Polymicrobial Osteomyelitis Research Articles

MICROBIOLOGICAL EPIDEMIOLOGY AT CHRIS HANI BARAGWANATH ACADEMIC HOSPITAL: POLYMICROBIAL OSTEOMYELITIS ANALYSIS

Most patients treated at our clinical setting present during chronic osteomyelitis stage, which is anecdotally likely to be poly-microbial. Adults with poly-microbial infection have a predilection for gram-negative bacteria and anaerobes, a scenario that hypothetically leads to a higher morbidity of poly-microbial osteomyelitis following trauma. Our study looks into the epidemiology of poly-microbial osteomyelitis treated at our Tumour and Infection unit.Retrospective study of patients treated for osteomyelitis from 2016 to 2020. Records of eligible patients were retrieved for examination. Demographics such as age, sex and race were recorded. Clinical presentation, organisms cultured, including their anti-microbial sensitivities were documented.There were 63 participants in the study. 31 (49.21%) had mono-microbial osteomyelitis with 32 (50.79%) having poly-microbial osteomyelitis. Majority of the poly-microbial patients presented with a sinus (68.75%) mostly located in the tibia (50%).Multiple mixed pathogens (both gam-positive and gram-negative) were cultured in our patients and this comprised 71.21% of the total bacteria cultured. Staphylococcus Aureus was the commonest bacteria (30%) isolated, followed by Enterococcus faecalis (12%). The commonest gram-negative bacteriae cultured was Enterococcus cloacae (10%) followed by Acinetobacter baumannii (7%). Most enterobacteriacae species were sensitive to Ertapenem and Ceftazidime.A slightly higher incidence of poly-microbial osteomyelitis was found in our study than that reported in literature. Furthermore, our study demonstrated a wide variety of organisms found in poly-microbial osteomyelitis, with a large contribution made by gram-negative anaerobic rod-shaped bacteria

Sustained Release of Antifungal and Antibacterial Agents from Novel Hybrid Degradable Nanofibers for the Treatment of Polymicrobial Osteomyelitis

This study aimed to develop a drug delivery system with hybrid biodegradable antifungal and antibacterial agents incorporated into poly lactic-co-glycolic acid (PLGA) nanofibers, facilitating an extended release of fluconazole, vancomycin, and ceftazidime to treat polymicrobial osteomyelitis. The nanofibers were assessed using scanning electron microscopy, tensile testing, water contact angle analysis, differential scanning calorimetry, and Fourier-transform infrared spectroscopy. The in vitro release of the antimicrobial agents was assessed using an elution method and a high-performance liquid chromatography assay. The in vivo elution pattern of nanofibrous mats was assessed using a rat femoral model. The experimental results demonstrated that the antimicrobial agent-loaded nanofibers released high levels of fluconazole, vancomycin, and ceftazidime for 30 and 56 days in vitro and in vivo, respectively. Histological assays revealed no notable tissue inflammation. Therefore, hybrid biodegradable PLGA nanofibers with a sustainable release of antifungal and antibacterial agents may be employed for the treatment of polymicrobial osteomyelitis.

Microbiological Epidemiology at Chris Hani Baragwanath Academic Hospital: Poly-Microbial Osteomyelitis Analysis

Background: The majority of the patients seen and treated at our clinical setting present during chronic osteomyelitis stage, which is anecdotally likely to be poly-microbial. Adults with poly-microbial infection have a predilection for gram-negative bacteria and anaerobes, a scenario that hypothetically leads to a higher morbidity of poly-microbial osteomyelitis following high-energy trauma. Our study looks into the epidemiology of poly-microbial osteomyelitis treated at our Tumour and Infection unit. Methods: This was a retrospective study of patients treated for osteomyelitis from 1st of June 2016 to 30th of May 2021. Medical records of eligible patients were retrieved for examination. Demographic data such as age, sex and race were recorded. Clinical presentation, and organisms cultured, including their anti-microbial sensitivities were documented. Results: There were 63 participants in the study. Thirty-one (49.21%) participants had mono-microbial osteomyelitis with 32 (50.79%) participants having poly-microbial osteomyelitis. Majority of the poly-microbial patients presented with a draining sinus (68.75%) and most was located in the tibia (50%). Multiple mixed pathogens (both gram-positive and gram-negative) were cultured in combination in our patients and this comprised 71.21% of the total bacteria cultured. Staphylococcus Aureus was the commonest bacteria (30%) isolated, followed by Enterococcus faecalis (12%). The commonest gram-negative bacteriae cultured was Enterococcus cloacae (10%) followed by Acinetobacter baumannii at 7%. Most enterobacteriacae species were sensitive to Ertapenem and Ceftazidime. Conclusion: A slightly higher incidence of poly-microbial osteomyelitis was found in our study than that reported in literature. Furthermore, our study demonstrated a wide variety of organisms found in poly-microbial osteomyelitis, with a large contribution made by gram-negative anaerobic rod-shaped bacteria. Cephalosporins were not shown to be valuable as broad-spectrum cover drugs, and most bacteria cultured were found to be insensitive to them. What we suggest is tailoring antibiotics to the specific cultured bacteria and sensitivity. Prompt management of patients with open fractures with early administration of intravenous antibiotics and adequate surgical management may lead to a reduction in the prevalence of chronic osteomyelitis.

