Lower Extremity Amputation in Fracture-Related Infection.

OBJECTIVES: To analyze demographics, comorbidities, fracture characteristics, presenting characteristics, microbiology, and treatment course of patients with fracture-related infections (FRIs) to determine risk factors leading to amputation. DESIGN: Retrospective cohort. SETTING: Single Level I Trauma Center (2013-2020). PATIENT SELECTION CRITERIA: Adults with lower extremity (femur and tibia) FRIs were identified through a review of an institutional database. Inclusion criteria were operatively managed fracture of the femur or tibia with an FRI and adequate documentation present in the electronic medical record. This included patients whose primary injury was managed at this institution and who were referred to this institution after the onset of FRI as long as all characteristics and risk factors assessed in the analysis were documented. Exclusion criteria were infected chronic osteomyelitis from a non-fracture-related pathology and a follow-up of less than 6 months. OUTCOME MEASURES AND COMPARISONS: Risk factors (demographics, comorbidities, and surgical, injury, and perioperative characteristics) leading to amputation in patients with FRIs were evaluated. RESULTS: A total of 196 patients were included in this study. The average age of the study group was 44±16 years. Most patients were men (63%) and White (71%). The overall amputation rate was 9.2%. There were significantly higher rates of chronic kidney disease (CKD; P = 0.039), open fractures (P = 0.034), transfusion required during open reduction internal fixation (P = 0.033), Gram-negative infections (P = 0.048), and FRI-related operations (P = 0.001) in the amputation cohort. On multivariate, patients with CKD were 28.8 times more likely to undergo amputation (aOR = 28.8 [2.27 to 366, P = 0.010). A subanalysis of 79 patients with either a methicillin-sensitive Staphylococcus aureus or methicillin-resistant S. aureus (MRSA) infection showed that patients with MRSA were significantly more likely to undergo amputation compared with patients with methicillin-sensitive Staphylococcus aureus (P = 0.031). MRSA was present in all cases of amputation in the Staphylococcal subanalysis. CONCLUSIONS: Findings from this study highlight CKD as a risk factor of amputation in the tibia and femur with fracture-related infection. In addition, MRSA was present in all cases of Staphylococcal amputation. Identifying patients and infection patterns that carry a higher risk of amputation can assist surgeons in minimizing the burden on these individuals. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The diabetic sausage toe: Prevalence, presentation and outcomes.

Osteomyelitis (OM) in diabetic foot infection could have many presentations such as an infected ulcer spreading to the bone or superimposed to Charcot neuroarthropathy. However, the sausage toe as a diabetic OM presentation was very rarely investigated; therefore, this study aims to assess the prevalence and signs of this presentation along with treatment modalities and outcomes. This is a retrospective series of patients presenting a sausage toe on admission. Several methods were conducted to diagnose OM, and three treatment modalities were applied. Two groups were compared: acute and chronic sausage toes. Outcomes were defined as sausage toe prevalence, ulcer location, OM prevalence, and comparative treatment results. Out of 82 diabetic toe infection cases, 24 (30%) presented as 'sausage toe'. The side of the proximal interphalangeal joint of the lateral toes was the most frequent ulcer location (50%), mostly on the dorsal aspect followed by the side aspect. There were 15 (62.5%) acute cases and 9 (37.5%) chronic cases. MRI showed signs of OM in 21 (87.5%) cases and signs of septic arthritis in 3 (12.5%) cases. At the final follow-up, a successful treatment was recorded in five (20%) cases with antibiotics alone. Out of the 19 (42%) procedures, conservative surgery was performed successfully in 8 (58%) cases while amputation was needed in 11 (45.8%) cases. There was no significant difference in amputation frequency between acute and chronic groups. This is the first study documenting the sausage toe as a prevalent presentation of diabetic toe infection. The deformity is conclusive of deep infection with a very high osteomyelitis frequency. Surgery is often required for infection control and healing, mainly for chronic cases, and treatment outcomes did not differ between acute and chronic sausage toe groups. It could be beneficial to include this entity in the diabetic wound classification systems.

Clinical outcomes in people with diabetes-related foot infections: Analysis from a limb preservation service infection database.

