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Current concepts in the management of infections in bones and joints
Abstract:
Significant changes have taken place in the epidemiology, microbiology and antibiotic therapy of bone and joint infections. Gram-negative bacilli have become an increasingly common cause, particularly in immunocompromised patients; anaerobes have been implicated in osteomyelitis associated with metallic foreign bodies; and there is increasing use of oral antibiotic regimens following an initial period of parenteral treatment. Gram-negative bacilli and anaerobes are found in polymicrobial non-haematogenous osteomyelitis (e.g. post-traumatic, post-surgical), but Staphylococcus aureus remains the most common cause of acute haematogenous osteomyelitis, with streptococci and Haemophilus influenzae responsible for most of the remainder. A precise microbiological diagnosis is essential. Diagnosis is based on Gram stain and culture of bone biopsies or aspirated pus, or on blood cultures. Specimens should be obtained before starting therapy. Any suspected primary foci of infection should be cultured. Parenteral antibiotics are given as soon as specimens are obtained, and continued for at least 3 weeks. The common causative organisms in septic arthritis are the same as in osteomyelitis, with the addition of Neisseria gonorrhoeae in young, sexually active adults. As in osteomyelitis, a precise microbiological diagnosis is of paramount importance, ideally by joint aspiration for cell count, Gram stain, biochemical analysis and culture, or by blood cultures. Optimum therapy is with antibiotics, repeated therapeutic aspirations, and resting the joint. Parenteral antibiotics should be started as soon as specimens are obtained and continued for 4 to 6 weeks. Gonococcal arthritis, however, can be treated successfully with 1 week of antibiotics. When treatment of either osteomyelitis or septic arthritis is continued with oral antibiotics, serum antibiotic concentrations or serum bactericidal levels are mandatory to ensure adequate absorption.
Insights
Bone and joint infections are changing, with Gram-negative bacilli and anaerobes increasingly implicated. Accurate microbiological diagnosis and appropriate antibiotic therapy, including oral regimens, are crucial for effective treatment.
Area of Science:
- Infectious Diseases
- Orthopedics
- Microbiology
Background:
- Bone and joint infections show evolving epidemiology, microbiology, and antibiotic treatment strategies.
- Gram-negative bacilli and anaerobes are increasingly significant pathogens, especially in immunocompromised patients and those with foreign bodies.
- Staphylococcus aureus remains the primary cause of acute hematogenous osteomyelitis.
Purpose of the Study:
- To outline the current landscape of bone and joint infections, focusing on changes in causative organisms and therapeutic approaches.
- To emphasize the critical role of precise microbiological diagnosis in guiding effective treatment.
- To discuss optimal antibiotic regimens, including parenteral and oral options, for osteomyelitis and septic arthritis.
Main Methods:
- Diagnosis relies on Gram stain and culture of bone biopsies, aspirated pus, or blood cultures.
- Specimens must be obtained prior to initiating antibiotic therapy.
- Culture of suspected primary infection foci is recommended.
Main Results:
- Parenteral antibiotic therapy for osteomyelitis typically lasts at least 3 weeks.
- Septic arthritis shares common causative organisms with osteomyelitis, plus Neisseria gonorrhoeae in specific populations.
- Treatment for septic arthritis involves antibiotics, joint aspiration, rest, and 4-6 weeks of parenteral therapy, with shorter courses for gonococcal arthritis.
Conclusions:
- Accurate microbiological diagnosis is paramount for both osteomyelitis and septic arthritis.
- Parenteral antibiotic administration should commence promptly after specimen collection.
- Oral antibiotic continuation requires monitoring of serum antibiotic concentrations or bactericidal levels to ensure efficacy.