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Bone and Joint Infections. July, 2009. Case 1.

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case 1
Case 1
  • A 12 year old female soccer player sustained a nasty bruise below her R knee during a particularly physical game. Two weeks later she complained of increased pain over the area accompanied by a low grade fever and sweats. She didn’t tell her parents. Her coach told her to quit complaining. However, her symptoms persisted and 2 weeks later she went to her pediatrician. Physical exam revealed a temperature of 38 C and a slightly swollen and warm left proximal tibia.
case 11
Case 1
  • What tests would you order?

Plain film, blood culture, ESR

case 12
Case 1

case 13
Case 1
  • What tests might have been positive 2 weeks earlier?

Bone scan, WBC scan, AB-CD15 scan, Gallium scan, MRI

case 14
Case 1

case 15
Case 1
  • What is the most likely organism?
  • Do you need to perform a needle biopsy for diagnosis?
  • How would you treat this patient? Does she need debridement? Which antibiotics and for how long?

S. aureus > streptococci

BC+: no. Needle biopsy culture sensitivity ~ 40%,

Histopathology increases yield

Antibiotics, probably not, many choices; nafcillin,

Ceftriaxone, oral abx. Empiric treatment for MRSA?

case 2
Case 2
  • A 26 year old thrill-seeker suffered an open fracture of his right tibia and fibula while roller-blading behind a motorcycle driven by his ex-girlfriend. The fracture was reduced and fixed with the placement of screws, plates and rods. He did remarkably well until 4 months later when he noted a pimple followed by a little drainage from one of wounds. Four days later he was chasing his ex-girlfriend up some stairs and heard a loud crack and looked down to find hardware and bone protruding through his right leg.
case 21
Case 2
  • Why did his leg break (the second time)?
  • What is the most likely bug?
  • What specimens do you want sent to the lab?
  • Can you rely on cultures taken from the sinus tract?

Pathologic fracture

S. aureus, CoNS > GNR

Bone cultures

Generally no

If S. aureus or single organism - some + predictive value

diagnosis culture
Diagnosis - Culture
  • Gold standard is open bone biopsy for histopathology and culture.
  • Needle biopsy has a sensitivity of 87% and a specificity of 93%. However, in the post-operative or post-trauma setting its performance is compromised.
  • Histopathology of needle biopsy yields diagnosis even if a specific organism is not identified
diagnosis culture1
Diagnosis - Culture
  • Superficial or sinus tract cultures correlate poorly with bone cultures in most studies (< 50%).
  • Perry (1991) found a 62% correlation between wound swab and operative cultures and a 55% correlation between needle biopsy and operative cultures. Better correlation demonstrated for mono-microbial infections (80 and 76%) and S. aureus infections (69% and 74%).
  • Bottom line: don't trust sinus cultures unless the results yields a single organism or S. aureus
case 22
Case 2
  • Should all the hardware be removed or can the leg be set and he be treated with antibiotics alone?
  • What antibiotics would you recommend, by what route and how long would you treat him?

Best: 2 or 3 step procedure: remove hardware,

antibiotics, new hardware later

Some success without removing hardware if infection

detected early, sensitive bug


A long time

clinical presentation
Clinical Presentation

Cierny-Mader staging

  • Anatomic stage
    • Stage 1 – medullary infection only, hematogenous spread or spread through an intramedullary prosthesis
    • Stage 2 – superficial infection, due to a contiguous soft tissue infection, could also be termed osteotis
    • Stage 3 – localized infection, full thickness infection (one cortex), bone integrity maintained
    • Stage 4 – diffuse infection (both cortexes), destabilizes bone (or resection would destabilize bone)

Cierny-Mader staging

  • Stage 1 – Antibiotics alone. Patients with rods in place require removal. Adults without hardware may require medullary reaming.
  • Stage 2 – Debride to bleeding bone and antibiotics
  • Stage 3 – Follow principles of removal of necrotic bone, elimination of dead space and soft tissue coverage plus antibiotics
  • Stage 4 – Same as stage 3 plus fracture stabilization.
case 3
Case 3
  • A 72 yo male who underwent a right THR 6 months ago, then developed an enterococcal UTI 3 months ago and now presents with low grade fevers and pain in the right hip that prevents ambulation.
case 31
Case 3
  • Imaging reveals a peri-prosthetic fluid collection
  • Culture of this fluid grows MRSA and enterococcus

(Lew, Lancet, 2004)

case 32
Case 3
  • How should he be treated?

