1. Hematogenous Klebsiella Pneumoniae Osteomyelitis1
血行性克雷伯氏肺炎菌骨髓炎: 臨床經驗
Hematogenous Klebsiella Pneumoniae Osteomyelitis
簡欣怡、陳理維、楊國強、徐圭璋
劉文忠、林政達、何彥儀
高雄榮民總醫院 外科部 重建整形外科 1 1

2. Clinical Scenario 73 y/o woman without trauma history. Past history2
73 y/o woman without trauma history.
Past history
Type 2 DM.
Recurrent K.p related liver abscess.
Redness
Swelling
Pain 2

3. Debridement, antibiotic therapy and hyperbaric therapy.3
Diagnosis
R’t leg tibia/fibula K.p osteomyelitis complicated with K.p bacteremia.
Management
Debridement, antibiotic therapy and hyperbaric therapy.

4. Introduction of K.p OM 4
Gram-negative, non-motile, aerobic rod-shaped bacterium.
K.p is normal flora of the human mouth, skin and intestine.
Non-hematogenous K.p OM infection mostly came from wound.
Hematogenous K.p OM infection came from wound, GU/GI tract or systemic infection. 4

5. Exclusion: Bone culture without K.p
Materials and Methods 5
Osteomyelitis
(ICD 9: )
K.P infection
(ICD 10: B96.1 )
VGHKS retrospective study
63 patients
Exclusion: Bone culture without K.p
Contributing Factors ?
Recurrent Risk Factor ?
Contributing Factor ? 5

6. 6 Pearson’s Chi-Squared Test Bacteremia Group Non-bacteremia Group
Table 1. Univariate Analysis of Contributing Factors in Hematogenous K.p OM Group Versus
Non-hematogenous K.P OM. 6
Pearson’s Chi-Squared Test
Bacteremia Group
Non-bacteremia Group
P-Value
Odds Ratio
Gender
Men
Woman
11/15 (73%)
4/15 (27%)
7/12 (58%)
5/12 (42%)
0.569
0.324
Age, median
Location
Extremities
Trunk
Diabetes mellitus
Hypertension
Alcoholic liver disease
Liver cirrhosis
Chronic inflammatory liver disease
Other Infection
Anemia
Malignancy
COPD or Asthma
ESRD
Wound
Recurrence
52 yrs
7/15 (46.7%)
8 /15 (53.3%)
6/15 (40%)
5/15 (33.3%)
6/15(40%)
10/15(67%)
2/15 (13.3%)
3/15 (20%)
0/15 (0%)
9/15(60%)
65 yrs
8/12 (66.7%)
4 /12 (33.3%)
3/12 (25%)
0/12 (0%)
1/12(8%)
1/12 (8%)
0/12 (0%)
12/12 (100%)
7/12(58%)
0.133
0.378
0.015
0.061
0.143
0.04
0.595
0.832
0.204
0.24
<0.0001
0.3
2.254
0.778
5.882
0.283
3.5
3.889
4.215
0.045
1.615
1.383
0.7 6 6

7. 7 Binary Logistic Regression Bacteremia Group Non-bacteremia Group
Table 2. Multivariate Analysis of Contributing Factors in Bacteremia K.p OM Group Versus
Non-bacteremia K.p OM Group 7
Binary Logistic Regression
Bacteremia Group
Non-bacteremia Group
P-Value
Odds Ratio
Gender
Men
Woman
11/15 (73%)
4/15 (27%)
7/12 (58%)
5/12 (42%)
0.758
0.095
Age, median
Location
Extremities
Trunk
Diabetes mellitus
Hypertension
Alcoholic liver disease
Liver cirrhosis
Chronic inflammatory liver disease
Other Infection
Anemia
Malignancy
COPD or Asthma
ESRD
Wound
Recurrence
52 yrs
7/15 (46.7%)
8 /15 (53.3%)
6/15 (40%)
5/15 (33.3%)
6/15(40%)
10/15(67%)
2/15 (13.3%)
3/15 (20%)
0/15 (0%)
9/15(60%)
65 yrs
8/12 (66.7%)
4 /12 (33.3%)
3/12 (25%)
0/12 (0%)
1/12(8%)
1/12 (8%)
0/12 (0%)
12/12 (100%)
7/12(58%)
0.365
0.512
0.998
0.603
0.999
0.438
0.691
0.725
1.0
0.997
0.821
0.429
0.000
0.27
1.651
0.158
0.124 7

