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Principles of Infection: Tutorial 2

OSTEOMYELITIS & UTIs
Learn OM for exam; UTI for SAQs also
Urinary tract infection in a 19-year-ol !o"an
The patient was a 19-year-old female with a history of rinary tra!t
infe!tion " months prior to admission for whi!h she was treated
with oral ampi!illin withot !ompli!ations# $i%e days prior to
admission she &e'an to note nasea whi!h was a!!ompanied &y
%omitin'# One day later( she de%eloped left )an* pain( fe%er( ri'ors
and !hills( whi!h ha%e &een a!!ompanied &y in!reased rinary
fre+en!y# She noted fol-smellin' rine on the day prior to
admission# She presented with a temperatre of ,9#-
o
. and physi!al
examination re%ealed left !osto-%erte&ral an'le tenderness#
Urinalysis of a mid-stream rine sample showed / 01 white !ells(
,-11 red &lood !ells and ,2 &a!teria per !m
,
• 3hat is !ystitis4 3hat is pyelonephritis4 Mana'ement4
• 5ad a!te n!ompli!ated !ystitis pre%iosly
• UTIs 6 Upper and Lower
- n!ompli!ated 7 in a normal rinary tra!t
- a&normal fn!tion or a&normal 7 !ompli!ated
- .al!li( tmors( stri!tres( *inds( s!ar tisse 6
anatomi!al a&normalities
- .ompli!ated 6 more refra!tory
• Usally dx &y 89 withot !ltre:sensiti%ity reslts
- One test 6 dipsti!* test
- Loo*in' for nitrates and le*o!ytes
- Le*o!yte esterase tests 6 ps !ells in rine 7 indire!t for
pyrria
- ;itrite test 6 &a!teria prod!e nitrate red!tase 7
entero&a!teria <no other spp prod!e= e#'# ># !oli( 9rotes(
?le&siella
• Oral ampi!illin4 ;ot a!!epta&le treatment
- Optimal therapy for a!te n!ompli!ated !ystitis4
- , day <for woman of !hild&earin' a'e=
- men 6 @ wee*s
- Tri"et#opri" or co-tri"o$a%ole <add slphonamide
7 slphamethoxaAole=
- Brst line treatment nless lo!al resistan!e or
aller'y
- 2
n
line: &uoro'uinolone ( !ipro)oxa!in 7 if they
1
!anCt tolerate
the Brst line
- AlsoD &eta la!tams 7 1
st
'en !ephalo; nitrofrantoin <1
wee*=
1) *#at o t#e la+oratory ,nin-s inicate.

showed > 50 white cells, 3-10 red blood cells and 3+
bacteria per cm
3

Culture of the urine showed >100,000 CFU/ml of a lactose
fermenting gram- negative bacillus

5i'h 3..( EF.s 6 si'nify haematria( &a!teria si'niB!ant
- S''esti%e of UTI

3.. a&normal if /0-11 per hi'h-power Beld 6 pyria
- 59$ 6 mi!ros!ope %iew
- mm, 6 done on a !ontin' !ham&er; 0 &i' s+ares 6 G !ells
per mm,

EF.s 6 haematria

Fa!teria is either !ase of UTI or Hst &adly !olle!ted spe!imen

.ltreD /111(111 <11I0= 6 si'niB!ant &a!terira of one
single species
- more than 1 spe!iesD !ontaminated or !hroni! infe!tion
- 11I0 6 infe!tion( not !ontamination

Qantitati%e !ltreD loop method
- 5olds 1#111ml rine 7 ino!late J in!&ate
- >a!h !olony 6 1 &a!teria
- Mltiply x 1(111 to 'et .$Us

