An aggressive treatment approach for adult osteomyelitis

Osteomyelitis in the adult patient has been associated with failure of eradication, late recurrence, nonunion, and prolonged hospitalization. A staged aggressive approach has been used for the past seven years to treat 53 patients with adult osteomyelitis. This approach includes: evaluation of bone necrosis and identification of the etiologic organisms by deep bone culture; radical surgical debridement of devascularized tissue; intensive systemic antibiotics; and early bone and soft tissue reconstruction. All patients have been followed at least 1 year (mean, 33 months). Lower extremity bones predominated in the series (24 tibias, 13 femurs); and 19 patients had bony instability. Thirty-seven patients had initial successful eradication of their infections with 26 of these returning to full activity status. The remaining 16 patients developed recurrent infection; however, 11 patients totally responded to further aggressive treatment. Of the five failures in the total series, three patients required amputation and two patients have persistent infection. Fifteen of the 19 patients with bony instability healed with initial treatment, and the remaining four patients healed with subsequent treatment. Six patients had primary muscle flap soft tissue reconstruction, and an additional two patients had reconstruction as a secondary procedure. In all these patients with tibial instability, bony union was accelerated compared to those patients with tibial instability not receiving muscle flaps (4 months vs 12 months). The muscle coverage provided by either pedicled flaps or transferred by microvascular anastomoses.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term intravenous antibiotic therapy in chronic osteomyelitis

Because the optimal treatment of chronic osteomyelitis is not well established, we studied the efficacy of prolonged (three months or more) outpatient intravenous antibiotic therapy via a Hickman catheter. Seventeen patients were entered into our protocol (13 with chronic osteomyelitis, three with chronic septic arthritis, and one with subacute osteomyelitis). Pseudomonas aeruginosa was the most common bone isolate, followed by Staphylococcus aureus. Most patients had polymicrobial isolates. Patients were followed up with clinical examinations, serial measurements of erythrocyte sedimentation rate, and scans using technetium Tc 99m medronate and gallium citrate Ga 67. Of the ten patients with chronic osteomyelitis who completed therapy, eight were considered cured. After further follow-up, three of the cured patients had recurrences requiring additional therapy.

Adherent bacterial colonization in the pathogenesis of osteomyelitis

Direct scanning electron microscopy of material obtained during surgical debridement of osteomyelitic bone showed that the infecting bacteria grew in coherent microcolonies in an adherent biofilm so extensive it often obscured the infected bone surfaces. Transmission electron microscopy showed this biofilm to have a fibrous matrix, to contain some host cells, and to contain many bacteria around which matrix fibers were often concentrated. Many bacterial morphotypes were present in these biofilms, and each bacterium was surrounded by exopolysaccharide polymers, which are known to mediate formation of microcolonies and adhesion of bacteria to surfaces in natural ecosystems and in infections related biomaterials. The adherent mode of growth may reduce the susceptibility of these organisms to host clearance mechanisms and antibiotic therapy and thus may be a fundamental factor in acute and chronic osteomyelitis.

Systemic mycosis in Scottish red deer (Cervus elaphus)

The pathological features of 10 cases of systemic infection of young red deer by fungi morphologically identified as phycomycetes are described. The most frequently affected organs were the kidneys, followed by liver and central nervous system. The fungi stimulated an acute pyogenic inflammatory reaction and a phagocytic giant cell response. Vasculitis with thrombosis and spread of fungi to the surrounding tissue was a common finding. Culture was attempted in 4 cases; one yielded Absidia, 2 Aspergillus and the other an unidentified fungal growth. Analysis of the histories suggests that, in nine of the ten cases, stressful husbandry may have been a predisposing factor.

Avian leukosis virus-induced osteopetrosis is associated with the persistent synthesis of viral DNA

DNAs from 19 cases of avian leukosis virus-induced osteopetrosis have been analyzed for viral sequences. Among these were instances of rapid, intermediate, and slow onset osteopetrosis. The DNAs from osteopetrotic bone contained no evidence for osteopetrosis being caused by proviral insertions into or viral transductions of a host protooncogene. Instead, DNAs from osteopetrotic bone displayed evidence for osteopetrosis being associated with the persistent synthesis of viral DNA. Each of the 19 DNAs contained unintegrated as well as integrated viral DNA. Rapid onset osteopetrosis contained about 3X more viral and proviral DNA than intermediate or late onset osteopetrosis. Unintegrated viral DNA could not be detected in DNAs extracted from the bursa bone marrow of osteopetrotic chickens or in DNA extracted from the normal bones of an avian leukosis virus-infected chicken. Thus, the persistent synthesis of unintegrated viral DNA was observed in osteopetrotic but not normal tissues of avian leukosis virus-infected chickens.

