2. 2
It was "reliable" if the specimen was not so contaminated. Differences in the incidence of various
species of bacteria isolated from unreliable versus reliable sources were noted.
Deep surgical specimens from 250 patients with diabetic foot ulcers and bone biopsies from 250
patients with osteomyelitis of one of the bones of the foot were cultured by Klainer and Bisaccia.
Many other species of aerobes and anaerobes have been isolated and the importance of these
species should not be underestimated.
The variation in species identification procedures from different laboratories and changes in taxonomic
classification contribute to confusion in comparing different studies. Some authors grouped organisms
belonging to Peptostreptococcus, Peptococcus, Porphyromonas (formerly Bacteroides), Prevotella
(formerly Bacteroides), or Clostridium genera without speciating. Peptostreptococcus magnus,
Peptostreptococcus prevotii, Peptostreptococcus asaccharolyticus, and Peptostreptococcus anaerobius
represented 58% of anaerobes isolated by Lambe and Ferguson. Porphyromonas asaccharolytica
(formerly Bacteroides asaccharolyticus), and Prevotella intermedia (formerly Bacteroides intermedius)
were reported only by Lambe and Ferguson; these two species plus Prevotella melaninogenica
(formerly Bacteroides melaninogenicus) comprised 12% of anaerobes isolated.
More recent studies that speciated anaerobes reported a high incidence of anaerobes, including P.
asaccharolytica, P. intermedia, P. melaninogenica, Bacteroides fragilis, other Bacteroides species,
members of the genus Peptostreptococcus including P. magnus, P. prevotii, P. asaccharolyticus, P.
anaerobius, other Peptostreptococcus species, anaerobic Streptococcus species, Peptococcus species,
Veillonella parvula, Propionibacterium species, and various species of Clostridium, including C.
perfringens. The ten most common anaerobic species isolated by Lambe included P. magnus, P.
prevotii, P. asaccharolyticus, P. asaccharolytica , Propionibacterium acnes, B. fragilis, P. anaerobius, P.
melaninogenica, V. parvula, and Eubacterium lentum.
Two important points are noteworthy. Black pigmented anaerobes, including P. asaccharolytica, P.
melaninogenica, and P. intermedia, the twelfth most common anaerobe isolated by Lambe, were
isolated with very high frequency from these infections. These extremely fastidious anaerobes were
notably absent in reports of many studies. These, and other fastidious, organisms require freshly
prepared, reduced or pre-reduced, anaerobically sterilized (PRAS) agar media and an incubation period
of up to ten days for growth. Many strains of the genera Prevotella and Porphyromonas may take
seven to ten days of incubation to grow and produce black pigment. Secondly, E. lentum, another
slow-growing anaerobe, may take seven or more days to produce visible colonies. The identification
of the black pigmenting anaerobic bacilli (P. asaccharolytica, P. melaninogenica, and P. intermedia) is
important because this group of bacilli produce important toxins such as endotoxin, collagenase,
fibrinolysin, deoxyribonuclease and ribonuclease. This group of bacilli are important pathogens in head
and neck infections as well as in diabetic foot infections.
Anaerobic bacteria are particularly prevalent in more serious infections, such as necrotizing infections
and those involving osteomyelitis. Sapico reported that anaerobes outnumbered aerobes 10:1 in a
study in which deep tissue samples were cultured.
Mode of Bacterial Growth in Diabetic Infections and Osteomyelitis
3. 3
In about one-third of diabetic patients hospitalized with foot infections, the soft tissue infection spreads
to the medullary cavity of the bone, causing osteomyelitis. Osteomyelitis generally requires longer term
antibiotic therapy than soft tissue infections and surgical intervention is frequently necessary.
Numerous reports have reviewed the microbiology of osteomyelitis. Generally, there are two types of
osteomyelitis, with different organisms involved. Acute osteomyelitis is frequently found in children
with associated skin or soft tissue infections, or in adults associated with intravenous drug abuse.
