Osteomyelitis Revisited

Transcription

1 Osteomyelitis Revisited Alan Jay Block, DPM, MS, FASPS, FACFAS Assistant Professor Dept Of Orthopeadics The Ohio State University Medical Board Kent State University Editor-in -Chief The Journal of the American Society of Podiatric Surgeons Past President The Ohio Foot & Ankle Medical Association

2 Igantz Simmelweis 1849

3 Louis Pasteur

4 Blood Agar

5 Culture: Culture and Sensitivity TEM-PCRTM (Target Enriched Multiplex Polymerase Chain Reaction MRI Bone Biopsy

6 4 fundamental questions regarding treatment of chronic osteomyelitis in adults: (1) Are certain antibiotic agents preferred choices? (2) Are oral regimens acceptable for selected cases? (3) For how long should antibiotic therapy be given? (4) Is surgical debridement always necessary for cure?

7 Oral antibiotic therapy with highly bioavailable agents is an acceptable alternative to parenteral therapy The widely held preference for parenteral therapy for chronic osteomyelitis is based more on custom than evidence There are actually fewer published studies of parenteral than oral therapy for osteomyelitis Success rates are consistently similar for both routes

8 oral therapy is generally simpler for the patient avoids risks associated with intravenous catheters less expensive. Preferred oral agents, based on both pharmacokinetic and clinical data particularly in the context of concomitant surgical debridement.

9 Although the theory is still being debated no evidence that bactericidal agents are superior to bacteriostatic In the treatment of osteomyelitis

10 Clinicians must individualize the duration of antibiotic therapy based on the patient s clinical and radiographic response with continued monitoring after cessation of therapy No strong evidence supports the standard recommendation of 4 6 weeks of therapy after surgical debridement No evidence that more prolonged therapy further improves cure rates. There are no well established markers of successful treatment and relapse rates remain substantial, even after prolonged antibiotic therapy Defining the optimal duration of therapy for chronic osteomyelitis is an area of urgent need

11 Surgical resection of necrotic and infected bone, in conjunction with antibiotic therapy, appears to increase the cure rate of chronic osteomyelitis

12 not all cases of chronic osteomyelitis require surgical debridement for cure studies to clarify which may and which may not. comparative effectiveness studies to answer these and a number of other questions regarding therapy of chronic osteomyelitis.

13 DURATION OF THERAPY Although it has been traditionally recommended that four to six weeks of parenteral therapy is sufficient to treat osteomyelitis, the optimal duration has never precisely been established -No residual infected tissue days -Residual infected soft tissue 2-4 weeks -Residual infected bone 4-6 weeks -No surgery -> 3 months IDSA Diabetic Foot Guidelines, CID, Oct 2004

14 Need for Culture Generally accepted poor concordance between superficial wound cultures and bone cultures -Senneville Khatri. Mackowak, 1978 and others Directs and allows tapering of antibiotics Performed during surgical debridement or independently How long off antibiotics??

15 Deep Sinus Cultures Bernard, et al, Int. JID 2009 Non-randomized, prospective study 147 patients 154 episodes of Osteomyelitis 4 samples Two consecutive sinus tract cultures with bone contact at different times - A Surgical biopsy through the sinus tract- B Surgical debridement through a non-infected site (gold standard) - C

16 Results When both sinus tract cultures yielded the same organism: -concordance between A&C = 96% -Sensitivity = 91% -Specificity = 86% - Accuracy = 90% No difference if antibiotic were stopped or not

17 Non-Surgical Studies Embil, Foot & Ankle Intl, Oct pts. 93 episodes of osteomyelitis -Mean of1.6pathogensfrom culture -3+/- 1 oral agent ( with/without initial short IV) -Bone debridement in 26 (28%) toe amp in 9 Mean duration of oral therapy = 40 +/-30 weeks -75 (80.5%) put into remission Conclusion: Diabetic foot osteomyelitis was effectively managed with oral antibiotic with or with out limited office debridement

18 Bone Penetration There has never been a standardized technique for determination i.e. 1 g Cefazolin levels range from 4-43 ug Clinical relevance has never adequately been studied All antibiotics penetrate adequately What s Important: Will the antibiotic cover the organism in the bone.

19 Antibiotic Issues Culture Directed Spectrum of empirical choice Bone penetration? Route of Administration( IV vs PO) - is IV better Duration of therapy FDA indication

20 Antibiotic Consensus International working Group of the Diabetic Foot (IWGDF) NO specific agent has been shown to be most effective Empiric coverage should include anti-staph ( including MRSA?) NO data indicates superiority of any particular route of administration NO data to inform duration of therapy -IDSA Guidelines appears Useful

21 International working Group of the Diabetic Foot Diabetic Foot Osteomyelitis Systemic Review Findings: 1168 papers identified only 19 met criteria ( only3 were controlled clinical trials ) No significant differences in outcome were associated with any particular treatment strategy There was no evidence that surgical debridement of the infected bone is routinely necessary There was no data to support the superiority of any particular route of delivery of systemic antibiotics or to inform the optimal duration of antibiotic therapy No available evidence supports the use of any adjunctive therapies such as hyperbaric oxygen, granulocyte-colony stimulating factor or larvae.

22 Conclusions of Spellberg and Lipsky Oral antibiotic therapy with high bioavailable agents is an acceptable alternative to parenteral therapy Adding rifampin to a variety of antibiotic regimens improves cure rates Individualize duration of therapy based on patient s clinical and radiographic response - No strong evidence supports 4-6 weeks of therapy after surgical debridement Surgical resection appears to increase cure rates. However, not all cases of chronic osteomyelitis require it

23 Conclusions This accumulated evidence suggests it is time to revisit the traditional belief in the need for routine surgical intervention Jeffcoate & Lipsky CID 2004

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25 TEM-PCR Distinctions Target Enriched Multiplex Polymerase Chain Reaction One day results* Detection of bacteria in the presence of antibiotics Simultaneous identification of bacteria, viruses, parasites, Candida and antibiotic resistance Increased sensitivity and specificity Simplicity of single sample collection * Determined by sample receipt.

26 COMMINUTED PILON 49 Y.O. Train wreck 10 Months S/P Pilon FX Casted for 8 months KIDNEY/PANCREAS TRANSPLANT IMMUNOSUPPRESSIVE DRUGS DIABETIC/Peripheral Vascular Disease

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