Two stage replacement with 2 - 6 wks between surgeries.

Time between operations for tough-to-treat organisms - 6 to 8 wks.

Stop abx 1 -2 wks before 2nd operation - if cultures neg - stop, if

cultures +, continue abx for 3 months (6 months for knees).

case 33
Case 3
  • Are there situations when the prosthesis can be retained after debridement?

Symptoms < 3 weeks

Stable implant

Easy to treat organism

Success rates 82-100%

case 34
Case 3
  • Are there indications for single stage replacement?

Symptoms >3 weeks

Soft tissue in good shape

No co-morbidities

Easy to treat organism

Success rates 86-100%

  • Ciprofloxacin/rifampin for Osteomyelitis (Zimmerli, 1998)
  • N=33, stable implants
  • Staphylococcus
  • All treated with debridement and 2 weeks of rifampin + vancomycin or flucloxacin
  • Then either cipro/rifampin or cipro/placebo
  • Prostheses retained
  • Median duration of symptoms 5d

Prosthesis removed: hips (42%), knees (60%), bone plates (50%)

All 11 failures occurred in patients with retained prostheses (8) or resistant

staphylococcus (8) or both (6) (Drancourt 1993)


All had native bone infection or prosthesis removal, all treated with

2 weeks of nafcillin, vancomycin or cefazolin initially - then ceftriaxone

2 gms/d for 4 to 5 weeks (Guglielmo, 2000)

case 4
Case 4
  • A 39 year old IVDU reports to the ER with fever and back pain. He mixes his drugs with dirty tap water and does not prep his skin before injecting. On exam his temperature is 39 C, he has a 3/6 holo-systolic murmur and tenderness over his thoracic spine on percussion. Neurological exam is initially normal.
case 41
Case 4
  • Diagnoses?
  • Likely organisms?
  • Initial antibiotics?
  • Imaging studies?

Endocarditis, vertebral OM, epidural abscess

Staphylococcus > streptococci > GNR > fungi

Nafcillin and gentamicin or vancomycin and gentamicin


case 42
Case 4
  • The lab reports that 3/4 blood cultures have turned positive in 4 hours and are growing a GPC, the following day the lab reports that 2 blood cultures are also growing GNR.
  • Likely organisms?
  • The patient starts complaining of mid-thoracic radicular pain. What does this represent?

S. aureus > streptococci; P. aeruginosa > other GNR

Spinal ache - first sign of epidural abscess

case 43
Case 4





case 44
Case 4
  • What do you recommend?
  • What are indications for debridement of vertebral osteomyelitis?

MRI, decompression (laminectomy or aspiration)



Cord compression

Cervical infection

Medical failure

Neurological signs or symptoms

case 5
Case 5
  • A 56 year old diabetic man visits his PCP for a routine visit. He is noted to have a 2.5 cm ulcer on the plantar surface of his foot at the first metatarsal head, extending up to the great toe. He was unaware of the ulcer although, in retrospect, he recalls that his socks have been stained and foul smelling lately. He has not noted fevers or chills. His physician notes a hard, gritty surface at the base of the ulcer.
case 51
Case 5
  • Recommended work-up

In this case, plain films, ESR sufficient

Of all imaging modalities - MR is most accurate

(sensitivity > 90%, specificity > 80%)

Combination of WBC scan or ABscan with MRI can

improve specificity

  • The gold standard is histopathologic evidence for osteomyelitis with supporting microbiologic data
  • However, in many cases the diagnosis rests on clinical, laboratory and radiographic data

Sometimes it’s easy:

  • Compatible history and physical exam, elevated ESR, elevated WBC (acute osteomyelitis)
  • Positive blood cultures (50% in cases of acute osteomyelitis)
  • Classic radiographic findings

In many cases the diagnosis is difficult

  • Atypical presentations
  • Non-specific symptomatology
  • Co-morbid local and generalized conditions that confound and obscure the infection
diabetic foot infections
Diabetic Foot Infections

What are exam findings that predict bone involvement?

