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Pediatric osteomyelitis: III. anaerobic microorganisms.

Primary osteomyelitis consequent to obligate anaerobic microorganisms represents an infrequently encountered type of infection in pediatric patients. Unlike osteomyelitis caused by more common microorganisms such as Staphylococcus, children with osseous lesions due to anaerobic microorganisms are frequently minimally symptomatic and rarely present the classic signs of fulminant osteomyelitis. Radiographically, the lesions may mimic malignant osseous tumors. Fastidious microbiologic analysis of the material obtained at surgery is necessary to isolate obligate anaerobes. Basic treatment, comprising surgical drainage and appropriate antimicrobial agents, does not differ from that for osteomyelitis caused by aerobic or by facultative anaerobic microorganisms.

Adolescent

[An experimental study on pyogenic osteomyelitis with special reference to the analysis of the therapeutic effects of antibiotics in vivo (author's transl)].

Experimental osteomyelitis was produced in mice by the Ueno's method for the purpose of evaluating therapeutic effects of the antibiotics. The results were as follows: 1) Experimental osteomyelitis produced with penicillin-G sensitive bacteria was completely cured by PC-G 1.8 mg per mouse a day, which provided maintenance of the concentration in serum more than 10 times of MIC for over 12 hours. The dosis of 0.18 mg per mouse per day was insufficient to bring a complete healing. 2) Experimental osteomyelitis produced with penicillin-G resistant bacteria did not heal completely, despite the administration of MPI-PC, a synthetic penicillin designed against penicillin resistant staphylococci, in a dosis of 5 mg twice a day, probably by the following reasons. Since MPI-PC is water-soluble, it is difficult to maintain the concentration in serum more than 10 times of MIC for over 1 hour. In other word, the bacteria was exposed to the effective antibiotic concentration for only one hour twice a day. 3) It was experimentally proved that earlier administration of antibiotics following inoculation provided quicker elimination of bacteria. 4) When bactericidal antibiotics were used, administration twice a day in half dosis gave better results compared with the full dosis once a day. 5) This experimental model of osteomyelitis proved quite useful for quantitative analysis of the effects of antibiotics, which would be applicable as a good method for evaluation of antibiotics to be developed in the future.

Animals

[The value of scintigraphy for the early detection of osteomyelitis (author's transl)].

For therapy and development of acute haematogenic osteomyelitis early detection of this disease is decisive. In our study 74 children were investigated scintigraphically with Tc-pyrophosphat because of suspicion of an inflammatory bone process. In all 23 cases of osteomyelitis scintigraphy showed an indication in form of increased activity in the respective bones; so the sensivity of this investigation, found in our study, was 1.0. In 10 of 51 cases without osteomyelitis scintigraphy, however, also showed increased activity. Because of this limited specifity of scanning further investigations are needed in the diagnosis of osteomyelitis. The main advantage of scintigraphy as compared with roentgen observation is the high sensitivity in the first days of illness. In addition scanning may supply valuable informations about the inflammatory process as long as it is active.

Child

Haemophilus influenzae type b osteomyelitis.

Three children had osteomyelitis due to Haemophilus influenzae type b. They were seen with signs and symptoms indistinguishable from infection caused by other organisms. One child was initially misdiagnosed as having septic arthritis because of failure to appreciate that Hemophilus may also cause bone infection. In the second patient osteomyelitis and arthritis developed during ampicillin sodium therapy for treatment of Hemophilus meningitis. His initial infection was caused by an ampicillin-sensitive isolate but his orthopedic infection subsequently responded to therapy only after changing to a regimen of chloramphenicol. In the third patient, bone scintigraphy was helpful in diagnosis since serial roentgenograms were not diagnostic of osteomyelitis. The anticapsular antibody responses of these patients were measured by radioimmune assay. The levels found were low but comparable to age-matched control children with H influenzae type b meningitis.

Antibodies, Bacterial

Group B streptococcal osteomyelitis and septic arthritis. Its occurrence in infants less than 2 months old.

Nine infants less than 2 months of age with group B streptococcal (GBS) osteomyelitis or septic arthritis, or both, were seen from January 1975 through January 1978. The infants had local joint signs, usually in the absence of systemic signs. The bones and joints involved were equally distributed between proximal humerus and proximal and distal femur. An infant had involvement of the talus. Treatment consisted of two to three weeks of parenteral antibiotics, arthrotomy in infants with arthritis, and bone decompression in infants with osteomyelitis. Clinical follow-up showed normal growth and function of the affected joint. Of the organisms, five were typed: four were type III and one was type Ib. Group B streptococcal osteomyelitis and/or septic arthritis was the second most common late-onset GSB infection, being surpassed only by meningitis.

