PREVALENCE OF OSTEOMYELITIS IN HIV INFECTED PATIENTS. PRESENTERS: 1. MOHAMED M. NOORANY- MBChB V (MUSOM) 2. MUKOYA AQUINATA (Sr)- MBChB V (MUSOM) FACILITATORS: 1. DR. JAMES OBONDI (Chief Orthopedic Specialist) 2. DR. STEVE OKELLO (MBChB, MMED registrar- ortho) 1

BACKGROUND Osteomyelitis is an infection of bone leading to inflammatory destruction and necrosis of bone, and new bone formation. It may be acute, sub acute or chronic. M:F- 2:1. It has a bimodal distribution; acute infection mostly in children & adolescent, while chronic form in >45 years. The tibia & femur are the most commonly affected bones. Immunosuppression, SCD and local trauma, among others predispose to osteomyelitis. 2

Staphylococcus aureus is the organism most commonly implicated in this infection, followed by Streptococcus pyogenes and Hemophilus influenza. Definitive management mainly involves intravenous antibiotics (e.g Flucloxacillin mg IV QID ) until systemic symptoms decline after which oral antibiotics are continued for 4-6 weeks. 3

4 Apley and Solomon’s Concise System of Orthopaedics and Trauma 4 th Ed, pg18-9

OBJECTIVES To compare prevalence of osteomyelitis in HIV infected population to the general population. To determine the common causative organisms of osteomyelitis in HIV infected population To find out the risk factors for osteomyelitis in HIV infected patients To compare management of osteomyelitis in HIV infected population to the general population 5

METHODOLOGY A review of current literature on osteomyelitis in HIV infected patients was done. ‘Google Scholar’ and ‘Pubmed’ were the main reference platforms A total of 7 studies were analyzed, ranging from 1 case report to a cohort of 4023 participants The articles were published from as early as 1995 to

RESULTS 1. PREVALENCE The annual incidence rate of osteomyelitis was found to be 13 per 100,000 in the general population The prevalence of osteomyelitis in HIV infected patients was seen as 348 per % of patients who developed osteomyelitis also showed positive results for HIV 7

2. COMMON CAUSATIVE ORGANISM 3 of the 7 studies analyzed vouched for Staphylococcus aureus as the main culprit leading to osteomyelitis in HIV infected patients 2 studies grew more of Streptococcus pneumoniae in their bacterial cultures 1 study found that Staphylococcus aureus was commoner in HIV non infected patients while Streptococcus pneumoniae was found more often in HIV infected patients 8

3. RISK FACTORS All of the studies that addressed this concern (3 of 7) described IV drug abuse as a significant risk factor for osteomyelitis in HIV infected patients No other risk factors were mentioned 9

4. MANAGEMENT APPROACH There was no particular approach described for patients with concomitant HIV and osteomyelitis infections Use of broad spectrum antibiotics before culture results, changed to targeted antibiotic therapy after culture was chorused. No specific modifications to the ARV treatments were mentioned Use of anti pneumococcal vaccine in HIV infected patients. To give or not to give is the question. 10

DISCUSSION Despite being a rare infection in HIV infected patients, osteomyelitis is commoner in them than in the general population An imunosuppressed state, caused by HIV infection leads to increased susceptibility of the patients to invasion by infectious microbes leading to infections e.g osteomyelitis. Also, the more advanced stages of HIV infection lead to rapid progression of osteomyelitis, manifesting more with complications than in the immunocompetent individuals 11

The unsterility adopted by IV drug users predisposes them to infectious microbes from their infected partners leading to a greater incidence of both HIV and osteomyelitis in these individuals S. aureus most commonly causes osteomyelitis. Both, this & Streptococcus pneumoniae are also opportunistic organisms that lead to infections more often in immunosuppressed patients Various organisms can lead to osteomyelitis. Culture may take up to 2 weeks, as such, broad spectrum antibiotics are started as empirical therapy, and later changed to definitive treatment based on culture results 12

CONCLUSION Osteomyelitis is commoner in HIV infected patients as compared to the general population. Staphylococcus aureus and Streptococcus pneumoniae are the commonest organisms isolated in osteomyelitis in HIV infected patients. There is mixed evidence on which of the two is commoner IV drug abuse is a significant risk factor for osteomyelitis in HIV infected patients Broad spectrum antibiotics should be initiated in such patients. 13

RECOMMENDATIONS Most of the researches were conducted in developed countries which have different disease burdens as compared to developing countries. As such, we need local data to understand the actual burden, pathogenesis and clinical course of osteomyelitis in HIV patients to aid its proper diagnosis and management. Investigate on importance on pneumococcal vaccine in HIV infected patients 14

REFERENCES 1. African Journal of Pediatric Surgery, 2014, vol11,issue 4, pg BMC pediatrics 2008, pg 8-45, © Risse et al Journal of Paediatric Orthopaedics, 2012 March, 32 (2), pg New England Journal of Medicine, Heart Lung Jan-Feb; 28 (1): Presse Med Nov 4;24 (33): Acta Orthop Scand Dec; 68 (6): Medicine (Baltimore) Jul; 76 (4): Apleys and Solomon’s concise system of orthopedics and trauma, 4 th Ed- pg