What Does Current Guidance Say On This Issue
There is currently no national guidance on the management of bone and joint infection, but several local NHS guidance documents exist. For example, NHS Bolton recommends that the infection is confirmed either through bone, blood or deep tissue samples before initiation of antibiotic therapy.
Although the nature of the infection impacts upon the exact antibiotic regime, IV antibiotics are always the first line treatment. However, the type of antibiotic and duration of treatment does differ according to the exact indication.
For example, acute bone infection will be treated with IV antibiotics for four to six weeks, although after two weeks a switch to oral antibiotics may be considered.
What Did This Study Do
The OVIVA randomised controlled trial had 1,015 participants from 26 UK centres. Patients were enrolled within seven days of either surgery or IV antibiotics to treat infection in the bone or joint. Causes ranged from a joint replacement infection to diabetes complications. Most had Staphylococcus aureus infections, and over 90% had initial surgical treatment.
Both the IV and the oral group received antibiotics for at least six weeks. In accordance with usual practice, the IV group could also be given oral antibiotics, such as rifampicin. Similarly, the oral group could have up to five consecutive days of IV antibiotics for unrelated infections over 80% of the oral group started with IV antibiotics. The primary outcome was treatment failure within one year.
Why Was This Study Needed
Bone infection in adults can occur as a serious complication of joint replacement surgery, or when infection travels through the bloodstream from another source, or a side effect of diabetes.
IV antibiotics for four to six weeks or longer are the usual treatment. The prolonged intravenous access carries its own risk and can pose a considerable inconvenience to patients due to long hospital stays or therapy at home. Costs are approximately 10 times that of oral therapy.
IV antibiotics continue to be used, in part because of a long-standing assumption and prior research that this mode of delivery is more effective. However, a recent Cochrane review of small trials did not demonstrate that IV antibiotics were any better than those given orally, but the evidence was uncertain. This large trial aimed to see if there were any long term differences.
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Bone And Joint Infections
The Oral versus Intravenous Antibiotics for Bone and Joint Infection trial was conducted at multiple centres across the UK.16 It compared early switching from intravenous to oral therapy to continuing intravenous antibiotics for at least six weeks. It included all adults with suspected bone and joint infections, irrespective of surgical intervention or antibiotic choice, who were planned to receive at least six weeks of antibiotic therapy. Comparing the outcomes at one year suggested that appropriately selected oral therapy is non-inferior to intravenous therapy. However, there are several important caveats:
- the trial was not powered to evaluate the outcome between different types of infection
- Gram-negative infections were under-represented
- most patients had surgical management of the infection
- rifampicin was used as a treatment option in approximately one-third of the cohort
- the clinicians managing the patients were specialist-led teams.
Although the events were not necessarily related to the antibiotics, one in four patients experienced a serious adverse event. This shows that ongoing monitoring is still required even with an oral antibiotic regimen.16,17 Further studies are required to look more closely at the different types of infection and the varying antibiotic regimens. Ideally these trials should be performed in the Australian healthcare system.
Antibiotic Treatment For 6 Weeks Versus 12 Weeks In Patients With Pyogenic Vertebral Osteomyelitis: An Open
- Louis BernardCorrespondenceCorrespondence to: Prof Louis Bernard, Division of Infectious Diseases, Bretonneau Hospital, University Hospitals of Tours, 37044 Tours, FranceDivision of Infectious Diseases, University Hospital Bretonneau, Tours, FranceDivision of Infectious Diseases, Bretonneau University Hospital, Tours, France
- on behalf of the Duration of Treatment for Spondylodiscitis study group
- Members listed in appendix
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Using Oral Rather Than Parenteral Antibiotics
Major advantages of oral over the intravenous route are the absence of cannula-related infections or thrombophlebitis, a lower drug cost, and a reduction in hidden costs such as the need for a health professional and equipment to administer intravenous antibiotics. Oral therapy may potentially enable an early discharge from the hospital4,5 or directly from the emergency department.6 For example, a single dose of intravenous antibiotic for paediatric uncomplicated urinary tract infections did not reduce the rate of representation or readmission. This suggests most children with a urinary tract infection can be managed with oral antibiotics alone.7
A key consideration is the bioavailability of oral antibiotics. This varies in comparison to intravenous formulations . Some oral antibiotics have equivalent bioavailability to the intravenous drug. They could be substituted, depending on the condition being treated and the required site of drug penetration.
