Descripción de la tasa de mortalidad por osteomielitis según variables demográficas durante el periodo del 2016-2020 en Chile / Description of the osteomyelitis mortality rate according to demographic variables during the 2016-2020 period in Chile

Introducción: La osteomielitis es un proceso infeccioso óseo. En adultos, presenta alta mortalidad por sus complicaciones sistémicas, influida por factores de riesgos asociados. Por lo anterior el objetivo del estudio es describir la tasa de mortalidad por osteomielitis según sexo, rango etario y región, en el periodo 2016 - 2020 en Chile. Materiales y Métodos: Estudio ecológico de las defunciones por osteomielitis en los años 2016-2020 en Chile, según sexo, grupo etario y región (n=218). Datos obtenidos del departamento de estadística e información en salud. Se calculó tasa de mortalidad. No se requirió aprobación del comité de ética. Resultados: En el periodo estudiado se presentó una tasa de mortalidad de 0,22 x 100.000 habitantes. El sexo masculino presento un 52% de las defunciones en personas de 70 a 89 años, seguido del 25% en los pacientes de 80-89 años de edad. La región que presentó una mayor tasa de mortalidad fué Los Ríos con 0,49. Discusión: Se reportó mayor número de defunciones en grupos etarios avanzados, pudiendo deberse a que es una patología asociada a enfermedades crónicas no transmisibles y en Chile hay gran prevalencia de éstas. La distribución geográfica de la enfermedad evidenció más reportes de defunciones en la zona sur, sin embargo, hay escasas publicaciones que expliquen las posibles causas de ello. Conclusión: Se requieren mayores estudios nacionales para profundizar en los hallazgos encontrados. Es importante conocer más variables sociodemográficas que influyan en la mortalidad por osteomielitis en adultos.

Introduction: Osteomyelitis is a bone infectious process. In the adult stage, it presents a high mortality due to its systemic complications, influenced by associated risk factors. The aim of this work is to describe the mortality rate due to osteomyelitis according to sex, age range, and region, in the period 2016 - 2020 in Chile. Materials and Methods: Ecological study of deaths due to osteomyelitis in the years 2016-2020 in Chile, according to sex, age group, and region (n=218). Data obtained from the Department of Statistics and Health Information. Mortality rate was calculated. Ethics committee approval was not required. Results: During the period studied, the mortality rate was 0.22 per 100,000 inhabitants. The male sex accounted for 52% of deaths in persons between 70 and 89 years of age, followed by 25% in patients between 80 and 89 years of age. The region with the highest mortality rate was Los Ríos with 0.49. Discussion: A greater number of deaths were reported in advanced age groups, which may be due to the fact that it is a pathology associated with chronic non-communicable diseases and in Chile there is a high prevalence of these diseases. The geographical distribution of the disease showed more reports of deaths due to this cause in the south, however there are few publications on possible causes of geographical distribution. Conclusion: Further national studies are required to deepen the findings. It is important to know more sociodemographic variables that influence osteomyelitis mortality in the adult population.

How is the microbial diagnosis of bacterial vertebral osteomyelitis performed? An 11-year retrospective study.

Vertebral osteomyelitis (VOM) is often diagnosed with delays, resulting in poorer outcomes. Microbial documentation is particularly challenging and obtained using blood cultures (BCs) and vertebral biopsies (VBs; CT-guided or surgical). We retrospectively analysed VOM cases in a tertiary reference centre between 2004 and 2015, focusing on how and how quickly microbiological diagnosis was performed. Among 220 VOM, 88.2% had documentation, including Gram-positive cocci (GPC) (70.6%), Gram-negative rods (GNR) (9.3%), anaerobes (3.6%), polybacterial infections (6.7%) and tuberculosis (9.8%). BCs were performed in 98.2% and positive in 59.3%, identifying most GPC (80.3%) and half of GNR (54.6%). VBs were performed in fewer cases (37.7%), but were more frequently positive (68.8% for CT-guided and 81.0% for surgical biopsies). They documented all anaerobes (100.0%), most M. tuberculosis (84.2%) and polybacterial infections (76.9%), and GNR (45.4%). Extra-vertebral samples highly contributed to tuberculosis diagnosis (52.6%, and 15.8% as the only positive sample). Documentations most often followed radiological diagnosis (53.4%). They were obtained earlier by BCs than by VB after first clinical symptoms (median of 14 versus 51 days). Antibiotic treatments were mostly initiated after samplings (88.0%). BCs allow the documentation of most VOM and should be performed without delay in case of clinical or radiological suspicion; however, they may miss 1 out of 5 GPC and 1 out of 2 GNR. VBs have a higher positivity rate and should be rapidly performed if negative BCs. It is likely that delayed and missed diagnoses result from the insufficient use of VB.

