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While patients with chronic osteomyelitis should probably be referred, those with acute forms can often be managed with short, inexpensive courses of oral antibiotics. Do you know how to proceed? [ABSTRACT FROM AUTHOR]

EXECUTIVE SUMMARY: 1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II). The team managing these infections should include, or have ready access to, an infectious diseases specialist or a medical microbiologist (B-II). 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic Gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with Gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Send appropriately obtained specimens for culture before starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but MRI (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I). 8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management. 9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care. 10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic Gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III). 11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I). 12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 12 weeks usually suffices, but some require an additional 12 weeks; for moderate and severe infections, usually 24 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 46 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II). 13. If an infection in a clinically stable patient fails to respond to 1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III). 14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible. 15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds. 16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III). 17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors. 18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from noninfectious osteoarthropathy. Clinical examination and imaging tests may suffice, but bone biopsy is valuable for establishing the diagnosis of osteomyelitis, for defining the pathogenic organism(s), and for determining the antibiotic susceptibilities of such organisms (B-II). 19. Although this field has matured, further research is much needed. The committee especially recommends that adequately powered prospective studies be undertaken to elucidate and validate systems for classifying infection, diagnosing osteomyelitis, defining optimal antibiotic regimens in various situations, and clarifying the role of surgery in treating osteomyelitis (A-III).

Objectives and Design: To determine the most appropriate approach to antibiotic therapy for osteomyelitis, the medical literature for articles published from 1968 to 2000 was reviewed., Results: Ninety-three clinical trials in children and adults were identified using almost every antibiotic class. Most studies were non-comparative and the comparative trials involved relatively few patients. Publications generally did not provide clinically important information regarding infection staging or classification, surgical treatment provided, or the presence of orthopedic hardware. The median duration of follow-up after treatment was only 12 months. The clinical outcome was better for acute than chronic osteomyelitis in eight of the 12 studies allowing comparison. In the comparative trials, few statistically significant differences were observed between the tested treatments. In one small trial, the combination of nafcillin plus rifampin was more effective than nafcillin alone. In pediatric osteomyelitis, oral therapy with cloxacillin was more effective than tetracycline in one study, and oral clindamycin was as effective as parenteral anti-staphylococcal penicillins in another. In several investigations oral fluoroquinolones were as effective as standard parenteral treatments., Conclusions: Although the optimal duration of antibiotic therapy remains undefined, most investigators treated patients for about six weeks. Despite three decades of research, the available literature on the treatment of osteomyelitis is inadequate to determine the best agent(s), route, or duration of antibiotic therapy.

For the staged management of infected total knee arthroplasty (TKA), antibiotic laden polymethylmethacrylate (PMMA) spacers have been recommended. Antibiotic-impregnated PMMA spacers target drug delivery, achieving high local levels while limiting the potential for host toxicity associated with parenteral antimicrobial therapy. This study examined the elution characteristics of an articulating PMMA TKA spacer that has been useful clinically. Tobramycin and vancomycin are both active against many organisms leading to joint infections. We used various combined antibiotic concentrations (maintaining a relative ratio of 55% tobramycin to 45% vancomycin w/w), and then assayed the elution profile of the TKA spacer in vitro. Additionally, the elution qualities of two brands of bone cement, Simplex and Palacos, were compared. Briefly, three groups of PMMA spacers, impregnated with different antibiotic loads, were fashioned from a mold replicating a femoral TKA component. The entire spacer surface area was immersed in sterile phosphate buffered saline (PBS) in a 1:6 ratio of grams of cement to milliliters of PBS and incubated at 37 degrees C for 24 h. After 24 h, aliquot eluates were taken, the PBS discarded, and replaced with fresh, sterile PBS. PBS was changed daily and an aliquot was taken at least weekly for nine weeks. Eluate samples were stored at -70 degrees C until assayed. Each spacer eluate sample's antibiotic concentration was determined by disc diffusion bioassay against Bacillus subtilis. Mean zone inhibition diameters were extrapolated from the standard curve to yield micrograms per milliliter of antibiotic in PBS. In all groups the Palacos spacers demonstrated higher elution levels, above the MIC for the organism used, for a longer period of time than those made with Simplex. Based on the observed elution profiles, antibiotic-impregnated Palacos bone cement may offer a more effective vehicle for local drug delivery during staged treatment of infected TKA.