BACKGROUND: Diabetes-related foot infections are common and represent a significant clinical challenge. There are scant data about outcomes from large cohorts. The purpose of this study was to report clinical outcomes from a large cohort of people with diabetes-related foot infections. METHODS: A tertiary referral hospital limb preservation service database was established in 2018, and all new episodes of foot infections were captured prospectively using an electronic database (REDCap). People with foot infections between January 2018 and May 2023, for whom complete data were available on infection episodes, were included. Infection outcomes were compared between skin and soft tissue infections (SST-DFI) and osteomyelitis (OM) using chi-square tests. RESULTS: Data extraction identified 647 complete DFI episodes in 397 patients. The data set was divided into two cohorts identifying each infection episode and its severity as either SST-DFI (N = 326, 50%) or OM (N = 321, 50%). Most infection presentations were classified as being moderate (PEDIS 3 = 327, 51%), with 36% mild (PEDIS 2 = 239) and 13% severe (PEDIS 4 = 81). Infection resolution occurred in 69% (n = 449) of episodes with failure in 31% (n = 198). Infection failures were more common with OM than SST-DFI (OM = 140, 71% vs. SST-DFI = 58, 29%, p < 0.00001). In patients with SST-DFI a greater number of infection failures were observed in the presence of peripheral arterial disease (PAD) compared to the patients without PAD (failure occurred in 30% (31/103) of episodes with PAD and 12% (27/223) of episodes without PAD; p < 0.001). In contrast, the number of observed infection failures in OM episodes were similar in patients with and without PAD (failure occurred in 45% (57/128) of episodes with PAD and 55% (83/193) of episodes without PAD; p = 0.78). CONCLUSIONS: This study provides important epidemiological data on the risk of poor outcomes for DFI and factors associated with poor outcomes in an Australian setting. It highlights the association of PAD and treatment failure, reinforcing the need for early intervention to improve PAD in patients with DFI. Future randomised trials should assess the benefits of revascularisation and surgery in people with DFI and particularly those with OM where outcomes are worse.

Osteomyelitis of the Jaw: A 10-Year Retrospective Analysis at a Tertiary Health Care Centre in Canada.

BACKGROUND: Osteomyelitis (OM) of the jaw is a rare medical condition. In this review, we provide a descriptive analysis of the experience with this condition at a single tertiary health care centre in Canada over 10 years. MATERIALS AND METHODS: We conducted a retrospective chart review of adult patients aged ≥ 18 years presenting with OM of the jaw at the University of Manitoba Health Sciences Centre between January 2009 and May 2019. We included cases with consistent clinical symptoms and radiographic and/or microbiologic evidence of OM of the jaw. Excluded were cases with a previous history of head and neck cancer, radiation therapy in the head and neck regions and use of anti-resorptive medications. RESULTS: Of the 37 patients who met our criteria, the mean age was 44 years (standard deviation [SD] ± 16 years), 21 (56.8%) were male, 16 (43.2%) were diagnosed with acute OM and 21 (57.8%) with chronic OM. Underlying comorbidities, such as diabetes mellitus and chronic kidney diseases, were reported in 6 (16.2%) and 3 patients (8.1%), respectively. Traumatic injuries to the facial skeleton were the most common predisposing factor (11 patients [29.7%]). The most commonly isolated infective organisms were viridans group streptococci (VGS; 75.8%), followed by Prevotella spp. (45.4%). Results showed a higher level of resistance to penicillin of the isolated organisms in chronic OM compared with acute OM. CONCLUSIONS: This description of acute and chronic forms of OM of the jaw will enable clinicians to better understand OM patient profiles, leading to early diagnosis, improved patient care and better outcomes.

Type 2 diabetes mediates the causal relationship between obesity and osteomyelitis: A Mendelian randomization study.

Mendelian randomization (MR) analysis was used to determine the causal relationship between Type 2 diabetes (T2D) and osteomyelitis (OM). We performed MR analysis using pooled data from different large-scale genome-wide association studies (GWAS). Instrumental variables were selected based on genome-wide significance, instrumental strength was assessed using F-values, and thresholds for the number of exposed phenotypes were further adjusted by Bonferroni correction. univariable and multivariable MR analyses were performed to assess causal effects and proportions mediated by T2D. IVW (inverse variance weighting) showed a significant genetic effect of osteomyelitis on the following: After correction by Bonferroni, univariable analyses showed that childhood body mass index (BMI) was not significantly associated with genetic susceptibility to OM [odds ratio (OR), 1.26; 95% confidence interval (CI), 1.02, 1.55; P = .030], not significantly associated with adulthood BMI (OR, 1.28; 95% CI, 1.02, 1.61; P = .034), significantly associated with waist circumference (OR, 1.84; 95% CI, 1.51, 2.24; P < .001), and significantly associated with hip circumference (OR, 1.52; 95% CI, 1.31, 1.76; P < .001). Meanwhile, multivariable analyses showed no significant effect of childhood BMI on OM (OR, 1.16; 95% CI, 0.84, 1.62; P = .370), no significant effect of adulthood BMI on OM (OR, 0.42; 95% CI, 0.21, 0.84; P = .015), a significant association between waist circumference and OM (OR, 4.30; 95% CI, 1.89, 9.82; P = .001), T2D mediated 10% (95% CI, 0.02, 0.14), and no significant association between hip circumference and OM (OR, 1.01; 95% CI, 0.54, 1.90; P = .968). Our study provides evidence for a genetically predicted causal relationship among obesity, T2D, and OM. We demonstrate that increased waist circumference is positively associated with an increased risk of OM and that T2D mediates this relationship. Clinicians should be more cautious in the perioperative management of osteomyelitis surgery in obese patients with T2D. In addition, waist circumference may be a more important criterion to emphasize and strictly control than other measures of obesity.