Vertebral Osteomyelitis After Spine Surgery: A Disease With Distinct Characteristics.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: We aimed to determine the 2-year survival and to identify clinical and microbiological characteristics of patients with native vertebral osteomyelitis (VO) as compared to postoperative VO to find further strategies for improvement of the management of VO. SUMMARY OF BACKGROUND DATA: A relevant subgroup (20%-30%) of patients with VO has a history of spine surgery. Infection in these patients might be clinically different from native VO. However, clinical, microbiological, and outcome characteristics of this disease entity have not been well studied as most trials either excluded these patients or are limited by a small cohort and short observation period. METHODS: Between 2008 and 2013, patients who presented at a tertiary care center with symptoms and imaging findings suggestive of VO were reviewed by specialists in infectious diseases, clinical microbiology, and orthopedics to confirm the diagnosis and followed prospectively for a period of 2 years. Statistical analysis for group comparisons, survival analysis, and uni- and multivariable Cox regression models were performed. RESULTS: Thirty percent of the patients with VO (56/189) reported a history of spine surgery in the same segment. Patients with postoperative infection had a lower ASA score (American Society of Anesthesiologists) (P = 0.01) and were less likely to suffer from comorbidities compared to native cases (P = 0.003). Infections caused by coagulase-negative staphylococci (33.3 vs. 6.5%, P < 0.001) and other bacteria of the skin flora (15.2 vs. 0%, P = 0.002) were more prevalent in postoperative patients. Suffering from native VO increased the 2-year mortality risk 3-fold, also when adjusted for the remaining risk factors ASA score and number of comorbidities (hazard ratio 2.916 [95% confidence interval 1.215 -6.999], P = 0.017). CONCLUSION: Beside clear microbiological differences, the significant better 2-year survival supports the concept of postoperative VO presenting a distinct disease entity. The subtle disease presentation of patients with postoperative VO should not attenuate clinical suspicion of physicians. LEVEL OF EVIDENCE: 3.

Sternoclavicular Joint Infections: Improved Outcomes With Myocutaneous Flaps.

Sternoclavicular joint (SCJ) infection is a rare disease and its management remains controversial. Our institution has adopted an aggressive surgical approach of radical SCJ resection combined with myocutaneous flap (MCF) closure whenever possible. We reviewed our experience with this approach in the management of this condition. From July 2004 to June 2018, 50 consecutive patients were treated surgically for SCJ infections. Patient demographics, imaging studies, microbiology, and operative variables were analyzed. All patients underwent ipsilateral SCJ resection. Wound closure was performed with primary pectoralis advancement MCF closure at the initial operation in 25 patients, delayed MCF closure following temporary wound vacuum therapy and redebridement in 19 patients, and definitive wound vacuum therapy (DWVT) in 6 patients. End points were recurrence of infection, perioperative morbidity, and mortality. Localized swelling (100%) and pain (100%) were the most common presenting symptoms. MSSA was isolated in 50% of tissue cultures. Comorbidities included tobacco smoking 52%, diabetes mellitus 50%, intravenous drug use 34%, poor dental hygiene 32%, and obesity 28%. We had no deaths within 90 days of operation. Complications; seroma in 1 patient (2%), chest wall hernia in 1 patient (2%), retained drains in 1 patient (2%), recurrent osteomyelitis infection in 3 patients (6%), and hematomas in 5 patients (10%). Patients treated with primary MCF closure at the initial operation had a 0% (0/25) rate of recurrence compared to 5.26% (1/19) in delayed MCF closure. Overall, there was only a 2.27% (1/44) recurrence of infection in primary and delayed MCF closure combined, compared to 33.33% (2/6) in patients treated with DWVT closure. SCJ infections require an aggressive approach. Wound closure with an MCF (primary or delayed) is associated with less recurrence of infections compared with DWVT closure. Radical resection of the entire SCJ with MCF (primary or delayed) should be considered the preferred management strategy in patients with SCJ infections.