These infections usually involve one organism, frequently S. aureus, and respond well to antimicrobial
therapy. Chronic osteomyelitis is usually associated with an older age group, and may follow trauma
or skeletal surgery, frequently with the implantation of a prosthetic device. Lower extremities are
usually involved. The microbiology of this type of osteomyelitis is quite different from acute
osteomyelitis, and is much more difficult to treat. There is usually a polymicrobic infection, involving
anaerobes and aerobes.
Until several years ago, the incidence of anaerobes in bone infection was underestimated. An early
report by Taylor and Davies demonstrated that anaerobes were common in long bones of patients
secondary to war injuries. Their techniques of anaerobic isolation and identification were primitive
compared with those of today, and clostridia were primarily isolated. Although sporadic reports of
anaerobic involvement in osteomyelitis appeared throughout the century, the importance of anaerobes
was not emphasized until Ziment's 1968 report in which he described features of osteomyelitis
involving anaerobes, including foul odor, Gram stain results, failure to isolate aerobic pathogens, soft
tissue gas, and the presence of black discharge and necrotic tissue. Specimens from seventeen patients
with foot infections (eight cases), skull infections (five cases) and long bone infections (four cases) all
yielded anaerobes, including B. fragilis, Peptostreptococcus, Peptococcus, Sphaerophorus,
Fusobacterium and Bifidobacterium. With the improvement of transport and culture techniques for
anaerobes, the importance of these organisms in osteomyelitis became apparent. Lewis' review of
anaerobes in bone infections, through 1975, cites over 700 cases of anaerobic osteomyelitis reported in
the literature. The anaerobes most frequently isolated have been B. fragilis, black pigmented anaerobic
Gram negative rods, and anaerobic cocci, although numerous species of anaerobes have been reported
The longer duration of chronic disease, the more anaerobic species are isolated.
Generally, surgery is required, with removal of necrotic tissue and any implanted foreign body, along
with long-term antibiotic therapy. Gristina has emphasized the importance of adherent bacteria in the
persistence of osteomyelitis.
Bacterial Glycocalyx
The role of bacterial growth on a bone surface contributes to development and persistence of chronic
diseases such as osteomyelitis. The mode of growth involves the glycocalyx in a network of exo-
polysaccharide polymers elaborated by bacteria. The term glycocalyx includes bacterial capsule and
"slime" which detaches from the cell, floats away and adheres to surrounding tissue.
This glycocalyx mediates attachment of the bacterial cells to each other, forming microcolonies, and to
a wide variety of surfaces including substrates in the natural environment, bone, and artificial
4. 4
prostheses. The microcolonies form thick biofilms composed of bacteria and glycocalyx, which render
the bacteria resistant to surfactants, antibiotics, and to destruction by host defense mechanisms such as
antibodies and phagocytosis.
Bacterial glycocalyces are present in chronic diseases such as cystic fibrosis, and in foreign body related
infections. The glycocalyx therefore plays a role in the persistence of many chronic diseases, including
osteomyelitis. Ultrastructural studies in animal models of experimentally induced osteomyelitis have
shown that glycocalyces are formed by S. aureus, Prevotella bivia (formerly Bacteroides bivius),
Prevotella disiens (formerly Bacteroides disiens), Bacteroides thetaiotaomicron, B. fragilis, and P.
intermedia The same mode of growth observed in animal models is seen in human Osteomyelitis.
Foreign bodies such as surgically implanted biomaterials and prosthetic devices, are reported to
enhance infection rates, presumably by serving as substrates for sessile, glycocalyx-enclosed
microorganisms.
Osteomyelitis is a disease that is recalcitrant to medical and surgical forms of treatment, although
reasons for this were unknown until the role of the glycocalyx was elucidated. We established several
rabbit models of osteomyelitis which demonstrated that the mode of bacterial growth and the
production of glycocalyx were important factors in treating osteomyelitis. A description of these
animal models and the mode of bacterial growth follow.
