Chronic recurrent multifocal osteomyelitis (CRMO) is a little known inflammatory bone disease occurring primarily in children and adolescents. Delays in referral and diagnosis may lead to prolonged ...courses of antibiotics with in-patient care, unnecessary radiation exposure from multiple plain radiographs or bone scans and repeated surgery including bone biopsies. Children (aged < 18 years) diagnosed with CRMO between January 2005 and December 2012, reviewed at Bristol Royal Hospital for Children were included and all available data collected. Information regarding CRMO was sent to all orthopaedic surgeons in the region in 2009. The aim of the study was to examine the features of the cohort, to examine the length of time to diagnosis and to explore the criteria used for diagnosis with and without biopsy.
Over an 8 year period, 41 patients were diagnosed with CRMO. Symptom onset occurred at a median of 9 years of age and time to diagnosis had a median of 15 months (range 0-92). Correlation coefficient analysis for time to diagnosis by year showed statistical significance with a decreasing trend. From the cohort data, diagnostic criteria were developed; applied retrospectively, 34 (83 %) children may have been diagnosed using the criteria, without a biopsy.
The data suggest that increasing knowledge of this condition may shorten time to diagnosis. Use of the Bristol diagnostic criteria by an experienced clinician may obviate the need for biopsy in some patients.
Osteomyelitis Schmitt, Steven K
Infectious disease clinics of North America,
06/2017, Letnik:
31, Številka:
2
Journal Article
Recenzirano
Osteomyelitis is an ancient disease with varied pathophysiology. The several clinical syndromes associated with bone infection have specific clinical presentations and microbiology. Successful ...recognition and management of the disease requires a knowledge of these mechanisms and the organisms most common in each. Diagnosis is made by a combination of clinical examination, supportive blood testing, and appropriate radiography. With these elements in place, patient presentation can be placed in the framework of a staging system, which often helps to suggest the appropriate mix of antimicrobial and surgical therapies.
Little information is available concerning the natural history and optimal treatment of chronic nonbacterial osteomyelitis (CNO). We conducted a retrospective review to assess the clinical ...characteristics and treatment responses of a large cohort of pediatric CNO patients.
Children diagnosed with CNO at 3 tertiary care centers in the United States between 1985 and 2009 were identified. Their charts were reviewed, and clinical, laboratory, histopathologic, and radiologic data were extracted.
Seventy children with CNO (67% female patients) were identified. Median age at onset was 9.6 years (range 3-17), and median follow-up was 1.8 years (range 0-13). Half of the patients had comorbid autoimmune diseases, and 49% had a family history of autoimmunity. Patients with comorbid autoimmune diseases had more bone lesions (P < .001), higher erythrocyte sedimentation rate (P < .05), and higher use of second line therapy (P = .02). Treatment response to nonsteroidal antiinflammatory drugs (NSAIDs), sulfasalazine, methotrexate, tumor necrosis factor α inhibitors, and corticosteroids was evaluated. The only significant predictor of a positive treatment response was the agent used (P < .0001). Estimated probability of response was 57% for NSAIDs, 66% for sulfasalazine, 91% for methotrexate, 91% for tumor necrosis factor α inhibitors, and 95% for corticosteroids.
In a US cohort of 70 children with CNO, coexisting autoimmunity was a risk factor for multifocal involvement and treatment with immunosuppressive agents. Disease-modifying antirheumatic drugs and biologics were more likely to lead to clinical improvement than NSAIDs.
Many infections of the musculoskeletal system are biofilm infections that develop on non‐living surfaces. Microorganisms adhere either on dead bone (sequesters) or implants. As a rule for a curative ...concept, chronic osteomyelitis or implant‐associated bone infection must be treated with a combination of surgery and antimicrobial therapy. If an implant is kept in place, or a new device is implanted before complete healing of infection, a biofilm‐active antibiotic should be used. Rifamycins are active against biofilms of staphylococci, and fluoroquinolones against those of Gram‐negative bacilli. In this review, the management of chronic osteomyelitis, periprosthetic joint infection and implant‐associated osteomyelitis of long bones is presented.
Recommendations
Classification/diagnosis
Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low).
Assess the ...severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate).
Osteomyelitis
For an infected open wound, perform a probe‐to‐bone test; in a patient at low risk for osteomyelitis, a negative test largely rules out the diagnosis, while in a high‐risk patient, a positive test is largely diagnostic (strong; high).
Markedly elevated serum inflammatory markers, especially erythrocyte sedimentation rate, are suggestive of osteomyelitis in suspected cases (weak; moderate).
A definite diagnosis of bone infection usually requires positive results on microbiological (and, optimally, histological) examinations of an aseptically obtained bone sample, but this is usually required only when the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial (strong; moderate).
A probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe‐to‐bone, serum inflammatory markers, plain X‐ray, magnetic resonance imaging (MRI) or radionuclide scanning (strong; weak).
