Osteomyelitis and its management

Osteomyelitis and its management

1. OSTEOMYELITIS AND ITS MANAGEMENT PRESENTED BY: MISS.SHWETA SHARMA M.SC. NURSING 1ST YEAR AIIMS, JODHPUR

2. INTRODUCTION Osteomyelitis is an infection of the bone that results in inflammation, necrosis and formation of new bone . Osteomyelitis is classified as: • Hematogenous osteomyelitis (i.e. due to bloodborne spread of infection) • Contiguous-focus osteomyelitis- from contamination from bone surgery, open fracture or traumatic injury (e.g., gunshot wound) • Osteomyelitis with vascular insufficiency , seen most commonly among patients with diabetes and peripheral vascular disease, most commonly affecting the feet.

3. EPIDEMIOLOGY •Incidence increases with every decade of life. •Acute hematogenous osteomyelitis is most commonly seen in children, with 85% of affected individuals usually under the age of 1. •The prevalence among children is 1 in 5,000 . Among individuals who have been treated for an episode of acute osteomyelitis, the prevalence of chronic osteomyelitis is about 5% to 25% in the India. •Prevalence can be as high as 30% to 40% in individuals with diabetes and 16% after foot puncture .

4. AT RISK PATIENTS •Older adults •Poorly nourished •Obese •Impaired immune system •Chronic illness (e.g. diabetes, rheumatoid arthritis) •Receiving long-term corticosteroid therapy or immunosuppressive agents •Intravenous drug users

5. CAUSATIVE ORGANISMS •Staphylococcus aureus (more than 50% of bone infections) •Gram-positive organisms streptococci and enterococci •Gram-negative bacteria- pseudomonas •Salmonella •E. coli •Mycobacterium tuberculosis •Neisseria gonorrhoea

6. PATHOPHYSIOLOGY Sequestrum formation

7. CLINICAL MANIFESTATIONS • Sepsis (e.g., chills, high fever, rapid pulse, general malaise) •The infected area becomes painful, swollen and extremely tender. • Constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material (i.e. pus) • Chronic osteomyelitis- non- healing ulcer that overlies the infected bone with a connecting sinus that will intermittently and spontaneously drain pus.

8. ASSESSMENT AND DIAGNOSTIC FINDINGS Acute osteomyelitis •X-ray- soft tissue edema •Radioisotope bone scan •Isotope labelled white blood cell scan •Bone or soft tissue biopsy •Magnetic resonance imaging (MRI) •Blood studies- leukocytosis and an elevated ESR. •Wound and blood culture

9. Chronic osteomyelitis •X-ray- Large, irregular cavities, raised periosteum, sequestra , or dense bone formations. •Bone scan •ESR and WBC count •Anaemia •Blood culture

10. PREVENTION • Elective orthopaedic surgery should be postponed if the patient has a current infection (e.g. urinary tract infection, sore throat). •During surgery, careful attention is paid to the surgical environment. • Prophylactic antibiotics , administered to achieve adequate tissue levels at the time of surgery and for 24 hours after surgery, are helpful. • Urinary catheters and drains are removed as soon as possible to decrease the incidence of hematogenous spread of infection.

11. Aseptic postoperative wound care reduces the incidence of superficial infections and osteomyelitis. • Prompt management of soft tissue infections reduces extension of infection to the bone or hematogenous spread. •When patients who have had joint replacement surgery undergo extensive dental procedures or other invasive procedures (e.g., cystoscopy), prophylactic antibiotics are recommended before the procedure.

12. MEDICAL MANAGEMENT The initial goal of therapy is to control and halt the infective process. General supportive measures (e.g., hydration, diet high in vitamins and protein, correction of anaemia ) are instituted. The area affected with osteomyelitis is immobilised to decrease discomfort and to prevent pathologic fracture of the weakened bone. Pharmacologic therapy- Because there is decreased penetration by medications, antibiotic therapy is longer term than with other infections; typically it continues for 3 to 6 weeks. After the infection appears to be controlled, the antibiotic may be administered orally.

13. SURGICAL MANAGEMENT • Surgical debridement- The infected bone is surgically exposed, the purulent and necrotic material is removed, and the area is irrigated with sterile saline solution.

14. • Sequestrectomy- removal of enough involucrum to enable the surgeon to remove the sequestrum.

15. WHEN TO DO A SEQUESTRECTOMY? ?

16. • Saucerization- sufficient bone is removed to convert a deep cavity into a shallow saucer. •A closed suction irrigation system may be used to remove debris. •Wound irrigation using sterile physiologic saline solution may be performed for a week. •The wound is either closed tightly to obliterate the dead space or packed and closed later by granulation or possibly by grafting.