[Examples of signs of biogenic decomposition in bones long buried]

This investigation is based on twenty human bones, which mostly were stained red, black and violet, and always showed special dead bone decomposition, strictly limited to the stained areas. Histological examinations, biochemical and physical analysis in combination with microbiological isolation and cultivation tests could limit the cause of these phenomena to the biogenous sector--in this case microorganisms--and enabled the formulation of the following model on biogenous dead bone decomposition: Microorganisms are able to grow on buried bone by superficial settlement and invasion of physiological cavities. By means of excretion of enzymatic and acid metabolites for extracorporal dissociation of utilizable sources of energy the structural integrity of the tissue will be destructed. If this process is limited to the nearby environment of the growing organism, this leads to production of specific osteolysis (microscopical focal destruction). Expanded diffusion of enzymatic metabolites leads to leaching and departure of organic components, without producing microscopical focal destruction. The result is a shrinkage of the left material, that sometimes reminds of thermical influences. On the other side, an acidification of the medium by saprophagous microorganisms may lead to fractional crystallization of the mineral components by means of brushite-genesis. The result is further structural decomposition. In addition, the invading microorganism may excrete staining and fluorescing secondary metabolites into the bone, and impregnate the tissue durable. These processes are favoured in nearly isolated systems, like in crypts and stone coffins.

Pasteurella pneumotropica isolated from bone and joint infections

Pasteurella pneumotropica is a normal inhabitant of the oropharynx of mice, rats, cats, and dogs. We describe here the first reported case of joint and bone involvement in a human. The need for culturing and adequate prophylactic treatment is discussed.

Phialophora richardsiae isolated from infected human bone: morphological, physiological and antifungal susceptibility studies

A dematiaceous fungus, Phialophora richardsiae (Nannf.) Conant, was isolated from human bone. In culture the fungus produced no yeast forms and was less pigmented than two other P. richardsiae isolates. While growth rates were similar, colonial forms differed. Phialides were of two kinds. While both had broad bases and tapered at the tips, only one terminated with a cupulate or rarely a saucer-shaped collarette. Most phialides were hyaline with a few lightly pigmented ones in older cultures. Broth dilution susceptibility testing of the isolates against amphotericin B, miconazole, ketoconazole, clotrimazole, and 5-fluorocytosine showed the fungus was susceptible to miconazole, ketoconazole and amphotericin B at achievable serum levels and resistant to 5-fluorocytosine and clotrimazole. The other isolates were reported to differ in their resistance to miconazole and amphotericin B. Enzyme and salinity studies showed minor difference among the isolates.

[Microbial contamination of ABO antigens in bone tissue]

Fragments of human bones were stored in different media for two years and then expression of the ABO antigens was indicated. Simultaneously, microbiological investigations were performed. In almost all cases, different ABO substances were detected in putrefied and fresh bones taken from the same person. Blood group antigens found in putrefied bones were compared with serological activity of bacterium cultured from these tissues. Attempts were made to remove unspecific reactions. The authors assume that bacteria are responsible for nonspecific serological reactions, not only as a carrier of blood-group-like substances, but also as a source of enzymes responsible for changes in the structure of ABO antigens in putrefied bones.

Efficacy of a topical antibiotic irrigant in decreasing or eliminating bacterial contamination in surgical wounds

Using a simple in vitro system, the authors showed that colony counts of Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, and Pseudomonas species can be reduced by 12%-56% with saline irrigation; the reduction of colony numbers, however, especially for S. aureus, was not always statistically significant. However, even if it were statistically significant, the amount of reduction would not be clinically significant. A topical antibiotic irrigant containing bacitracin/neomycin was effective against S. aureus, S. epidermidis-, and E. coli-treated agar plates. Except for a single plate containing Pseudomonas organisms, the growth of Pseudomonas colonies was also prevented by antibiotic irrigation. Tissue samples of muscle, fat, and bone obtained during operation showed antibiotic levels comparable with, and in most cases greater than, those found in the blood agar plates. These data may be clinically significant and suggest that bacitracin/neomycin irrigation can be safely used to reduce the incidence of postoperative infection.