Arthritis, Infectious

Rhizopus osteomyelitis. A case report and review.

Mucormycosis osteomyelitis has previously been described exclusively in association with contiguous infections of rhinocerebral mucormycosis. In a patient with corticosteroid-dependent neutropenia and anemia osteomyelitis of the femur developed caused by the Mucoraceae Rhizopus. Although a primary focus was not identified, we believe this infection was hematogenous in origin. Mitogen stimulation to phytohemagglutinin (PHA) of the patient's lymphocytes revealed depressed cellullar immunity; however, there was specific response to Rhizopus extract. Treatment with systemic amphotericin B prevented further progression of the infection. A review of mucormycosis osteomyelitis is presented.

Adolescent

Oral antibiotic therapy for skeletal infections of children. II. Therapy of osteomyelitis and suppurative arthritis.

Antimicrobial regimens consisting of a brief initial period of parenteral therapy followed by oral therapy were investigated in infants and children with suppurative bone and joint disease. There were 30 patients with acute hematogenous disease (19 osteomyelitis; three osteoarthritis; eight arthritis) and five with subacute or chronic osteomyelitis. Disease was due to Staphylococcus aureus in 26, Hemophilus influenzae in five, streptococci in three, and S. aureus plus Streptococcus pyogenes in one patient. Pus was removed by surgical drainage or needle aspiration. Oral therapy was monitored by assay of antibiotic concentration and bactericidal activity in serum. Adjustments in dosage were made when necessary to assure a peak serum bactericidal titer of at least 1:8. One patient progressed to chronic osteomyelitis but all other patients with acute disease responded well. Oral therapy provides increased patient comfort and decreases the risk of nosocomial infection associated with prolonged intravenous therapy. It should be carried out only under carefully monitored conditions in hospital to assure compliance and adequacy of serum bactericidal activity.

Administration, Oral

An etiologic shift in infantile osteomyelitis: the emergence of the group B streptococcus.

Twenty-one infants from six to 52 days of age (mean 23.3 days) with osteomyelitis were studied between 1965 and 1977. The etiologic agents were group B streptococcus (8), staphylococcus aureus (6), gramnegative bacilli (4), Streptococcus pneumoniae (1), and unknown (2). Patients with group B streptococcal osteomyelitis were characterized by an uncomplicated neonatal course, single bone involvement with a predilection for involvement of the proximal humerus, and lack of inflammatory signs. In contrast, patients with osteomyelitis due to other organisms frequently had had manipulative procedures predisposing to infection and were more likely to have multiple bone involvement, fever, and leukocytosis at the time of diagnosis. Functional impairment was detected in only one of 17 patients evaluated a mean of 36 months after diagnosis.

Female

Scintigraphy in diagnosis of osteomyelitis of the jaws.

The symptoms of an acute osteomyelitis of the jaws are often uncharacteristic, and typical radiographic changes usually do not appear until after the first weeks of disease. Even when such changes are established it is difficult to distinguish an active infectious disease from lasting changes due to a sterilized osteomyelitis. Scintigraphy with bone-seeking radiopharmaceuticals appears to be a valuable diagnostic technique. A case of osteomyelitis of the mandible is reported.

Female

Vertebral osteomyelitis as a complication of Pseudomonas aeruginosa pneumonia.

A patient with Pseudomonas aeruginosa pneumonia treated with gentamicin subsequently developed thoracovertebral osteomyelitis over the area of a preexisting compression fracture. Increasing back pain and progressive destruction with sclerosis of the involved vertebrae led to a needle biopsy examination of the vertebrae which showed evidence of chronic osteomyelitis and grew P aeruginosa on culture. P aeruginosa bacteremia was documented six months before the demonstration of the organism in the vertebrae. Treatment with a combination of gentamicin and carbenicillin coupled with bed rest cured the vertebral osteomyelitis.

Carbenicillin

Value of bone scan in primary sternal osteomyelitis.

Roentgenographic examination of the sternum is particularly difficult and offers little clinical assistance in the early stage of acute osteomyelitis. With only a few cases of primary sternal osteomyelitis reported, there are almost no data available regarding the role of bone scan in the diagnosis of this lesion. The present case illustrates the usefulness of the scan both in diagnosis and management of sternal osteomyelitis.

Debridement

Choice of antibiotics in management of acute osteomyelitis and acute septic arthritis in children.