Lower !onts !an mean infe!tion ifD
- had prior anti&ioti! treatment
- patient is male
- spe!ies mltiplies more slowly( e#'# 82; also( yeasts
2
- in !ystitis( !an 'et lower nm&er <?ass ded!ed nm&er from
pts with pyelonephritis=
2) /i0en t#e a+o0e escription !#at is t#e "ost li1ely
+acteria causin- #er infection. 2an you na"e
any ot#er +acteria t#at fre'uently cause urinary tract
infection in t#is patient3s a-e an se$. *#y o t#ese
+acteria cause t#is type of infection.
• La!tose fermenter 7 on Ma!.on*ey a'ar 6/ pin* !olony
- E) coli4 5le+siella
- ?le&siella 6 lar'e( m!oid !olonies
• 6lso proteus spp
7) 6re urinary tract infections "ore fre'uent in !o"en t#an
in "en. /i0e a reason for your ans!er) 6re t#ere ot#er
factors t#at preispose patients to urinary tract infection.
• Shorter rethra <0!m %s# 10!m male=
• 9roximity to ano 'enital re'ion
• ;o prostati! )id
• Other predisposin' fa!torsD
- o&str!ti%e lesions
- !atheter( instrmentation
- introital !olonisation &y entero&a!teria <remo%al of normal
la!to&a!ills=
- spermi!ideD de!reases la!to&a!illi 7 depends on a'e of pt
<only present in reprod!ti%e years=
- anythin' that de!reases la!to&a!illi 6/ I UTI
- ;onoxynol-9 in spermi!ides; anti&ioti!s; post
menopasal
- past hx UTI
- menD la!* of !ir!m!ision in yon' &oys
- in!omplete &ladder emptyin'
-
8) 9i t#is !o"an #a0e cystitis or pyelonep#ritis. *#y is it
i"portant to i:erentiate t#e t!o. *#at co"plications are
associate !it# t#is infection.
• 9$: a!te pyelonephritis
- fe%er( ri'ors( !hills( nasea and %omitin'
- left &an1 pain
- renal an-le or costo0erte+ral an-le pain
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- .an &e pre!eded &y symptoms of !ystitis
• 2ystitis: lo!al featres 7 lin*ed to &ladder
- dysria( r'en!y( fre+en!y
- sprap&i! hea%iness( tenderness
- 1:, ha%e haematria
• Mana'ement totally diKerent 7 A9; is m!h more !ompli!ated
Pyelonep#ritis also has se%ere !omps if improperly treated
- SepsisD 8-
- Septi! sho!*
- A&!essD not % !ommon
- >mphysematos pyelitis( pyelonephritisD dia&eti! patients 7
'l!ose &ein' &ro*en down &y &a!teria
- >9;D % hi'h mortality 7 "1-01L
- ?idney %isi&le on ME de to 'as within 7 &la!*
- 9apillary ne!rosisD also dia&eti! patients
- Impaired fn!tion
- 9reterm deli%ery or LF3 infants
;) *#at 0irulence factors oes t#is +acteria #a0e !#ic#
ena+le it to prouce infection of t#e urinary tract.
• Pili: type 1 an
- Type 1 7 mannose 7 !ystitis
- 9 pili 7 9yelonephritis
• 2apsule: pyelonephritis
• <ae"olysins
• Urease: 9rotes sp# 7 prod!es ammonia( in! p5( MA9 <ma'-
am- phos stones=
• =la-ella: allows as!ension 7 9rotes 6 hyper)a'ellated;
Nswarmin'O !olonies
• I-6 protease
>) 2an you su--est a rational approac# to #er "ana-e"ent
?of acute pyelonep#ritis.
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• 5as severe, acute pyelonephritis <!lassiBed to mild( moderate
and se%ere=
• Mana'ement has to &e indi%idalised 7 !onsiderationsD
- Se%erity
- 5ost statsD !ompli!ated4 Immne stats4
- Eelia&ilityD i#e# !omplian!e
- Spport system at home J me!hanism for medi!al follow p
• Se%ere 6 mst &e treated in hospital if
- se%erely ill
- persistent %omitin'
- !ompli!ated UTI
- immno!ompromised
• Admit se%ere( do &lood !ltres <1:, positi%e=( start IP )ids
and A&s
- I@ f'3s or 7
r
-en) cep#alosporin 7 @:, days( swit!h to
oral therapy
- total dration 6 1" days
• Mild disease 6 no %omitin'( low 'rade temp
- tolerates oral therapy
- treat at home
Oral &uoro'uinolones 7 !ipro 7 11-1" days
• Moderate 6 IP )ids to rehydrate( initial parenteral A&
- no impro%ement  admission
- feelin' &etter( !an ta*e )ids 9O  oral therapy