The projected increase of vertebral osteomyelitis in Germany implies a demanding challenge for future healthcare management of aging populations.

PURPOSE: Since an increase in the occurrence of native vertebral osteomyelitis (VO) is expected and reliable projections are missing, it is urgent to provide a reliable forecast model and make it a part of future health care considerations. METHODS: Comprehensive nationwide data provided by the Federal Statistical Office of Germany were used to forecast total numbers and incidence rates (IR) of VO as a function of age and gender until 2040. Projections were done using autoregressive integrated moving average model on historical data from 2005 to 2019 in relation to official population projections from 2020 to 2040. RESULTS: The IR of VO is expected to increase from 12.4 in 2019 to 21.5 per 100,000 inhabitants [95% CI 20.9-22.1] in 2040. The highest increase is predicted in patients over 75 years of age for both men and women leading to a steep increase in absolute numbers, which is fourfold higher compared to patients younger than 75 years. While the IR per age group will not increase any further after 2035, the subsequent increase is due to a higher number of individuals aged 75 years or older. CONCLUSIONS: Our data suggest that increasing IR of VO will seriously challenge healthcare systems, particularly due to demographic change and increasing proportions of populations turning 75 years and older. With respect to globally fast aging populations, future health care policies need to address this burden by anticipating limitations in financial and human resources and developing high-level evidence-based guidelines for prevention and interdisciplinary treatment.

High Prevalence of Panton-Valentine Leukocidin Among Staphylococcus aureus Causing Acute Hematogenous Bone and Joint Infections From a Tertiary Children's Hospital in Vietnam.

BACKGROUND: We aimed to investigate the clinical features, antimicrobial susceptibility and pvl gene expression in Staphylococcus aureus causing acute hematogenous bone and joint infections (BJIs) in children in Vietnam. METHODS: In this prospective study, the demographics, microbiology and clinical outcomes of pediatric patients with acute hematogenous BJIs were collected from September 2022 to September 2023. Antimicrobial susceptibility profiles were determined using VITEK2 Compact system. The pvl gene encoding the Panton-Valentine leukocidin (PVL) toxin was detected by using polymerase chain reaction. Mann-Whitney, χ 2 and Fisher test were used for statistical analysis. RESULTS: In total, 78 patients (46 boys) with S. aureus acute hematogenous BJIs were recruited at the National Children's Hospital, Hanoi, Vietnam. Of all S. aureus isolates, 84.6% were methicillin-resistant S. aureus . All S. aureus isolates were susceptible to vancomycin, ciprofloxacin and levofloxacin; 97% of methicillin-resistant S. aureus isolates was resistant to clindamycin (minimum inhibitory concentration ≥8 µg/mL). The pvl gene was detected in 83.3% of isolates, including 57 methicillin-resistant S. aureus isolates. Patients in the pvl -positive group had significantly higher C-reactive protein levels than those in the pvl -negative group ( P = 0.04). In addition, all 8 children with septic shock were infected with pvl -positive S. aureus . CONCLUSIONS: PVL is a prevalent virulence factor of S. aureus in Vietnam. Furthermore, high inflammatory parameters (C-reactive protein) may be present at the time of diagnosis in PVL positivity-related acute hematogenous BJIs. Further research is necessary to enhance our understanding of the varying correlations between virulence factors and outcomes of S. aureus BJIs.

MRSA infection, re-infection and clinical outcomes in diabetic foot infections.

The aim was to investigate methicillin-resistant Staphylococcus aureus (MRSA) incidence, conversion and outcomes in diabetic foot infections (DFIs). This is a pooled patient-level analysis of combined data sets from two randomised clinical trials including 219 patients admitted to the hospital with moderate or severe DFIs. Intraoperative bone and tissue cultures identified bacterial pathogens. We identified pathogens at index infections and subsequent re-infections. We identified MRSA conversion (MSSA to MRSA) in re-infections. MRSA incidence in index infections was 10.5%, with no difference between soft tissue infections (STIs) and osteomyelitis (OM). MRSA conversion occurred in 7.7% of the re-infections in patients who initially had MSSA in their cultures. Patients with re-infection were 2.2 times more likely to have MRSA compared to the first infection (10.5% vs. 25.8%, relative risk [RR] = 2.2, p = 0.001). Patients with MRSA had longer antibiotic treatment during the 1-year follow-up, compared to other pathogens (other 49.8 ± 34.7 days, MRSA 65.3 ± 41.5 days, p = 0.04). Furthermore, there were no differences in healing, time to heal, length of stay, re-infection, amputation, re-ulceration, re-admission, surgery after discharge and amputation after discharge compared to other pathogens. The incidence of MRSA at the index was 10.5% with no difference in STI and OM. MRSA incidence was 25.8% in re-infections. The RR of having MRSA was 2.2 times higher in re-infections. Patients with MRSA used more antibiotics during the 1-year follow-up. Furthermore, there were no differences in clinical outcomes compared to other bacterial pathogens.