Relapsed boyhood tibia polymicrobial osteomyelitis linked to dermatophytosis: a case report

BackgroundRelapsed childhood polymicrobial osteomyelitis associated with dermatophytosis has not been reported in the literature.Case presentationHere we report on a case of a 45-year-old man who had left tibial osteomyelitis for 29 years, accompanied by skin fungal infection of the ipsilateral heel for 20 years, and underwent a second operation due to recurrence of polymicrobial infection 6 years ago. The patient had a history of injury from a rusty object, which penetrated the anterior skin of the left tibia middle segment causing subsequent bone infection, but was asymptomatic after receiving treatments in 1983. The patient was physically normal until dermatophytosis occurred on the ipsilateral heel skin in 1998. The patient complained that the dermatophytosis was gradually getting worse, and the tibial wound site became itchy, red, and swollen. The left tibial infection resurged in May 2012, leading to the patient receiving debridement and antibiotic treatment. H&E and Gram-stained histology was performed on biopsy specimens of sequestrum and surrounding inflammatory tissue. Tissue culture and microbiology examination confirmed polymicrobial infection with Staphylococcus aureus (S. aureus) and Corynebacterium and a fungus. Additionally, the patient also received potassium permanganate for dermatophytosis when he was admitted into the hospital.ConclusionsTogether with longitudinal follow-up of medical history, surgical findings, histopathological and microbiology culture evidence, we conclude that boyhood tibia polymicrobial osteomyelitis with S. aureus and Corynebacterium occurred in this patient, and the fungal activation of dermatophytosis may have led to osteomyelitis relapse.

Sustained Release of Antifungal and Antibacterial Agents from Novel Hybrid Degradable Nanofibers for the Treatment of Polymicrobial Osteomyelitis

Sustained Release of Antifungal and Antibacterial Agents from Novel Hybrid Degradable Nanofibers for the Treatment of Polymicrobial Osteomyelitis

Polymicrobial Infection as a Rare Cause of Osteomyelitis: Case Presentation and Review of the Literature

This case report presents a 48-year-old patient with suspicion for chronic osteomyelitis caused by oral pathogens including species of Actinomyces, Eikenella and Stenotrophomonas. The symptoms included progressive swelling of the right thigh and hyperpyrexia with up to 41°C. Imaging methods included standard X-ray as well as MRI. Furthermore, two operations were necessary for surgical infection therapy. Histological and microbiological investigations of intraoperative samples showed polymicrobial osteomyelitis. Since local trauma could be excluded as the cause for the disease, the patient’s dental status was evaluated and proved as the possible infectious focus with a hematogenous spread. The patient was treated with intravenous antibiotics for two weeks and oral antibiotics for four further weeks. The patient’s clinical condition drastically improved with that treatment.

Ceftolozane/Tazobactam for the Treatment of Osteomyelitis Due to Multidrug-Resistant Pseudomonas aeruginosa

Abstract We conducted a retrospective study of 18 patients who were treated with ceftolozane/tazobactam (C/T) for greater than 48 hours for multidrug-resistant Pseudomonas aeruginosa (MDR-PA) osteomyelitis. Osteomyelitis was diagnosed by imaging, presence of systemic inflammatory signs and symptoms, elevated C-reactive protein, and positive culture for MDR-PA. Clinical cure was defined as complete or partial resolution of signs and symptoms of infection without need for escalation of antimicrobials during inpatient and outpatient therapy. The cohort was mostly male (81.2%) with a median age of 58.5 (53.5–68.5) years. The majority had polymicrobial osteomyelitis (77.8%) and a previous episode of osteomyelitis (83.3%). Clinical cure was achieved in 50% of patients, and C/T was well tolerated. These preliminary data suggest C/T maybe an option for treating patients with MDR-PA osteomyelitis, but more data are needed.

