Clindamycin unresponsive anaerobic osteomyelitis treated with oral metronidazole

A Review of the Clinical Utilization of Oral Antibacterial Therapy in the Treatment of Bone Infections in Adults

Chronic osteomyelitis in adults is managed with prolonged courses of intravenous antibiotics in conjunction with surgical debridement of necrotic bone. Over the past 40 years, there has been no paradigm shift in this approach, as randomized controlled trials of this standard of care compared to alternatives such as prolonged oral antibiotics are scarce. However, there have been many small trials, case reports, and review papers evaluating the effectiveness of oral treatment for chronic osteomyelitis. The oral route for infections requiring prolonged treatment is intuitively and practically more favorable due to several advantages, the most important of which is the avoidance of long-term IV antimicrobial therapy with its complications, inconvenience, and cost. In this paper, we review the literature evaluating oral antibiotic therapy in the management of chronic bone infections since 1975. The majority of osteomyelitis infections are caused by Staphylococcus aureus, hence we focus on its treatment using oral antibiotics; however, we also emphasize subpopulations of patients with diabetes, implanted hardware, and with less common bacterial organisms. The primary objective of this review is to promulgate clinical recommendations on the use of oral antibiotics in bone infections in the context of initial therapy, transition from intravenous therapy, and the role of chronic suppression. The secondary objective is to summarize current knowledge of the specific oral antimicrobial agents that are commonly utilized, together with a synopsis of the available literature pertaining to their pharmacokinetic/pharmacodynamic properties and duration of therapy in bone infection.

Systemic antibiotic therapy for chronic osteomyelitis in adults

The standard recommendation for treating chronic osteomyelitis is 6 weeks of parenteral antibiotic therapy. However, oral antibiotics are available that achieve adequate levels in bone, and there are now more published studies of oral than parenteral antibiotic therapy for patients with chronic osteomyelitis. Oral and parenteral therapies achieve similar cure rates; however, oral therapy avoids risks associated with intravenous catheters and is generally less expensive, making it a reasonable choice for osteomyelitis caused by susceptible organisms. Addition of adjunctive rifampin to other antibiotics may improve cure rates. The optimal duration of therapy for chronic osteomyelitis remains uncertain. There is no evidence that antibiotic therapy for >4-6 weeks improves outcomes compared with shorter regimens. In view of concerns about encouraging antibiotic resistance to unnecessarily prolonged treatment, defining the optimal route and duration of antibiotic therapy and the role of surgical debridement in treating chronic osteomyelitis are important, unmet needs.

A systematic approach to diabetic foot infections

Foot infection is the most common reason for hospitalization and subsequent lower extremity amputation among persons with diabetes. Foot ulceration caused by diabetic neuropathy, trauma, and peripheral vascular disease can lead to a limbor life-threatening infection. The optimum treatment of these potentially devastating conditions depends on a multidisciplinary approach that addresses the related or underlying disorders and thus ensures proper wound healing and a positive outcome. In addition to antibiotic therapy, severe soft-tissue or bone infections may necessitate surgical treatment, including drainage, débridement, and vascular reconstruction. Initial (empiric) antibiotic therapy should provide coverage against staphylococci and streptococci and should be revised according culture results. Antibiotic therapy is not indicated in clinically noninfected wounds. The duration of antibiotic treatment can range from 1 week for mild infections to 6 weeks or more for residual osteomyelitis and severe deep tissue infections. Aggressive (and sometimes repeated or staged) surgical intervention and appropriate antibiotic therapy can reduce the likelihood of a major amputation and the duration of hospitalization.

