiographs </li></ul><ul><li>Inconclusive laboratory data </li></ul><ul><li>Negative cultures/ biopsy </li></ul><ul><li>Difficult to distinguish from bone tumors e.g. Ewing’s, osteosarcoma </li></ul>
  21. 21. <ul><li>Brodie’s abscess </li></ul><ul><li>a well defined cavity </li></ul><ul><li>in cancellous bone </li></ul>
  22. 22. Chronic Osteomyelitis <ul><li>Factors responsible for chronicity </li></ul><ul><li>Local factors: </li></ul><ul><li>Cavity, sequestrum, sinus, foreign body, degree of bone necrosis </li></ul><ul><li>General: </li></ul><ul><li>Nutritional status of the involved tissues, vascular disease, DM, low immunity </li></ul><ul><li>Organism: </li></ul><ul><li>Virulence </li></ul><ul><li>Treatment: </li></ul><ul><li>Appropriateness and compliance </li></ul><ul><li>Risk factors: </li></ul><ul><li>Penetrating trauma, prosthesis, animal bite </li></ul>
  23. 23. Chronic Osteomyelitis <ul><li>Types </li></ul><ul><li>A complication of Acute Osteomyelitis </li></ul><ul><li>Post traumatic </li></ul><ul><li>Post operative </li></ul>
  24. 24. Chronic Osteomyelitis <ul><li>Organisms </li></ul><ul><li>Usually mixed infection </li></ul><ul><li>Mostly Staph aureus, E. Coli, Strep pyogenes, Proteus </li></ul>
  25. 25. Chronic Osteomyelitis <ul><li>Pathology </li></ul><ul><li>Cavities </li></ul><ul><li>Dead bone </li></ul><ul><li>Histological picture is one of chronic inflammation </li></ul>
  26. 26. Chronic Osteomyelitis <ul><li>Clinical picture </li></ul><ul><li>Continuous or intermittent suppuration </li></ul><ul><li>Sinus formation with acute exacerbations </li></ul><ul><li>Pain, fever, redness, and tenderness during acute exacerbations </li></ul><ul><li>Discharging sinus with +ve/-ve culture </li></ul><ul><li>Pathological fracture </li></ul>
  27. 27. Chronic Osteomyelitis <ul><li>Investigations </li></ul><ul><li>Lab tests </li></ul><ul><li>Culture and sensitivity </li></ul><ul><li>Biopsy </li></ul><ul><li>Plain X-ray: </li></ul><ul><li>Bone rarefaction surrounded by the dense sclerosis, sequestration and cavity formation </li></ul><ul><li>Sinogram </li></ul><ul><li>Bone scan and gallium scan </li></ul><ul><li>To detect chronic multifocal osteomyelitis </li></ul><ul><li>CT Scan and MRI </li></ul>
  28. 29. Chronic Osteomyelitis <ul><li>Treatment </li></ul><ul><li>Antibiotics for 6 months </li></ul><ul><li>Surgical treatment </li></ul><ul><li>Preoperative assessment and preparation </li></ul><ul><li>Derbridement </li></ul><ul><li>Sequestrectomy </li></ul><ul><li>Local antibiotics </li></ul><ul><li>Stability </li></ul><ul><li>Treatment of bone cavity </li></ul>
  29. 30. Chronic Osteomyelitis <ul><li>Complications </li></ul><ul><li>Recurrence and Recurrence and Recurrence </li></ul><ul><li>Pathological fractures </li></ul><ul><li>Growth disturbance </li></ul><ul><li>Amyloid disease </li></ul><ul><li>Epidermoid carcinoma of the fistula </li></ul>
  30. 32. Acute Septic Arthritis <ul><li>Septic arthritis is usually a bacterial infection of the joint, as viral arthritis is usually self limiting and treatment is supportive </li></ul><ul><li>Vertebral body </li></ul><ul><li>Large joints </li></ul><ul><li>50% of cases in children <3 years </li></ul><ul><li>The hip joint is the common site in <3years </li></ul><ul><li>The knee joint is more common in older children </li></ul>
  31. 33. Acute Septic Arthritis <ul><li>Organisms </li></ul><ul><li>Staphylococus aureus </li></ul><ul><li>Streptococcus pyogenes </li></ul><ul><li>Escherichia coli </li></ul><ul><li>Haemophilus influenzae </li></ul>