Treatment of Polymicrobial Osteomyelitis with Ceftolozane-Tazobactam: Case Report and Sensitivity Testing of Isolates.

Stenotrophomonas maltophilia is an inherently multidrug resistant (MDR) opportunistic pathogen with many mechanisms of resistance. SENTRY studies reveal decreasing sensitivities of S. maltophilia to trimethoprim-sulfamethoxazole and fluoroquinolones. Ceftolozane-tazobactam (Zerbaxa, Merck & Co., Inc.) a novel intravenous combination agent of a third-generation cephalosporin and β-lactamase inhibitor was demonstrated to have in vitro activity against many Gram-positive, Gram-negative, and MDR organisms. Data for ceftolozane-tazobactam's use outside of Food and Drug Administration (FDA) approved indications has been limited thus far to two case reports which demonstrated its efficacy in pan-resistant Pseudomonas aeruginosa pneumonia. Herein, we describe the first published case of treatment of MDR S. maltophilia in polymicrobial osteomyelitis with long-term (>14 days) ceftolozane-tazobactam and metronidazole. Ceftolozane-tazobactam may offer a possible alternative for clinicians faced with limited options in the treatment of resistant pathogens including MDR S. maltophilia.

A Brief Reprt of Polymicrobial Osteomyelitis of Odontoid Process with Epidural Abscess

A Brief Reprt of Polymicrobial Osteomyelitis of Odontoid Process with Epidural Abscess

Piperacillin–tazobactam-induced acute interstitial nephritis with possible meropenem cross-sensitivity in a patient with osteomyelitis

A 56-year-old man with no known medical history was treated with piperacillin–tazobactam for polymicrobial osteomyelitis and developed acute renal failure with fever and rash after six weeks of therapy. A gallium scan showed mildly increased uptake of radioactive tracer in both kidneys diffusely. A renal ultrasound showed normalsized kidneys without hydronephrosis. Urinalysis revealed eosinophils 5–25% (normal, <1%), hyaline casts, white blood cells, and proteinuria (>1000 mg/dL; normal range, 0–30 mg/dL). He received dialysis and was treated with empirical corticosteroids for acute interstitial nephritis (AIN). The patient’s hospital course was complicated by nosocomial infections requiring treatment with meropenem. After receiving meropenem, the patient developed worsening renal function and a rash that abated after the discontinuation of meropenem, indicating possible cross-sensitivity with piperacillin–tazobactam. AIN can be caused by autoimmune disorders, infections, sarcoidosis, or medications.1,–5 Many drugs (e.g., methicillin, cephalosporins, rifampin, ciprofloxacin, sulfonamides, nonsteroidal antiinflammatory drugs, cimetidine, omeprazole, indinavir) have been reported to cause drug-induced AIN.5,6 Drug-induced AIN is believed to be a hypersensitivity reaction.1 The diagnosis of AIN is usually made by examining the patient’s history, the temporal relation between the onset of AIN and initiation of the offending agent, the presence of certain clinical features and certain laboratory test findings, the exclusion of alternative causes of acute renal failure, a renal biopsy, and an empirical trial with corticosteroids.6

Ertapenem for treatment of osteomyelitis: a case series

BackgroundErtapenem is a once-daily broad spectrum carbapenem that is increasingly used to treat polymicrobial osteomyelitis due to diabetic foot and traumatic wound infections. However, limited data exists on ertapenem use for osteomyelitis. This study aimed to characterize outcomes and adverse effects with empiric use of ertapenem for osteomyelitis.FindingsA total of 112 patients presenting to Duke, Durham Regional or Durham VA Medical Centers with a suspected diagnosis of osteomyelitis and ertapenem use from 11/2001 to 8/2009 were screened, and 12 subjects met inclusion criteria for the study. Mean age was 60 ± 16 years, 68% were female, 75% were Caucasian, and the most common comorbidities included diabetes (58%), peripheral vascular disease (42%), and history of tobacco use (75%). Over half of the patients presented to a primary care clinic or emergency room greater than six months after the onset of clinical symptoms. Bone culture was obtained for diagnostic guidance in only two cases; and surgical intervention was pursued in three cases. Patients received a mean duration of 34.6 ± 7.8 days of therapy, and in three cases, subsequent suppressive oral antibiotics were given. Six (50%) patients met criteria for clinical success, defined as resolution of clinical signs and symptoms of infection such that discontinuation of antibiotics was deemed appropriate at end of ertapenem therapy, without recurrence at one year follow-up. No adverse drug effects were noted.ConclusionsIn this case series of mostly community-acquired, lower extremity osteomyelitis, bone biopsy was infrequent, and an average six-week course of empiric ertapenem was well-tolerated with curative rates of 50% at one year.