Clinical manifestations and outcomes of musculoskeletal nontuberculous mycobacterial infections.

To investigate the clinical manifestations and outcomes of musculoskeletal (MSK) nontuberculous mycobacterium (NTM) infections. This study was a retrospective cohort study using the Siriraj Hospital database from 2005 to 2017. Enrolled were all patients aged 15 or older who had an MSK infection with NTM identified in synovial fluid, pus, or tissue by an acid-fast bacilli stain, culture, or polymerase chain reaction. Of 1529 cases who were diagnosed with NTM infections, 39 (2.6%) had an MSK infection. However, only 28 patients met our inclusion criteria. Their mean age (SD) was 54.1 (16.1) years, and half were male. Of this cohort, 25% had previous musculoskeletal trauma, 18% prior bone and joint surgery, 14% prosthetic joint replacement, and 11% HIV infection. The median symptom duration (IQR) was 16 (37.4) weeks. The most common MSK manifestation was arthritis (61%), followed by osteomyelitis (50%), tenosynovitis (25%), and spondylodiscitis (14%). The most common organism was M. abscessus (18%), and M. kansasii (18%), followed by M. intracellulare (14%), M. marinum (14%), M. fortuitum (7%), and M. haemophilum (7%). In addition to medical treatment, most patients underwent surgery (82%), comprising debridement, osteotomy, prosthesis removal, and amputation, while 18% received only medical treatment. The treatment outcomes were complete recovery in 46%, improvement with some residual disability and deformities in 29%, and death in 3.6%. Musculoskeletal NTM infections were uncommon. Most patients had underlying joint disease or were immunocompromised hosts. Surgical management, as an adjunct to medical therapy, was necessary.

The prevalence and impact of cervical spine pathologies in patients with nasopharyngeal carcinoma.

OBJECTIVES: Nasopharyngeal carcinoma (NPC) and its treatment can lead to cervical spine pathologies such as metastases, osteoradionecrosis (ORN) and infection. However, the occurrence rate and relationship between timing of diagnosis and outcomes of the ever-advancing technology of radiation therapy is largely unknown. Hence, the aim of this study is to determine the prevalence and impact of cervical spine pathologies in patients with NPC. MATERIALS AND METHODS: This was a cross-sectional study of all newly diagnosed cases of NPC from 2007 to 2016 at a tertiary referral oncology and spine centre with minimum 1-year post-treatment follow-up. All cervical spine pathologies, their treatment and outcomes were determined. Presentation, onset time and correlations of the cervical spine pathologies with mortality and risk factors were also analysed. RESULTS: Out of 605 cases of verified cases of NPC, cervical spine pathologies were seen in 8.9% of patients. New onset neck pain was seen in 5.3%, symptomatic cervical spondylosis in 4.8%, cervical spine metastases in 2.5%, local tumour invasion in 0.8%, cervical ORN in 0.7%, osteomyelitis in 0.7%, radiculopathy in 0.3%, and myelopathy in 0.3%. Cervical spine pathologies were associated with an increased risk (odds ratio: 2.73) in overall mortality. Cervical spine metastases, invasion, ORN and infection were associated with significantly higher risk of mortality (p = 0.01-0.02). CONCLUSION: Cervical spine pathologies in patients with NPC are heterogenous but not uncommon. Neck pain is prevalent but is often benign. ORN and osteomyelitis of the cervical spine is uncommon but have large clinical implications including higher mortality with subtle presentations.

[Treatment of Sternal Osteomyelitis after Median Sternotomy in 130 Patients with Pedicled Myocutaneous Latissimus Flap]. / Therapie der Sternumosteomyelitis nach medianer Sternotomie bei 130 Patienten mittels gestielter myokutaner Latissimuslappenplastik.

