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.

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.

The value of successive Infecton scans in assessing the presence of chronic bone and joint infection and in predicting its evolution after treatment and after a prolonged follow-up.

OBJECTIVE: Our objective was to monitor the evolution of bone and/or joint infections with the aid of successive radiolabelled ciprofloxacin (Infecton) scans during antimicrobial treatment and to compare the results of an Infecton scan at the end of therapy with the respective results of clinical evaluation, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in predicting resolution or recurrence of infection after a long period of posttreatment follow-up. METHODS: Thirty-three patients with documented bone and/or joint infection were subjected to successive Infecton scans on two or three visits. Infecton scans were evaluated visually and scored accordingly. Clinical evaluation was scored by the referring clinicians. ESR and CRP values were evaluated independently. A minimum of 2-year free-of-infection follow-up after discontinuation of the antibiotic treatment served as a measure of successful antimicrobial therapy and nonrecurrence of infection. Statistics included survival analysis (Cox regression). RESULTS: During follow-up, five patients in the study presented with recurrence, and three died as a result of an irrelevant cause. The remaining patients were followed up for a median of 108 months (range 97-132 months) without any signs of recurrence of infection. Recurrence of infection was 4.2 times more likely to occur in patients with positive Infecton scans [hazard ratio (HR): 4.2, confidence intervals 95%: 1.39-12.67, P=0.011]. Infecton had the highest sensitivity (83.3%), accuracy (69.69%) and negative predictive value (94.74%), whereas CRP had the highest specificity (76.92%). CONCLUSION: Infecton scintigraphy proved to be more sensitive and accurate and had a higher negative predictive value compared with clinical evaluation, ESR and CRP in predicting infection resolution or recurrence in patients with chronic bone and joint infections.

Pott's puffy tumor in children.

INTRODUCTION: Pott's puffy tumor is characterized by subperiosteal abscess associated with osteomyelitis of frontal bone. Reports are limited for this rare entity in the antibiotics era but increase during past decade. METHODS: We had clinical analysis of a series with six consecutive pediatric patients of Pott's puffy tumor during 20 years in a tertiary medical center via retrospective chart review. One case was described in detail. RESULTS: Male-to-female ratio was 5:1. The mean age at the time of diagnosis was 13 years-3 months. The risk factors were acute sinusitis in two (33%), chronic sinusitis in two (33%), recent head trauma in two (33%), and acupuncture therapy on skull in one (17%). The commonest presenting symptoms were fever, headache, forehead tenderness, vomiting, and fatigue/malaise (100%). Pott's puffy tumor was diagnosed on average the seventh day after fever, and half had intracranial involvement at diagnosis. All had intracranial infections, and most of them had subdural empyema. The most often involved sinus was frontal sinus (100%). The frontal lobe was the most common site of intracranial infection (100%), two thirds of which are polymicrobial from two or more sites. The initial operation was performed on average on the 5.8th days after diagnosis. Half of the patients underwent reoperation. The mortality rate was 17% (one of six). CONCLUSION: The symptoms of Pott's puffy tumor are inconspicuous even though early intracranial involvement often occurred. The importance of early diagnosis and aggravated and prompt treatment with prolonged antibiotic therapy is emphasized for better outcome.