Staphylococcus aureus Rabbit Model of Osteomyelitis
Osteomyelitis was induced in the rabbit using S. aureus . A piece of silicone-coated rubber catheter
(foreign body) was surgically implanted in the marrow cavity of a rabbit tibia, with the introduction of a
sclerosing agent and bacterial cells. Osteomyelitis developed in 60% of animals infected with S.
aureus, as determined by radiologic and histologic examination. Organisms were recovered from
infected samples of animals with osteomyelitis. Samples of bone marrow, bone chips and foreign
bodies were examined by transmission (TEM) and scanning electron microscopy (SEM). Infection
with the accompanying production of glycocalyx advanced from the injection site into nearby bone
and the foreign body.
The model of osteomyelitis in the rabbit shares many similarities with the human disease. Animals
which developed osteomyelitis showed weight loss and radiological evidence of progressive disease.
Histological samples of rabbit tibia showed striking morphological changes in infected animals
consistent with a diagnosis of osteomyelitis. This model showed a high rate of induction of
osteomyelitis, with recovery of S. aureus in pure culture from infected tibia, and gram (+) positive
cocci were seen histologically.
Ultrastructural studies performed using this model showed that large quantities of S. aureus glycocalyx
was present in the infection. TEM of samples from bone scrapings and bone marrow showed
microcolonies of Gram-positive cocci surrounded by glycocalyx either condensed on the bacterial cell
surface or in a fibrous intracellular network. Material from the interior of the foreign body showed
masses of Gram (+) positive cocci embedded in glycocalyx. It appears that this mode of growth, that
is, large amounts of glycocalyx surrounding masses of bacterial microcolonies, is typical of
osteomyelitis. Thus, it is not surprising that this disease is so difficult to treat with antibiotics which fail
5. 5
to penetrate the glycocalyx.
Normal topographical features of the bone were altered dramatically by copious material adhering to
the bone. Further magnification of this material revealed coccoid forms embedded in a matrix of
accreted material. The accretions were observed on the interior and exterior surfaces of the foreign
body. The accreted material observed for the rabbit model of osteomyelitis was far more extensive
than has been previously described for the adhesion of uropathogens to polypropylene surfaces.
S. aureus cells in this rabbit model grew in thick, adherent, glycocalyx-enclosed biofilms. This
aggregated mode of growth of the pathogen presented a fibrous exopolysaccharide bacterial cell
surface to the host defense mechanisms and a thick anionic barrier to the penetration of antibiotics.
This mode of growth helps to explain the persistence of these pathogens in osteomyelitis.
Additional Rabbit Models of Osteomyelitis with Gram-Negative Anaerobes
and Staphylococcus
Following the development of the S. aureus osteomyelitis rabbit model, other bacteria were studied in
this animal model to determine if a similar mode of growth was occurring with certain Gram (-)
negative anaerobes and staphylococci. The organisms examined included B. fragilis, B.
thetaiotaomicron, P. bivia, P. disiens, S. aureus, and S. epidermidis, alone or in combination. The
mode of growth and the formation of glycocalyx found with these bacteria in osteomyelitis was similar
to that observed with S. aureus alone. A description of the bacterial growth on the foreign body, in
bone marrow and on the bone surface follows.
The pathogenicity of the organisms tested in the rabbit model varied. B. fragilis induced osteomyelitis
at high rates, alone or in combination with S. epidermidis. The B. fragilis isolate when the rabbit model
came from a patient with osteomyelitis, and such strains are more virulent than strains isolated from
other types of clinical infection. B. thetaiotaomicron and S. epidermidis can induce alone or in
combination.