To investigate whether Hyperbaric Oxygen Therapy (HBO2) could improve neurologic deficits and regional cerebral blood flow (rCBF) in chronic traumatic brain injuries (TBI), the authors employed a nonrandomized control pilot trial. Five subjects, at least three years post head injury, received HBO2. Five head injured controls (HIC) were matched for age, sex, and type of injury. Five healthy subjects served as normal controls. Sixty-eight normal volunteers comprised a reference data bank against which to compare SPECT brain scans. HBO2 subjects received 120 HBO2 in blocks of 80 and 40 treatments with an interval five-month break. Normal controls underwent a single SPECT brain scan, HBO2, and repeat SPECT battery. TBI subjects were evaluated by neurologic, neuropsychometric, exercise testing, and pre and post study MRIs, or CT scans if MRI was contraindicated. Statistical Parametric Mapping was applied to SPECT scans for rCBF analysis. There were no significant objective changes in neurologic, neuropsychometric, exercise testing, MRIs, or rCBF. In this small pilot study, HBO2 did not effect clinical or regional cerebral blood flow improvement in TBI subjects.

Osteomyelitis in long bones remains challenging and expensive to treat, despite advances in antibiotics and new operative techniques. Plain radiographs still provide the best screening for acute and chronic osteomyelitis. Other imaging techniques may be used to determine diagnosis and aid in treatment decisions. The decision to use oral or parenteral antibiotics should be based on results regarding microorganism sensitivity, patient compliance, infectious disease consultation, and the surgeon's experience. A suppressive antibiotic regimen should be directed by the results of cultures. Standard operative treatment is not feasible for all patients because of the functional impairment caused by the disease, the reconstructive operations, and the metabolic consequences of an aggressive therapy regimen. Operative treatment includes debridement, obliteration of dead space, restoration of blood supply, adequate soft-tissue coverage, stabilization, and reconstruction.

The management of musculoskeletal infections is an increasing challenge to clinicians. Bioimplants provide a unique system for skeletal specific drug delivery. Antibiotic-impregnated beads and spacers can be used to treat chronic osteomyelitis and deep soft-tissue infections locally with higher antibiotic concentrations, while avoiding potential systemic side effects.

Acute septic arthritis may develop as a result of hematogenous seeding, direct introduction, or extension from a contiguous focus of infection. The pathogenesis of acute septic arthritis is multifactorial and depends on the interaction of the host immune response and the adherence factors, toxins, and immunoavoidance strategies of the invading pathogen. Neisseria gonorrhoeae and Staphylococcus aureus are used in discussing the host-pathogen interaction in the pathogenesis of acute septic arthritis. While diagnosis rests on isolation of the bacterial species from synovial fluid samples, patient history, clinical presentation, laboratory findings, and imaging studies are also important. Acute nongonococcal septic arthritis is a medical emergency that can lead to significant morbidity and mortality. Therefore, prompt recognition, rapid and aggressive antimicrobial therapy, and surgical treatment are critical to ensuring a good prognosis. Even with prompt diagnosis and treatment, high mortality and morbidity rates still occur. In contrast, gonococcal arthritis is often successfully treated with antimicrobial therapy alone and demonstrates a very low rate of complications and an excellent prognosis for full return of normal joint function. In the case of prosthetic joint infections, the hardware must be eventually removed by a two-stage revision in order to cure the infection.

Osteomyelitis is a complex disease that is often associated with high morbidity and considerable health care costs. Bacteremia, contiguous focuses of infection, penetrating trauma, or surgery are the major predisposing factors for this infection. Bone necrosis and bone destruction occur early in the course of osteomyelitis, leading to a chronic process and eliminating the host's ability to eradicate the pathogens. The presence of poorly vascularized tissues, the adherence to bone structures and implants, and a slow bacterial replication rate are recognized as important factors for the persistence of the infection. Treatment of osteomyelitis is particularly challenging and involves adequate antimicrobial therapy and surgical debridement of all necrotic bone and soft tissues. Antibiotic treatment is usually started on an empiric basis and then modified according to the results of cultures and sensitivity tests. Surgical treatment consists of debridement, obliteration of dead space, adequate soft tissue coverage, restoration of blood supply, and stabilization.

Two methods currently are available for the delivery of antibiotics: intravenous injection with a long-term indwelling catheter and local implant of antibiotic-containing polymethylmethacrylate beads. Both of these methods have significant disadvantages. A fibrin sealant implant, impregnated with tobramycin, was evaluated in a rabbit model of osteomyelitis to determine whether it has the potential of supplying a basis for bone reconstruction and providing an improved treatment method for the delivery of antibiotics to orthopaedic infections. Localized tibial osteomyelitis, with methicillin-sensitive Staphylococcus aureus, was developed surgically in female New Zealand White rabbits. After 2 weeks, rabbits with evidence of osteomyelitis were treated with debridement alone, debridement plus systemic tobramycin, debridement plus fibrin sealant, debridement plus fibrin sealant loaded with tobramycin, polymethylmethacrylate beads loaded with tobramycin, or not treated at all (control). After 4 weeks of therapy, the rabbits were sacrificed and the involved bones were cultured for concentrations of methicillin-sensitive Staphylococcus aureus per gram of bone and marrow. Preliminary data (N = 14) indicate fibrin sealant plus tobramycin may be as effective as polymethylmethacrylate beads plus tobramycin against methicillin-sensitive Staphylococcus aureus osteomyelitis in a rabbit model.