• 2ystitis treat"ent: , day !orse 1
st
line trimetho:!o trimox
• .ran&erry Hi!e !an pre0ent recurrent sy"pto"atic UTIs
<, per year=
- drops &y 1@-@1L
- not eKe!ti%e in treatment
- MOAD proantho!tanidins inhi&it atta!hment of &a!teria to
roepithelim
5
26SE
A 00-year-old man was in%ol%ed in a serios !ar a!!ident , months
a'o# 5e sstained se%ere inHries whi!h in%ol%ed mltiple
fra!tres in!ldin' a !ompond fra!tre of his ri'ht femr( whi!h
needed the insertion of an intramedllary nail# 5e also sstained
trama to his spleen whi!h ne!essitated its remo%al# 5e spent 0
wee*s in I.U and , wee*s in an orthopaedi! ward for mana'ement
of his fra!tred femr#
After dis!har'e he is &ein' followed p at the orthopaedi! !lini!
where it is noti!ed that he has some dis!har'e from the wond site
on his le'# An x-ray of his le' shows in!reased s!lerosis of the &one
and periostem &eneath the site of the wond# A swa& is ta*en of
the dis!har'e and is reported as showin' 222 'ram positi%e !o!!i
in !lmps with 2222 netrophils#
1) *#at is t#e ia-nosis.
- Proper $D post traumatic chronic osteomyelitis my notes
not correct!
- ;ot Hst osteomyelitis
- 8i%e info on rote
- 5aemato'enos and !ontin'os spread
- .onti'os fo!i of &one 6 o%erlyin' infe!tion
- Qire!t ino!lation is another rote 7 e#'# trama( &ites(
sr'ery
- QrationD when was &a!teria introd!ed 7 when was he
infe!ted
</Rw 6 !hroni!=
- 9ost tramati!
2) 9iscuss t#e classi,cation of t#is conition)
- .lassiB!ationD &ased on
1# Qration 7 a!te( s&a!te or !hroni!
- A!teD infe!tion dx within @w of symptoms
- S&D @-Rw
- .hroni!D Rw
@# 3ald%o'el system
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- 5aemato'enos %#s# !onti'os
- !an ha%e a!te or !hroni! of either
,# Fased on host stats( lo!ation and extent 7 .ierny-Mader
system
- for sr'eons
- Anatomi! type and 9hysiolo'i! <5ost= type
- also ha%e $a!tors aKe!tin' immne system( meta&olism and
%as!lar
7) *#at is t#e presu"pti0e or-anis" +ase on t#e -ra"
stain.
<o! !ill t#e la+oratory furt#er ientify t#e +acteria t#at
are t#e cause
of t#is "an3s infection.
- Sins 6 a str!tre:!hannel !onne!tin' &one:or'an to s*in
srfa!e 7 sins tra!t
- $istla 6 tra!t !onne!tin' one or'an to another <e#'# !oloni!
!ar!inoma 7 !onne!tin' lar'e int to other parts=
- 9atients with .hroni! OM often ha%e sins tra!t
- Qrainin' sins with soft tisse dis!oloration <2 ne!rosis=
- poor %as!larisation !ases this
- or tisse inHry at time of trama
- .hroni! OMD se+estrm  extends into periostem  sins
tra!t 7 ps on s*in
- Staphylo!o!!i 6 spe!ies &ased on 8ram stain
- li*ely Staph# Ares &t !anCt say from 8 stain
- Staphylo!o!!i ares identiB!ationD
.oa'lase test 7 slide <!lmpin' 6 2  FOU;Q .OA8ULAS> 7
&indin' B&rino'en=; t&e test <B&rin !lot 6 2  $E>>
.OA8ULAS>=
- .oa' 2 6 mst &e positi%e for S# ares
- Fone !ltre mst &e performed to de"nitively dx
osteomyelitis
- M. !aseD S# ares
- others 7 entero!o!!s sp#( psedomonas( .o;S
- culture of sinus tract is not relia+le 7 !ontamination
- @:, of .5EO;I. are polymi!ro&ial <a!te 7 tends to &e
nimi!ro&ial=
8) 6re t#ere any ot#er in0esti-ations t#at t#e la+oratory
s#oul carry
7
out.
- Anti&ioti! sensiti%ity for S# ares 7 Methi!illin sensiti%e:not
- Meth sens4 9E9s <peni!illinase resistant= 7 )!lox( naB!illin
- 9eni!illinsD natral( peni!illinase-resistant( amino( extended-
spe!trm
- MESA 6 %an!omy!in:tei!oplanin for this 6 'ly!opeptides
- .ommnity a!+ MESA 7 simple s*in infe!tion 7 responds to
other A&s apart from 'ly!opeptides 7 clina"ycin4 co-
tri"o$a%ole
- $or all other se%ere infe!tions( se 'peptide
;) *#at ot#er conitions "ay occur if t#is conition re"ains