However, the incidence of osteomyelitis is higher in polymicrobic infection (95%) than in animals
infected with either species alone. In addition, the presence of foreign body enhanced the incidence of
osteomyelitis monoinfected in rabbits. However, when in combination with S. epidermidis, 73% of
rabbits developed osteomyelitis, compared with 25% infected with S. epidermidis alone. Thus,
there is an important synergistic relationship between S. epidermidis and certain anaerobic negative
bacilli.
Treatment of Staphylococcal Osteomyelitis with Clindamycin
After induction of experimental osteomyelitis with S. aureus, animals were treated with clindamycin
phosphate for one, two or three week periods. SEM of infected bone samples showed masses of
coccoid profiles embedded in a matrix of condensed glycocalyx. This material was present in untreated
animals and those treated with clindamycin for one week. After two to three weeks of clindamycin
treatment, SEM revealed few coccoid profiles adhering to the bone and marrow. Cultures of bone
6. 6
marrow and bone were negative. Many aspects of the rabbit model of osteomyelitis are quite similar to
human osteomyelitis. Roentgenologic evidence of progressive disease was seen in animals with
osteomyelitis, and histologic observations showed changes in the tissues consistent with human
osteomyelitis. Infecting microorganisms can also be recovered from sites of infection in the animal
model, as with human osteomyelitis.
Human Osteomyeltitis
Ultrastructural studies of specimens from patients with osteomyelitis show that the mode of bacterial
growth is the same in human and experimentally induced osteomyelitis. A 69-year-old diabetic male
developed osteomyelitis in the right hallux, which was amputated. A pre-surgical specimen cultured by
the hospital clinical laboratory yielded beta-hemolytic Streptococcus and Staphylococcus. A portion of
bone from the amputated toe cultured in the hospital laboratory was negative for anaerobes and
aerobes. Another portion of the bone was placed in a sterile Petri plate in an anaerobe jar, and
transported to an anaerobe chamber within 20 minutes of removal from the patient. Culture of this
bone yielded no aerobes, but the anaerobes B. fragilis, P. asaccharolytica, P. anaerobius, P. magnus,
and P. acnes were found. SEM of the bone surface showed bacilli connected by strands of glycocalyx.
Another bone surface at a greater magnification showed a bacillus surrounded by a profusion of
glycocalyx strands.
Influence of Glycocalyx on Infection
In an in vitro study to examine the effect of sub-inhibitory concentrations of clindamycin on the
adherence of bacteria to bone, S. aureus and P. intermedia were grown in broth media containing discs
of rabbit tibia in the absence or presence of varying concentrations of clindamycin.
In the absence of clindamycin, S. aureus colonized the bone surface extensively, and formed large
microcolonies surrounded by glycocalyx. When grown in 0.1 minimal inhibitory concentration (MIC)
of clindamycin, S. aureus adherence to bone surfaces decreased 80% with fewer and smaller
microcolonies present. At a concentration of 0.25 MIC clindamycin, only a rare microcolony was
seen, with most of the bone surface uncolonized. No colonization occurred at 0.5 MIC clindamycin.
Another SEM shows colonization of the bone surface by P. intermedia in the absence of antibiotic.
Unlike S. aureus, 0.1 MIC clindamycin had little effect upon adherence of P. intermedia. A
concentration of 0.25 MIC clindamycin was required to dislodge 80% of P. intermedia from the bone.
At a concentration of 0.5 MIC clindamycin, single cells and small microcolonies were observed, with
bone surface visible. With 1.0 MIC clindamycin no colonization was observed.
