Infections of Bones and

Joints
Masitah Ismail
MSSK Module
Learning Objective
• To learn and understand
Types, causative agents and pathogenesis of
osteomyelitis and septic arthritis
Risk factors, diagnosis and treatment of
osteomyelitis and septic arthritis
 Infections of bones and joints
• May exists separately or together. Both are common in infancy
and childhood.
• They are usually caused by blood-borne (haematogenous)
spread to the infected site but can also result from local trauma
with secondary infection
• Sometimes there may be local spread from a contiguous soft
tissue infection, often associated with the presence of a foreign
body at the site of the primary wound.
 Infections of bones and joints
• Can be devastating if they are inadequately treated, because inflammation
and resultant tissue necrosis may produce irreparable damage.
• The presence of pus under pressure can compromise normal blood flow
and even cause destruction of blood vessels with avascular necrosis of
tissue.
When this condition develops, a sequestrum can result, can which a
part of the cartilage or bone become totally separated from its blood
supply and cannot be incorporated into the healing process
• In the acute phase of infection, bacteraemia may also cause sepsis and
metastatic infections in sites such as the lungs and heart
The result may be fatal
 Infections of bones and joints

Infections of Osteomyelitis
bones and
joints

Septic arthritis
 Osteomyelitis
• Inflammation and destruction of bone caused by bacteria,
mycobacteria or fungi.
• It is heterogeneous disease in its pathophysiology, clinical
presentation and management.
• It is a disease of antiquity and is one of the most difficult to
treat infectious disease
 Osteomyelitis

• Common symptoms are localized bone pain and tenderness with

constitutional symptoms (in acute osteomyelitis) or without
constitutional symptoms (in chronic osteomyelitis).
Osteomyelitis - Aetiology
Osteomyelitis caused by:
• Contiguous spread from infected tissue or an infected
prosthetic joint
• Blood borne organisms (haematogenous osteomyelitis)
• Open wounds (from contaminated open fractures or bone
surgery)
• Trauma, ischemia and foreign bodies predispose to
osteomyelitis.
It may form under deep pressure ulcers.
Osteomyelitis - Aetiology
• About 80% of osteomyelitis results from contiguous spread or from
open wounds; it is often polymicrobial.
• Staphylococcus aureus (including both MSSA and MRSA strain) is
present in >50% of patients, other common bacteria include
Streptococci, gram negative enteric organisms and anaerobic
bacteria.
• Osteomyelitis that result from contiguous spread is common in the
feet (in patient with diabetes or peripheral vascular disease) at sites
Where bone was penetrated during trauma or surgery
damaged by radiation therapy,
In bones contiguous to pressure ulcers such as the hips and sacrum
Osteomyelitis - Aetiology
• Haematogenously spread osteomyelitis usually results from a
single organism
• In children, gram positive bacteria are common, usually affecting
the metaphyses of tibia, femur and humerus.
• In adults, haematogenously spread osteomyelitis
usually affects the vertebrae.
• Risk factors in adults are older age, debilitation,
hemodialysis, sickle cell disease and injection drug
use.
Osteomyelitis – Common aetiology agent
• Staphylococcus aureus - is the primary agent of osteomyelitis (MRSA
is also common) and other common bacteria include Streptococci,
gram negative enteric organisms and anaerobic bacteria.
• In injection drug users: S. aureus, Pseudomonas aeruginosa and
Serratia spp.
• Salmonella spp. are common in patients with sickle cell disease, liver
disease or immunocompromised.
• Fungi and Mycobacteria can cause haematogenous osteomyelitis
usually in immunocompromised patients or in area of endemic
infection with histoplasmosis, blastomycosis or coccidioidomycosis.
The vertebrae are often involved
Osteomyelitis – Pathogenesis
Osteomyelitis – Symptoms and Signs
• Patients with acute osteomyelitis of peripheral bones usually
experience weigh loss, fatigue, fever and localized warmth,
swelling, erythema and tenderness.