17. •The debrided cavity may be packed with cancellous bone graft to stimulate healing. •With a large defect, the cavity may be filled with a vascularized bone transfer or muscle flap (in which a muscle is moved from an adjacent area with intact blood supply). •These microsurgery techniques enhance the blood supply . The improved blood supply facilitates bone healing and eradication of the infection. •These surgical procedures may be staged over time to ensure healing. •Because surgical debridement weakens the bone, internal fixation or external supportive devices may be needed to stabilize or support the bone to prevent pathologic fracture.

18. COMPLICATIONS •Septicaemia •Septic arthritis •Pathologic fractures •Amyloidosis

19. NURSING MANAGEMENT Nursing assessment •Assess the sign and symptoms- localized pain, edema, erythema, fever, etc or recurrent drainage of an infected sinus with associated pain, edema and low-grade fever. •Assess for risk factors- older age, diabetes, long term corticosteroid therapy and a history of previous injury, infection, or orthopaedic surgery. •Assess the gait as it may be altered as the patient avoids pressure and movement of the area. •In acute hematogenous osteomyelitis, the patient exhibits generalized weakness due to the systemic reaction to the infection. •Assess for inflamed, markedly edematous, warm area that is tender, purulent drainage, elevated temperature, etc.

20. NURSING DIAGNOSIS • Acute pain related to inflammation and edema. • Impaired physical mobility related to pain, use of immobilization devices, and weight-bearing limitations. • Infection related to bone abscess formation. • Deficient knowledge related to the treatment regimen.

21. RESEARCH ARTICLES •Chronic Osteomyelitis - Bacterial Flora, Antibiotic Sensitivity and Treatment Challenges A single surgeon, prospective cohort study on 30 consecutive patients with clinically and radiologically diagnosed chronic osteomyelitis presented to a hospital was done. The objectives of the study were to determine bacterial flora and antibiotic sensitivity, and to evaluate the outcome of an aggressive surgical approach to chronic osteomyelitis. Demographic, clinical, radiological features, treatment protocol, microbiologic results of culture and sensitivity were recorded. The main treatment outcome measures were clinical signs of eradication of infection. Microbiologic results showed that Gram-negative and mixed flora accounts for more than half of chronic osteomyelitis cases while Staphylococcus aureus was a dominating single pathogen (39%). The study presented the high rate of MRSA strains is alarming and calls for updating of the antibiotic therapy guidelines in the country. Good results in treatment of chronic osteomyelitis can be achieved by a single-stage protocol including radical debridement combined with systemic and topical antibiotic.

22. •The Relationship Between Osteomyelitis Complication and Drug-Resistant Infection Risk in Diabetic Foot Ulcer: A Meta-analysis A meta-analysis was done to find out the relationship between Osteomyelitis complication and drug-resistant infection risk in diabetic foot ulcer. Searches of MEDLINE and ISI databases were performed for the studies. Odds ratios (ORs) for drug-resistant infection incidence were calculated for diabetic foot ulcer patients with or without osteomyelitis complications. Eleven studies (12 cohorts) with 1526 patients were included in this study. Significant publication bias was found. The meta-regression showed that drug-resistant incidence and published year were not related with the OR changes. In conclusion, this meta-analysis indicates that osteomyelitis complications are related with drug-resistant infection risk in diabetic foot ulcer . The study suggests bone culture–based narrow-spectrum antibiotic therapy for osteomyelitis for prevention drug-resistant infection in diabetic foot ulcer.

23. SUMMARY AND CONCLUSION •As discussed throughout the presentation, learning about osteomyelitis and its management will help nurses to care for patients of osteomyelitis. •Nurses can do assessment of patients with osteomyelitis, observe the sign and symptoms, provide the necessary nursing care, prevent complications and support the patient psychologically. •Nurses can also counsel the patients and their family for various options available in treatment for osteomyelitis.

24. REFERENCES 1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no.1147-1150. 2.Lewis. Medical Surgical Nursing Assessment and Management of clinical problems.2015. New Delhi. Elsevier. 2nd Edition. Volume II. Pg. no.1600-1603. 3.OMICS International. Osteomyelitis. Available from https://www.omicsonline.org/india/osteomyelitis-peer-reviewed-pdf-ppt-articles/ [cited 9 nov 2019] 4.PubMed. Chronic Osteomyelitis - Bacterial Flora, Antibiotic Sensitivity and Treatment Challenges. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5925860/ [cited 10 nov 2019] 5.PubMed. The Relationship Between Osteomyelitis Complication and Drug-Resistant Infection Risk in Diabetic Foot Ulcer: A Meta-analysis. Available from https://journals.sagepub.com/doi/abs/10.1177/1534734617728642 [cited 10 nov 2019]