BACKGROUND: After median sternotomy in cardiac surgery, deep sternal wound infections develop in 0.8 - 8% of patients, resulting in prolonged hospital stay and increased morbidity and mortality. Our treatment strategy combines radical surgical debridement, removal of extraneous material and reconstruction of large and deep defects by a pedicled M. latissimus dorsi flap. With retrospective analysis of patient characteristics and pre- und perioperative data we could identify risk factors in regard to proper wound healing and bleeding complications. MATERIAL AND METHODS: Patient characteristics (age, BMI, gender), medical history (diabetes mellitus, chronic obstructive lung disease, renal insufficiency and pre- and perioperative data (anticoagulation, bacterial colonization during reconstruction) were collected for 130 patients treated by latissimus flap to cover sternal wounds between 2009 and 2015. RESULTS: The mean age was 68.72 ± 9.53 years; 37% of patients were female. The in-hospital mortality was 3.8%. Reoperation rate because of wound healing problems was 21.5%; bleeding complications leading to reoperation occurred in 10.8% of all patients. At the point of reconstruction, Staphylococcus (S.) aureus and S. epidermidis were detected most frequently. Age over 80 (p = 0.04), female sex (p = 0.002), detection of fecal bacteria (p = 0.006), or multiresistant bacteria (p = 0.007) and Klebsiellae were regarded as significant risk factors for wound healing problems leading to reoperation after flap surgery. High dose therapy with danaparoid/fondaparinux was a significant risk factor for bleeding complications needing reoperation. CONCLUSION: The pedicled latissimus flap has to be considered as the preferred method in large sternal wounds to achieve sufficient defect filling. The risk of wound healing disruption is significantly influenced by bacteria detected in the sternal wound at the point of reconstructive surgery.

The Epidemiology of Vertebral Osteomyelitis in the United States From 1998 to 2013.

STUDY DESIGN: This is a epidemiological database analysis. OBJECTIVES: The objectives of this article are to assess the following characteristics of vertebral osteomyelitis (VO): (1) incidence and patient demographics, (2) mortality rate, (3) length-of-stay (LOS), and (4) admission costs. SUMMARY OF BACKGROUND: VO is a serious disease with potentially devastating clinical consequences. At present, there is limited data on the epidemiology of VO in the United States as previous reports are based on older studies with small sample sizes. METHODS: We used the Nationwide Inpatient Sample database and estimated that 228,044 patients were admitted for VO in the United States between 1998 and 2013. Data were extracted on patient demographics, comorbidities, inpatient mortality, LOS, and inflation-adjusted hospitalization charges. Multivariable regression analyses were performed. RESULTS: The incidence of VO admission was 4.8 per 100,000, increasing from 8021 cases (2.9/ 100,000) in 1998 to 16,917 cases (5.4/100,000) in 2013. Majority of patients were white (74%), male (51%), younger than 59 years of age (49.5%), and carried Medicare insurance (50%). The increase in incidence for male and females was similar. The mortality rate during hospital stay was 2.1%, decreasing from 2% in 1998 to 1.7% in 2006 and increasing to 2.2% in 2013. Risk factors for mortality included increased age, male sex, and higher comorbidity score. History of congestive heart failure [odds ratio (OR)=2.45], cerebrovascular disease (OR=1.92), liver disease (OR=2.33), hepatitis C (OR=2.36), and renal disease (OR=1.88) was associated with higher mortality rate. Mean LOS was 9.2 days, decreasing from 9.1 days in 1998 to 8.8 days in 2013. The mean estimated hospital charges for admission were $54,599, however, this increased from $24,102 in 1998 (total of $188.8 millions) to $80,786 in 2013 (total of $1.3 billions). CONCLUSION: This condition is associated with lengthy and expensive hospital stays resulting in a significant burden to patients and the health care system.

Long-term prognosis of hematogenous vertebral osteomyelitis: Mortality, quality of life, and pain.

BACKGROUND: Hematogenous vertebral osteomyelitis (HVO) has a generally favorable prognosis if appropriate treatment is initiated in its early phase; however, some intractable cases with HVO can develop neurological impairment as well as spinal deformity during the course of treatment and these sequelae may lead to impaired quality of life (QOL). In this study, we aimed to evaluate the long-term relapse rate, mortality, and QOL of patients with HVO. METHODS: In this retrospective case series study, medical records of 60 patients with HVO with a mean follow-up period of 8 years (5-23 years) were reviewed to assess demographic data, details of infection, and clinical course. Mortality rate was assessed using a Kaplan-Meier plot. QOL was measured using the EuroQol 5 Dimension (EQ-5D) questionnaire and residual pain using a numeric rating scale (NRS). RESULTS: HVO relapsed in 4 of 60 patients (7%). Overall 5-year survival rate in 60 patients with HVO was 85%. The factors associated with increased mortality were malignant tumor, diabetes mellitus, chronic use of glucocorticoids, and drug-resistant strains of staphylococcus. Female-to-male ratio, NRS, prevalence of neurological impairment were significantly higher in patients with low EQ-5D score (poor health) compared to those with high EQ-5D score (good health). CONCLUSIONS: Patients with HVO have shorter life expectancy if they have malignancy, diabetes mellitus, chronic use of glucocorticoids, and a history of drug-resistant strains of staphylococcus infection. Female gender, residual neurological defects and persistent back pain are associated with impaired QOL in patients with HVO.