  • Larger (> 2cm, 92% specificity) and deeper ( > 3mm) associated with osteomyelitis
  • Probe to bone – 66% sensitivity and 85% specificity, PPV around 55%, NPV 98%
  • ESR > 70: 100% specificity (only 28% sensitivity)

(Grayson, JAMA,1995;273:721-3)

(Newman, JAMA, 1991;266:1246-51)

(Kaleta, J Am Pod Med Assoc, 2001;91:445-50)

(Dinh, CID, 2008;47:519-27)

diabetic foot infections1
Diabetic Foot Infections

What are the best imaging modalities?

  • Plain film
  • CT scan
  • MRI scan
  • Nuclear medicine studies
diabetic foot infections2
Diabetic Foot Infections

Plain films

  • Need 30 to 50% mineral loss for x-ray changes to be evident - takes at least 14 days
  • Sensitivity 43-75%, specificity 75-83%
  • Insensitive with acute osteomyelitis
  • In chronic infection - sclerosis, periosteal elevation and sequestra.

(Lipsky, CID, 1997;25:1318-26)


diabetic foot infections3
Diabetic Foot Infections


  • Best method for detecting small areas of necrosis, gas, foreign bodies
  • Metallic foreign bodies compromise the image


diabetic foot infections4
Diabetic Foot Infections


  • Sensitivity 82-100%
  • Specificity 53-94% (tumors, fractures, post surgery, sympathetic edema, infarction – all can look the same; light up on T2 weighted image)
  • Location important -
    • Heel and malleoli with ulcer = osteo
    • Midfoot, joint-centered, no ulcer - Charcot
  • Combine with Ind-111 WBC scans or gallium scans to increase specificity


(Eckman, JAMA, 1995;273:712-20)

(Croll, J Vasc Surg,1996:24:266-70)

(Craig, Radiology, 1997;203:849-55)

(Enderle, Diabetes Care, 1999;22:294-9)

diabetic foot infections5
Diabetic Foot Infections

Bone scan (TC-99 labeled phosphorus)

  • Soft tissue infection will be positive in the immediate (blood flow) and 15 minute (blood pool) phases while osteomyelitis will be positive in these 2 plus the delayed (> 4 hour) images.
  • Sensitivity 69-100% (> 95% in acute osteomyelitis), specificity 38-82% (tumors, fractures, post-surgery, septic arthritis, Paget’s disease, Charcot foot)


(Eckman, JAMA, 1995;273:712-20)

(Enderle, Diabetes Care, 1999;22:294-9)

diabetic foot infections6
Diabetic Foot Infections

AB + WBC scan (Ind-111)

  • Will be positive prior to bone scan
  • Useful p-surgery (better than MRI) which will always be abnormal
  • When combined with bone scan has specificity in the 90% range, sensitivity in the 70% range and PP value in the 90% range


(Becker, QJ Nuc Med, 1999;43:9-20)

(Unal, Clin Nuc Med, 2001;26:1016-21)

newer imaging tests
Newer Imaging Tests
  • Tc-99 monoclonal (Fab fragments) against CD-15: sensitivity and specificity ~ 85%
  • IND-111 biotin: used and concentrated in bacteria: sensitivity and specificity for vertebral OM ~ 95%
  • PET: better than WBC scans for chronic vertebral OM. Limited use in patients with diabetes and cancer
case 52
Case 5
  • What organisms are likely responsible for this infection?


case 53
Case 5
  • Recommended treatment

Surgical debridement (with bone cultures)

Re-vascularization if needed

Long-term abx

Recent retrospective studies suggest abx alone

May be sufficient treatment in many cases (Jeffcoate, 04)

diabetic foot infections8
Diabetic Foot Infections
  • Which antibiotics should I prescribe and for how long?


diabetic foot infections9
Diabetic Foot Infections
  • Basic principles for choosing antibiotics:
    • Should always include coverage for Gram-positive cocci, especially S. aureus
    • Add Gram-negative coverage for chronic wounds, for patients previously treated with abx and for wounds classified as moderate to severe
    • Provide anaerobic coverage for obviously necrotic wounds or those with a feculent odor
    • Narrow coverage based on culture results