We present a case of systemic fungal infection caused by Apophysomyces elegans in a 50-year-old patient who developed a progressive skin lesion after a motor vehicle crash. Histopathological and mycological examination of the surgical sample showed non-septated hyphae characteristic of mucoraceous fungi. Despite extensive surgical debridement, and parenteral administration of amphotericin B, the patient died of multi-organ failure. Autopsy findings suggested systemic involvement. The fungi recovered from culture had non-apophyseal and globose sporangi, and branched sporaniophores and was identified as Apophysomyces elegans.

A biofilm may be defined as a microbially derived, sessile community characterized by cells that attach to an interface, embed in a matrix of exopolysaccharide, and demonstrate an altered phenotype. This review covers the current understanding of the nature of biofilms and the impact that molecular interactions may have on biofilm development and phenotype using the motile gram-negative rod Pseudomonas aeruginosa and the nonmotile gram-positive cocci Staphylococcus aureus as examples.

A calcium hydroxyapatite antibiotic implant was evaluated to determine its efficacy as an antibiotic delivery system in a localized osteomyelitis rabbit model. Localized rabbit tibial osteomyelitis was developed with an intramedullary injection of methicillin resistant Staphylococcus aureus. Infected rabbits were randomized and divided into eight groups depending on treatment with or without debridement, systemic antibiotics, antibiotic-impregnated polymethylmethacrylate beads, or calcium hydroxyapatite implants with and without antibiotic impregnation. All treatments began 2 weeks after infection. After 4 weeks of therapy, the involved bones were cultured for concentrations of Staphylococcus aureus per gram of bone. Rabbits (n = 11) that had calcium hydroxyapatite (impregnated with vancomycin) implanted into the dead space after the debridement surgery had an 81.8% infection clearance after treatment. Rabbits (n = 10) that had polymethylmethacrylate beads (impregnated with vancomycin) implanted into the dead space after debridement surgery had a 70% clearance rate. All other treatment modalities resulted in less than 50% clearance rates. Calcium hydroxyapatite may be an effective alternative to polymethylmethacrylate for providing local antibiotic therapy in cases of methicillin resistant Staphylococcus aureus osteomyelitis.

Mycobacteria, both tuberculous and nontuberculous, are recognized as a cause of chronic bone and joint infection. However, the diagnosis of mycobacterial infection is easily missed because of the absence of systemic involvement. Moreover, specific microbiologic techniques are required to detect mycobacteria in clinical specimens. Infections due to uncommon pathogens such as mycobacteria are more likely to occur in the immunocompromised host. A case of septic arthritis of the ankle and osteomyelitis of the foot due to both tuberculous and nontuberculous mycobacteria in an immunocompetent host is reported here.

The effectiveness of oral gatifloxacin was compared to that of standard parenteral antibiotic therapy (nafcillin) for the treatment of experimental methicillin-sensitive Staphylococcus aureus-induced osteomyelitis in a rabbit model. Gatifloxacin was as effective as nafcillin in clearing the infection. Therefore, oral gatifloxacin treatment of osteomyelitis may be an effective alternative to intravenous nafcillin treatment.

Methicillin-susceptible Staphylococcus aureus (MSSA) is the most common pathogen recovered from osteomyelitis patients. The current standard therapeutic method for acute phase osteomyelitis is parenteral antibiotic therapy. However, parenteral administration has negative aspects, such as secondary infection, patient inconvenience and high cost. The use of single oral antibiotic therapy may alleviate these problems. Therefore, the purpose of this study was to compare the effectiveness of standard once per day dosing of oral levofloxacin with a standard parenteral antibiotic regimen (nafcillin four times daily) for the treatment of experimental MSSA osteomyelitis in rabbits. Nearly all tibias from untreated infected controls (n = 27) revealed positive cultures (93%) for S. aureus, while the levofloxacin-treated group (n = 20) demonstrated significantly lower percentages of S. aureus infection (50%). The infected tibias of the nafcillin-treated group (n = 20) demonstrated significantly lower percentages (10%) of infected tibias than either the controls or the levofloxacin-treated groups (P < 0.05). The inferior efficacy of levofloxacin may have been due to the pharmacokinetic profile of this fluoroquinolone. The serum kinetics demonstrated that following single dose administration, levofloxacin was almost undetectable after 12 h. Studies in which levofloxacin is dosed every 12 h or given at increased doses in order to obtain bactericidal concentrations throughout the treatment regimen are needed.

