Chronic Osteomyelitis In Adults Research Articles

A Review of the Clinical Utilization of Oral Antibacterial Therapy in the Treatment of Bone Infections in Adults.

Chronic osteomyelitis in adults is managed with prolonged courses of intravenous antibiotics in conjunction with surgical debridement of necrotic bone. Over the past 40 years, there has been no paradigm shift in this approach, as randomized controlled trials of this standard of care compared to alternatives such as prolonged oral antibiotics are scarce. However, there have been many small trials, case reports, and review papers evaluating the effectiveness of oral treatment for chronic osteomyelitis. The oral route for infections requiring prolonged treatment is intuitively and practically more favorable due to several advantages, the most important of which is the avoidance of long-term IV antimicrobial therapy with its complications, inconvenience, and cost. In this paper, we review the literature evaluating oral antibiotic therapy in the management of chronic bone infections since 1975. The majority of osteomyelitis infections are caused by Staphylococcus aureus, hence we focus on its treatment using oral antibiotics; however, we also emphasize subpopulations of patients with diabetes, implanted hardware, and with less common bacterial organisms. The primary objective of this review is to promulgate clinical recommendations on the use of oral antibiotics in bone infections in the context of initial therapy, transition from intravenous therapy, and the role of chronic suppression. The secondary objective is to summarize current knowledge of the specific oral antimicrobial agents that are commonly utilized, together with a synopsis of the available literature pertaining to their pharmacokinetic/pharmacodynamic properties and duration of therapy in bone infection.

Systemic Antimicrobial Treatment of Chronic Osteomyelitis in Adults: A Narrative Review.

Chronic osteomyelitis in adults is a complex condition that requires prolonged and intensive antimicrobial therapy, but evidence on optimal selection and duration of antibiotics is limited. A review of PubMed and Ovid Embase databases was conducted to identify systematic reviews, meta-analyses, retrospective and randomised controlled trials (RCTs) on antibiotic treatment outcomes in adults with chronic osteomyelitis. Three main areas of interest were investigated: short-term versus long-term antibiotic therapy, oral versus parenteral antibiotic therapy, and combination antibiotic therapy with rifampicin versus without rifampicin. A total of 36 articles were identified and findings were synthesised using a narrative review approach. The available literature suffers from limitations, including a lack of high-quality studies, inconsistent definitions, and varying inclusion/exclusion criteria among studies. Most studies are open-labelled and lack blinding. Limited high-quality evidence exists that oral therapy is non-inferior to parenteral therapy and that shorter antibiotic duration might be appropriate in low-risk patients. Studies on the impact of rifampicin are inconclusive. Further well-designed studies are needed to provide more robust evidence in these areas.

The management of chronic osteomyelitis in adults: outcomes of an integrated approach

ABSTRACT BACKGROUND: This study presents the outcomes of the management of chronic osteomyelitis of the appendicular skeleton according to an integrated approach at a dedicated bone infection unit in South Africa. METHODS: A retrospective record review identified 80 patients who were treated between January 2016 and December 2018. RESULTS: Sixty patients (75%) presented with fracture-related infections, 17 patients (21%) developed chronic osteomyelitis following haematogenous spread and three (4%) from contiguous wounds. According to the Cierny and Mader classification, 21 patients presented with anatomical type I, 14 with type II, 24 with type III and 21 with type IV chronic osteomyelitis. Positive microbial cultures were obtained in 63 (79%) cases. Follow-up for the cohort ranged from 1 to 29 months, with a mean follow-up of 10.4 months. The overall complication rate for the cohort was 6% and included sterile drainage from the surgical site after management with bioactive glass (S53P4), refracture after hardware removal, and development of non-union. Five patients experienced recurrence after the initial procedure to eradicate infection, resulting in an overall resolution rate of 94%. CONCLUSION: Using single-stage surgeries and tailored dead space management strategies according to a comprehensive integrated approach developed in South Africa, results comparable to international literature can be achieved. Level of evidence: Level 4. Keywords: chronic osteomyelitis, dead space management, bioactive glass, Lautenbach technique

Advances in clinical diagnosis and treatment of chronic osteomyelitis in adults

To review the progress of clinical diagnosis and treatment of chronic osteomyelitis in adults. The literature related to chronic osteomyelitis in recent years was extensively reviewed, and the clinical diagnosis and treatment methods were summarized. Clinical characteristics and laboratory examination can help to diagnose chronic osteomyelitis in adults. Pathogenic identification is the basis for choosing antibiotics. Diagnostic imaging is specific. The treatment includes systemic treatment and local treatment, and the local treatment is the key to radical cure. The diagnosis of chronic osteomyelitis in adults should be made as early as possible. According to the anatomical and physiological classification of the patients, the appropriate treatment plan should be made.