Incubation period and sources of exposure for cutaneous Mycobacterium marinum infection: case report and review of the literature

The diagnosis of cutaneous Mycobacterium marinum infection is often delayed for months after presentation, perhaps because important clinical clues in the patient's history are frequently overlooked. Knowledge of the incubation period allows the clinician to target questions about the patient's history. Prompted by a case with a prolonged incubation period, we sought to determine more precisely the incubation period of M. marinum infection. The MEDLINE database for the period 1966-1996 was searched for information regarding incubation period and type of exposure preceding M. marinum infection. Ninety-nine articles were identified, describing 652 cases. Forty cases had known incubation periods (median, 21 days; range, 5-270 days). Thirty-five percent of cases had an incubation period > or =30 days. Of 193 infections with known exposures, 49% were aquarium-related, 27.4% were related to fish or shellfish injuries, and 8.8% were related to injuries associated with saltwater or brackish water. Because the incubation period for cutaneous M. marinum infection can be prolonged, patients with atypical cutaneous infections should be questioned about high-risk exposures that may have occurred up to 9 months before the onset of symptoms.

Unusually aggressive osteomyelitis of the jaws. A report of two cases

Two cases of unusually aggressive osteomyelitis of the jaws are reported. Both cases manifested severe, rapidly progressive lytic destruction of the maxilla in spite of the fact that patients were young, healthy adults with no local or systemic factors that would predispose them to severe infection in either case. Characteristic historical, clinical, radiographic, and histologic features are elaborated. Also, theoretical aspects of this disease entity are discussed in an effort to explain the unusually aggressive manner in which these cases presented.

Infectious foci in chronic osteomyelitis of the jaws

Chronic osteomyelitis of the jaws has a varied clinical appearance and an unclear etiology. In a retrospective study based on case histories and histological material from 24 patients with chronic osteomyelitis, no specific correlation could be found between clinical symptoms and morphological changes in bone. In 10 patients, bacteria were found in certain foci such as osteocytic lacunae of necrotic bone and dentinal tubules of embedded tooth fragments. In these foci, the bacteria probably escaped the immunological response as well as the antibiotic treatment. From these foci, the bacteria might maintain an inflammatory reaction in the surrounding bone. In some patients, the mandibular canal seemed to be a pathway for the spreading of the inflammatory process.

On the mutagenicity of nitroimidazoles

Regarding mutagenicity, metronidazole is one of the best-investigated compounds of the nitroimidazoles. This drug is mutagenic on bacteria, especially if base-pair tester strains are used and bacterial nitroreductases are present. The serum levels attained in man after intake of this drug are sufficient to cause mutations in bacteria. Furthermore, interaction with and binding to DNA occurs under anaerobic conditions and sometimes DNA breaks are observed. However, metronidazole does not show mutagenic activity in mammalian cells in vitro; the micronucleus test is negative and chromosome aberrations are only found under anaerobic conditions. With microbial systems the mutagenicity of 47 nitroimidazoles has been investigated. Only 4 compounds were always negative in the applied test systems. Because with base-pair tester strains mutagenicity was assessed, this class of compounds should be regarded as a base-pair mutagen. In fungi, some compounds (e.g. ZK 26173 and azathioprine) are potent mutagens, whilst with most investigated nitroimidazoles only a weak or no mutagenic activity could be detected. Somewhat similar observations have been made in tests with Drosophila melanogaster, a test for gene mutations in mammalian cells, the micronucleus test, cytogenic tests and the dominant lethal test. The reduction products of metronidazole, misonidazole and 1-methyl-2-nitro-5-vinylimidazole, cause DNA damage if the nitro group is reduced in the presence of DNA. Reduction products are formed by microbes in the gut or by mammalian cells under anaerobic conditions. No teratological effect due to metronidazole or most other nitroimidazoles has been observed. Metronidazole is carcinogenic in mice and rats, and dimetridazole in rats. Up to the present, no carcinogenic effects have been observed in man. Azathioprine is probably carcinogenic for man. It is unlikely that the therapeutic applications of the presently used nitroimidazoles, except for azathioprine, will cause an increase in the tumor incidence in man or will cause other genotoxic effects, although such effects cannot be excluded with certainty.