Study Design: Retrospective., Objectives: To determine the incidence, clinical presentation, diagnostic laboratory values, imaging characteristics, and optimal treatment of hematogenous pyogenic facet joint infections., Summary of Background Data: There are 27 documented cases of hematogenous pyogenic facet joint infections. Data regarding incidence, clinical presentation, diagnosis, and treatment response are incomplete because of the paucity of reported cases., Methods: This is a retrospective study of all cases of hematogenous pyogenic facet joint infection treated at one institution. Data from previous publications were combined with the present series to identify pertinent clinical characteristics and response to treatment., Results: A total of six cases (4%) of hematogenous pyogenic facet joint infection were identified of 140 cases of hematogenous pyogenic spinal infection at our institution. Combining all reported cases reveals the following: The average patient age is 55 years. Ninety-seven percent of cases occur in the lumbar spine. Epidural abscess formation complicates 25% of the cases of which 38% develop severe neurologic deficit. Erythrocyte sedimentation rate and C-reactive protein are elevated in all cases. Staphylococcus aureus is the most common infecting organism. Magnetic resonance imaging is accurate in identifying the septic joint and associated abscess formation. Percutaneous drainage of the involved joint has a higher rate of success (85%) than treatment with antibiotics alone (71%), but the difference is not significant (P = 0.37)., Conclusions: Hematogenous pyogenic facet joint infection is a rare but underdiagnosed clinical entity. Facet joint infections may be complicated by abscess formation in the epidural space or in the paraspinal muscles. Uncomplicated cases treated with percutaneous drainage and antibiotics may fare better than those treated with antibiotics alone. Cases complicated by an epidural abscess and severe neurologic deficit should undergo immediate decompressive laminectomy.

Two types of haematogenous osteomyelitis that are seen in the elderly are vertebral and long bone osteomyelitis. Osteomyelitis secondary to contiguous foci of infection can occur in older adults without vascular insufficiency (secondary to pressure ulcers) or with vascular insufficiency due to diabetes mellitus or peripheral vascular disease from atherosclerosis. Most cases of osteomyelitis can be reasonably treated with adequate drainage, thorough debridement, obliteration of dead space, wound protection, and antimicrobial therapy. Patients are initially given a broad spectrum antimicrobial that is changed to specific antimicrobial therapy based on meticulous bone cultures taken at debridement surgery or from deep bone biopsies. Surgical management is often required in the treatment of osteomyelitis and includes adequate drainage, extensive debridement of all necrotic tissue, obliteration of dead spaces, stabilisation, adequate soft tissue coverage, and restoration of an effective blood supply. Bone repair and bone mineral density may be significantly retarded and may be corrected by eliminating risk factors, supplementing the diet with calcium, bisphosphonates, and/or vitamin D, and treating with testosterone and/or estrogen when deficient. Sodium fluoride treatment and anabolic steroids may be used as alternatives. Septic arthritis is a medical emergency, and prompt recognition and rapid and aggressive treatment are critical to ensuring a good prognosis. The treatment of septic arthritis includes appropriate antimicrobial therapy and joint drainage. Adverse effects of prescribed antibacterials occur more often in the elderly patient than in young adults. The physician can help to minimise the incidence of adverse effects and improve outcomes by being aware of the principles of clinical pharmacology, the characteristics of specific drugs, and the special physical, psychological and social needs of older patients.

Chronic osteomyelitis has been a difficult problem for patients and the treating physicians. Appropriate antibiotic therapy is necessary to arrest osteomyelitis along with adequate surgical therapy. Factors involved in choosing the appropriate antibiotic(s) include infection type, infecting organism, sensitivity results, host factors, and antibiotic characteristics. Initially, antibiotics are chosen on the basis of the organisms that are suspected to be causing the infection. Once the infecting organism(s) is isolated and sensitivities are established, the initial antibiotic(s) may be modified. In selecting specific antibiotics for the treatment of osteomyelitis, the type of infection, current hospital sensitivity resistance patterns, and the risk of adverse reactions must be strongly appraised. Antibiotic classes used in the treatment of osteomyelitis include penicillins, beta-lactamase inhibitors, cephalosporins, other beta-lactams (aztreonam and imipenem), vancomycin, clindamycin, rifampin, aminoglycosides, fluoroquinolones, trimethoprim-sulfamethoxazole, metronidazole, and new investigational agents including teicoplanin, quinupristin/dalfopristin, and oxazolidinones. Traditional treatments have used operative procedures followed by 4 to 6 weeks of parenteral antibiotics. Adjunctive therapy for treating chronic osteomyelitis may be achieved by using beads, spacers, or coated implants to deliver local antibiotic therapy and/or by using hyperbaric oxygen therapy (once per day for 90-120 minutes at two to three atmospheres at 100% oxygen).