• Chronic osteomyelitis causes intermittent (months to many

years) bone pain, tenderness and draining sinuses.
Osteomyelitis - Diagnosis
• ESR or C- reactive protein
• X-rays, MRI or radio isotopic bone scanning
• Culture of bone abscess or both
• Acute osteomyelitis is suspected in patients with localized
peripheral bone pain, fever and malaise or with localized
refractory vertebral pain particularly in patient with recent risk
factors for bacteraemia.
• Chronic osteomyelitis is suspected in patients with persistent
localized bone pain, particularly if they have risk factors.
Osteomyelitis - Diagnosis
• If osteomyelitis is suspected, CBC and ESR or C –reactive
protein as well as plain x-rays of the affected bone, are
obtained. Leukocytosis and elevations of the ESR and C –
reactive protein support the diagnosis of osteomyelitis.
• However, ESR or C–reactive protein may be elevated in
inflammatory conditions, such as RA or normal in infection
caused by some pathogens. Thus the results of these tests
must be considered in the context of physical examination and
imaging study results.
Osteomyelitis - Diagnosis
• X- rays become abnormal after 2 to 4 weeks, showing perosteal
elevation, bone destruction, soft-tissue swelling and in the
vertebrae, loss of vertebral body height or narrowing of the
adjacent infected intervertebral disk space.
 Osteomyelitis - Diagnosis
• If x-rays are equivocal or symptoms are acute, CT and MRI are
the current imaging techniques of choice to define abnormalities
and reveal abscesses.
• Alternatively, a radioisotope bone scan with technetium-99m
can be done. The bone scan shows abnormalities earlier than
plain x-rays but does not distinguish between infection, fractures
and tumors.
Osteomyelitis - Diagnosis
• Bacteriologic diagnosis is necessary for optimal
therapy of osteomyelitis: bone biopsy with a needle or
surgical excision and aspiration or debridement of
abscesses provides tissue for culture and antibiotic
sensitivity testing.
• Culture of sinus drainage does not necessarily
reveal the bone pathogen.
• Biopsy and culture should be precede antibiotic therapy
unless the patient is in shock or has neurologic disorder.
Osteomyelitis - Treatment
• For acute osteomyelitis, early intervention is important.
• Management include vigorous use of bactericidal antibiotics,
often continued for several weeks to ensure a bacteriologic cure
and prevent progression to chronic osteomyelitis.
• Surgical drainage is also essential if there is significant pressure
from the localized purulent process.
• Initial antibiotic treatment should be include a penicillinase-
resistant semi-synthetic penicillin (eg, nafcillin or oxacillin)
or vancomycin (MRSA is prevalent in a community) and a 3rd or
4th generation cephalosporin (such as ceftazidime or
cefepime).
Osteomyelitis - Treatment
• Chronic osteomyelitis, patients require long term antibiotic
treatment (for several months) combined with surgical
procedures to drain the abscesses and remove necrotic, infected
tissues.
• Particularly in patients with diabetes, empiric treatment must be
effective against anaerobic organisms in addition to Gram-
positive and Gram-negative aerobes.
• Ampicillin/sulbactam or piperacillin/tazobactam is commonly
used vancomycin is added when infection is severe or MRSA is
prevalent.
• Antibiotic must be given parenterally for 4 to 8 weeks and tailored
to results of appropriate cultures.
Osteomyelitis - Surgery
• If any constitutional findings (eg fever, malaise, weight loss)
persist or if large areas of bone are destroyed, necrotic tissue is
debrided surgically.
• Surgery may also be needed to drain coexisting paravertebral
or epidural abscesses or to stabilize the spine to prevent injury.
• Skin or pedicle grafts may b needed to close large surgical
defects. Broad spectrum antibiotics should be continued for
>3wk after surgery. Long term antibiotic therapy may be
needed.
 Septic arthritis
• Infectious arthritis is infection in the fluid and tissues of a joint
usually by bacteria but occasionally by viruses or fungi.
• Bacteria, viruses or fungi may spread through the bloodstream or
from a nearby infection into a joint causing infection.
• Pain, swelling and fever… within hours or a couple of days
 Acute infectious arthritis
• Acute Infectious Arthritis is caused by bacteria and it begins
quickly.
It account for 95% of infectious arthritis.
It can affect healthy people as well as people at high risk.
Cartilage within the joint which is essential for normal joint function, can be
destroyed or damaged within hours or days.
• Sometimes arthritis develops in people who have infections that do
not involve the bones or joints such as infection of the genital organs
or digestive organs.
This type of arthritis is a reaction to that infection so is called reactive
arthritis.
In reactive arthritis, the joint is inflamed but not actually infected.