(Lipsky, Clin Micro Infect, 2007;13:351-53)

diabetic foot infections10
Diabetic Foot Infections
  • Basic principles for choosing antibiotics:
    • Consider risk factors for MRSA when choosing Gram-positive coverage
    • Coverage for enterococci usually not necessary unless it is the only organism isolated
    • Coverage for Pseudomonas may also not be necessary unless the wound had been treated with hydrotherapy or Pseudomonas is present and the patient is not improving without anti-Pseudomonal treatment
    • Avirulent organisms (e.g. coagulase negative staphylococci, Corynebacterium species) may become real pathogens in immunocompromised hosts with significant tissue necrosis

(Lipsky, Clin Micro Infect, 2007;13:351-53)

recent antibiotic trials for dfi
Recent Antibiotic Trials for DFI
  • Ertapenam Vs Piperacillin/tazobactam (SIDESTEP) (Lipsky, Lancet, 2005;366:1695-1702)
    • R,DB,MCT, N=586. Mod-severe DFI (not osteo): 5 days or IV Ertapenam or Pip/tazo - then up to 23 days of amoxacillin-clavulanic acid (could add vanco for MRSA or enterococus)
    • Response rates at DCIV 94%/92%, at 10 day FUA 87%/83%
    • No difference between groups in those with MRSA or PsA even if not on abx active against these organisms
  • Linezolid Vs Amp-sulbactam or Amo-clavulinate (Lipsky, CID, 2004;38:17-24)
    • R,OL,MCT, N=371, All types of DFI: Could add Vanco for MRSA and Aztreonam for GNR if either not covered by study medication
    • Response rates: L/Pcn: Overall 81%/71% (NS), Subgroups with infected ulcer 81%/68% and those without osteo 87%/72% - both favor linezolid
    • More anemia and thrombocytopenia in the linezolid group - all reversible
recent antibiotic trials for dfi1
Recent Antibiotic Trials for DFI
  • Daptomycin Vs Vancomycin or Semi-synthetic Pcn (Lipsky, JAC, 2005;55:240-45)
    • Randomized study, N=133, Infected ulcer (no osteo), Comparator was Vanco if MRSA suspected, could add aztreonam for GNR and metronidazole for anaerobes
    • Response rates Dapto/Comparator: Overall 66%/70% (NS), Dapto/SS-PCN 64%/70%, Dapto/Vanco 71%/69%
    • Only one MRSA infection in the daptomycin group
  • Moxifloxacin Vs Pip-Tazo/Amox-clav
    • Subset analysis of P,DB study of 617 patients: only 78 with DFI were evaluable for cure 10-42 days after therapy
    • Response rates Moxi/PT-AC 68%/61%
  • Piperacillin/tazobactam Vs Ampicillin/sulbactam (Harkless, Surg Infect, 2005;6:27-40)
    • P,R,OL,MCT, N=314, Mod-severe DFI (ulcers). If MRSA could use vanco
    • Response rates P-T/A-C 81% 83%
diabetic foot infections11
Diabetic Foot Infections

(Lipsky, Clin Micro Infect, 2007;13:351-53)

diabetic foot infections12
Diabetic Foot Infections
  • Duration of therapy
    • Mild infections 1-2 weeks
    • Moderate to severe infections: 2-4 weeks
    • Osteomyelitis: 4-6 weeks (or longer)
diabetic foot infections13
Diabetic Foot Infections

Adjuvant Therapies

  • G-CSF
    • Cruciani, Diabetes Care, 2005;28:454460
      • Meta-analysis of 5 studies including 167 pateints
      • No effect on wound healing
      • Did reduce the risk for amputation (RR 0.41) and for any type of surgery (major debridement, revascularization, angioplasty and amputation) (RR 0.38)
  • Hyperbaric Oxygen
    • Roeckl-Wiedman, Br J Surg, 2005;92:24-32
      • Meta-analysis of 6 studies, including 5 on patients with DFI (118 patients)
      • No effect on ulcer healing or minor amputation
      • Did reduce the risk of major amputation: RR 0.31
case 6
Case 6
  • A 43 year old male immigrant from Pakistan reports to urgent care complaining of back pain for the last 12 months. He has lost ~15 pounds. During the last 2 weeks he noticed some mild weakness in his right leg. Examination reveals a thin, stooped, muscular male with normal vital signs. His back has a tender deformity at T6. His right knee is tender and swollen. Plain films of his T-spine show anterior wedge-shaped collapse of T6.
case 61
Case 6


case 62
Case 6
  • Differential
  • Diagnostic tests:

TB > Staphylococcus > other

MRI spine


Blood cultures



Leg films

case 63
Case 6
  • MRI of his spine reveals complete destruction of T6, a 20 anterior acute angle deformity and a large para-spinal fluid collection. Biopsy reveals granulomas, no AFB.
  • Does he need anti-tuberculous therapy?
  • Does he need surgery?



case 64
Case 6
  • What are indications for surgery in Pott’s disease?
  • What about his knee?

