Management of Chronic Osteomyelitis and Antibiotic Stewardship; An Effort to Delay the Post-Antibiotic Era.

OBJECTIVE: To develop an effective antimicrobial strategy for the management of chronic osteomyelitis. STUDY DESIGN: Observational study. Place and Duration of the Study: Departments of Microbiology and Orthopaedics, Combined Military Hospital Malir, Karachi, Pakistan, from January 2021 to February 2022. METHODOLOGY: Bone biopsies of 45 enrolled participants were taken for microbiological evaluation. Intravenous antibiotic therapy was begun as per empirical therapy based on the local antibiogram and antibiotic policy. Once the susceptibility pattern was available, targeted therapy started and continued for 28 to 42 days. Patients were evaluated based on inflammatory markers and clinical conditions for a minimum of six months to a maximum of one year. RESULTS:  Out of the 45 patients, the majority 29% were soldiers, 40% belonging to the age group of 31-60 years. The common predisposing factor was trauma/fractures followed by diabetes and implants leading to chronic sinus discharge and decubitus ulcers. The most commonly isolated organism was Staphylococcus aureus (38%) followed by Methicillin-resistant Staphylococcus aureus (MRSA) (31%). Cotrimoxazole and Rifampicin turned out to be good treatment options. Only 4.4% showed unsatisfactory prognosis, nonetheless, no mortality was observed during the course of treatment. CONCLUSION: In this study, highly resistant strains were observed with limited treatment options for chronic osteomyelitis, however, effective stewardship programmes with accurate diagnostic reporting and judicious use of antimicrobials can prevent overuse of the valuable resources. KEY WORDS: Antimicrobial stewardship, Osteomyelitis, Methicillin-resistant Staphylococcus aureus, Empirical therapy, Antimicrobial resistance.

Cardiac Troponin-I, A Biomarker for Predicting COVID-Induced Myocardial Damage Prognosis.

OBJECTIVE: To analyse the utility of cardiac Troponin-I as a prognostic marker in COVID-19-induced myocardial injury. STUDY DESIGN: A descriptive study. Place and Duration of the Study: COVID Intensive Therapeutic Unit (ITC) and Pathology Department, Combined Military Hospital (CMH), Malir, Karachi, from September 2021 to February 2022. METHODOLOGY: Patients with chest pain, who tested positive for COVID-19 by real-time PCR, were inducted. Blood samples were screened for inflammatory and cardiac biomarkers. The levels of cardiac Troponin I (cTn-I) were categorised as normal (99th percentile = ≤0.01 ng/ml), raised (5 times the 99th percentile = >0.01 ng/ml), and markedly raised (>10 times the 99th percentile = >10 ng/ml) based on serial monitoring over a duration of 6-8 hours. RESULTS: Out of a total of 104 patients, the mean age was 48 ± 15.94 years; 78 (75%) were males and 26 (25%) were females. The mean levels of cardiac Troponin I (cTn-I) were 1.91 ng/ml, C-reactive protein (CRP) was 85 mg/l, Interleukin-6 (IL-6) was 43.3 ng/ml, Procalcitonin (PCT) was 1.40 ng/ml, Creatinine Kinase (CK) was 203 U/l, CK MB was 31 U/l, and Ferritin was 471 ng/ml. Forty-four (42.4%) had normal cTn-I levels, 38 (36.5%) had raised levels, and 22 (21.1%) had markedly raised levels. A persistent rising pattern of cTn-I with a maximum rise up to 30 ng/ml was observed in 16 patients (15.3%) labelled as myocarditis, while only 8 (7.6%) showed a rise-fall pattern. Cardiac Tn-I and CRP were significantly higher in patients with myocarditis (p <0.01). Six out of 104 patients (5.7%) died due to COVID- induced myocardial injury all having raised cTn-I. CONCLUSION: Cardiac Troponin-I is an effective biomarker for measuring myocardial injury in COVID-19 patients and can be an independent predictor to assess for severity of cardiac injury than other inflammatory markers in COVID-19. KEY WORDS: COVID-19, Cardiac Troponin I, Inflammatory markers, Myocardial injury, Prognosis.