Infection of bones and joints

Osteomyelitis may be acute or chronic and the causative bacteria arrive in the bloodstream or are implanted directly (through a compound fracture, chronic local infection of local tissue, or surgical operation). Staphylococcus aureus is the commonest isolate in all patient groups but Haemophilus influenzae is frequently seen in children (much reduced now by the Hib vaccine), and Salmonella species in the tropics. Chronic osteomyelitis of the lower limbs (especially when underlying chronic skin infection in the elderly) frequently involves obligate anaerobes (such as Bacteroides species) and coliforms.

Strenuous efforts should be made to obtain bone for culture because superficial and sinus cultures are poorly predictive of the underlying flora, and prolonged therapy is required for chronic osteomyelitis (usually 6-8 weeks, sometimes longer). The outcome of chronic osteomyelitis is improved if dead bone can be removed surgically.

Definitive therapy is guided by the results of culture but commonly used regimens include flucloxacillin with or without fusidic acid (for Staphylococcus aureus), cefotaxime or co-amoxiclav (in children), and ciprofloxacin (for coliforms). Short courses of therapy (3 weeks) may suffice for acute osteomyelitis.

Septic arthritis is a medical emergency if good joint function is to be retained. Staphylococcus aureus is the commonest pathogen, but a very wide range of bacteria may be involved including streptococci coliforms and Neisseria. Aspiration of the joint allows specific microbiological diagnosis, differentiation from noninfectious causes such as crystal synovitis, and has therapeutic benefit, e.g. for the hip joint where formal drainage is recommended. Initial therapy is as for chronic osteomyelitis.

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