Neonatal osteomyelitis in Nigerian infants

Twenty-seven Nigerian infants with osteomyelitis during the first 28 days of life are presented to highlight the severity of the clinical manifestations and the radiological features of this infection. The clinical signs include limitation of movement of the extremities involved and localized swelling. Severe constitutional changes such as fever (greater than 39 degrees C) and abdominal distension were common. This contrasts with results from North America and Europe which emphasize the paucity of clinical signs despite involvement of multiple sites. Multiple site involvement was encountered in only eight cases. Staphylococcus aureus, proteus mirabilis and candida albicans were the main pathogens isolated. The long bones were more frequently affected. Aggressive bone destruction was a constant radiological finding peculiar to staphylococcal osteomyelitis while the formation of sequestrum, a rare occurrence in the newborn, was present in six patients. The mortality rate was 7.4% and the morbidity rate was equally low.

Experimental chronic staphylococcal osteomyelitis in rabbits: treatment with rifampin alone and in combination with other antimicrobial agents

The efficacy of rifampin alone and in combination with sisomicin, cephalothin, sisomicin and cephalothin, or trimethoprim was measured in an experimental model of chronic osteomyelitis due to Staphylococcus aureus in rabbits. Single-drug regimens used for 28 days were relatively ineffective (bone sterilization rate, 5%-55%). Combinations of rifampin with other agents were more effective (bone sterilization rate, 75%-100%). The combination of rifampin, sisomicin, and cephalothin given for only 14 days sterilized the bones of all treated rabbits. Staphylococci isolated from the bones of rabbits that had received rifampin alone or in combination with other antibiotics were highly resistant to rifampin; in contrast, these organisms remained sensitive to the other agents used. Results of in vitro studies of synergy correlated with in vivo results in some but not all instances. The results obtained with rifampin in the treatment of experimental chronic osteomyelitis caused by S. aureus suggest that clinical trials of this agent for the treatment of osteomyelitis in humans are warranted.

Osteomyelitis beneath pressure sores

Twenty-eight pressure sores were evaluated prospectively. Osteomyelitis was reported histologically in nine of 28 bones and pressure-related changes were reported in 14 bones. Roentgenograms suggested the presence of osteomyelitis in four instances of histologically proved osteomyelitis. Technetium Tc 99m medronate bone scans were highly sensitive, showing increased uptake in all cases of osteomyelitis; however, increased uptake also occurred commonly in uninfected bones due to pressure-related changes or other noninfectious causes. Cultures of bone biopsy samples usually disclosed anaerobic bacteria, gram-negative bacilli, or both. The diagnosis of osteomyelitis must be considered if a pressure sore does not respond to local therapy. If the technetium Tc 99m medronate uptake is increased in the involved area, or roentgenographic findings are abnormal, the diagnosis can only be made with certainty by histologic examination of bone. Antibacterial treatment should be selected based on the results of bone culture.

[Tetracycline-like fluorescence in buried human skeleton parts]

Some ubiquitous soil-living micro-organisms are producing tetracycline-like fluorescences in skeletal remains. For this reason, the possibility of using tetracycline fluorescences in dating or allocating displaced skeletal parts is severely limited.

Nonclostridial gas gangrene: late infection after hip pinning

An 86-year-old diabetic man had a late, gas-forming infection about Knowles pins. Although blood cultures were negative, a urinary tract infection followed by infection with the same organism in bone, muscle, and lung strongly supports hematogenous spread of E coli from the genitourinary system in this patient. The genitourinary system is well recognized as a source of bacteremia, and the skeletal system is the most often affected distant tissue when this occurs. A hematogenous cause of nonclostridial gas gangrene about an implant has not previously been reported.

Edwardsiella tarda osteomyelitis in a patient with SC hemoglobinopathy

Edwardsiella tarda is a recently identified gram-negative organism of the family Enterobacteriaceae. Reports of human infections with E tarda have been infrequent. We review 14 cases of systemic edwardsiellosis reported in the literature and report a case of E tarda osteomyelitis in a patient with sickle cell-hemoglobin C disease. In our case the remains of a snake may have been the source of the organism. Systemic edwardsiellosis is rare, and it may present as meningitis, endocarditis, bacteremia, liver abscess, or osteomyelitis. In 12 of 15 cases reported, systemic E tarda infection occurred in patients suffering from additional debilitating illnesses.

Immunohistological demonstration of respiratory syncytial virus antigens in Paget disease of bone

Respiratory syncytial virus antisera have been found to produce a positive immunohistologic response in osteoclasts in bone sections or in cells cultured from Paget disease lesions in 12 out of 12 patients tested. These experiments were carefully controlled by several means. Use of experimentally infected cells served as positive controls. Adsorption of antisera on human bone powder and KB cells did not remove the specific immunologic stain, but adsorption of the antisera by the virus did. Negative results were also obtained in osteoclasts of patients with primary or secondary hyperparathyroidism. In addition, negative results in specimens of Paget disease were found with antisera to measles; parainfluenza 1, 2, and 3; influenza A, B and C; rubella; and herpes simplex. These results are consistent with the hypothesis that the nuclear and cytoplasmic inclusions in the osteoclasts of Paget disease are a result of viral activity.