Systemic antibiotic treatment of chronic osteomyelitis in adults.

Chronic osteomyelitis is a difficult to treat infection of the bone, which requires a combined medical and surgical approach and often persists intermittently for years, with relapses and failures. The optimal type, route of administration, and duration of antibiotic treatment remain controversial, and the emergence of multi-drug resistant organisms poses major therapeutic challenges. Identification of the causative agent and subsequent targeted antibiotic treatment has a major impact on patients' outcome. In this review, we summarize which intravenous and oral antibiotics are the best options available for the treatment of chronic osteomyelitis, according to specific aetiologies.

Chronic Osteomyelitis in Adults: A Prospective Study

Chronic Osteomyelitis in Adults: A Prospective Study

Antibiotics for treating chronic osteomyelitis in adults

Chronic osteomyelitis is generally treated with antibiotics and surgical debridement but can persist intermittently for years with frequent therapeutic failure or relapse. Despite advances in both antibiotic and surgical treatment, the long-term recurrence rate remains around 20%. This is an update of a Cochrane review first published in 2009. To determine the effects of different systemic antibiotic treatment regimens for treating chronic osteomyelitis in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 9), MEDLINE (January 1948 to September Week 4 2012), EMBASE (January 1980 to 2012 Week 40), LILACS (October 2012), the WHO International Clinical Trials Registry Platform (June 2012) and reference lists of relevant articles. Randomised controlled trials (RCTs) or quasi-RCTs addressing the effects of different antibiotic treatments given after surgical debridement for chronic osteomyelitis in adults. Two review authors independently screened papers for inclusion, extracted data and appraised risk of bias in the included trials. Where appropriate, we pooled data using the fixed-effect model. We included eight small trials involving a total of 282 participants with chronic osteomyelitis. Data were available from 248 participants. Most participants were male with post-traumatic osteomyelitis, usually affecting the tibia and femur, where recorded. The antibiotic regimens, duration of treatment and follow-up varied between trials. All trials mentioned surgical debridement before starting on antibiotic therapy as part of treatment, but it was unclear in four trials whether all participants underwent surgical debridement.We found that study quality and reporting were often inadequate. In particular, we judged almost all trials to be at moderate to high risk of bias due to failure to conceal allocation and inadequate follow-up.Four trials compared oral versus parenteral route for administration of antibiotics. There was no statistically significant difference between the two groups in the remission at the end of treatment (70/80 versus 58/70; risk ratio (RR) 1.04, 95% confidence interval (CI) 0.92 to 1.18; four trials, 150 participants). There was no statistically significant difference between the two groups in the remission rate 12 or more months after treatment (49/64 versus 44/54; RR 0.94, 95% CI 0.78 to 1.13; three trials, 118 participants). There was also no significant difference between the two groups in the occurrence of mild adverse events (11/64 versus 8/54; RR 1.08, 95% CI 0.49 to 2.42; three trials, 118 participants) or moderate and severe adverse events (3/49 versus 4/42; RR 0.69, 95% CI 0.19 to 2.57; three trials, 91 participants). Superinfection occurred in participants of both groups (5/66 in the oral group versus 4/58 in the parenteral group; RR 1.08, 95% CI 0.33 to 3.60; three trials, 124 participants).Single trials with few participants found no statistical significant differences for remission or adverse events for the following four comparisons: oral only versus parenteral plus oral administration; parenteral plus oral versus parenteral only administration; two different parenteral antibiotic regimens; and two different oral antibiotic regimens. No trials compared different durations of antibiotic treatment for chronic osteomyelitis, or adjusted the remission rate for bacteria species or severity of disease. Limited and low quality evidence suggests that the route of antibiotic administration (oral versus parenteral) does not affect the rate of disease remission if the bacteria are susceptible to the antibiotic used. However, this and the lack of statistically significant differences in adverse effects need confirmation. No or insufficient evidence exists for other aspects of antibiotic therapy for chronic osteomyelitis.The majority of the included trials were conducted over 20 years ago and currently we are faced with a far higher prevalence of bacteria that are resistant to many of the available antibiotics used for healthcare. This continuously evolving bacterial resistance represents another challenge in the choice of antibiotics for treating chronic osteomyelitis.