untreate.
- .ompli!ation of !hroni! osteomyelitis4
- Sepsis
- Pat#olo-ical fracture 7 !lassi! 6 fra!tre in a &one in pt
with mali'nan!y; any diseased &one
- @ rare A seconary a"yloiosis 7 any infe!tion !an !ase
- S' cell carcino"a - S1L after @T years
- 2o"plications of 62UTE4
- !hroni! OM 7 de to inappropriate:delayed treatment
- septi! arthritis
- aKe!ts 'rowth plate 7 a&normal 'rowth 7 shorter:lon'er
- 2o"plications of Stap# 6ureus.
- S# ares sepsis
- Toxi! sho!* syndrome <from Toxi! Sho!* Syndrome Toxin-1=D
now( non-menstral !ases with lo!alised infe!tions( sr'ery
- TSS: hi'h fe%er( rash <'en#=( des+amation <1 wee* later=(
hypotension leadin' to mltior'an failre
- TSST-1 6 Speranti'en
>) 6re t#ere any factors in t#e patient3s #istory t#at "i-#t
preispose
#i" to so"e of t#ese conitions.
- Eeasons are always there
8
- 1# 2o"poun fracture
- en%ironmental !ontamination
- soft tisse inHry
- %as!lar inHry
- wond de&ridement and !losre mst &e rapid and not
delayed
- 11L lead to !hroni! OM <p to @,-@0L=
- @) IM Bail
- parti!larly if &a!teria !an form &ioBlm <nail wold need to
&e remo%ed=
- ,# Splenecto"ise
- At ris* to infe!tion4 3hat spe!iB! infe!tions4
- MaHor lon' term ris* for ful"inant4 potentially life-
t#reatenin- infe!tion
- O9SID o%erwhelmin' post splene!tomy infe!tion
- Se%ere sepsis 7 9SSSD post splene!tomy sepsis syndrome
3hy4
- no pha'o!ytosis &y ma!ropha'es
- no anti&ody
O9SI
- M. !ased &y encapsulated bacteria UStrepto!o!!s
pnemonia <01-91L=( 5# in)enAa( ;# menin'itis( ># !oli( 8FS(
?le&siellaV
- initial symptoms 6 ) li*e; rapid pro'ression to septi! sho!*
<"-"- h=
- re+ire %a!!inations and prophyla!ti! anti&ioti!s
- WSpleni! !onser%ation:partial splene!tomy important
- also !an do ato-transplantation <small pie!e into
mesentery=
- "# Lon- #ospital stay
C) *#at is t#e "ana-e"ent of t#is conition D2<EOBI2 OMF.
- More refra!tory !ompared to a!te
- de to ne!roti! &one tisse and poor perfsion to inHred
tisse
- Infe!tion !annot &e remo%ed ntil nius of infe!tion is
remo%ed
- Sr'ery J Anti&ioti!s 7 need &othX
- Sr'ery to de&ride( drain ps and ex!ise dead &one( sinses
and s!ar tisse
9
- i#e# remo%e anythin' that is not %ia&le
- remo%e !ontaminated forei'n material
- Qality of de&ridment 6 most important fa!tor in treatment
s!!ess- will not respond to anti&ioti! therapy if not done well
- ;e!essary to o&literate the dead spa!e
- pt in ms!le( &one( other tisse or &one 'raft
- Anti&ioti!s 7 if possi&le( do ;OT start treatment ntil we *now
what the &a!teria and the A& sensiti%ity is
- infe!tion has &een there for months( donCt need to treat
immediately
- also( is polymi!ro&ial often
- 5ow4 IP for @-, wee*s( oral for remainer of R wee*s
- Meth sensiti%e 6 )!loxa!illin
- MESA 6 %an!o 2:- 'entamy!in
/EBEE6L BOTES:
- .ase a&o%e is not a !lassi!al presentation( a!te is % diKerent
- A'e( dration % important
- Mltiple( !ompond fx <i#e# &rea*s s*in 7 exposed to
en%ironment=
- other types are !losed and not exposed
- IM nail 7 thro'h shaft <I$Q 6 internal Bxation de%i!e=
- 3hy4 Sta&ilise fx
- 3onCt heal properly with mo%ement
- Infe!tion may impair healin' and lead to non-nion
- Splene!tomy is rele%ant -
- Qsx from wond site4 ME to !he!* &one
- s!lerosis 6 in!reased density 7 more &one deposition4
- !an &e thi!*ened !ortex with it
- lyti! 6 &one destr!tion:demineralisation
- diKse( with &oth 6 c#ronic OM
- se'uestru" is opposite of in0olucru"
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- se+estrm seen in .5EO;I. OM - /R wee*s
- in%ol!rm 6 new &one
- 8ram 2 !ells in !lsters 6 Staph ares
- OM se!ondary to trama 7 B'hts( &ites( falls