Effects of bone wax on bacterial clearance

The hemostatic benefit of bone wax placed in cancellous bone occurs at the expense of the wax persisting at the bony site for years. As such, bone wax appears to act as a foreign body. This study examines the effect of bone wax on the ability of cancellous bone to clear bacteria. The iliac crest of rabbits was penetrated to a standard depth with an 18-gauge needle. Subsequently, nothing or Staphylococcus aureus, 10(5) colony-forming units, was innoculated in the needle site and followed by the subcortical placement of a cylinder of bone wax or similarly sized stainless steel rod. Ten days later, the site of bony penetration was excised and cultured. Eighty percent of animals whose bone was implanted with bacteria and bone wax together had positive cultures. Forty percent of animals whose bone was implanted with bacteria and a steel rod also had positive cultures. The difference between these groups (bacteria with bone wax or with steel rod) was not statistically significant. However, these combinations of bacteria with foreign body were significantly different from the bacteria only or bone wax only or steel rod only groups in which no positive cultures were observed. The data indicate that bone wax significantly impairs the ability of cancellous bone of rabbits to clear a standard inoculum of S. aureus. This effect appears to be the same as that observed with a different but similarly sized foreign body (steel rod).

Cryptococcosis with multiple squamous cell tumors associated with a T-cell defect

A 54-year-old male with multiple squamous cell tumors was shown to have capsule deficient cryptococcosis confined to bone. Further investigations revealed a severe defect of cell-mediated immunity and the presence of serum antinuclear factor. An underlying T-cell defect might explain the unusual cryptococcal infection and the extremely aggressive behavior of the skin tumors.

Virally induced periosteal osteogenesis in mice

Inoculation of Moloney murine sarcoma virus (M-MSV) into shank muscles of adult NMRI mice resulted in localized sarcoma and periosteal membrane proliferation with subsequent periosteal bone formation. Newly formed bone arose from outer surface of shank bones. Two weeks after M-MSV inoculation the width of bone cortex increased nearly 4 times. The spaces between newly formed bone ossicles were filled with bone marrow. In the later stages these bone marrow cavities were merged with medullar cavities. No extraskeletal bone formation was observed. The regression of M-MSV-induced sarcomas coincides with cessation of the proliferation of bone therefore allowing the maturation and rebuilding of bone. Newly formed bone was not resorbed during a 6-month observation period.

Determination of the physicochemical and microbiological quality of carcass, bone and blood meal

The pH value and the moisture, fat and protein content of abattoir by-products which are commercially available in the Republic of South Africa were examined, and the total bacterial count and the extent of Salmonella, Escherichia coli, Bacillus, yeast and fungus contamination were determined. The extremes and reasonably attainable quality standards were deduced from the highest frequency and mean values of these figures. The total bacterial count was not statistically predictable from variables such as pH, moisture, protein and fat, but was found to be related to the combined effect of all 4 independent variables.

Time course of C-type retrovirus expression in mice submitted to osteosarcomagenic doses of 224radium

Virus particles with the biochemical properties of C-type retroviruses appeared transiently in bone tissues of (C3H x 101) f1 hybrid mice early after treatment with 224 Radium; such particles were then again detected in the bones of the irradiated animals at the onset of osteosarcoma formation and in the osteosarcomas. Antibodies against a murine retrovirus isolated from a 224 Ra-induced osteosarcoma were produced and detected in the serum of the 224 Ra-treated animals within a month after treatment began. The antibody levels plateaued to a maximum after about 2 months and remained elevated until the tumors started to develop. The antibody concentration in the serum of these irradiated animals decreased then progressively to reach levels similar to those observed in untreated controls. It thus appears that the imminence of osteosarcoma development can be predicted by monitoring the anti-C-type virus antibody levels in the serum of the irradiated mice. These experiments also strongly suggest that treatment with 224Radium induces expression of endogenous viruses in the animals.

Antibacterial activity of cefuroxime in human bone

Bone samples were taken at orthopaedic surgery from 12 patients, who had been treated with 2 doses of 750 mg cefuroxime by intravenous infusion. After grinding, extraction and assay by the agar diffusion method the levels of cefuroxime ranged between 0.4--1.9 micrograms/g bone. Using an electrophoretic method followed by microbiological assay, higher levels of cefuroxime were measured, possibly because of a diminution in the binding capacity of the bone.