Phar 352 - Bone And Joint Infections

Front 1

What are the signs and symptoms of Bone & Joint Infections?(6)

Back 1

1) Fever

2) Pain

3) Redness

4) Swelling

5) Tenderness over affected area

6) Loss of function or movement (limping)

Front 2

How do we diagnose Bone Infections? (6)

Back 2

1) Signs and Symptoms

2) WBC + diff

3) ESR/CRP

4) Blood Culture

5) X-Ray: (lags behind 10-14days)

6) Bone Scan: (allows for early diagnosis)

Front 3

How do we diagnose Joint Infections? (5)

Back 3

1) Signs and Symptoms

2) WBC + diff

3) ESR/CRP

4) Blood Culture

5) Synovial Fluid

Front 4

What are the goals of therapy for Bone and Joint Infections?(4)

Back 4

1) Cure the Infection

2) Minimize Morbidity (loss of limb/joint function)

3) Prevent Recurrence

4) Prevent progression to chronic osteomyelitis

Front 5

What are the sources of Bone Infections? (4)

Back 5

1) Hematogenous: Infection spreads through blood to the bones

2) Contigous: Spread to bone from adjacent infection

3) Penetrating Trauma: Via Puncture Wound

4) Vascular Insufficiency: Poor perfusion/circulation to area

Front 6

Which group of patients are more likely to experience Hematogenous Infection?

Back 6

Children

Front 7

Which bones are more likely to be affected by Hematogenous Infections?

Back 7

Usually long bones & Joints affected.

[Vertebrae may be affected in adults>50 yrs]

Front 8

Which bones are more likely to be affected by Contigous Infections?

Back 8

Femur, Tibia, and Mandible

[more common in adults >50 yrs]

Front 9

Which bones are more likely to be affected by Vascular Insufficiency?

Back 9

Usually involves bones in feet and toes [common in >50 yrs old]

Front 10

What are the sources of Joint Infections? (6)

Back 10

1) Bone Infection Adjacent

2) Trauma over Joint

3) Prosthetic Joints

4) IV Drug Abuse

5) Gonococcal Infection

6) Rheumatoid Arthritis

Front 11

"Gonococcal Infections easily penetrate joint fluid" True or False

Back 11

TRUE

Front 12

What is Debridement?

Back 12

The medical removal of dead/damaged tissue

Front 13

What factors affect poor outcomes in the treatment of Bone&Joint Infections?(4)

Back 13

1) Inadequate Initial Debridement

2) Prosthetic Material

3) Duration of Infections

4) Previous Treatment failure

Front 14

What are the general treatment principles for Bone & Joint Infections? (6)

Back 14

1) Surgical aspiration/exploration

2) Early initiation of Antibiotics (within 48hrs)

3) Empiric coverage of likely pathogens

4) Targeted antibiotic therapy once the pathogen is identified

5) Intravenous drug therapy initially

6) Long duration of therapy

Front 15

What are the usual pathogens for Hematogenous Osteomyelitis in Neonates?

Back 15

1) Group B Strep

2) Gram -ve Enterococcus

3) Staph Aureus

Front 16

What are the usual pathogens for Hematogenous Osteomyelitis in Children?

Back 16

1) Staph Aureus

2) Group A Strep

{more rare: H.influenzae, S.pneumoniae, gram -ve enterococcus}

Front 17

What are the usual pathogens for Hematogenous Osteomyelitis in Adults?

Back 17

1) Staph Aureus

{more rare: gram -ve enterococcus}

Front 18

What are the usual pathogens for Contigous Osteomyelitis involving the Head/Neck?

Back 18

1) Staph Aureus

2) Anaerobes

3) gram -ve organims

4) Mixed infection is very common

Front 19

What are the usual pathogens for Contigous Osteomyelitis involving Soft Tissues?

Back 19

1) Staph Aureus

2) Streptocci

Front 20

What are the usual pathogens for Contigous Osteomyelitis involving Penetrating Trauma? (e.g. Nail in foot)

Back 20

1) Pseudomonas (most common by far)

2) Staph Aureus

3) Bacillus

4) Anaerobes

Front 21

What are the usual pathogens for Contigous Osteomyelitis involving Vascular Insufficiency? (e.g. Diabetic foot ulcers)

Back 21

1) Staph Aureus

2) Streptococci

3) gram -ve bacilli

4) Anaerobes

5) Polymicrobial Infections

Front 22

What are the usual pathogens for Contigous Osteomyelitis involving Septic Arthritis?

Back 22

1) Staph Aureus

2) Streptococci

{most rare: Candida spp, Pseudomonas, Enterobacteriacea}

Front 23

What are the usual pathogens for Contigous Osteomyelitis involving a Prosthetic Joint (with Early Onset <3months)?

Back 23

1) Staph Aureus

2) Coagulase -ve Staph

3) Enterobacteriacae

Front 24

What are the usual pathogens for Contigous Osteomyelitis involving a Prosthetic Joint (with Delayed Onset 3-24 months)?

Back 24

1) Coagulase -ve strep

2) Propionibacterium

3) Other anaerobes

4) Staph Aureus

Front 25

What is the recommended empiric therapy for Hematogenous Osteomyelitis in Neonates?

Back 25

1) Cloxacillin + Cefotaxime

2) Vancomycin + Cefotaxime

[if MRSA is possible]

Front 26

What is the recommended empiric therapy for Hematogenous Osteomyelitis in Children?

Back 26

1) Cloxacillin

2) Vancomycin [if MRSA is possible] {+Cefotaxime if patient is not immunized for H.influenza}

Front 27

What is the recommended empiric therapy for Hematogenous Osteomyelitis in Adults?