[Sternal osteomyelitis - Surgical treatment concepts]. / Sternumosteomyelitis - chirurgische Behandlungskonzepte.

Sternal osteomyelitis is a potentially fatal condition following cardiac surgery. Sternal osteomyelitis should be diagnosed as early as possible followed by an interdisciplinary radical debridement. Subsequently plastic reconstructive surgery is necessary for defect reconstruction. This can be achieved by a number of established pedicled and free flap plastic surgery procedures. The choice of flap procedures is based on defect geometry and the individual patient situation, including potential flap donor sites. Smaller defects can generally be reconstructed by pedicled flap transfer. For extensive sternal defects, free flap transplantation is now a well-established therapeutic option. In some patients lacking sufficient recipient vessels, the creation of an arteriovenous (AV) loop as recipient vessel is necessary. In summary, successful therapy of sternal osteomyelitis is based on early interdisciplinary treatment by the various surgical subspecialties.

Chronic osteomyelitis increases long-term mortality risk in the elderly: a nationwide population-based cohort study.

BACKGROUND: The elderly are predisposed to chronic osteomyelitis because of the immunocompromised nature of aging and increasing number of chronic comorbidities. Chronic osteomyelitis may significantly affect the health of the elderly; however, its impact on long-term mortality remains unclear. We conceived this retrospective nationwide population-based cohort study to address this issue. METHODS: We identified 10,615 elderly patients (≥65 years) comprising 965 patients with chronic osteomyelitis and 9650 without chronic osteomyelitis matched at a ratio of 1:10 by age and gender between 1999 and 2010 from the Taiwan National Health Insurance Research Database. The risk of chronic osteomyelitis between the two cohorts was compared by a following-up until 2011. RESULTS: Patients with chronic osteomyelitis had a significantly higher mortality risk than those without chronic osteomyelitis [incidence rate ratio (IRR): 2.29; 95 % confidence interval (CI): 2.01-2.59], particularly the old elderly (≥85 years; IRR: 3.27; 95 % CI: 2.22-4.82) and males (IRR: 2.7; 95 % CI: 2.31-3.16). The highest mortality risk was observed in the first month (IRR: 5.01; 95 % CI: 2.02-12.42), and it remained persistently higher even after 6 years (IRR: 1.53; 95 % CI: 1.13-2.06) of follow-up. Cox proportional hazard regression analysis showed that chronic osteomyelitis [adjusted hazard ratio (AHR): 1.89; 95 % CI: 1.66-2.15], advanced age (≥85 years; AHR: 2.02; 95 % CI: 1.70-2.41), male (AHR: 1.34; 95 % CI: 1.22-1.48), and chronic comorbidities were independent predictors of mortality. CONCLUSIONS: This study demonstrated that chronic osteomyelitis significantly increased the long-term mortality risk in the elderly. Therefore, strategies for prevention and treatment of chronic osteomyelitis and concomitant control of chronic comorbidities are very important for the management of the elderly, particularly for a future with an increasingly aged population worldwide.

Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009.

BACKGROUND: The epidemiology of osteomyelitis in the United States is largely unknown. The purpose of this study was to determine long-term secular trends in the incidence of osteomyelitis in a population-based setting. METHODS: The study population comprised 760 incident cases of osteomyelitis first diagnosed between January 1, 1969, and December 31, 2009, among residents of Olmsted County, Minnesota. The complete medical records for each potential subject were reviewed to confirm the osteomyelitis diagnosis and to extract details on anatomical sites, infecting organisms, etiological risk factors, and outcomes. RESULTS: The overall age and sex-adjusted annual incidence of osteomyelitis was 21.8 cases per 100,000 person-years. The annual incidence was higher for men than for women and increased with age (p < 0.001). Rates increased with the calendar year (p < 0.001) from 11.4 cases per 100,000 person-years in the period from 1969 to 1979 to 24.4 per 100,000 person-years in the period from 2000 to 2009. The incidence remained relatively stable among children and young adults but almost tripled among individuals older than sixty years; this was partly driven by a significant increase in diabetes-related osteomyelitis from 2.3 cases per 100,000 person-years in the period from 1969 to 1979 to 7.6 cases per 100,000 person-years in the period from 2000 to 2009 (p < 0.001). Forty-four percent of cases involved Staphylococcus aureus infections. CONCLUSIONS: The reasons for the increase in osteomyelitis between 1969 and 2009 are unclear but could comprise a variety of factors, including changes in diagnosing patterns or increases in the prevalence of risk factors (e.g., diabetes) in this population.