Inhibition of Phagocytosis by Glycocalyx
Veringa showed that subinhibitory concentrations of clindamycin and trospectomycin significantly
enhanced the phagocytosis of glycocalyx-enclosed Bacteroides. Without antibiotic treatment, few
bacterial cells were phagocytized. The bacterial cells that were phagocytized contained little or no
glycocalyx. A moderate amount of glycocalyx was observed surrounding B. thetaiotaomicron, but a
thick layer surrounded B. fragilis clindamycin treated cells. Homologous, or heterologous glycocalyx
7. 7
added to preopsonized, preadhered B. fragilis, B. thetaiotaomicron, or S. epidermidis prior to
incubation with polymorphonuclear leukocytes has no effect upon phagocytosis of untreated bacteria,
because the untreated bacterial cells already had glycocalyx that was antiphagocytic. However, when
isolated glycocalyx from B. thetaiotaomicron or B. fragilis was added to clindamycin or
trospectomycin treated bacteria, phagocytosis was significantly reduced.
This effect of glycocalyx on phagocytosis was quantitative, the more glycocalyx added, the less
phagocytosis. The antibiotic altered the glycocalyx in some unknown way so that the glycocalyx was
no longer antiphagocytic. The decrease in phagocytosis caused by the addition of glycocalyx to
antibiotic treated cells demonstrates that glycocalyx per se is antiphagocytic. Glycocalyx preparations
from Bacteroides and Staphylococcus significantly inhibited the chemiluminescence and chemotactic
responses of viable polymorphonuclear leukocytes, without toxicity to the polymorphonuclear
leukocytes. These studies showed that the glycocalyx specifically inhibits phagocytosis,
chemiluminescence, and chemotactic responses of viable PMNs. Certain other antibiotics such as
amdinocillin, ceftriazone and ciprofloxacin did not alter the glycocalyx, thus they did not enhance
phagocytosis.
Inhibition of Lymphocyte Proliferation by Glycocalyx
Ten to 100 μg/ml glycocalyx isolated from Staphylococcus lugdunensis or S. epidermidis and
partially purified under endotoxin-free conditions inhibited the phytohemagglutinin-stimulated
proliferation of peripheral blood mononuclear cells.
When peripheral blood mononuclear cells were depleted of adherent monocytes, the
phytohemagglutinin-stimulated proliferation of nonadherent cells (PBL) occurred in the presence or
absence of glycocalyx. Therefore, the mechanism of glycocalix mediated inhibition required the
presence of adherent monocytes. Culture supernatants of monocytes stimulated by glycocalyx
contained a soluble factor which inhibited proliferation of monocyte depleted peripheral blood
mononuclear cells.
The soluble factor was not produced in the absence of glycocalyx. Nor was it produced when
glycocalyx was added to peripheral blood mononuclear cells along with indomethacin, which inhibits
the synthesis of prostaglandin E2, a product of adherent blood monocytes. Therefore, the glycocalyx
does not have a direct effect upon T lymphocytes, but rather inhibits proliferation indirectly by
stimulating monocyte production of prostaglandin E2, which in turn inhibits lymphocyte proliferation.
Concluding Remarks
The role of bacteria in diabetic foot infections, and the number and species of aerobic and anaerobic
microorganisms, were reviewed in this section. The role of glycocalyx and several models of animal
and human osteomyelitis were also presented. Finally, the treatment of staphylococcal osteomyelitis
with the antibiotic clindamycin, was elucidated. It may be important that you be aware of this material
for board certification examinations.
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Additional References:
Stapp, M and Taylor, R: Edema, Hematoma and Infection. McGlamry’s Comprehensive
Textbook of Foot and Ankle Surgery. Lippincott, Williams Wilkins, Baltimore, 2002.
Oloff, L: Osteomyelitis. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery.
Lippincott, Williams and Wilkins, Baltimore, 2002.
Noll. J: Hemostasis: McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery.
Lippincott, Williams and Wilkins, Baltimore, 2002.
Malay, S: Nail Trauma. McGlamry’s Comprehensive Textbook of Foot and Ankle
Surgery. Lippincott, Williams and Wilkins, Baltimore, 2002.
Wallace, G: Nonosseous Injuries. McGlamry’s Comprehensive Textbook of Foot and
Ankle Surgery. Lippincott, Williams and Wilkins, Baltimore, 2002.
