Educational Workshops 2013 Bone and Joint Infections Osteomyelitis Martin Dedicoat Itisha Gupta Heart of England NHS Foundation Trust

22 year old female self referred to ED June 2012 Recurrent abscess over her back. History since a depot contraceptive injection in February over the left buttock. Done at a Sexual Health clinic. Developed pain a day after injection Increasing pain for 4/12 ---

Past history Known IDDM since 2006 Been under investigation for PR bleed under Gastroenterologists in 2011 In May 2012 diagnosed as ? Crohn’s proctitis. Started on Mesalazine A nurse by profession

What additional information you would like to know in history?

Facilitator Slide 1 There is h/o fever and night sweats Mesalazine is anti-inflammatory drug used to treat inflammatory bowel disease such as Ulcerative colitis and mild to moderate Crohn’s disease. It is bowel specific amino- salicylic and acts locally in the gut with few systemic side effects. It is not immuno- suppressive Treatment history

Antibiotic history Flucloxacillin 500mgqds in May for 1 week Co-amoxiclav for 5d about 2 weeks back No response

Examination Referred back to GP as scan booked History of fever, however apyrexial on admission. Examination Soft tender left sided swelling lateral to the spine over renal area No spinal tenderness Referred back to GP as scan booked

Investigation WCC12 and CRP 27 US scan booked by GP- normal abdomen. A swelling on left renal area with subcutaneous collection with no vascular flow ? Haematoma ? seroma GP referred back to hospital

What would you suggest be the next steps?

Facilitator slide 2 Surgical drainage and explore what samples to send for microbiology. What organisms to look for e.g. bacterial, fungal and if anyone says TB culture to be requested! Can consider CT at this stage

Surgical drainages 1) Drainage of 8x4 cm collection discharged on Co-amox for 7days Sample- Microbiology No growth 2) Re-presented 4d later with warm tender fluctuant swelling- re-accumulation 100mls of haemo-purulent fluid drained

Surgical drainages continued Returned 2 days later ↑ in pain and size No fever 6x4 cm hard swelling, warm, no erythema What further action?

Facilitator slide 3 - CT Scan ABSCESS

CT report- Facilitator slide-4 A large thin wall fluid collection seen in the subcutaneous fat of the left paraspinal region, abutting the left paraspinal muscles, measuring 9x5x 7.5cm. This appears continuous with a bony destructive lesion in the left iliac bone associated small involucrum and cortical destruction medially as well as periosteal reaction laterally. The bony lesion measures 26x 20x25mm with the involucrum. measuring 6mm. There is associated low density and swelling of the left iliacus muscle which may be involved. Left psoas muscle is raised but does not appear involved. A small collection is also noted between the iliacus and psoas , measuring 17 mm Features are likely due to osteomyelitis of the left iliac bone with an associated large abscess extending to the iliacus muscle and subcutaneous tissue on the left, with small abscess anteriorly between the psoas and iliacus muscles.

CT report Paraspinal fluid collection with bony destruction of left iliac bone and small involucrum An abscess in iliacus muscle Small collections between iliacus and psoas muscle

What further management?

3) Surgical Drainage after CT report I&D drainage under GA 20ml of loculated cavity and erosion of iliac bone Started on high dose of IV fluclox 2gqds Pus sent for culture- No growth

What management to consider now? Any further history?

More History Born and brought-up in UK Grandparents from Jamaica Lives with mum and dad No known history of TB BCG vaccinated

Antibiotics Fluclox high dose ↓ 3 days Rifampicin 450mg BD added to fluclox ↓ 7 days Both changed to Ceftriaxone 2gOD ↓ 3 days Sent Home on IV therapy – Ceftriaxone for total 6 weeks

Is that the whole story?

3d after discharge Pus- culture positive for M. tuberculosis Fully sensitive

Facilitator slide-5 Treatment options? Mandell Text book WHO guidelines for TB treatment NICE guidelines and risk assessment for drug resistance and HIV Recommendation of 9-12 months in total. Surgical treatment not recommended Alternative methods of contraception in this age group

Treatment of Bone and Joint TB Extrapulmonary foci usually respond to treatment rapidly than cavitary pulmonary TB Drug sensitive TB 4 drug regimens ( INH, RMP, PZA and EMB) for 2 months followed by INH and RMP for 6- 9 months Surgery can be needed for diagnosis

ATT Started on Rifater plus Ethambutol Rifampicin and INH Recent MRI much improved Treatment stopped in July 2013 2 months continuation phase 9 months

Risk assessment for adherence to treatment Surgical therapy not recommended unless chemotherapy has failed and serious joint instability Consider alternative non-hormonal methods of contraception throughout treatment and 1 month subsequently

Been in Bay What actions to take? What additional investigations needed?

Been in Bay Facilitator slide-6 Discussion regarding risk assessment of drug resistance, Need to know HIV status and CXR for pulmonary TB Contact tracing-( we did gather list of all patients in the bay as a precaution but not needed as smear negative and no pulmonary involvement) Use of masks in HCWs ( NICE guidelines) If MDR TB suspected and aerosol generating procedures are being performed

Facilitator slide-7 Risk assessment for drug resistant TB NICE guidelines H/o prior treatment/ failure Contact with known drug resistant TB Birth in country of high incidence HIV infection Residence in London Age profile and male gender Highest groups between 25-44 year age group

Been in Bay IPC precautions and actions List of all patients in the bay Inform District nurses for Vac dressing To wear masks at time of wound care and dressings HIV negative

CXR normal

Infectiousness Presence of cough Cavitation on CXR Infectiousness of patients with TB correlates with number of organisms expelled Presence of cough Cavitation on CXR Positive AFB in smear Respiratory tract disease with involvement of lung, pleura and larynx Cough inducing procedures or aerosol generating procedures

Extrapulmonary TB ? Infectious If have concomitant pulmonary TB, laryngeal TB Open abscess and drainage Aerosolisation of drainage fluid Globally extra-pulmonary without pulmonary involvement comprises of 14% of notified cases

Case – Extended typing of Mtb available SIRU and MIRU typing shows identical 24 loci match to another nurse in the workplace with smear positive pulmonary TB few years back. Patient was not contact screened at the time of the incident.

Facilitator slide-8 Slides for information Further slides are for information only Can cover if time permits Are present in Delegate version

Slides for information Further slides are for information only

Active case finding infection Human to human transmission prevention Screening * Household contacts irrespective of site of infection * For sputum smear-positive other close contacts should be assesses e.g. frequent visitors and workplace * Casual contacts should not normally be assessed

Contact tracing and IPC implication of active TB NICE Guidelines 2011 Diagnosis Offer Mantoux test to diagnose latent TB ( LTB) Household contacts Non household close contacts- e.g. Workplace Consider IFN-gamma if Mantoux is positive or if it is unreliable i.e. Previous BCG vaccination Assessment for presence of active TB

For HCWs Mantoux to new NHS employees who will be in contact are not new entrants not had BCG vaccination Offer IFN gamma recent arrival from high incidence countries

Management of latent TB About 5-10% of LTBI will develop active disease Considered if active TB excluded by CXR and examination 35 years or younger Any age with HIV Any age and HCW and are either →Mantoux positive and without BCG vaccination →Strong Mantoux positive (>15mm), IFN-γ pos and prior BCG