Prevalence of radiographic findings in chronic osteomyelitis.

BACKGROUND: Simple radiography in conjunction with pertinent medical history and a comprehensive physical examination is typically adequate for diagnosing chronic osteomyelitis (CO). However, radiographic manifestations of CO lack specificity; therefore, the concordance among specialists in this regard has not been systematically assessed. This study aimed to compare and evaluate the proficiency of orthopedic surgeons and radiologists in identifying radiographic indicators present in simple radiographs for diagnosing CO. METHODS: This cross-sectional study was a correlational investigation utilizing plain radiographs obtained from a cohort of 60 patients diagnosed with CO. Comprehensive assessments of the demographic and clinical characteristics, comorbidities, and microbiological parameters were conducted. Additional variables included the anatomical location of the CO, existence of fistulas, disease duration, and presence of pseudoarthrosis. This study meticulously documented the presence or absence of six specific findings: bone destruction, which incorporates erosion and radiolucencies around implants; bone sclerosis; cortical thinning concomitant with erosion; cortical thickening; sequestrum formation; and soft-tissue swelling. RESULTS: Most patients were men (75%), with a mean age of 45.1 years. Hematogenous etiology of CO represented 23%. Bone sclerosis (71.3%) and cortical thickening (67.7%) were the most common radiographic findings, followed by soft-tissue swelling (51.3%), sequestration (47.3%), bone destruction (33.3%), and cortical erosion (30.3%). The mean agreement was 74.2%, showing a marked disagreement rate of 25.8% among all radiographic findings. The presence or absence of soft tissue edema, a prominent radiographic finding that was more important than the other findings, showed the greatest disagreement. CONCLUSIONS: Radiographic findings in CO were universally observed in all patients, demonstrating a high degree of concordance among specialists, with the exception of soft tissue swelling.

Retention of Antibiotic Cement Delivery Implants in Orthopedic Infection Associated With United Fractures Does Not Increase Recurrence Risk.

OBJECTIVES: To evaluate whether retention of antibiotic cement delivery devices after resolution of orthopaedic infection is associated with recurrence. DESIGN: Retrospective cohort. SETTING: Academic medical center. PATIENT SELECTION CRITERIA: Patients with a fracture definitively treated with internal fixation that went on to unite and develop a confirmed fracture-related infection or osteomyelitis after a remote fracture surgery and had implantation of antibiotic-impregnated cement for infection management. OUTCOME MEASURES AND COMPARISONS: Patients were divided into whom the antibiotic implants were retained (Retained Cohort) and whom the antibiotic implants were removed (Removed Cohort). Outcome measures included clinical infection resolution, infection recurrence, time to resolution of infection signs, symptoms and laboratory values, reoperation and readmission rates, and need for soft tissue coverage (local flap vs. free tissue transfer) because of recurrence. RESULTS: Of 98 patients treated for fracture-related infection in united fractures or osteomyelitis after a remote fracture surgery, 39 (39.8%) underwent implantation of antibiotic-impregnated cement delivery devices: 21 (21.4%) beads, 7 (7.1%) rods, and 11 (11.2%) blocks. Twenty patients (51.3%) comprised the Retained Cohort and 19 patients (48.7%) comprised the Removed Cohort. There were few differences in demographics ([American Society of Anesthesiology Score, P = 0.026] and [diabetes, P = 0.047]), infection location, and pathogenic profiles. The cohorts demonstrated no difference in eventual resolution of infection (100% in the Retained Cohort, 95% in the Removed Cohort, P = 0.487) and experienced similar time to clinical infection resolution, based on signs, symptoms, and laboratory values ( P = 0.360). There was no difference in incidence of subsequent infection recurrence after clinical infection resolution (1 recurrence Retained vs. 2 recurrences Removed, P = 0.605) for those considered "cured." Compared with the Retained Cohort, the Removed Cohort underwent more reoperations (0.40 vs. 1.84 reoperations, P < 0.001) and admissions after implantation ( P < 0.001). CONCLUSIONS: Retention of antibiotic-impregnated cement delivery devices in patients with orthopaedic infection after fractured bones that have healed was not associated with infection recurrence. Additional surgical intervention with the sole purpose of removing antibiotic delivery devices may not be warranted. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment Effect of Zoledronic Acid in Chronic Non-bacterial Osteomyelitis of the Jaw: A Case Series.

