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

2. 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
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3. 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

4. What additional information you would like
to know in history?

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

6. 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

7. 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

8. What would you suggest be the next steps?

9. 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

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

11. CT Scan
ABSCESS

12. 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

13. What further management?

14. 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

15. What management to consider now?
Any further history?

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

17. 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

18. Is that the whole story?

19. 3d after discharge
Pus- culture positive for M. tuberculosis Fully sensitive

20. Treatment considerations

21. 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

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

23. 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

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

25. 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

26. CXR normal

27. 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

28. 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

29. 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.

30. Slides for information
Further slides are for information only

31. 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

32. 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

33. 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

34. 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