Fungal Infections of the Spine.

STUDY DESIGN: Review of the literature. OBJECTIVE: To retrospectively examine the frequency of published fungal infections by species and the treatment algorithms used to eradicate the disease. SUMMARY OF BACKGROUND DATA: Fungal infections of the spine present unique challenges to the modern multispecialty treatment team. Although rare in comparison with bacterial infections, fungal infections have been increasing in incidence over the past several decades. Evidences-based practice is limited to referencing smaller case series. METHODS: MEDLINE, Scopus, and EMBASE searches were carried out by one of the authors as well as by the research desk at the University of Miami/Calder Memorial Library. We included peer-reviewed articles published between 1948 and September 2010; case reports, series, and reviews were all examined and compiled into a database. RESULTS: A total of 130 articles, representing 157 cases, were included in the review. Aspergillus (60 cases, 38.2% of the total) and Candida species (36 cases, 22.9% of the total) were the 2 most common organisms. Surgery was associated with a greater survival rate than medical management alone in patients with Aspergillus (26.9% mortality in surgical patients; 60% in medically treated patients) and Candida (0% vs. 28.6%). Overall mortality was 19.3%. The overall recurrence rate was 7.4%. Amphotericin use was associated with a higher mortality rate than azoles. CONCLUSION: Aspergillus is the most common published pathogen in fungal infections of the spine. Recent publications depicting the use of newer antifungal medications such as azoles report higher survival rates. Surgically treated patients in combination with antifungal therapy showed highest frequencies of patient survival in Aspergillus and Candida infections. LEVEL OF EVIDENCE: 3.

Perioperative morbidity and mortality comparison in circumferential cervical fusion for osteomyelitis versus cervical spondylotic myelopathy.

OBJECT: The most common indications for circumferential cervical decompression and fusion are cervical spondylotic myelopathy (CSM) and cervical osteomyelitis (COM). Currently, the informed consent process prior to circumferential cervical fusion surgery is not different for these two groups of patients, as details of their diagnosis-specific risk profiles have not been quantified. The authors compared two patient cohorts with either CSM or COM treated using circumferential fusion. They sought to quantify perioperative morbidity and postoperative mortality in these two groups to assist with a diagnosis-specific informed consent process for future patients undergoing this type of surgery. METHODS: Perioperative and follow-up data from two cohorts of patients who had undergone circumferential cervical decompression and fusion were analyzed. Estimated blood loss (EBL), length of stay (LOS), perioperative complications, hospital readmission, 30-day reoperation rates, change in Nurick grade, and mortality were compared between the two groups. RESULTS: Twenty-two patients were in the COM cohort, and 24 were in the CSM cohort. Complications, hospital readmission, 30-day reoperation rates, EBL, and mortality were not statistically different, although patients with COM trended higher in each of these categories. There was a significantly greater LOS (p < 0.001) in the COM group and greater improvement in Nurick grade in the CSM group (p < 0.001). CONCLUSIONS: When advising patients undergoing circumferential fusion about perioperative risk factors, it is important for those with COM to know that they are likely to have a higher rate of complications and mortality than those with CSM who are undergoing similar surgery. Furthermore, COM patients have less neurological improvement than CSM patients after surgery. This information may be useful to surgeons and patients in providing appropriate informed consent during preoperative planning.

Anterior thoracic surgical approaches in the treatment of spinal infections and neoplasms.