Neurological deficits


Cervical disease

Medical failure including non-adherence

Needs evaluation

Skeletal TB more common in young people with Pott’s

Medical treatment alone usually sufficient

If severe destruction with abscess - debride

skeletal tuberculosis
Skeletal Tuberculosis


  • In developed countries skeletal TB is a disease of adults and represents reactivation of an old focus of infection.
  • In the developing world most cases of skeletal TB occur in patients who recently acquired TB. Therefore, most skeletal TB occurs in childhood. Many patients give a history of recent trauma to the involved area.
skeletal tuberculosis1
Skeletal Tuberculosis


  • Accounts for 35% of cases of extra-pulmonary TB and 2% of all cases of TB
  • Indolent course, average duration of symptoms prior to diagnosis: 16 to 19 months.
  • Local swelling, pain, fluctuance; systemic symptoms (fever, sweats, etc) often absent.
  • Pulmonary disease present in 30%. PPD+ in > 85%
skeletal tuberculosis2
Skeletal Tuberculosis


  • Pott’s disease (tuberculous spondylitis)
    • Responsible for 1/3 of cases of skeletal TB.
    • Infection begins in the anterior aspect of the vertebral body leading to anterior collapse and spread of the infection along the anterior ligament
    • Most cases involve the lumber and lower thoracic spine
    • 50% of cases have associated abscesses (if calcified is diagnostic for TB)
skeletal tuberculosis3
Skeletal Tuberculosis

skeletal tuberculosis4
Skeletal Tuberculosis


  • Pott’s disease
    • 50% have weakness or paralysis at the time of presentation or during Rx
    • 50% associated with disc involvement
    • 50% without disc involvement are younger and more likely to have other skeletal lesions
    • 77% have epidural involvement by MRI (Pertuiset, 1999)
skeletal tuberculosis5
Skeletal Tuberculosis


  • Other bones: any bone; weight bearing, flat, ribs - relatively unique to TB


  • AFB stain and culture of biopsy specimen (sensitivity ~85%)
skeletal tuberculosis6
Skeletal Tuberculosis


  • Chemotherapy: Duration - 9 to 18 months. Although recent studies suggest that 6 months of treatment, when combined with surgery, is as effective as longer course of antibiotics.
  • Debridement of abscesses will lead to faster resolution and less kyphosis in those with severe disease at presentation.
skeletal tuberculosis7
Skeletal Tuberculosis


  • Criteria for surgical intervention in Pott’s
    • Neurological deficit
    • Spinal instability
    • Cervical spine disease
    • Failure of medical therapy
    • Non-adherence to medical therapy.
case 7
Case 7
  • A 43 year old female with a long history of rheumatoid arthritis requiring multiple joint replacements complains to her rheumatologist of a flare of her disease with pain and swelling in one of her IP joints and her right wrist. Her temperature is 37.5C, her right wrist is warm, swollen and red as is one of her IP joints on the same hand.
  • Why isn't this just a flare of her RA?
  • How would you differentiate infected from non-infected joint fluid?

Too few joints

Aspiration: Gram stain 50-75%, Culture 90%, BC 50%

case 71
Case 7
  • What is the bug?
  • Which antibiotics would you use and for how long?
  • Do the joints need to be drained? How?

S. aureus - 80% in RA

Anti-staph (anti-MRSA?), 4 to 6 weeks


Serial aspiration or open procedure

case 72
Case 7
  • What are indications for open drainage?