Back 27

1) Cloxacillin

2) Cefazolin

3) Vancomycin (if MRSA is possible)

Front 28

What is the recommended empiric therapy for Contigous Osteomyelitis involving the Head/Neck?

Back 28

Clindamycin ± Gentamicin

Front 29

What is the recommended empiric therapy for Contigous Osteomyelitis involving the Soft Tissue?

Back 29

1) Cloxacillin

2) Cefazolin

Front 30

What is the recommended empiric therapy for Contigous Osteomyelitis involving Penetrating Trauma in Children? (e.g.nail in foot)

Back 30

Cloxacillin + Ceftazidime + Gentamicin

Front 31

What is the recommended empiric therapy for Contigous Osteomyelitis involving Penetrating Trauma in Adults? (e.g.nail in foot)

Back 31

Ciprofloxacin ± Cloxacillin/Cefazolin

Front 32

What is the recommended empiric therapy for Contigous Osteomyelitis involving Vascular Insufficiency?(e.g. Diabetic Foot Ulcer)

Back 32

1) Carbapenem

2) Piperacillin/Tazobactam

3) Ciprofloxacin ± Clindamycin /Metronidazole

4) Vancomycin (if MRSA Is suspected)

Front 33

What is the recommended empiric therapy for Contigous Osteomyelitis involving Septic Arthritis?

Back 33

1) Cloxacillin ± Ciprofloxacin/Gentamicin

2) Cefazolin ± Ciprofloxacin/Gentamicin

3) Vancomycin (if MRSA or Beta Lactam allergy)

Front 34

What is the recommended empiric therapy for Contigous Osteomyelitis involving a Prosthetic Joint?

Back 34

Vancomycin ± Rifampin ± Ciprofloxacin/ Gentamicin

Front 35

What is the definitive therapy for MSSA?

Back 35

1) Cloxacillin (2g IV q4-6h)

2) Cefazolin (2g IV q8h)

3) Clindamycin (600mg IV q8h)

Front 36

What is the definitive therapy for MRSA?

Back 36

1) Vancomycin (20mg/kg IV q8-12h) ± Rifampin (600mg PO daily)

Front 37

What is the definitive therapy for Coagulase -ve Staph?

Back 37

1) Vancomycin (20mg/kg IV q8-12h)

Front 38

What is the definitive therapy for Group A/B Streptococcus?

Back 38

1) Penicillin G 4 million units IV q4h

Front 39

What is the definitive therapy for Enteric gram -ve bacilli?

Back 39

1) Cefotaxime (2g IV q8h)

Front 40

What is the definitive therapy for Pseudomonas?

Back 40

1) Ceftazidime (2g IV q8h) + Gentamicin (1-2.5mg/kg/dose IV q8h)

Front 41

What is the definitive therapy for Mixed Aerobic/Anaerobic?

Back 41

1) Imipenem (500mg IV q6h)

2) Piperacillin/ Tazobactam (4.5g IV q6h)

Front 42

What is the typical duration of therapy for Osteomyelitis?

Back 42

4-6 weeks

Front 43

What is the typical duration of therapy for Septic Arthritis?

Back 43

2-4 weeks

Front 44

What is the typical duration of therapy for Prosthetic Joint Infections (Debridment & Retention/ One Stage Exchange)?

Back 44

3-6 months (step-down IV-> PO in 2-4 weeks)

Front 45

What is the typical duration of therapy for Prosthetic Joint Infections (Two Stage Exchange)?

Back 45

4-8 weeks + >2 weeks antibiotic free and -ve culture

Front 46

When would you step-down from IV to Oral therapy for Bone & Joint Infections?(3)

Back 46

1) Patient is systemically better

2) Afebrile

3) Local signs of inflammation and tenderness have improved/resolved

Front 47

When would you NEVER step-down from IV to Oral therapy for Bone & Joint Infections?(8)

Back 47

1) Neonates (0-28days old)

2) Not expected to follow up appointments

3) Immunocompromised

4) MRSA if resistant to Clindamycin

5) Poor Adherence

6) Recurrent/Chronic Osteomyelitis

7) Patient unable to take oral medications

8) No oral formulations/poor absorption of oral antibiotics

Front 48

What are the efficacy monitoring parameters for Bone & Joint Infections? (9)

Back 48

1) Temp (q6h)

2) Vital Signs (q6h)

3) WBC + diff (twice weekly)

4) Local Tenderness, pain erythema, movement/function (daily)

5) ESR/CRP (weekly)

6) Blood Cultures (daily)

7) Vancomycin trough levels (once weekly)

8) Gentamicin levels peak & trough (once weekly)

9) Adherence

Front 49

What are the safety monitoring parameters for Vancomycin?(4)

Back 49

1) SCr, Urea (2-3x/week)

2) Urine Output (daily)

3) Red Neck Syndrome

4) Vestibular testing

Front 50

What are the safety monitoring parameters for Gentamicin?(3)

Back 50

1) Peak and Trough Levels (once weekly)

2) SCr, Urea (2-3x/week)

3) Audiology Testing

Front 51

What are the safety monitoring parameters for Rifampin?(6)

Back 51

1) Rash

2) Urinalysis (q2 weeks)

3) Signs of Jaundice

4) CBC + diff (weekly)

5) Drug Interactions

6) Orange/Red staining of tear, urine and feces

Front 52

What are the safety monitoring parameters for Beta Lactams?(4)

Back 52

1) Rash (daily)

2) Urinalysis (q1-2 weeks)

3) CBC (weekly)

4) SCr (1-2x/week)

Front 53

What are the safety monitoring parameters for Fluroquinolones?(3)

Back 53

1) Rash

2) Blood Glucose (weekly)

3) CBC (weekly)

Front 54

What are the safety monitoring parameters for Clindamycin?(2)

Back 54

1) Rash

2) Diarrhea