Avoid using results of soft tissue or sinus tract specimens for selecting antibiotic therapy for osteomyelitis as they do not accurately reflect bone culture results (strong; moderate).
Obtain plain X‐rays of the foot in all cases of non‐superficial diabetic foot infection (strong; low).
Use MRI when an advanced imaging test is needed for diagnosing diabetic foot osteomyelitis (strong; moderate).
When MRI is not available or contraindicated, consider a white blood cell‐labelled radionuclide scan, or possibly single‐photon emission computed tomography (CT) and CT (SPECT/CT) or fluorine‐18‐fluorodeoxyglucose positron emission tomography/CT scans (weak; moderate).
Assessing severity
At initial evaluation of any infected foot, obtain vital signs and appropriate blood tests, debride the wound and probe and assess the depth and extent of the infection to establish its severity (strong; moderate).
At initial evaluation, assess arterial perfusion and decide whether and when further vascular assessment or revascularization is needed (strong; low).
Microbiological considerations
Obtain cultures, preferably of a tissue specimen rather than a swab, of infected wounds to determine the causative microorganisms and their antibiotic sensitivity (strong; high).
Do not obtain repeat cultures unless the patient is not clinically responding to treatment, or occasionally for infection control surveillance of resistant pathogens (strong; low).
Send collected specimens to the microbiology laboratory promptly, in sterile transport containers, accompanied by clinical information on the type of specimen and location of the wound (strong; low).
Surgical treatment
Consult a surgical specialist in selected cases of moderate, and all cases of severe, diabetic foot infection (weak; low).
Perform urgent surgical interventions in cases of deep abscesses, compartment syndrome and virtually all necrotizing soft tissue infections (strong; low).
Consider surgical intervention in cases of osteomyelitis accompanied by spreading soft tissue infection, destroyed soft tissue envelope, progressive bone destruction on X‐ray or bone protruding through the ulcer (strong; low).
Antimicrobial therapy
While virtually all clinically infected diabetic foot wounds require antimicrobial therapy, do not treat clinically uninfected wounds with antimicrobial therapy (Strong; Low)
Select specific antibiotic agents for treatment based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy of the agent for diabetic foot infection and costs (strong; moderate).
A course of antibiotic therapy of 1–2 weeks is usually adequate for most mild and moderate infections (strong; high).
Administer parenteral therapy initially for most severe infections and some moderate infections, with a switch to oral therapy when the infection is responding (strong; low).
Do not select a specific type of dressing for a diabetic foot infection with the aim of preventing an infection or improving its outcome (strong; high).
For diabetic foot osteomyelitis, we recommend 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone and no more than a week of antibiotic treatment if all infected bone is resected (strong; moderate).
We suggest not using any adjunctive treatments for diabetic foot infection (weak; low).
When treating a diabetic foot infection, assess for use of traditional remedies and previous antibiotic use and consider local bacterial pathogens and their susceptibility profile (strong; low).
Cranial osteomyelitis is a rare but potentially life-threatening condition that requires early diagnosis with prompt and appropriate management by neurosurgeons to prevent further central nervous ...system complications.
The literature in the Medline database was comprehensively reviewed with the keywords “cranial osteomyelitis,” “skull base osteomyelitis (SBO),” “central skull base osteomyelitis,” and “temporal bone osteomyelitis.” Items in the reference list of each article relevant to the objective of this study were reviewed.
This review produced 183 articles: 13 book chapters, 24 case reports, 17 case series, 98 original articles, 30 review articles, and 1 meta-analysis. We classified cranial osteomyelitis as sinorhino-otogenic, including anterior, middle, and posterior skull base osteomyelitis; and non-sinorhino-otogenic, including iatrogenic, posttraumatic, hematologic, and osteomyelitis with other causes.
New diagnostic modalities, the introduction of broad-spectrum antibiotics, and recent advances in neurosurgical procedures have led to a decrease in the rate of treatment failure in cranial osteomyelitis. Early recognition of initial nonspecific symptoms is key to diagnosing and managing this treatable but life-threatening condition. Early identification of the causative pathogen, appropriate broad-spectrum antibiotic therapy over a period of 8–20 weeks, and aggressive surgical debridement are essential for managing cranial osteomyelitis. On the other hand, inadequate treatment is responsible for refractory cases and poses a great diagnostic challenge. A new classification dividing cranial osteomyelitis into sinorhino-otogenic versus nonsinorhino-otogenic groups could prove valuable for clinical communication and treatment.
Acute hematogenous osteomyelitis (AHO) in children is an ideal condition to study due to its representation of a wide spectrum of disorders that comprise pediatric musculoskeletal infection. Proper ...care for children with AHO is multidisciplinary and collaborative. AHO continues to present a significant clinical challenge due to evolving epidemiology and complex pathogenesis. A guideline-driven, multidisciplinary approach has been introduced and shown to effectively reduce hospital stay, improve the timing and selection of empirical antibiotic administration, reduce delay to initial MRI, reduce the rate of readmission, and shorten antibiotic duration.
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