A survey of 158 children with acute haematogenous osteomyelitis, and of 94 children with acute septic arthritis over an 8-year period was made to determine which bacteria cause these infections. In the osteomyelitis group the organism most frequently detected was Staphylococcus aureus (74% of cases). In 16% of cases streptococci were found. Staph. aureus was also the most frequently grown organism in cases of acute septic arthritis (55% of cases), but Haemophilus influenzae accounted for 24% of positive cultures. On the basis of the survey it is the current practice of the author to use a combination of methicillin or cloxacillin and penicillin for acute haematogenous osteomyelitis, and methicilline or cloxacillin and ampicillin for acute septic arthritis. The choice of antibiotics is vitally important as treatment must start before the results of culture are known. Repeated evaluation of trends in the pattern of causative organisms is strongly recommended, in order to be aware of changing sensitivity of organisms to antibiotics.

Adolescent

Osteomyelitis in a neonatal intensive care unit.

Neonatal osteomyelitis presents with few clinical signs despite multiple sites of involvement. Four cases of osteomyelitis due to Staphylococcus aureus or Candida albicans were encountered in a neonatal intensive care unit. Three were unsuspected clinically and were detected as incidental radiologic findings. The fourth presented with soft-tissue abscesses. Long bone metaphyses were most frequently affected. Other sites included iliac bones, clavicles, and spine. On follow-up the bones healed, but one patient was left with hip deformity secondary to destruction of the cartilaginous femoral heads and another patient developed obstructive hydrocephalus due to Candida ventriculitis. Complete skeletal survey is indicated in any infant with osteomyelitis at one site to seek additional silent areas of involvement.

Abscess

Candida osteomyelitis as a complication of parenteral nutrition in an infant. Successful treatment with flucytosine.

Hematogenous Candida osteomyelitis is described in a two-month-old infant, as a complication of Candida septicemia which occurred during a parenteral hyperalimentation regimen. Treatment with flucytosine led to full recovery. The scarcity of reports on hematogenous Candida osteomyelitis in infants, despite an increased incidence of Candida septicemia, and the non-specific symptomatology which the disease may assume in this age group, indicate the need for greater awareness of this complication. Flucytosine is an antifungal drug which can also be given by mouth and carries relatively low toxicity. We found flucytosine to be extremely effective in the treatment of disseminated infantile Candida osteomyelitis.

Administration, Oral

[Contribution to the treatment of acute haematogenous anc chronic secondary osteomyelitis in children (author's transl)].

The possibility of utilizing antistaphylococcal vaccine and local phage lysate for complex therapy of chronic and acute haematogenous osteomyelitis in children is demonstrated on three clinical cases. The study reassurmes good experience with this therapy in adult patients with chronic osteomyelitis. The results obtained so far in children suggest that the application of antistaphylococcal vaccine and of local phage lysate positively influences the course of the osteomyelitic disease and reduces the number of relpases. In order to specify and intensify the clinical effect of the above mentioned preparations, this method is being employed in other cases of chronic and acute haematogenous osteomyelitis.

Acute Disease

[Pathogenesis of acute osteomyelitis].

Pathogenesis of acute osteomyelitis is analyzed from the standpoint of disorders in the bone microcirculation. It is stated that in acute osteomyelitis there occur some disorders in microcirculation due to extravascular compression and intravascular occlusion of the bone vessels. The analysis of pathogenesis of acute osteomyelitis from the standpoint of disorders in the microcirculation of the osseous tissue is believed to be expedient for the correct understanding of pathological processes occurring in the bone, and for purposeful pathogenetic therapy.

Acute Disease

Serum enzyme activity in bone tumors and osteomyelitis (LDH, GOT, GPT, CPK, CHE, ALP, AP, PP, ALD).

Enzyme activity of lactate dehydrogenase, glutamate-oxalacetate and glutamate-pyruvate transaminase, creatine phosphokinase, cholinesterase, alkaline, acid and prostatic phosphatase and aldolase has been studied in a total of 213 subjects, of whom 97 were of good health, 63 had bone tumors and 53 suffered from osteomyelitis. The activities of the majority of the enzymes were found to become significantly changed in comparison with the norm. In both patient groups, the more striking differences being noted in that of osteomyelitis. However, enzymatic activity alone does not allow to differentiate the group of bone tumors from that of osteomyelitis, the differences between these two groups not being of significance in any one of the enzymes followed.

Acid Phosphatase

Resorption of the zygomatic arch after elevation of a depressed fracture and subsequent osteomyelitis: report of case.

A case of osteomyelitis of the zygomatic arch with complete resorption has been presented. The cause of osteomyelitis of the facial bones was discussed. Infection of the soft tissue after intraoral elevation of fractured zygomas does occur, but rarely leads to osteomyelitis and subsequent bony resorption of the underlying bone. Antibiotics have reduced the incidence of osteomyelitic infections in the past 20 years; however, a vigorous regimen of preoperative and postoperative attention to aseptic technique, proper antibiotics, and close follow-up is required to control these problems.

Adult