8. 8 + Gender Age Location Underlying Disease Other K.p Infection
Table 3. Patient Information of Bateremia Without Wound Group 8
Gender
Age
Location
Underlying Disease
Other K.p
Infection
Treatment
Recurrence
5/11(45%)
No. 1 M 71
R’t tibial
DM/HTN/COPD/Liver cirrhosis, Child-Pugh A -
Antibiotic/
Debridement +
No. 2 F 54 DM
liver abscess
Antibiotic
No. 3 87
T7 spine
HTN
No. 4 67
L2 spine
DM/Alcololism/Liver cirrhosis, Child-Pugh A
No. 5 64
R’t 1st rib
DM/HTN/Liver cirrhosis, Child-Pugh C/ Cholangiocarcinoma
No. 6 52
L4-L5 spine
Asthma
No.7 69
SI joint
No. 8 42
R’t sterno-clavicle
Liver cirrhosis, Child-Pugh C/Magaloblastic anemia
No. 9 34
L’t tibial
Aplastic anemia
No. 10 75
R’t humeral
Cholangiocarcinoma
No. 11 72
R’t tibial-fibula
Debridement/HBO 8

9. Alcoholism/Liver cirrhosis, Child-Pugh C9
Table 4. Patient Information of Bateremia With Wound Group
Gender
Age
Location
Underlying Disease
Other K.p Infection
Treatment
Recurrence
4/4(100%)
No. 1 M 35
L’t femur
DM/Alcololism -
Antibiotic +
No. 2 45
Pre-sacral
Alcoholism/Liver cirrhosis, Child-Pugh C
UTI
Antibiotic/
Pigtail drainage
No. 3 47
L5-S1 spine
No. 4
R’t tibial
HTN
Debridement 9

10. 10 Pearson’s Chi-Squared Test Bacteremia Without Wound Group
Table 6. Univariate Analysis of Contributing Factors in Bacteremia With Wound Group
Versus Bacteremia Without Wound Group.
Pearson’s Chi-Squared Test
Bacteremia Without
Wound Group
Bacteremia With
P-Value
Odds Ratio
Gender
Men
Woman
Age, median
Location
Extremities
Trunk
Diabetes mellitus
Hypertension
Alcoholic liver disease
Liver cirrhosis
Child-Pugh A B C
Other K.p infection
Anemia
Malignancy
COPD/Asthma
ESRD
Recurrence
6/11 (55%)
5/11 (45%)
67 yrs
4/11 (36%)
1/11 (9%)
5/11(45%)
2/11 (18%)
0/0 (0%)
3/11 (27%)
0/11 (0%)
4/4 (100%)
0/4 (0%)
45 yrs
2/4 (50%)
1/4 (25%)
3/4 (75%)
2/4(50%)
4/4(100%)
0.099
0.031
0.876
0.475
0.68
0.011
0.381
0.36
1.0
0.218
0.057
2.727
4.63
0.024
0.511
0.17
6.516
1.932
0.839
0.000
1.519
3.636 10 10