Anaerobic osteomyelitis associated with intraosseous and soft-tissue pneumatosis

IntroductionA 13-year-old girl with paraplegia from a traffic accidentpresented to our hospital with fever and swelling of the leftthigh for 1 month. Initial laboratory findings revealedleukocytosis, elevated C-reactive protein (31 mg/dl) andincreased creatinine (2.38 mg/dl). A plain radiograph of theleft hip and CT showed gas within the femur head, iliacbone and surrounding soft tissue, and extensive soft-tissueswelling in the pelvis, hip joint and thigh (Figs. 1 and 2).Surgical debridement and drainage of the soft-tissue abscesswereperformed.Culturesofboththeabscessandthefemoralhead grew Bacteroides fragilis, B. thetaiotaomicron andFusobacterium necrophorum.Intraosseous gas was first detected by CT in 1981 whenreported in three cases of polymicrobial osteomyelitis [1].This condition is extremely rare, particularly in the absenceof a compound fracture, surgery or other direct communica-tion between the bone and air [2]. The pathogens are oftenpolymicrobial and anaerobic. The presumed mechanism forthe formation of intraosseous gas involves anaerobic metab-olismwiththeproductionofhydrogenandcarbondioxide[2].Anaerobic osteomyelitis can become fulminant and invasive.References

Polymicrobial Osteomyelitis of the Odontoid Process with Epidural Abscess: Case Report and Review of Literature.

Osteomyelitis of the odontoid process is a rare disease and Staphylococcus aureus is the usual causative organism. We present a case caused by a synergistic infection with Staphylococcus aureus and Proteus mirabilis, which has not been reported previously. A high index of suspicion is required for diagnosis, and early institution of broad antimicrobial therapy, including agents active against gram-negative organisms, is mandatory.

Polymicrobial Osteomyelitis of the Odontoid Process with Epidural Abscess: Case Report and Review of Literature

Polymicrobial Osteomyelitis of the Odontoid Process with Epidural Abscess: Case Report and Review of Literature

HISTOLOGICALLY PROVEN PRESSURE SORE-RELATED OSTEOMYELITIS IN THE SETTING OF NEGATIVE TECHNETIUM BONE SCANS

Pressure sores are common in patients with spinal cord injury, stroke or debilitating medical illness. Contiguous osteomyelitis is a well recognized complication of pressure ulcers, but remains a challenging diagnostic and management problem. Technetium bone scan is purported to be an extremely sensitive, although nonspecific diagnostic test for osteomyelitis. Indeed, a negative bone scan is thought to virtually exclude bone infection. We report three cases of pressure sore-related polymicrobial osteomyelitis where technetium bone scan was normal, yet bone biopsy demonstrated characteristic histopathologic changes of osteomyelitis. These cases raise questions regarding the sensitivity of bone scanning in the setting of pressure sores, and they demonstrate the need for further investigation into the correlation between nuclear medicine scan results and bone biopsy histopathology. Bone biopsy remains the gold standard for diagnosis of osteomyelitis, which can be present in bone underlying a pressure ulcer, even in the setting of a normal bone scan.

Oral ciprofloxacin compared with parenteral antibiotics in the treatment of osteomyelitis

