The microbiology of chronic osteomyelitis: Changes over ten years
Introduction
Osteomyelitis is a frequent and feared complication of trauma, affecting up to one third of patients who present with severe limb injury or open fracture during their recovery.1, 2, 3 In addition, haematogenous seeding and soft tissue infections, especially in patients with diabetes mellitus and pressure ulceration, can result in osteomyelitis.4, 5
A number of previous studies have demonstrated a variety of microorganisms isolated in osteomyelitis.1, 6 However, few have focused on the prevalence of multi-drug resistant (MDR) bacteria and how they can influence the choice of empiric local and systemic antimicrobial therapy. Some concern has been voiced regarding the rising frequency of MDR pathogens in orthopaedic infections, in the UK and worldwide.7, 8
Here, we compare two prospectively identified cohorts of patients with osteomyelitis from the same specialist bone infection centre treated ten years apart. The aims of this study were to (i) investigate whether clinical features of osteomyelitis correlate with microbiology, (ii) quantify the change in the incidence of osteomyelitis caused by MDR organisms over a 10-year time period and (iii) ascertain changes in resistance patterns to local and systemic empirical antibiotic regimens.
Section snippets
Patients and methods
All patients with surgically treated osteomyelitis during a four year period (March 2013 – May 2017) in one specialist unit were included (see Fig. 1).9, 10 Some patients had given informed consent for participation in cohort studies. Further analysis of anonymised, unidentifiable data for the purpose of service evaluation and quality improvement (selection of empiric antimicrobial regimens) was supported by institutional review (#5071).
Cessation of all antimicrobial therapy at least two weeks
Patient demographics
A total of 223 patients with a diagnosis of osteomyelitis were included as part of the 2013 – 2017 cohort. These patients were compared to an earlier cohort of 157 patients from between 2001 and 2004 that has been previously reported by Sheehy et al. 2010.4 Baseline characteristics from both cohorts are described in Table 1.
Anatomical information and surgical management in the 2013–2017 cohort
The most common sites of osteomyelitis were the tibia (100/223; 44.8%), femur (54/223; 24.2%) and the humerus (27/223; 12.1%). Other sites included the forearm (16/223;
Discussion
This prospective cohort study reviewed the change in microbiology of osteomyelitis in one tertiary referral centre over a ten year period and investigated possible associations with clinical features.
Conclusions
In our centre, we have seen a reduction in MRSA osteomyelitis to almost one third of the proportion observed ten years ago; the possible association with pre-operative decolonisation therapy, suggested by the absence of MRSA infection in patients with iatrogenic infection, merits further investigation. We did not observe an increase in MDR bacterial chronic osteomyelitis over the past ten years, despite subjecting classifiable bacterial isolates to more relevant susceptibility tests, and
Conflicts of interest
The authors declare no conflicts of interest with this study.
Ethics
Ethical approval was sought and granted by the local research and development committee in our hospital.
Acknowledgments
We are grateful for support and provision of primary data for analysis by Professor Nick Athanasou, Dr. Zsolt Orosz, Mr. David Stubbs, Professor Parham Sendi and Professor Philip Bejon. MD and AJH are funded through an Academic Clinical Fellowship, and SHH through an Academic Clinical Lectureship, by the National Institutes of Health Research. We declare that we have no conflicts of interest.
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These authors contributed equally to this work.