11. 11 Binary Logistic Regression Bacteremia Without Wound Group
Table 7. Multivariate Analysis of Contributing Factors in Bacteremia With Wound Group Versus
Bacteremia Without Wound Group 11
Binary Logistic Regression
Bacteremia Without
Wound Group
Bacteremia With
P-Value
Odds Ratio
Gender
Men
Woman
Age, median
Location
Extremities
Trunk
Diabetes mellitus
Hypertension
Alcoholic liver disease
Liver cirrhosis
Child-Pugh A B C
Other Infection
Anemia
Malignancy
COPD/Asthma
ESRD
Recurrence
6/11 (55%)
5/11 (45%)
yrs
4/11 (36%)
1/11 (9%)
5/11(45%)
2/11 (18%)
0/0 (0%)
3/11 (27%)
0/11 (0%)
4/4 (100%)
0/4 (0%)
2/4 (50%)
1/4 (25%)
3/4 (75%)
2/4(50%)
4/4(100%)
0.999
0.18
0.998
0.134
1.0
0.888
0.000
1.801
2.243
0.02

12. 12 Pearson’s Chi-Squared Test Recurrence No Recurrence P-Value
Table 8. Univariate Analysis of Risk Factors of Recurrence in Hematogenous K.p OM Patients 12
Pearson’s Chi-Squared Test
Recurrence
No Recurrence
P-Value
Odds Ratio
Gender
Men
Woman
8/9 (89%)
1/9 (11%)
2/6 (33.3%)
4/6 (66.7%)
0.025 5
Age, median
Location
Extremities
Trunk
Diabetes mellitus
Hypertension
Alcoholic liver disease
Liver cirrhosis
Child-Pugh A B C
Other Infection
Anemia
Malignancy
COPD or Asthma
ESRD
Wound
Debridement
47 yrs
4/9 (44.4%)
5/9 (55.6%)
3/9 (33.3%)
4/9 (44%)
6/9(66.7%)
0/6 (0%)
1/9 (11.1%)
2/9 (22.2%)
0/9 (0%)
4/9(44.4%)
61.5 yrs
3/6 (50%)
0/6 (0%)
0/6(0%)
0/0 (0%)
0 /0 (0%)
1/6 (16.7%)
2/6(33.3%)
0.406
0.833
0.667
1.0
0.057
0.036
0.215
0.264
0.756
0.69
0.045
0.185
0.000
3.636
6.667
1.538
1.25
0.096
0.0963 12

13. 13 Binary Logistic Regression Recurrence No Recurrence P-Value
Table 9. Multivariate Analysis of Risk Factors of Recurrence in Hematogenous K.p OM Patients 13
Binary Logistic Regression
Recurrence
No Recurrence
P-Value
Odds Ratio
Gender
Men
Woman
8/9 (89%)
1/9 (11%)
2/6 (33.3%)
4/6 (66.7%)
0.999
0.000
Age, median
Location
Extremities
Trunk
Diabetes mellitus
Hypertension
Alcoholic liver disease
Liver cirrhosis
Child-Pugh A B C
Other Infection
Anemia
Malignancy
COPD or Asthma
ESRD
Without wound
Debridement
47 yrs
4/9 (44.4%)
5/9 (55.6%)
3/9 (33.3%)
4/9 (44%)
6/9(66.7%)
0/6 (0%)
1/9 (11.1%)
2/9 (22.2%)
0/9 (0%)
4/9(44.4%)
61.5 yrs
3/6 (50%)
0/6 (0%)
0/6(0%)
0/0 (0%)
0 /0 (0%)
1/6 (16.7%)
6/6 (100%)
2/6(33.3%)
0.544
1.0
0.711
0.368
0.137

14. Conclusion Hematogenous K.p OM.14
Hematogenous K.p OM.
DM and chronic inflammatory liver disease are the most crucial contributing factors.
Recurrent rate is high: 60%
Men and liver cirrhosis are high risk groups of recurrence.
Most of them did not receive debridement.
Only 33.3 % has GU/GI tract infection.
Most of the hematogenous K.p OM are without wound(73%). 14 14

15. 15
Liver is one of the largest filters into the body’s first line of immune system.
Chronic liver inflammation will induce hematogenous K.p OM.(67%)

16. Take Home Message 16
Hematogenous K.p OM are strongly correlated with chronic inflammatory liver disease and DM.
Recurrent hematogenous K.p OM are also closely related to chronic inflammatory liver disease.
DM 延伸