Posttraumatic tibial osteomyelitis results from trauma or nosocomial infection from the treatment of trauma that allows organisms to enter bone, proliferate in traumatized tissue, and cause subsequent bone infection. The resulting infection is usually polymicrobial. The patient may be classified using the May and the Cierny-Mader classification systems. The diagnosis is based on the isolation of the pathogen(s) from the bone, or blood cultures. Appropriate therapy of posttraumatic tibial osteomyelitis includes adequate drainage, thorough debridement, obliteration of dead space, stabilization when necessary, wound protection, and specific antimicrobial therapy.

Bone and joints are normally sterile areas. Bacteria may reach these sites by either haematogenous spread or spread from an exogenous or endogenous contiguous focus of infection. Bone infection, or osteomyelitis, is characterized by a progressive infectious process resulting in inflammatory destruction of bone, bone necrosis and new bone formation. Joint infections, or infectious arthritis, arise either from the haematogenous spread of organisms through the highly vascularized synovial membrane or from direct extension of a contiguous bone or soft tissue infection. The most commonly involved joints are the knee and the hip, although any joint can become infected. Infectious arthritis is monoarticular in 90% of cases. Some of the questions to be answered in this chapter include: how bacteria reach and cause damage in the bones and joints; what the current classification systems of bone and joint infections are; what some risk factors and host factors associated with bone and joint infection are; what some current characteristics of musculoskeletal infections are and whether the damage to joints can be diminished by treatment., (Copyright 1999 Harcourt Publishers Ltd.)

A rabbit model for Staphylococcus aureus osteomyelitis was used to compare 28-day combination antibiotic therapy using oral rifampin (40 mg/kg, twice daily) plus oral azithromycin (50 mg/kg, once per day), oral clarithromycin (80 mg/kg, twice daily), or parenteral nafcillin (30 mg/kg, four times daily). The left tibial metaphysis of New Zealand White rabbits was infected with Staphylococcus aureus. Grades 3 to 4 osteomyelitis (according to the Cierny-Mader classification system) development in the rabbits was confirmed radiographically. After antibiotic therapy regimens of 28 days, all tibias from controls that were infected but left untreated (n = 10) revealed positive cultures for Staphylococcus aureus at a mean concentration of 2.8 x 10(4) colony forming units/g bone. The rifampin plus clarithromycin (n = 15) and rifampin plus azithromycin (n = 15) groups showed significantly lower percentages of positive Staphylococcus aureus infection (20% and 13.3%, respectively) and bacterial concentrations (3.5 x 10(1) and 1.75 x 10(1) colony forming units/g bone, respectively). The osteomyelitic tibias of the nafcillin plus rifampin treated group (n = 7) showed no detectable Staphylococcus aureus infection (significantly lower than controls). The differences observed for bone bacterial concentrations and sterilization percentages between the antibiotic treated groups were not statistically significant. Although fluoroquinolones (including ofloxacin and ciprofloxacin) are the agents usually prescribed with rifampin, increasing resistance has been observed. Although macrolides traditionally are not used in the treatment of osteomyelitis, the results of this study indicate that azithromycin and clarithromycin may be attractive partners for rifampin for the treatment of Staphylococcus aureus osteomyelitis in humans.

We investigated the role of gallium citrate Ga 67 scanning in diagnosing spondylodiscitis. Scans of 41 patients with suspected spondylodiscitis showed increased radionuclide uptake in 39 patients; these findings correlated with those of magnetic resonance imaging and were proved by biopsy. Two patients with negative findings on gallium scans had been strongly suspected of having spondylodiscitis; biopsy findings in these patients showed degenerative changes. Thirteen patients had negative cultures, while 22 had polygenic infections and 4 had granulomatous infections. Gallium scanning proved to be 100% sensitive, specific, and accurate. The interrater accuracy was excellent. Follow-up scans were used to track therapeutic progress. We recommend complementary bone and gallium scans in cases of suspected spinal infections. If the scan is positive, a biopsy should be done. If the scans are negative, no further investigation is needed.