Hips, shoulders, prosthetic joints

Osteomyelitis with arthritis


When aspiration fails (thick pus)

case 8
Case 8
  • A 23 year old female reports to the ER with 2 days of diffuse arthralgias, low grade fever and then the development of swelling and increased pain in her right knee and wrist. She has a new boyfriend.
  • Diagnosis?
  • What do you find on exam?
  • Is the patient likely to be menstruating?

GC > reactive arthritis

Skin lesions (< 30), tenosynovitis, additive oligoarthritis

Yes; risks for DGI: certain strains of GC,

F > M, menses, complement deficiency

case 81
Case 8
  • Is she likely to have genital symptoms?
  • Will BC grow the organism? Joint fluid? Cervical culture?
  • Should her joints be drained? Open drainage?
  • Antibiotic therapy: drugs, route, duration?
  • Should anyone else be treated?

No (strains that don’t fix complement - less inflammation)

< 20% ~50% > 80%

Yes, Usually not necessary

Ceftriaxone until better (~2 d), then cefixime or

Quinolone (if quinolone susceptible) for 7-10 days


case 9
Case 9
  • The ex-boyfriend of the last patient is treated as a contact. Two weeks later he reports to urgent care with pain in his toes, right knee and left hip area. He also complains of a little dysuria. Exam reveals 2 sausage digits on his right foot, a swollen, warm right knee and pain and decreased range of motion of his left hip.
  • Differential diagnosis?
  • Would you order any imaging studies?

GC or reactive arthritis

MRI of hip

case 91
Case 9
  • Would you tap his knee? His hip? His hip and knee?
  • Antibiotics? Which ones? Until when?
  • Would you culture anything else?
  • What makes you think this is not a bacterial infection?

Yes Yes Yes

Anti-staph, strep, GC (e,g., ceftriaxone) - until cultures neg

Urethral and oral cultures

Sausage digits

Multiple sites (RA or GC > strep or staph)

Negative cultures

case 92
Case 9
  • Two days later he is no better and all the cultures are negative.
  • How would you treat him now?
  • How likely is he to HLA-B27 positive?
  • Is he likely to relapse?
  • Are antibiotics of any use in this disease?
  • What are other risk factors for this syndrome?

Anti-inflammatories (sulfasalazine, NSAIDS, steroids)

Post CT: > 90%, post enteric infections: 50-80%

Sure, more common post CT

Doxy or macrolides for RA post CT - maybe, otherwise - No

After any enteric infection, IBD

case 10
Case 10
  • A 37 year old male roofer sustained a T12-S1 fracture/dislocation due to a fall. His spine was initially stabilized with rods, plates and screws. Eight weeks post-operation he was diagnosed with osteomyelitis due to S. aureus and CNS. This infection was treated by debridement of necrotic tissue and bone, removal of almost all the original hardware and immediate replacement with new hardware and a tibial allograft. The patient also received 3 months of appropriate antibiotics (vancomycin, ciprofloxacin and rifampin).
  • He did well for 8 months, joined a wheelchair basketball team and then began noticing pain in his back, made worse by a rigorous game of hoops. His surgeon thinks (hopes) his pain is due to his recent increased activity but orders an ESR (32 mm/hr) and a CT (lots of post-operative changes but no obvious osteomyelitis).
case 101
Case 10
  • What diagnostic tests might you order now?
  • Was it a mistake to replace the infected hardware with new hardware at the same operation?
  • What about the placement of the tibial allograft?
  • What treatment strategy would you recommend at this point?

MRI-CT with WBC scan: Specificity 90%, PPV ~90%

Best to avoid this but in some cases not avoidable due to stabilization issues (spine)

Theoretically a bad idea (adding sequestrum!)

Nevertheless, some support in the surgical literature (Shuster)

Remove hardware, antibiotics

case 102
Case 10
  • The patient refuses any further treatment or work-up. A month later a draining sinus develops at the site of the original injury. The patient takes some antibiotics he had stashed at home and the sinus dries up. The infection intermittently flares over the next 15 years and each time it does the patient takes a short course of antibiotics that temporarily solves the problem. However, the most recent episode of drainage has not responded to his usual remedy and he comes back to see you. Your examination of his spine reveals an 8 cm area of tough, indurated skin with a necrotic, bleeding center draining green, purulent material.
  • What are you worried about?
  • What do you recommend?

Recurrent, resistant infection, squamous cell cancer

Image, debride, biopsy