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OSTEOMYELITIS INFECTIOUS ARTHRITIS D.Goldberg WRAMC Osteomyelitis Laboratory Tests White blood cell count Erythrocyte sedimentation rate C-reactive protein Bone aspirate Blood culture Antigen Assay Osteomyelitis Etiologic agents by age Organism Total S. aureus 198 (50%) Streptococci 37 (9%) HIb 16 (4%) CNS 10 (3%) Ps. aeruginosa 10 (3%) S. pneumoniae 6 (2%) Salmonella 6 (2%) E. coli 2 <2 33 13 14 7 1 6 3 1 2-5 56 13 2 1 2 0 3 1 6-10 66 6 0 0 5 0 0 0 >10 43 5 0 2 2 0 0 0 Osteomyelitis Specimen site No. done Blood Needle aspirate/surg spec Joint fluid Wound drainage 381 357 86 31 No. Pos 138 134 56 22 Nelson IDCNA 1995 (36%) (38%) (65%) (70%) Osteomyelitis BONE Femur Tibia Humerus Fibula Phalanx Calcaneos Radius Ischium Metatarsal Ulna Ilium Vertebra MONOSTEAL 92 89 50 16 18 18 13 15 8 6 7 7 POLYSTEAL 12 18 8 10 5 0 4 1 0 3 0 2 Osteomyelitis Neonatal Osteomyelitis Indolent process Nonspecific signs absent Swelling/tenderness Multiple sites in 50% Secondary joint space involvement S. aureus, group B strep, coliforms Osteomyelitis Sickle Cell Disease Salmonella GNR’s Staphylococcus Pneumococcus 60% 6% 8% 5% Radiologic Diagnosis X-rays: soft tissue swelling periosteal elevation focal osteopenia 2 week lag Radiologic Diagnosis Tc scan:accumulation in areas of inc blood flow and bone formation positive in 48 hrs Three-phase scan false-neg due to poor blood flow Radiologic Diagnosis gallium scan: inc uptake in areas of PMN’s, macrophages do not show bone well imaging at 24h and 72h high sens/high radiation MRI scan: bone vs soft tissue T2-inc signal in bone not for screening Septic Arthritis S.A. Volume Color Viscosity WBC’s PMN’s Glucose Bacteria +/+++ turbid reduced >50-100 >80% <0.25 50-75% Inf Arth +/+++ turbid reduced 5-50 >60-80% >0.50 0 Non-IA + sl turbid normal 1-5 <50% >0.80 0 Septic Arthritis Distribution of Infected Joints Knee Hip Ankle Elbow PIP/MCP Shoulder 30% 30 17 11 7 2 Nelson PED 1972 Septic Arthritis Organism S. aureus Hib Streptococci GNR N. gonnorrhea Unknown 0-1m (4%) 36% 7% 21% 14% 7% 35% 1m-5y (70%) 11% 31% 11% 2% 2% 34% >5 (26%) 33% 1% 18% 3% 7% Therapy Initial regimes: Neonates children < 5 children > 5 Sickle cell nafcillin and cefotaxime cefuroxime nafcillin/cefuroxime nafcillin and ceftriaxone Therapy: Minimal duration(clinical response, dec ESR) Gram negative Staph H. influenzae N. meningitis streptococci 4-6 weeks 4-6 weeks 2-4 weeks 2-4 weeks 2-4 weeks Dagan JPID 1992 Contraindications to oral therapy Inability to swallow Etiologic agent not established Inability to perform bacteriocidal levels No effective oral therapy Failure of parental abiotics