Chronic non-bacterial osteomyelitis (CNO) is an autoinflammatory, osteolytic bone disorder sometimes localized to a unifocal site in the jaw, causing long-term pain and reduced function. The aim of this study was to describe the patients with CNO of the jaw, focusing on treatment with zoledronic acid for pain relief. An analysis of medical records of 24 patients with CNO of the jaw, including treatment with zoledronic acid and effects on pain relief. Descriptive statistics and nonparametric tests were used to describe the population and compare treatment effects, respectively. The average treatment period was 33.4 months (median 23; Q1 11.5; Q3 42.0) with an average of 4.1 infusions (median 3; Q1 2; Q3 5) of zoledronic acid. The average pain VAS score (visual analogue scale) was significantly reduced from 7.7 (median 8; Q1 6.5; Q3 8.5) to 2.5 points (median 2; Q1 0.5; Q3 4.5) (p < 0.001). At final visit, 46% of patients reported no pain and 38% reported a reduction of pain. At least 67% of patients had at least one episode of pain recurrence, and most patients experienced the first recurrence within a year of initial treatment. Four patients (16%) had no pain relief from the treatment. In this group of patients with CNO of the jaw, there was a positive response to treatment with zoledronic acid on pain relief, averaging 5.2 points on a pain VAS score, with 84% of patients treated experiencing either a partial or a total reduction in pain after about 2.5 years.

Comportamiento de la osteomielitis en pacientes pediátricos / Behavior of osteomyelitis in pediatric patients / Comportamento da osteomielite em pacientes pediátricos

Introducción: La osteomielitis es una infección ósea, que afecta con frecuencia a pacientes en edades pediátricas, con comportamiento variado en dependencia de la vía de llegada al hueso, tipo de germen y respuesta del huésped. Objetivo: Describir el comportamiento de un grupo de pacientes pediátricos con osteomielitis. Método: Se realizó estudio observacional descriptivo en 39 pacientes atendidos en el Hospital Pediátrico Provincial Dr. Eduardo Agramonte Piña de la ciudad de Camagüey, en el periodo comprendido desde el primero de enero de 2018 al 31 de diciembre del año 2022, y un total de 60 meses con diagnóstico de osteomielitis. Resultados: De los 39 pacientes investigados predominó el sexo masculino sobre el femenino (2,2:1). La edad promedio fue de 9 años. El promedio de estadía hospitalaria fue de 14,8 días. Las zonas más afectadas fueron las manos, el fémur y tibia distal. Predominó el tratamiento quirúrgico (2,2:1) con relación al conservador. La vía hematógena de llegada al hueso fue la más frecuente en el 86,4 porciento de los casos. El paso a la cronicidad fue la complicación más encontrada (el 33 porciento). El germen aislado con mayor frecuencia fue el Staphylococcus aureus(en el 85 porciento de los enfermos). Los antimicrobianos más indicados fueron la cefazolina, amikacina y fosfocina. Conclusiones: Los resultados obtenidos en la investigación aportan elementos importantes desde el punto de vista epidemiológico en pacientes pediátricos que sufren de osteomielitis, lo que permite implementar estrategias de diagnósticas y terapéuticas en este grupo de pacientes.(AU)

Introduction: Osteomyelitis is an infection in the bone, most frequently affecting patients in pediatric ages, with a variety of behavior on how to reach the bone, type of germ and host response. Objective: To describe the behavior of a group of pediatric patients affected with osteomyelitis. Method: A descriptive observational study was conducted in 39 patients attended at the Hospital Provincial Pediátrico Dr. Eduardo Agramonte Piña in the city of Camagüey, from January 1 2018 to December 31 2022. Patients diagnosed with osteomyelitis throughout 60 months in total. Results: Of the 39 patients studied, the male sex predominated over the female (2.2 to 1). The average age was 9 years old. The average lenght of hospital stay was 14.8 days. The most affected areas were the hands, femur and distal tibia. Surgical treatment predominated (2.2 to 1) in relation to conservative treatment. In the 86.4 percent of cases, hematogenous osteomyelitis was the most frequent infection. The transition to chronic osteomyelitis was the most common complication (33 percent). The most common isolated germ was staphylococcus aureus (in 85 percent of the patients). The most indicated antimicrobials agents were cefazolin, amikacin and fostomycin (Fosfocin). Conclusions: The results of this research provided some important elements base on the epidemiological point of view for pediatric patients with osteomyelitis, also allowed the implementation of diagnostic and therapeutic strategies in this group of patients.(AU)

