Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy

On Behalf Of The Lyon Bji Study Group ,Johan Andrianasolo,Hristo Shipkov,Fabien Boucher,Fatiha Daoud,Joseph Chateau,Tristan Ferry,Christian Chidiac,Evelyne Braun,Thomas Perpoint,Frédéric Laurent,Florent Valour,Alain-Ali Mojallal,Claire Triffault-Fillit

doi:10.1186/s12879-018-3076-y

Abstract

BackgroundA two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated.MethodsAdult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis.ResultsSixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36–63)) were included. Osteomyelitis was mostly polymicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae spp. (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p = 0.022). An increased prevalence of coagulase negative staphylococci (p = 0.017) and Candida spp. (p = 0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae spp. was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p = 0.005). Treatment duration was as 20 (IQR, 14–27) weeks, including 11 (IQR, 8–15) after reconstruction. After a follow-up of 54 (IQR, 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p = 0.025) and Actinomyces spp. infection (OR, 9.5; p = 0.027).ConclusionsPressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. The lack of correlation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment.

Highlights

A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated
Stage 4 lesions of the revised national pressure ulcer advisory panel (NPUAP) pressure injury staging system are associated with deep-seated infections, including contiguous osteomyelitis that has been reported in 17 to 32% of patients [3,4,5]
The first surgical step consists in debridement of devitalized tissue and allows the realization of multiple bone biopsies aiming for microbiological documentation [2, 16, 17], and is followed by negative pressure therapy (NPT) [18]

Summary

Introduction

A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated. Antimicrobial therapy is started after the initial surgical debridement, adapted to bacteriological documentation, and prolonged for several weeks after flap coverage. In this context, the present study aimed to relate the experience of a French regional reference center for the management of complex bone and joint infection (CRIOAc Lyon) in such poorly evaluated two-stage surgical strategy, focusing on bacteriological findings and risk factor for treatment failure

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Discussion

Conclusion