 Chronic infectious arthritis
• Begins gradually over several weeks. It accounts for 5% of
infectious arthritis and most often affects people who are at risk.
• The joints most commonly infected are the knee, shoulder, wrist,
hip, elbow and the joints of the fingers.
• Most bacterial, fungal and mycobacterial infections affect only one
joint or occasionally, several joint
 For example, the bacteria that cause Lyme disease most often infect
knee joints
• Neiserria gonorrhoeae (gonococci), which cause gonorrhea,
viruses (such as hepatitis viruses), occasionally some other
bacteria can infect a few or many joints at the same time
Causes
• Infecting organisms mainly
bacteria, usually spread to the
joint from a nearby infection
(such as osteomyelitis or an
infected wound) or through
the bloodstream.
• A joint can be infected directly
if it is contaminated duing
surgery or by an injection or
an injury (such as a bite
wound).
 Causes
• Different bacteria can infect a joint, but the bacteria most likely to
cause infection depend on a person’s age.
• Infants and young children: Most often, Staphylococci,
Streptococci and Gram negative bacilli.
• Older children and adults: Most often, staphylococci,
Streptococci and gonococci.
• Spirochaetes, such as those that cause Lyme disease and
syphillis can infect joints.
• Viruses such as HIV, parvoviruses and those that cause rubella,
mumps and hepatitis Band C can infect joints in people of any age.
Risk factors of acute infectious arthritis
• A past history of joint infection
• An artificial joint or joint surgery
• Use of needles to inject drugs
• Chronic illnesess (such as diabetes, SLE, chronic lung or liver disorders
• Older age
• Alcoholism
• Behaviors that increase risk of sexually transmitted diseases
• Disorders that cause ongoing joint damage (including rheumatoid arthritis, ostheoarthritis
and arthritis caused by injury.
• Haemophilia
• People being treated with dialysis
• Skin Infections
• Sickle cell anemia
 Acute infectious arthritis – symptoms
Acute infectious arthritis
• Symptoms usually begin over hours to a few days.
• The infected joints usually becomes severely painful and sometimes red
and warm.
• Moving or touching it is very painful. Fluid collects in the infected joint,
causing it to swelled stiffen.
• Symptoms sometimes include fever and chills.
Gonococcal arthritis usually causes milder symptoms.
• People may have skin blisters, bumps, sores, rashes or sores on the
mouth or genitals and on the trunk, hand or legs.
• Pain may move from one joint to another before a joint becomes swollen
and tender. Tendons may become inflamed.
Infants and children tend not to move the infected joint, are irritable, may
refuse to eat, and have a high, low grade or fever. Young children with knees or
hips infections may refuse to walk.
Chronic infectious arthritis - symptoms
Chronic infectious arthritis:
• Symptoms are usually gradual swelling, mild warmth,
minimal or no redness of the joint area, and aching pain that
may be mild and less severe than in acute infectious
arthritis.
• Usually a single joint is involved.
• An infection that lasts a long time and that does not go away
after use of conventional antibiotics may be caused by
mycobacteria and fungi
 Diagnosis
• Analysis and culture of joint fluid
• Blood tests
• Sometimes sputum, spinal fluids and urine tests
• Sometimes magnetic resonance imaging (MRI) or ultrasonography.
• Usually, a sample of joint fluid is removed
• with a needle (called joint aspiration or arthrocentesis)
as soon as possible. It is examined for
an increased number of white blood cells
and tested for bacteria and other organisms.
 Treatment
• Antibiotics or antifungal drugs
• Removal of pus
• Splinting of the joint, followed by physical therapy
• It is important to start antibiotics as soon as an infection is
suspected, even before the laboratory has identified the
infecting organism.
 Treatment
• Often the clinician removes pus with a needle (aspiration) to
prevent its accumulation because accumulated pus may damage
a joint and may be more difficult to cure with antibiotics.
• If drainage with a needle is difficult (as with a hip joint) or
unsuccessful, arthroscopy (a procedure using small scope to view
the inside of the joint directly) or surgery may be needed to drain
the joint.
 Treatment
• Infections caused by fungi are treated with antifungal drugs.
Infections caused by mycobacteria are treated with a
combination of antibiotics.
• Infections caused by fungi and mycobacteria require long
term treatment.
• Infections caused by viruses usually get better without antibiotic
treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) can
help reduce pain, inflammation and fever.
 Summary
• Osteomyelitis
Types
Causes & Symptoms
Diagnosis, Treatment

• Septic arthritis
Types
Causes & Risk factors
Diagnosis, Treatment