Introdução: A osteomielite é uma infeção óssea, que afecta frequentemente afecta frequentemente doentes do grupo etário pediátrico, com um comportamento variado, dependendo da via de entrada no osso, do tipo de germe e da resposta do hospedeiro. Objectivo: Mostrar o comportamento de um grupo de doentes pediátricos com osteomielite. Método: Foi realizado um estudo observacional descritivo em 39 pacientes tratados no Hospital Pediátrico Provincial Dr. Eduardo Agramonte Piña, na cidade de Camagüey, no período de 1 de janeiro de 2018 a 31 de dezembro de 2022, e um total de 60 meses com diagnóstico de osteomielite. Resultados: Dos 39 pacientes investigados, o sexo masculino predominou sobre o feminino (2,2 para 1). A idade média foi de 9 anos. A média de permanência hospitalar foi de 14,8 dias. As regiões mais acometidas foram as mãos, o fêmur e a tíbia distal. O tratamento cirúrgico predominou (2,2 para 1) sobre o tratamento conservador. A via hematogénica para o osso foi a mais frequente em 86,4 porcento dos casos. A transição para a cronicidade é a complicação mais frequentemente encontrada (33 porcento). O germe mais frequentemente isolado foi o Staphylococcus aureus (em 85 porcento dos doentes). Os antimicrobianos mais frequentemente indicados foram a cefazolina, a amicacina e a fosfocina. Conclusões: Os resultados obtidos na pesquisa fornecem elementos importantes do ponto de vista epidemiológico em pacientes pediátricos portadores de osteomielite, permitindo a implementação de estratégias diagnósticas e terapêuticas neste grupo de pacientes.(AU)

Risk Factors and Outcomes of Hematogenous Vertebral Osteomyelitis in Patients With Staphylococcus aureus Bacteremia.

BACKGROUND: Hematogenous vertebral osteomyelitis (HVOM) is an incompletely understood complication of Staphylococcus aureus bacteremia (SAB). METHODS: Eligible SAB patients with and without HVOM were prospectively enrolled from 1995 through 2019 at Duke University Health System. HVOM was diagnosed either radiographically or microbiologically. Multivariable logistic regression analysis was performed to identify clinical and microbial factors associated with HVOM risk. All bloodstream S. aureus isolates were genotyped using spa typing. RESULTS: Of 3165 cases of SAB, 127 (4.0%) developed HVOM. Patients who experienced HVOM were more likely to have community-acquired SAB (30.7% vs 16.7%, P < .001), have a longer time to diagnosis of SAB (median, 5 days; interquartile range [IQR], 2-10.5 vs median, 2 days; IQR, 0-4; P < .001), and to exhibit persistent bacteremia (48.8% vs 20.6%, P < .001). A significant number of HVOM patients developed infective endocarditis (26% vs 15.2%, P = .002). Overall, 26.2% (n = 33) of SAB patients with HVOM underwent surgical intervention. Methicillin resistance (46.6% vs 41.7%, P = .318) and bacterial genotype were not associated with the development of HVOM. At the 12-month follow-up, 22% of patients with HVOM had died. Of the surviving patients, 20.4% remained on antibiotic therapy, and 29.6% had recurrence of either HVOM or SAB. CONCLUSIONS: Among patients with SAB, HVOM risk was associated with clinical factors and not bacterial genotype. Despite being a rare complication of SAB, patients with HVOM had high all-cause mortality rates and healthcare resource requirements up to 1 year after their HVOM diagnosis. Close clinical monitoring is indicated in this vulnerable population.

Risk factors of deep vein thrombosis in children with osteomyelitis.

OBJECTIVE: To investigate the risk factors for deep vein thrombosis (DVT) in children with osteomyelitis and provide diagnostic and treatment strategies for the prevention, early detection and treatment of DVT. STUDY DESIGN: The clinical data of nine children diagnosed with osteomyelitis and DVT between July 2012 and March 2021 were collected at our hospital, including age, sex, clinical manifestations, body temperature, coagulation function and other data, as well as the clinical data of 27 children diagnosed with osteomyelitis without DVT during the same period. Thirty-six children were divided into thrombus and thrombus-free groups. The clinical characteristics and risk factors for DVT in children with osteomyelitis were analysed. RESULTS: Among the 36 children in this study, nine cases of thrombus formation mainly occurred in the femoral vein, popliteal vein and iliac vein, all near the infection site. The main clinical manifestations were lower extremity pain, swelling and pulmonary embolism in three cases. Among them, intensive care unit (ICU) admission, sepsis, higher D-dimer, higher body temperature during hospitalization, and pathogen culture showed that methicillin-resistant Staphylococcus aureus (MRSA) was associated with DVT. MRSA was the independent risk factor for DVT. CONCLUSIONS: Admission to ICU, sepsis, higher D-dimer, higher body temperature during hospitalization, and MRSA are risk factors for thrombosis. MRSA is the independent risk factor for DVT. For patients with related risk factors, timely ultrasound examination of the infected site should be considered to achieve early detection and treatment.

Risk factors associated with pressure ulcer recurrence after reconstruction: Analysis of a national database.

In this study, we sought to clarify the patient traits and comorbidities that are associated with pressure injury recurrence following pressure injury reconstruction. An insurance claims database, PearlDiver, was used to conduct a retrospective cohort study. The two cohorts included patients who underwent pressure injury reconstruction without recurrence and patients who experienced recurrence with subsequent reconstruction. Multiple logistic regression analysis was used to identify risk factors for recurrence after reconstruction. Recurrence was associated with hypoalbuminemia (p < 0.05), paraplegia (p < 0.05), and osteomyelitis (p < 0.05). In patients with osteomyelitis, primary closure was associated with recurrence (p < 0.05) while flap reconstruction was not (p > 0.05). Osteomyelitis was not associated with recurrence after flap reconstruction. Prior to reconstruction, patients with osteomyelitis and hypoalbuminemia should have their nutrition and infection optimised.