I"portance of #$ trau"a in 1i !it# 6<O.
- >arly dx may &e missed 7 pain of trama %s# pain of infe!tion
- Trama may &e causal factor 7 !an !ase haematoma(
&lo!*in' %as!lar o&str!tion and ne!rosis 7 area ss!epti&le
to seedin' of &a!teria from transient &a!teraemia
- In!iden!e of animal &ite wondsD do's 7 1-@m &ites pa; !ats 7
"11(111
- &t !ats more dan'eros medi!ally
- !at &ite !an !ase septi! arthritis 7 dire!t &ite into &one
<teeth m!h sharper( lon'er=
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2lassic case: acute OM in c#il
1G yo =4 struc1 1nee o: pool4 syste"ically un!ell ne$t ay
?lo! -rae fe0er4 loss of appetite4 "alaiseH
Pain !orsene t#at ni-#t4 +rou-#t to 6&E
- #rogressively worsening right $nee pain
6ppeare !ell4 lo! -rae fe0er
E$a" ( "il pain4 tenerness on ri-#t "eial ti+ial plateau
!it# "il s!ellin-I rest of 1nee nor"alI full EOM
JE: nor"al
1) 9ia-nosis.
- A!te haemato'enos osteomyelitis <A5O=
- ;ot trama  do not 'et systemi! featres with trama; pain
'ets &etter in normal tramati! e%ents
- If pain 'ets worse( is infection
Eoutes.
- Mst &e haemato'enos
2) *#ic# part of +one is in0ol0e.
- .hildren  metaphysis
- *#y "etap#ysis.
- 1# Most %as!lar
- @# Low pha'o!yte nm&er
- ,# >nd arteries 7 donCt anastomose
- "# Sinsoids on %enos side ha%e slow( tr&lent )ow
- allows seedin' of &a!teria
- Most !ommon site 7 *nee; next 7 prox femr
7) 2ausati0e or-anis"s.
- QiKerent &ased on A'e and .lini!al S!enario; former most
important
- .hildren 1-1R 7 maHor 'rop that 'et A5O
- 91L of all !ases 6 Stap#) 6ureus
- Other 11LD 8rop A Strep <pyo'enes=( Strep
pnemonia( 5# in)enAa <donCt see m!h de to %a!!ine=
- /1yoD 8FS( >#.oli
- /1RyoaD Staph ares
- also 8-D 9sedo aer'#( Serratia mar!esans( ># !oli
- .lini!al s!enariosD
- 9rosthesisD Staph epidermis
- Si!*le !ell anaemiaD Salmonella
12
8) 2linical features.
- Insidios onset( o%er a few days
- 8eneralised symptoms
- 5allmar* 6 pro-ressi0ely !orsenin- +one pain
- 5allmar* 6 li"ite spontaneous "o0e"entI
pseuoparalysisI li"p
- 5allmar* 6 point tenerness
- Qo not appear extremely ill
- May see s*in !han'esD soft tisse swellin'( erythema
;) In0esti-ations.
- Eadiolo'i!alD plain ME( &one s!an( .T( MEI
- Ft plain ME is not sefl 7 ne'ati%e in early sta'es <low
sensiti%ity=
- early sta'es may Hst ha%e soft tisse swellin'
- lyti! lesions may de%elop o%er the !orse of wee*s 7
need to lose Y01L of &one &efore yo see 7 lucent lytic
lesions
- periosteal reaction may &e e%ident 7 de to s&-
periosteal a&!ess 7 early featre of a!te OM
- Fone s!an i#e# n!lear ima'in'
- sefl in Brst few days <"--T@ days=
- shows areas of in)ammation( in!reased ener'y sa'e
- a lot of false positi%es 7 any dama'e will ta*e p
radion!lide 7 not % spe!iB!
- sally Te! 99 sed; !an sed 'allim( indim
- MEI is % sefl for %erte&ral or pel%i! in%ol%ement( also lon'
&ones
- &etter than .T
- Mi!ro&iolo'i!al 6 "1-R1L positi%e identiB!ations
- ;eedle aspirationD sefl if is late presentation
- hi'h temp( se%ere pain indi!ati%e of ps
- Fone &iopsy
- Sr'ery 7 tisse:&one !ltres
>) Mana-e"ent.
- Staph ares in !hildren 6 most !ommon 7 mst !o%er with
empiri! A&
6 $l!oxa!illin <9eni!illinase resistant peni!illins=
13
- Tei!oplanin:Pan!o if MESA is sspe!ted
- 8 ne'ati%e 6 !ipro)oxa!in or ,
rd
'eneration !ephalo 7
!eftriaxone
- E"piric t#erapies:
6ults K>;yoaD F>;Z[L9>;I.ILLI; <8AS( Strep pnemonia=
2 $LU.LOMA.ILLI; <Staph ares=
6ults L>;: .I9EO <for 8ram ne'ati%es= 2 $LUM.LOMA.ILLI;
- Sr'ery not re+ired if treated early <Brst few days=
- prlent 7 needs draina'e 7 sally delayed
presentation
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