Systemic Antibiotic Therapy for Chronic Osteomyelitis in Adults

The standard recommendation for treating chronic osteomyelitis is 6 weeks of parenteral antibiotic therapy. However, oral antibiotics are available that achieve adequate levels in bone, and there are now more published studies of oral than parenteral antibiotic therapy for patients with chronic osteomyelitis. Oral and parenteral therapies achieve similar cure rates; however, oral therapy avoids risks associated with intravenous catheters and is generally less expensive, making it a reasonable choice for osteomyelitis caused by susceptible organisms. Addition of adjunctive rifampin to other antibiotics may improve cure rates. The optimal duration of therapy for chronic osteomyelitis remains uncertain. There is no evidence that antibiotic therapy for >4-6 weeks improves outcomes compared with shorter regimens. In view of concerns about encouraging antibiotic resistance to unnecessarily prolonged treatment, defining the optimal route and duration of antibiotic therapy and the role of surgical debridement in treating chronic osteomyelitis are important, unmet needs.

Duration of post-surgical antibiotic therapy for adult chronic osteomyelitis: a single-centre experience

The optimal duration of concomitant antibiotic therapy after surgical intervention for implant-free chronic osteomyelitis is unknown. No randomized data exist. Available recommendations are based on expert's opinion. We evaluated the duration of post-surgical antibiotic treatment related to remission of chronic osteomyelitis. This was a retrospective single-centre study at Geneva University Hospitals with a minimal follow-up of two years after treatment. We used multivariate logistic regression analysis with exclusion of pediatric cases and of implant-related chronic osteomyelitis. A total of 49 episodes of implant-free chronic osteomyelitis in 49 adult patients were studied. The median number of surgical interventions was two (range, 1-10). The median duration of post-debridement antibiotic treatment was eightweeks (range, 4-14weeks). Thirty-nine patients (80%) were in remission after a minimal follow-up of twoyears. In multivariate logistic regression analysis, one week of intravenous therapy had the same remission as two to threeweeks (0.2, 0.1-1.9) or ≥ 3weeks (0.3, 0.1-2.4). More than sixweeks of total antibiotic treatment equalled ≤ six weeks (0.8, 0.1-5.2). In chronic osteomyelitis in adults, a post-debridement antibiotic therapy beyond six weeks, or an IV treatment longer than one week, did not show enhanced remission incidences. Prospective randomized trials are required to confirm this observation.

Ostéite chronique de l’adulte. Diagnostic et prise en charge

Objective Update on the diagnostic procedures and management of chronic osteomyelitis in adults. Methods This update was produced from articles and reviews of the literature and our experience in this field. Pathogenesis Osteomyelitis in adults is mostly observed after trauma or bone surgery and can be associated with foreign-body implants. Chronic evolution and relapses are due to local factors (vascular insufficiency, presence of a foreign-body, persistence of bone sequestra…), host factors (diabetes, drepanocytosis…) and microbial factors (adhesion, synthesis of biofilm, development od small colony variants, resistance to antibiotics…). Diagnosis Clinical manifestations include bone pain and/or local swelling, a fistula; fever is rarely observed in chronic osteomyelitis. Computer tomography and magnetic resonance imaging are needed to evaluate the extension of the lesions and guide the surgical treatment. The most important part of the diagnosis is to isolate the offending organism(s). Multiple intraoperative tissue specimens must be taken and cultured for prolonged times in enriched media. Treatment A multidisciplinary approach is needed for the management of these infections. Surgical treatment consists of extensive debridment, removal of foreign material, dead bone and infected tissues. Antimicrobial therapy should associate antibiotics with good bone penetration that are active against the isolated microorganism(s), and well tolerated by the patient. High dose combination intravenous therapy is often needed during the first weeks of treatment.

Role of oral antimicrobial therapy in the management of osteomyelitis.

Medical therapy of chronic osteomyelitis is largely based on experimental models, historical observational or non-randomized studies, and expert opinions. A minimum of 4-6 weeks of intravenous antimicrobial therapy targeting the causative organism, given in conjunction with surgery, has become the standard for chronic long-bone osteomyelitis in adults. Given the expense, inconvenience, and potential complications inherent to such a treatment program, alternative strategies including effective oral antimicrobial regimens are desirable. Several oral antimicrobial agents have undergone evaluation for the treatment of acute and chronic osteomyelitis recently. These include fluoroquinolones, clindamycin, and linezolid. For the treatment of atypical causes of Gram-positive osteomyelitis, other oral therapies have been evaluated with reported success in small numbers of patients. The standard of care for chronic osteomyelitis in adults remains intravenous antimicrobial therapy, in combination with surgery, for at least 4-6 weeks. Acute osteomyelitis in the pediatric population as well as osteomyelitis caused by atypical Gram-positive organisms and some Gram-negative organisms may be treated successfully with oral antibiotics. Some antimicrobials have equivalent concentration in serum whether administered orally or parenterally. When therapy with these antimicrobials is indicated, the oral route is preferred in compliant patients. As research continues in this area and as new drug formulations are developed, oral therapy may become an accepted alternative in additional selected patients.