Characterization of an Emerging Enterococcus cecorum Outbreak Causing Severe Systemic Disease with Concurrent Leg Problems in a Broiler Integrator in the Southern United States.

Enterococcus cecorum has been associated mainly with osteomyelitis of the free thoracic vertebra in chickens. However, there are reports of E. cecorum producing septicemic lesions and having tropism for cartilages, resulting in the presentation of femoral head necrosis and synovitis. This paper discusses the presentation of E. cecorum as it relates to an outbreak in one vertical integrator where the main lesions were related to septicemia. Using a convenience sampling method, 100 broiler chicken cases received at the Poultry Research and Diagnostic Laboratory of Mississippi State University from April to December of 2021 were analyzed. The peak in cases was observed from June to August. The average age of broilers was 21 days with a range of 15-31 days. Most of these cases were related to systemic disease and leg problems, with gross lesions including characteristic pericarditis along with perihepatitis, osteomyelitis, and arthritis. In six of the 100 cases, E cecorum was isolated from the free thoracic vertebra, with the remaining being recovered from various other locations including liver, pericardium, hock/joint, femoral head, and bone marrow. Enterococcus cecorum identification was performed by using Vitek matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. These results were then sent to the research-use only SARAMIS database for analysis. Once the spectra of the isolates were imported, the relative and absolute taxonomy were analyzed. Two super spectrums and three clusters by homology were identified. The minimal inhibitory concentrations obtained by antimicrobial sensitivity tests were analyzed using WHONET Microbiology Laboratory Database Software. No isolates were pan-susceptible, 80% of isolates were noted to be resistant to ≥3 classes of antibiotics and, in general, isolates exhibited a high degree of variability when examining antimicrobial resistance patterns.

Reporte de caso- Caracterización de un brote reciente de Enterococcus cecorum causante de una enfermedad sistémica grave simultáneamente con problemas en las patas en un integrador de pollo de engorde en el sur de los Estados Unidos. La bacteria Enterococcus cecorum se ha asociado principalmente con osteomielitis de la vértebra torácica móvil de los pollos. Sin embargo, existen reportes de E. cecorum produciendo lesiones septicémicas y presentando tropismo por los cartílagos, resultando en la presentación de necrosis de la cabeza femoral y sinovitis. Este artículo analiza la presentación de E. cecorum relacionada con un brote en un integrador vertical donde las principales lesiones estaban relacionadas con septicemia. Utilizando un método de muestreo de conveniencia, se analizaron 100 casos de pollos de engorde recibidos en el Laboratorio de Investigación y Diagnóstico Avícolas de la Universidad Estatal de Mississippi de abril a diciembre del 2021. El mayor número de casos se observó de junio a agosto. La edad promedio de los pollos de engorde fue de 21 días con un rango de 15 a 31 días. La mayoría de estos casos estaban relacionados con enfermedad sistémica y problemas en las patas, con lesiones macroscópicas que incluían pericarditis característica junto con perihepatitis, osteomielitis y artritis. En seis de los 100 casos, E cecorum se aisló de la vértebra torácica móvil, y el resto de los casos se recuperó de otros lugares, incluyendo el hígado, el pericardio, articulación del corvejón, la cabeza femoral y la médula ósea. La identificación de E. cecorum se realizó utilizando la plataforma Vitek de espectrometría de masas MALDI-TOF. Posteriormente, estos resultados se enviaron a la base de datos SARAMIS de uso exclusivo para investigación para su análisis. Una vez importados los espectros de los aislados, se analizó la taxonomía relativa y absoluta. Se identificaron dos superespectros y tres grupos mediante homología. Las concentraciones inhibitorias mínimas obtenidas mediante pruebas de sensibilidad antimicrobiana se analizaron utilizando el software de base de datos de laboratorio de microbiología de WHONET. Ningún aislamiento fue pan-susceptible, se observó que el 80% de los aislamientos eran resistentes a tres o más clases de antibióticos y en general, los aislamientos exhibieron un alto grado de variabilidad al examinar los patrones de resistencia a los antimicrobianos.

Update on treatment responses and outcome measure development in chronic nonbacterial osteomyelitis.