Spondylodiscitis normally heals itself, but it can cause bone destruction leading to deformity and often pain. Debridement of these infections by percutaneous transpedicular discectomy with access from adjacent caudal pedicles can accelerate natural healing and prevent progression to bone destruction and deformity. We outline this technique and discuss a series of 28 patients treated using a percutaneous transpedicular approach to obtain culture and histopathology specimens, permit drainage and antibiotic irrigation, and provide a channel for granulation tissue to invade the infected space. This procedure is safe and effective, but it is contraindicated for epidural abscess or granulation tissue-induced neurocompression and it is ineffective against extensive bone destruction.

Objective: To document the incidence of complications occurring secondary to placement of tympanostomy tubes in patients undergoing hyperbaric oxygen therapy., Design: Retrospective chart review., Setting: Tertiary referral center., Patients: Forty-five patients referred to the Department of Otolaryngology for inability to tolerate hyperbaric oxygen therapy between January 1, 1990, and December 31, 1995., Interventions: All patients underwent bilateral myringotomy and tube placement., Outcome Measures: Charts were reviewed for complications of tube placement, including otorrhea, otalgia, hearing loss, persistent perforations, and tinnitus., Results: Seventeen (38%) of 45 patients experienced complications, with most having more than 1. Most complications occurred after conclusion of hyperbaric oxygen therapy. Otorrhea was most common, occurring in 13 patients (29%). Persistent tympanic membrane perforations occurred in 7 patients (16%)., Conclusions: The rate of complications is higher than reported for placement of tympanostomy tubes in other patient populations. Coexisting illness, such as diabetes mellitus, may contribute to the development of complications in patients undergoing hyperbaric oxygen therapy. Alternative methods of tympanostomy, with emphasis on shorter duration of intubation, should be considered in this patient population.

We report on the conservative and surgical management of a patient with blastomycosis of the lumbar spine, causing severe and crippling deformity. The diagnosis was made through biopsy. Curative removal, reconstruction and realignment of the spine were achieved. Imaging modalities were highlighted, with a detailed discussion of the histology and conservative and surgical management. We emphasize the importance of early, aggressive treatment of blastomycosis to prevent deformity and disability, and to enable identification of the best management of a destructive lesion with deformity. This case demonstrates that empirical treatment should not be used in cases of unusual sinus and abscess locations. Specific diagnosis and early treatment are indicated to prevent dreadful complications and spinal deformity resulting from blastomycosis. Aggressive antifungal therapy can cure the disease but does not control complications related to deformity. The latter can only be addressed by surgical reconstruction. We review the literature of surgical treatment, focusing on abscess drainage, bone fusion and posterior instrumentation in the absence of addressing the deformity component.

Unlabelled: This article explores the accumulation of 99mTc-tetraphenyl porphyrin sulfonate (TPPS4) at inflammatory sites, especially osteomyelitis, and compares the results with 111In Cl3 and 111In-WBC in an animal model., Methods: Osteomyelitis was induced in 12 New Zealand white rabbits by injecting staphylococcus aureus in the left tibia. Three weeks later, radiographs confirmed the disease. Two hours later, after injection of 74 MBq 99mTc-TPPS4, scintiphotos of the lower extremities were acquired and repeat scintiphotos were obtained 24 hr after injection of 5.55 MBq 111In Cl3. After these studies, 24- and 48-hr scintiphotos of the lower extremities were acquired after injecting 5.55 MBq 111In-labeled WBC., Results: The left tibia averaged three times the uptake with 99mTc-TPPS4 compared with right tibia; with 111In Cl3 and 111In WBC the ratios are two times. These three radiopharmaceuticals reveal positive images, but the image quality using 99mTc-TPPS4 is better, as would be expected from the more favorable physical characteristics of 99mTc and the higher uptake., Conclusion: The traditional combination of three-phase bone and 67Ga-citrate scintigraphy can be replaced by a single injection of 99mTc-TPPS4 with imaging as early as 2 hr. Finally, the use 99mTc-TPPS4 should result in a substantial reduction in radiopharmaceutical cost.

Osteomyelitis is traditionally staged by the Waldvogel classification system. The Waldvogel classification is an etiologic system and does not readily lend itself to guiding surgical or antibiotic therapy. Other classifications have been developed to emphasize different clinical aspects of osteomyelitis. These classifications include those of Ger, Kelly, Weiland, Gordon, May, and Cierny-Mader. The Cierny-Mader classification is based on the anatomy of bone infection and the physiology of the host. The Cierny-Mader classification permits the development of comprehensive treatment guidelines for each stage. The Cierny-Mader classification is used to demonstrate the application of staging for the diagnosis and treatment of osteomyelitis.