  32. 34. Acute Septic Arthritis <ul><li>Route of Infection </li></ul><ul><li>Direct invasion penetrating wound </li></ul><ul><li>intra articular inj </li></ul><ul><li>arthroscopy </li></ul><ul><li>Eruption of bone abscess </li></ul><ul><li>Haematogenous </li></ul>
  33. 35. Acute Septic Arthritis <ul><li>Pathology </li></ul><ul><li>Acute synovitis with purulent joint effusion </li></ul><ul><li>Articular cartilage attacked by bacterial toxin and cellular enzyme </li></ul><ul><li>Complete destruction of the articular cartilage </li></ul>
  34. 36. Acute Septic Arthritis <ul><li>Clinical Picture </li></ul><ul><li>General manifestations: </li></ul><ul><li>Constitutional symptoms and signs of acute infection </li></ul><ul><li>Local manifestation: </li></ul><ul><li>Swelling, hotness and redness </li></ul><ul><li>Deformity with muscle spasm </li></ul><ul><li>Restriction of all movements of the joint </li></ul><ul><li>The joint is fixed in the position of ease </li></ul>
  35. 37. Acute Septic Arthritis <ul><li>Investigations </li></ul><ul><li>Lab tests/ cultures </li></ul><ul><li>Aspiration: </li></ul><ul><li>If WBC >50,000 with >90% PMNLs suspect septic arthritis even if culture is negative </li></ul><ul><li>Plain X-ray </li></ul><ul><li>Bone scan and Gallium scan </li></ul><ul><li>Ultrasound </li></ul>
  36. 38. Acute Septic Arthritis <ul><li>Differential Diagnosis </li></ul><ul><li>Acute osteomyelitis </li></ul><ul><li>Transient synovitis of the hip (<10) </li></ul><ul><li>Acute rheumatic fever </li></ul><ul><li>Haemarthrosis </li></ul><ul><li>Haemophilic arthritis </li></ul>
  37. 39. Acute Septic Arthritis <ul><li>Treatment </li></ul><ul><li>Aspiration </li></ul><ul><li>Antibiotics </li></ul><ul><li>Splintage </li></ul><ul><li>Surgical drainage </li></ul><ul><li>Treatment of complications </li></ul>
  38. 41. Tuberculosis - Clinical Features <ul><li>Contact with TB patient </li></ul><ul><li>Pain, swelling, loss of weight </li></ul><ul><li>Joint swelling </li></ul><ul><li>Ankylosis </li></ul><ul><li>Deformity </li></ul>
  39. 42. Tuberculosis - Pathology <ul><li>Primary complex (in the lung or the gut) </li></ul><ul><li>Secondary spread </li></ul><ul><li>Tuberculous granuloma </li></ul>
  40. 43. Tuberculosis - Diagnosis <ul><li>Long history </li></ul><ul><li>Involvement of single joint </li></ul><ul><li>Marked thickening of the synovium </li></ul><ul><li>Marked muscle wasting </li></ul><ul><li>Periarticular osteoporosis </li></ul><ul><li>+ve Mantoux test </li></ul>
  41. 44. Tuberculosis - Investigations <ul><li>FBC, ESR </li></ul><ul><li>Mantoux </li></ul><ul><li>Xray soft tissue swelling </li></ul><ul><li> periarticular osteoporosis </li></ul><ul><li>joint appear washed out articular space narrowing </li></ul><ul><li>Joint aspiration AFB identified in 10-20% </li></ul><ul><ul><ul><ul><ul><li>culture +ve in 50% of cases </li></ul></ul></ul></ul></ul>
  42. 45. Tuberculosis - Differential diagnosis <ul><li>Transient synovitis </li></ul><ul><li>Monoarticular </li></ul><ul><li>Haemorrhagic arthritis </li></ul><ul><li>Pyogenic arthritis </li></ul>
  43. 46. Tuberculosis - Treatment <ul><li>Chemotherapy </li></ul><ul><li>rifampicin </li></ul><ul><li>isoniazid 8 weeks </li></ul><ul><li>ethambutol </li></ul><ul><li> rifampicin and isoniazid 6-12 month </li></ul><ul><li>Rest and splintage </li></ul><ul><li>Operative drainage rarely necessary </li></ul>

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