PURPOSE OF REVIEW: To review recent trends in treatment and recent progress in developing outcome measures needed for chronic nonbacterial osteomyelitis (CNO) clinical trials. RECENT FINDINGS: CNO is an autoinflammatory bone disease. In a minority of patients, the disease is genetically driven, and diagnosis can be made by DNA sequencing. However, for nonsyndromic CNO there is no diagnostic test. The number of children with CNO appears to be increasing and damage is common. Increases in CNO diagnosis is due to raised awareness, increased availability of whole-body magnetic resonance imaging and rising incidence. Treatment remains empiric and it is unclear which second line treatment is superior. Tumor necrosis factor inhibitors (TNFi) and bisphosphonates continue to be used as second line agents for nonsteroidal anti-inflammatory drugs (NSAID) refractory CNO; newer immune modulatory medications are used if this fails. Validated classification criteria, clinical outcome measures and imaging scoring standards are needed for successful clinical trials. SUMMARY: Best treatment for NSAID refractory CNO remains unclear. Classification criteria, clinical outcomes measures and standardized imaging scoring have been developed or are near completion. This will facilitate robust clinical trials in CNO with the goal of having approved medications for this painful disease.

The bacteriology of diabetic foot ulcers and infections and incidence of Staphylococcus aureus Small Colony Variants.

Introduction. Uninfected diabetes-related foot ulcer (DFU) progression to diabetes-related foot infection (DFI) is a prevalent complication for patients with diabetes. DFI often progresses to osteomyelitis (DFI-OM). Active (growing) Staphylococcus aureus is the most common pathogen in these infections. There is relapse in 40-60 % of cases even when the initial treatment at the DFI stage apparently clears infection.Hypothesis. S. aureus adopts the quasi-dormant Small Colony Variant (SCV) state during DFU and consequently infection, and when present in DFI cases also permits survival in non-diseased tissues as a reservoir to cause relapse.Aim. The aim of this study was to investigate the bacterial factors that facilitate persistent infections.Methodology. People with diabetes were recruited from two tertiary hospitals. Clinical and bacterial data was taken from 153 patients with diabetes (51 from a control group with no ulcer or infection) and samples taken from 102 patients with foot complications to identify bacterial species and their variant colony types, and then compare the bacterial composition in those with uninfected DFU, DFI and those with DFI-OM, of whom samples were taken both from wounds (DFI-OM/W) and bone (DFI-OM/B). Intracellular, extracellular and proximal 'healthy' bone were examined.Results. S. aureus was identified as the most prevalent pathogen in diabetes-related foot pathologies (25 % of all samples). For patients where disease progressed from DFU to DFI-OM, S. aureus was isolated as a diversity of colony types, with increasing numbers of SCVs present. Intracellular (bone) SCVs were found, and even within uninfected bone SCVs were present. Wounds of 24 % of patients with uninfected DFU contained active S. aureus. All patients with a DFI with a wound but not bone infection had previously had S. aureus isolated from an infection (including amputation), representing a relapse.Conclusion. The presence of S. aureus SCVs in recalcitrant pathologies highlights their importance in persistent infections through the colonization of reservoirs, such as bone. The survival of these cells in intracellular bone is an important clinical finding supporting in vitro data. Also, there seems to be a link between the genetics of S. aureus found in deeper infections compared to those only found in DFU.

Antibiotic Duration Following Abdominal Gunshot Injuries With Associated Pelvis or Spine Involvement: A 20-Year Single-Center Experience.

INTRODUCTION: Optimal antimicrobial prophylaxis duration following gunshot wounds (GSW) to the abdomen with an associated orthopedic fracture is unknown. This study evaluated the safety and efficacy of short versus long courses of prophylactic antibiotics following penetrating hollow viscus injury with communicating orthopedic fracture. METHODS: This retrospective study included adult patients admitted to the trauma service over a 20-y period who sustained an abdominal GSW with hollow viscus injury and communicating spine or pelvic fractures. Patients were stratified into cohorts based on prophylactic antibiotic duration: short course (SC, ≤48 h) and long course (>48 h). The primary outcome was the incidence of osteomyelitis and meningitis up to 1-y postinjury. Secondary outcomes included hospital length of stay and the incidence of multidrug-resistant organisms and Clostridioides difficile infections. Risk factors for osteomyelitis and meningitis were determined. RESULTS: A total of 125 patients were included with 45 (36%) in the SC group. Median prophylactic antibiotic durations were SC, 1 (interquartile range [IQR], 1-2) versus long course, 7 (IQR, 5-7) d (P < 0.001). There was no difference in osteomyelitis and meningitis incidence (2 [4.4%] versus 4 [5%], P = 0.77). Median hospital length of stay (7 [IQR, 6-11] versus 9 [IQR, 6-15] d, P = 0.072) and incidence of multidrug-resistant organisms (6 [13.3%] versus 13 [16.3%], P = 0.86) and Clostridioides difficile infections (0 [0%] versus 1 [1.3%], P = 0.77) were similar between groups. There were no independent risk factors identified for osteomyelitis or meningitis. CONCLUSIONS: A shorter course of antibiotic prophylaxis ≤48 h may be adequate following abdominal GSW that traverses a hollow viscus and results in pelvic fracture or spinal column injury.