BACKGROUND: Thoracic surgeons are commonly consulted to provide anterior thoracic exposure for infection and malignant neoplasms involving the thoracolumbar spine. These cases can present significant technical and management challenges secondary to the underlying pathology, associated anatomic inflammation, and impaired functional status. In this study, we review the perioperative outcomes in patients undergoing anterior spinal exposure for infection and neoplasm. METHODS: 130 consecutive patients (61 women, 69 men) undergoing corpectomy, debridement, or debulking for osteomyelitis (n=50) or neoplasms (n=80) with decompression/stabilization at a single institution were analyzed. Primary endpoints included morbidity, mortality, and perioperative neurologic outcomes. RESULTS: The mean age was 61.1 years. A cervical/sternotomy (n=8) approach was used for levels C7 to T2, thoracotomy (n=79) for levels T3 to T10, and thoracoabdominal (n=43) for T11 to L2 involvement. Primary spinal neoplasms (n=22, 16.9 %) and metastases (n=58, 44.6%) were treated with corpectomy and prosthetic stabilization and were associated with increased operative time (310 vs 243 minutes, p=0.02) and blood loss (825 vs 500 mL, p=0.002). Osteomyelitis was associated with longer hospital stays (12 vs 7 days, p<0.001). The 30-day and 90-day mortality was 9.2% and 20.8%, respectively. The major complication rate was 27.7%. The median length of stay was 9 days. Surgical intervention resulted in significant improvement in pain, numbness, weakness, and bowel and bladder dysfunction. CONCLUSIONS: Anterior spinal exposure represents an important modality in facilitating the treatment of patients with osteomyelitis, pathologic fractures, and spinal cord compression syndromes. These procedures are associated with a significant risk of morbidity and mortality, but they are effective in achieving spinal stabilization and alleviating neurologic symptoms.

Central skull base osteomyelitis: an emerging clinical entity.

OBJECTIVES/HYPOTHESIS: Skull base osteomyelitis (SBO) most commonly results as a complication of otitis externa in diabetic patients. Central or atypical presentations, unrelated to aural pathology, have been documented, though restricted to small patient series or case reports. The current study systematically analyzed the literature to construct the clinical profile of this rare entity. STUDY DESIGN: Systematic review of case series. METHODS: The MEDLINE database was searched for all published cases of central SBO. Four additional cases were included from the University of Texas Southwestern Medical Center. Statistical analysis was performed to identify trends affecting overall outcomes or differences in treatment. RESULTS: A total of 42 cases were included with mean age of 52 years and male:female ratio of 2.2:1. The most common presenting symptoms were headaches and cranial nerve palsies, including VI (31%), IX (29%), and X (29%). Staphylococcus aureus (21%) and Pseudomonas aeruginosa (19%) were the two most common causative pathogens. The mean duration of antimicrobial therapy was 21 weeks, with 55% requiring intravenous antibiotics for a mean duration of 6.9 weeks. Twenty of 42 patients (48%) received surgical biopsy for diagnosis, whereas 18 patients (43%) required adjunct surgical debridement. Women were more likely than men to require multiple courses of therapy (46% vs. 7%, P = .01). The overall mortality was 9.5%, with an additional 31% experiencing residual neurological dysfunction. CONCLUSIONS: Osteomyelitis of the central skull base poses significant challenges for timely and accurate diagnosis. Aggressive management with antimicrobials, coupled with surgical debridement in select cases, may avoid serious neurologic morbidity and mortality.

Fungal infection and increased mortality in patients with chronic granulomatous disease.

OBJECTIVE: Fungal infection presents a serious risk to individuals with compromised immune systems. Chronic granulomatous disease is a primary immunodeficiency with X-linked or autosomal recessive inheritance. Patients with CGD are predisposed to bacterial and fungal infections. The aim of this study was to determine the incidence of fungal infections, identify the most common fungal pathogens, and determine the risk factors associated with fungal infections and mortality in patients with chronic granulomatous disease (CGD). MATERIAL AND METHODS: We reviewed retrospectively 12 patients with CGD in the period of 1995-2008. All of the patients were suspected to fungal infections. The data was gathered from the medical records of all patients as having CGD. Twelve patients had adequate medical records to enter the study. The diagnostic of fungal infections were confirmed by histopathology and direct preparation, culture techniques, histopathology of surgical biopsies, and radiological examination of the affected site. RESULTS: We evaluated 12 cases of chronic granulomatosis. Patients that are susceptible to recurrent, sever infections. Patients consisted of seven males and five females. The median age of patients at the time of the study was 11.66 years (3 to18). Neutrophil oxidative burst were absent (NBT=0) in all patients. Fungal infections were confirmed in five patients (41/7%) by histology and mycological methods. The most common isolated fungi in this study were Aspergillus spp. Out of five cases of fungal infections identified, tree were Aspergillus spp, and two Fusarium spp. The most common manifestations of CGD due to fungal infections (in descending order) were osteomyelitis (42.8%), pulmonary infections (28.6%), lymphadenopathy (14.3%) and skin involvement (14.3%) during their illness. CONCLUSION: Invasive fungal infections are a frequent and life-threatening complication in CGD patients. The lungs and skeletal, were the most commonly affected organ; however, lymphatic, and skin involvement have also been described. Our present study showed that fusariosis also is a threat to CGD patients.