We undertook a prospective, randomized comparison of oral ciprofloxacin with standard parenteral therapies for the treatment of biopsy-proven osteomyelitis caused by susceptible organisms. Following surgical debridement, the ciprofloxacin patients received 750 mg twice a day, and the other patients received a broad-spectrum cephalosporin or a nafcillin-aminoglycoside combination intravenously (i.v.). There were 31 evaluable patients in the ciprofloxacin group, treated an average of 56 days, and 28 in the i.v. group, treated an average of 47 days. Clinical success rates were 24 of 31 (77%) for the ciprofloxacin group and 22 of 28 (79%) for the i.v. group. Of the seven failures in the ciprofloxacin group, one was due to a persistent Klebsiella pneumoniae infection and six were due to relapse of the infection within 1 year of therapy. Of the six failures in the i.v. group, one was due to an Enterobacter aerogenes strain which emerged resistant and five were due to relapse. The most troublesome etiology was polymicrobial osteomyelitis involving Pseudomonas aeruginosa, in which five of six (83%) regimens failed. Adverse reactions occurred infrequently, i.e., in 1 of 31 (3%) of the ciprofloxacin patients and in 4 of 28 (14%) of the i.v. patients, yet all reactions responded to therapy and none required protocol deviation. Our data indicate that oral ciprofloxacin monotherapy is as safe and effective as conventional parenteral therapy in cases of osteomyelitis caused by susceptible organisms.

Clinical utility of new quinolones in treatment of osteomyelitis and lower respiratory tract infections.

In the eight major clinical studies published on use of oral quinolones in therapy of contiguous osteomyelitis, clinical and microbiologic cure/improvement rates were 75% and 73%, respectively, when drug therapy was combined with appropriate surgical debridement. This included many cases of polymicrobial osteomyelitis, as well as infection caused by recalcitrant pathogens such as Pseudomonas aeruginosa. In contrast, the response of staphylococcal osteomyelitis to oral quinolones, especially in cases caused by methicillin-resistant strains, appeared suboptimal. Quinolones appear to have a limited role in the treatment of community-acquired pneumonia, since other established antibiotic regimens have been proven effective in such situations. Quinolones may play an important role in the treatment of nosocomially acquired aerobic gram-negative bacillary pneumonia, either as primary parenteral therapy or as transitional oral therapy when affected patients become outpatients. In cystic fibrosis-associated acute exacerbations of chronic pseudomonal pneumonitis, the outcome of oral ciprofloxacin therapy was very satisfactory in the six major studies reported (approximately 85% improvement rates). In three comparative studies oral quinolone treatment of such pulmonary exacerbations resulted in clinical response rates equivalent to those for aminoglycoside plus beta-lactam therapy given intravenously. Quinolone-resistant Pseudomonas aeruginosa strains were commonly isolated from sputum during treatment; however, such patients continued to respond clinically to quinolone treatment, and sputum became rapidly repopulated with quinolone-susceptible Pseudomonas aeruginosa strains after discontinuation of therapy.

Imipenem/cilastatin in the treatment of osteomyelitis

Thirty-four patients with osteomyelitis were treated for a mean of 32.5 days with 2 to 4 g per day of imipenem/cilastatin. Twenty-six infections involving the lower extremities were associated with accidents and prosthesis implantation, and 19 of 34 patients had more than one organism isolated. Gram-positive and gram-negative organisms were equally represented, but follow-up bone culture samples showed only 11 percent of gram-positive organisms persisted versus 23 percent of gram-negative organisms. Seventy-four percent of patients were cured or improved, and failures were related to resistant organisms and the inability to perform adequate surgical debridement. Adverse drug side effects included nausea, diarrhea, liver enzyme elevations, and neutropenia, but discontinuation of treatment was required in only three patients. Imipenem/cilastatin holds promise as monotherapy in complicated polymicrobial osteomyelitis.

Polymicrobial Osteomyelitis: Report of Three Cases and Review of the Literature

Five percent of patients with acute osteomyelitis and 30%-60% of patients with chronic osteomyelitis have polymicrobial infections. Three illustrative cases and a review of the literature involving 104 patients are presented in this report. There were 2.4 isolates per child among the 31 pediatric cases ad 3.9 isolates per adult among the 71 adult cases reviewed. Staphylococcus aureus was the single most common isolate involved in polymicrobial disease in both adults and children. In adults, one-third of the aerobic isolates were gram-negative bacterial species; some enterococci were also involved. Of the isolates from adults, 46% were anaerobic. The number of isolates per case was similar for the acute (3.2) and chronic (3.1) forms of infection. Polymicrobial osteomyelitis resulted most frequently from spread of infection from a contiguous focus (59% of cases) or occurred in the patient with peripheral vascular insufficiency or neuropathy (17% of cases); however, the hematogenous route can produce polymicrobial disease (13% of cases). Bones mot often involved are those of the skull, face, and feet. Standard antibiotic therapy for monomicrobial osteomyelitis with semisynthetic penicillins or cephalosporins may lead to failures of treatment in polymicrobial disease.