Plantar puncture wounds to the foot are a common injury. A small number (1.8%) of these puncture wounds become infected and progress to osteomyelitis. The purpose of this article is to report the cases of six patients who developed osteomyelitis of the calcaneus after a puncture wound to the heel caused by a nail. The characteristics of the patients, the pathogenic organism, and the outcome were studied. Patients who were healthy and had no systemic illness (N = 4) had only one pathogenic organism cultured, whereas patients who had systemic illness (diabetes mellitus, N = 2) had more than one pathogenic organism cultured. The only amputation in this group occurred in a patient with diabetes mellitus. It was concluded that diabetic patients who develop calcaneal osteomyelitis from a nail puncture wound are more likely to have multiple pathogens cultured. Furthermore, if a diabetic neuropathy is also present, the nail puncture wound may be the initial injury leading to a chronic ulceration, increasing the risk of amputation.

A biodegradable antibiotic implant was developed and evaluated in a localized osteomyelitic rabbit model. The biodegradable antibiotic implant was made of polylactic acid and poly(DL-lactide):co-glycolide combined with vancomycin. Localized rabbit tibial osteomyelitis was developed with Staphylococcus aureus. Infected rabbits were divided into eight groups, depending on treatment with or without debridement, systemic antibiotics, or biodegradable beads. After 4 weeks of therapy, the radiographs were obtained of the involved bones, which also were cultured for concentrations of Staphylococcus aureus per gram of bone. Treatment with antibiotic containing polylactic acid and poly(DL-lactide):co-glycolide beads, with and without systemic vancomycin, resulted in bone colony forming unit levels of 10(2.93) and 10(2.84) colony forming units per gram bone, respectively. These bacterial concentrations were approximately 100 times lower than those observed for all other treatment groups. A biodegradable antibiotic bead may provide extended bactericidal concentrations of antibiotics for the time needed to completely treat the particular orthopaedic infection and does not require the surgery needed to remove the polymethylmethacrylate beads.

Infectious arthritis arises from haematogenous spread of organisms through the synovial membrane or from the direct extension of a contiguous infection. The diagnosis rests on the isolation of the pathogen(s) from joint fluid obtained by aspiration or from debridement. Synovial fluid analysis and Gram stains provide clues to the aetiology. The treatment of septic arthritis includes appropriate antimicrobial therapy and joint drainage. Bone infections are currently classified by the Waldvogel or Cierny-Mader classification. Cierny-Mader staging allows stratification and development of comprehensive treatment guidelines for each stage. Osteomyelitis therapy emphasises early diagnosis and aggressive treatment. Radiographs and bone cultures are the mainstays of diagnosis. Radionuclide scans, computerised tomography or magnetic resonance imaging may be obtained when the diagnosis of osteomyelitis is equivocal or to help gauge the extent of the infection. Medical therapy includes improving any host deficiencies, initial antibiotic selection and antibiotic modification based on culture results. Surgical treatment involves debridement of necrotic bone and tissue, obtaining appropriate cultures, managing dead space and, when necessary, obtaining bone stability.

Antibiotic-impregnated beads are used in the dead bone space following debridement surgery to deliver local, high concentrations of antibiotics. Polymethylmethacrylate (PMMA), 2,000-molecular-weight (MW) polylactic acid (PLA), Poly(DL-lactide)-coglycolide (PL:CG; 90:10, 80:20, and 70:30), and the combination 2,000-MW PLA-70:20 PL:CG were individually mixed with clindamycin, tobramycin, or vancomycin. Beads were placed in 1 ml of phosphate-buffered saline (PBS) and incubated at 37 degrees C. The PBS was changed daily, and the removed PBS samples were stored at -70 degrees C until the antibiotic in each sample was determined by microbiological disk diffusion assay. Nondissolving PMMA beads with tobramycin and clindamycin had concentrations well above breakpoint sensitivity concentrations (i.e., the antibiotic concentrations at the transition point between bacterial killing and resistance to the antibiotic) for more than 90 days, but vancomycin concentrations dropped by day 12. ALl PLA, PL:CG, and the 2,000-MW PLA-70:30 PL:CG biodegradable beads release high concentrations of all the antibiotics in vitro for the period of time needed to treat bone infections (i.e., 4 to 8 weeks). Antibiotic-loaded PLA and PL:CG beads have the advantage of better antibiotic elution and the ability to biodegradable (thereby averting the need for secondary surgery for bead removal) compared to the PMMA beads presently used in the clinical setting.