Epidemiological and clinical features of pyogenic spondylodiscitis.

Pyogenic spondylodiscitis (PS) is an uncommon but important infection, that represents 3-5% of all cases of osteomyelitis. The annual incidence in Europe has been estimated to be from 0.4 to 2.4/100,000. A has been reported, with peaks at age less than 20 years and in the group aged 50-70 years. The incidence of PS seems to be increasing in the last years as a result of the higher life expectancy of older patients with chronic debilitating diseases, the rise in the prevalence of immunosuppressed patients, intravenous drug abuse, and the increase in spinal instrumentation and surgery. PS is in most cases a hematogenous infection. Staphylococcus aureus is the most frequent causative microorganism, accounting for about one half of the cases of PS. Gram-negative rods are causative agents in 7-33% of PS cases. Coagulase-negative staphylococci (CoNS) have been reported in 5-16% of cases. Staphylococcus epidermidis is often related to post-operative infections and intracardiac device-related bacteremia. Unremitting back pain, characteristically worsening during the night, is the most common presenting symptom, followed by fever that is present in about one half of the cases. The mortality of PS ranges from 0 to 11%. In a significant number of cases, recrudescence, residual neurological defects or persistent pain may occur.

Non-typhoidal Salmonella bacteraemia in elderly patients: an increased risk for endovascular infections, osteomyelitis and mortality.

Non-typhoidal Salmonella (NTS) is a common pathogen causing foodborne infections, bacteraemia, and extra-intestinal focal infections (EFIs) in humans. The study compares the clinical characteristics of elderly patients with NTS bacteraemia with those of young adults. Of 272 adults with NTS bacteraemia identified in this study, 162 (59·6%) were aged ⩾55 years. EFIs were observed in 36% of the 162 patients. The most common EFIs in the elderly patients (⩾55 years) was mycotic aneurysm, followed by pulmonary infections and bone/joint infections. Elderly patients more often had chronic heart, lung, renal and malignant diseases, had more EFIs, and a higher 30-day mortality rate. Independent factors of 30-day mortality in elderly patients were solid-organ tumour [adjusted odds ratio (aOR) 4·4, P=0·003], mycotic aneurysm (aOR 3·7, P=0·023) and shock (aOR 12·1, P<0·0001). HIV infection, autoimmune diseases, and receipt of immunosuppressive therapy were more often observed in young patients.

Osteomyelitis due to Aspergillus species in chronic granulomatous disease: an update of the literature.

Chronic granulomatous disease (CGD) is a rare inherited disorder characterised by inability of phagocytes to kill catalase-positive organisms including certain fungi. Aspergillus species are the most frequent fungal pathogens. This study is a systematic review of the reported cases of osteomyelitis due to Aspergillus species in CGD patients. Retrospective analysis of 46 osteomyelitis cases caused by Aspergillus species in 43 CGD patients (three females) published in the English literature (PubMed) was performed. Twenty-three cases were due to Aspergillus fumigatus (50%), 20 to Aspergillus nidulans (43.5%), one to Aspergillus flavus and two to unspecified Aspergillus species. The median age was 8 years (range 1.5-21). Osteomyelitis due to A. nidulans was associated with pulmonary infection and involved 'small bones' more frequently than A. fumigatus osteomyelitis (P = 0.001). Amphotericin B was used in 91.3% and surgical debridement in 67.4% of all cases. The overall mortality of osteomyelitis due to Aspergillus species in CGD patients was 37%; 55% for A. nidulans compared to 13% for A. fumigatus (P = 0.008). Aspergillus fumigatus causes osteomyelitis in CGD patients almost as frequently as A. nidulans and much more frequently than A. flavus. Osteomyelitis due to A. nidulans is associated with higher mortality than A. fumigatus.