Antimicrobial Therapy for Chronic Osteomyelitis in Adults: Role of the Quinolones

The development of antimicrobial therapy for osteomyelitis is reviewed. The disease, especially when chronic, is notoriously resistant to antibiotic therapy. The duration of disease defining chronicity has decreased considerably in the last 30 years. Successful therapy reflects increased appreciation of the combined roles of surgical debridement and prolonged antimicrobial courses. Parenteral high-dose beta-lactam agents yield clinical success for many patients with chronic osteomyelitis, particularly with prolonged administration and surgical debridement. Over the last decade, the initial success of oral quinolone therapy for gram-negative osteomyelitis was exploited further for staphylococcal diseases. Open clinical trials and comparative trials suggest success rates approximating those achieved with parenteral beta-lactams, particularly with appropriate surgery and adequate duration of therapy. The early results with quinolones and rifampin for prosthesis-related infection are encouraging. Overall, oral quinolones provide a new and frequently proportionate response to a disease that is difficult to treat.

Ciprofloxacin in the Treatment of Chronic Osteomyelitis in Adults

The use offluoroquinolones as a treatment modality in osteomyelitis is a consequence of their broad antibacterial spectrum, high degree of penetration into bone tissue and low incidence of adverse effects (Tice et al. 1988). Ciprofloxacin, which has high activity against Pseudomonas aeruginosa and other Gram-negative and Gram-positive bacteria (Canton et al. 1992; Desplaces & Acar 1988), should playa major role in the treatment of chronic post-traumatic osteomyelitis complicating open fractures. This study was designed to further test the efficacy and safety of intravenous ciprofloxacin followed by oral ciprofloxacin vs intravenous ceftriaxone plus amikacin in the treatment of chronic osteomyelitis. 70 adults with chronic post-traumatic osteomyelitis were enrolled in an open randomised comparative study. The patients were allocated to one of the 2 groups as follows: group A included 31 males and 4 females, mean age 32.7 years; and group B comprised 32 males and 3 females, mean age 35.7 years. Clinical diagnoses were confirmed by routine radiographs in all 70 patients. Bacteriological diagnoses were based upon analysis of material obtained by surgical excision or biopsy of the affected bony area in all 70 patients. Before treatment was begun, all patients from both groups underwent surgery, and 2 bone biopsy cultures were performed and repeated 3, 8, 15 and 21 days after the beginning of the treatment. The bone cultures were grown following standard microbiological procedures. All organisms isolated from bone tissue were identified, and their susceptibilities to ciprofloxacin, ceftriaxone and amikacin were determined using standard methods. The organisms isolated from group A and group B, respectively, included P. aeruginosa (7 and 6 strains), Escherichia coli (9 and II strains), Proteus mirabilis (3 and 5 strains), Klebsiella pneumoniae (7 and 5 strains), Enterobacter aerogenes (4 and 3 strains), and Staphylococcus aureus (5 and 6 strains). All organisms were sensitive to the 3 drugs. 35 patients from group A were treated with intravenous ciprofloxacin 200mg twice daily for 14 days, followed by oral administration of 500mg bid for 75 days. The 35 patients in group B received ceftriaxone plus amikacin intravenously (the ceftriaxone dose was 2 g/day and that of amikacin 500mg twice daily) for 90 days. Clinical and bacteriological assessment after a follow-up period averaging 12 months indicated cure in all patients from both groups. Adverse reactions occurred in 6 patients who were treated with ciprofloxacin and in 19 patients who received ceftriaxone plus amikacin; these are shown in table I. Our results show that the 2 antibiotic regimens were equally effective in the treatment ofpost-traumatic chronic osteomyelitis due to Gram-negative and Gram-positive bacteria. Ciprofloxacin administered orally is well tolerated and safe for prolonged administration. We conclude that surgical measures together with the intravenous administration of the antibiotics used in this study are of primary importance in the management of chronic osteomyelitis. The differences between the 2 groups with regard to the duration of intravenous therapy and the incidence of adverse effects were statistically significant.

Oral ciprofloxacin compared with standard parenteral antibiotic therapy for chronic osteomyelitis in adults.

A group of fourteen patients who had chronic osteomyelitis and were treated with oral ciprofloxacin was compared with a group of twelve patients of similar age who had chronic osteomyelitis and received standard parenteral antibiotic therapy consisting of nafcillin, clindamycin, and gentamicin, singly or in combination. The osteomyelitis was arrested at the end of therapy and on follow-up examination of eleven patients in the first group and ten in the second group. The average duration of antibiotic therapy (thirty-eight days) and follow-up (approximately thirty months) were about the same for both groups. Oral administration of ciprofloxacin was as effective and safe as parenteral therapy for the treatment of osteomyelitis in these adults.