Osteomyelitis can be classified by duration, pathogenesis, location, extent, and host status. Bone infections are currently classified by the Waldvogel or the Cierny-Mader classification. Because the Waldvogel classification is an etiologic system and the Cierny-Mader classification is descriptive, both classifications can be simultaneously used. The Cierny-Mader classification is based on the anatomy of the bone infection and the physiology of the host. Cierny-Mader staging allows stratification of long bone osteomyelitis and the development of comprehensive treatment guidelines for each stage. Current trends in long bone osteomyelitis therapy emphasize early diagnosis and aggressive treatment. Radiographs and bone cultures are the mainstays of diagnosis. Imaging with radionuclide scans, computerized tomography, and magnetic resonance imaging are used when the diagnosis of osteomyelitis is equivocal or to help guage the extent bone and soft tissue infection. Surgical treatment involves débridement of necrotic bone and tissue, obtaining appropriate cultures, managing dead space, and, when necessary, obtaining bone stability. Medical therapy includes improving any host deficiencies, initial antibiotic selection, and antibiotic modification based on culture results. Antibiotic delivery has expanded to include effective oral agents and local therapy with antibiotics mixed in polymethylmethacrylate. Cierny-Mader staging was developed to describe long bone osteomyelitis. This staging system has to be modified to describe diabetic foot osteomyelitis and vertebral osteomyelitis. Osteomyelitis in patients with diabetes mellitus involves the bones of the feet or ankles. The vascular and neurologic status of the patient must be carefully accessed. Patients may be managed with local débridement surgery or ablative surgery plus 2 to 4 weeks of antibiotic therapy depending on whether all of the osteomyelitis is surgically removed. If the patient does not wish surgery or is not a surgical candidate, suppressive antibiotic therapy can be used. Vertebral osteomyelitis is usually hematogenous in origin. The diagnosis is made by bone cultures, histology, and radiographs. Magnetic resonance imaging and technetium scans are useful in making the diagnosis and in gauging the extent of the bone and soft tissue infection. Therapy requires parenteral antibiotic therapy and may include early surgery and stabilization. The choice of an antibiotic therapy is guided by the bone biopsy or débridement culture results.

We present four head and neck cancer patients who apparently had rapid progression of clinically occult disease during or soon after undergoing hyperbaric oxygenation. This led us to review existing knowledge about the interaction of HBO with tumors. The literature can be summarized as follows: 1. HBO is a useful tool in several situations commonly encountered by head and neck surgeons-infections, radionecrosis, and wound-healing problems. 2. The use of HBO as a hypoxic cell sensitizer during radiation therapy has been extensively studied, with evidence supporting only marginal advantage to this logistically difficult undertaking. 3. Most reports regarding the interaction of HBO with transplanted tumor cells suggest no effect on tumor growth or metastases. 4. Studies of chemically induced carcinogenesis are less conclusive. Some evidence supports a role for HBO in enhancing growth of preexisting tumors. Better understanding of the interaction of HBO with existing tumors is required to ensure that informed choices-weighing potential risks and benefits of HBO treatment--may be made by head and neck surgeons and their patients. Further research into the interaction between HBO and tumor cells is warranted.

The complexities of osteomyelitis make its diagnosis and treatment challenging. Current trends emphasize early diagnosis and aggressive treatment. Imaging has improved, with nuclear scans and magnetic resonance imaging, and technique modifications have enhanced the specificity of these tests. Treatment depends on thorough debridement of necrotic bone and tissue, accurate cultures and administration of culture, and sensitivity-specific antibiotics. Antibiotic delivery has expanded to include effective oral agents and local agents mixed with polymethylmethacrylate or a biodegradable substance. Success rates in treating this disease have improved with the use of a systematic approach, making outcome more predictable.

Management of foot problems in the patient with diabetes mellitus requires attention to each system affected by the disease. Appropriate treatment of common clinical problems affecting the foot in diabetic patients, such as ulcerations and fractures, depends on a thorough understanding of the pathophysiology of the disease. Treatment of neuropathy is directed at pressure relief and prevention of deformity. Infection is addressed with antibiotics, debridement, and improvement of the vascularity and oxygenation of the tissues. Amputation should be viewed, not as evidence of treatment failure, but as a reconstructive procedure, the goal of which is to regain energy-efficient ambulation. The orthopaedic surgeon can play a critical role in the team approach to the care of the diabetic patient with foot problems.

The pathogen may proliferate years after seemingly successful treatment. The authors describe a classification system to evaluate both the disease and the patient's capacity to undergo the rigors of therapy. Two cases illustrate the clinical issues.