The microbiology of chronic osteomyelitis: Changes over ten years

doi:10.1016/j.jinf.2019.07.006

Journal of Infection

Volume 79, Issue 3, September 2019, Pages 189-198

https://doi.org/10.1016/j.jinf.2019.07.006 Get rights and content

Abstract

Aim

This study quantified changes in the microbiology of osteomyelitis over a ten year period from a single centre within the UK with regard to infection with multi-drug resistant (MDR) bacteria and susceptibility of antimicrobial regimens.

Method

Patients with chronic osteomyelitis undergoing definitive surgery from 2013–2017 were inluded (n = 223). Microbiology was compared to patients in a cohort from 2001–2004, using the same diagnostic criteria, and same deep tissue sampling technique (n = 157). Clinical features associated with MDR bacterial infection were analysed using logistic regression.

Results

Both cohorts had similar baseline characteristics. Despite a similar proportion of Staphylococcus aureus in both cohorts, the rate of methicillin resistant Staphylococcus aureus (MRSA) infection was lower in 2013–2017 compared to 2001–2004 (11.4% vs 30.8% of Staphylococcus aureus, p = 0.007). However, the proportion of MDR infections was similar in both cohorts (15.2% versus 17.2%). Metalwork was associated with MDR infection (unadjusted OR 5.0; 95% CI: 1.15 to 22.0). There was no change in resistance to glycopeptide / meropenem combination treatment (2.2% vs 2.5%, p > 0.9).

Conclusions

In this centre, rates of MRSA osteomyelitis have fallen by two thirds, over the past 10 years, in line with the reducing rate of MRSA bacteraemia nationally. A history of metalwork may predict MDR infection. A glycopeptide with an anti-pseudomonal carbapenem remains the post-operative empiric systemic regimen of choice. Resistance patterns support the use of a glycopeptide with an aminoglycoside in local antibiotic therapy.

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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¹: These authors contributed equally to this work.

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The microbiology of chronic osteomyelitis: Changes over ten years

Abstract

Aim

Method

Results

Conclusions

Introduction

Section snippets

Patients and methods

Patient demographics

Anatomical information and surgical management in the 2013–2017 cohort

Discussion

Conclusions

Conflicts of interest

Ethics

Acknowledgments

J Infect

J Hosp Infect

Clin Microbiol Infect

Clin Microbiol Infect

Int J Antimicrob Agents

Osteoarthr Cartil

Colloids Surf B Biointerfaces

Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses

J Bone Joint Surg Am

Complications following limb-threatening lower extremity trauma

J Orthop Trauma

The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma

J Bone Joint Surg Am

Incidence, outcomes, and cost of foot ulcers in patients with diabetes

Diabetes Care

Developing and evaluating outcomes of an evidence-based protocol for the treatment of osteomyelitis in stage IV pressure ulcers: a literature and wound electronic medical record database review

Ostomy Wound Manage

Risk and prognostic factors for multidrug-resistant acinetobacter baumannii complex Bacteremia: a retrospective study in a tertiary hospital of west china

PLoS ONE

Prevalence, resistance mechanisms, and susceptibility of multidrug-resistant bloodstream isolates of pseudomonas aeruginosa

Antimicrob Agents Chemother