Discharged With Iv Antibiotics: When Issues Arise Who Manages The Complications
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education , the University of California, Davis, Health must ensure balance, independence and objectivity in all its CME activities to promote improvements in health care and not proprietary interests of a commercial interest. Authors, reviewers and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. The Accreditation Council for Continuing Medical Education defines a commercial interest as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients and relevant financial relationships as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.
The author and reviewers for this Spotlight Case and Commentary have disclosed no relevant financial relationships with commercial interests related to this CME activity.
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Switching From Intravenous To Oral Therapy
To develop guidelines, there was a study of switching to oral therapy after 4872 hours of intravenous therapy. The main bacterial infections studied were respiratory tract infections, urinary tract infections, cholangitis, abdominal abscess and erysipelas. In the six weeks after completing the antibiotic course there was no recurrence of infection or readmissions due to reinfections. It was estimated that switching therapy avoided more than 6000 doses of intravenous antibiotics.11
A retrospective study of skin infections due to methicillin-resistant Staphylococcus aureus evaluated the treatment of hospitalised patients across 12 European countries. It estimated that more than one-third of the patients could have been changed from intravenous antibiotics to oral therapy earlier than occurred in practice.12
In a single tertiary hospital a printed checklist was placed in patients charts to encourage appropriate switching from intravenous to oral antibiotics at day three of treatment. The conditions predominantly studied were lower respiratory tract infections, urinary tract infections and intra-abdominal infections. Of the patients who were suitable for switching to oral antibiotics 61.4% were switched in response to the checklist. They had no increase in complications.13
- spectrum of activity
* Does not apply to infections that require high tissue concentrations or prolonged intravenous therapy .
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Ingredients In Sinuvil Sinus Relief
Sinuvil Sinus Relief is a homeopathic medicine that contains active ingredients that are listed in the Homeopathic Pharmacopeia of the United States .
Active Ingredients:Apis mellifica, Baptisia tinctoria, Colocynthis, Hepar sulphuris calcareum, Histaminum hydrochloricum, Hydrastis canadensis, Ignatia amara, Kali bichromicum, Lemna minor, Mercurius vivus, Pulsatilla, Rhus toxicodendron, Sabadilla, Thuja occidentalis.
- Temporary relief of symptoms due to inflamed sinuses
- Cold and flu nasal symptoms
- Sinus pain and headache
Whats The Evidence For Specific Management And Treatment Recommendations
Bernard, L, Dinh, A, Ghout, I, Simo, D, Zeller, V, Issartel, B, Le Moing, V, Belmatoug, N, Lesprit, P, Bru, JP, Therby, A, Bouhour, D, DÃ©nes, E, Debard, A, Chirouze, C, FÃ¨vre, K, Dupon, M, Aegerter, P, Mulleman, D. âDuration of Treatment for Spondylodiscitis study group. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trialâ. Lancet. vol. 385. 2015. pp. 875-82.
Betz, M, Landelle, C, Lipsky, BA, UÃ§kay, I. âLetter to the Editor concerning the review of Prof. Sheldon L. Kaplan âRecent lessons for the management of bone and joint infectionsââ Bacteriostatic or bactericidal agents in osteoarticular infectionsâ. J Infect. vol. 71. 2015. pp. 144-6.
Cierny, G, Mader, JT, Penninck, JJ. âA clinical staging system of adult osteomyelitisâ. Clin Orthop Relat Res. vol. 414. 2003. pp. 7-24.
Conterno, LO, da Silva Filho, CR. âAntibiotics for treating chronic osteomyelitis in adultsâ. Cochrane Database Syst Rev. vol. 3. 2009. pp. CD004439
Cui, Q, Mihalko, WM, Shields, JS, Ries, M, Saleh, KJ. âAntibiotic-impregnated cement spacers for the treatment of infection associated hip or knee arthroplastyâ. J Bone Joint Surg Am. vol. 89. 2007. pp. 871-82.
Grayson, ML, Gibbons, GW, Balogh, K, Levin, E, Karchmer, AW. âProbing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patientsâ. JAMA. vol. 273. 1995. pp. 721-3.
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Ingredients In Sinuvil Sinus Formula
Sinuvil Sinus Formula contains natural ingredients from plants, trees or herbs.Sinuvil’s gentle herbal formula helps stimulate the immune system and activate natural killer cells enabling the body’s own defense mechanism.*
|PELARGONIUM SIDOIDES is a medical plant native to Africa. Clinical studies show that it’s effective for supporting the respiratory tract..* .
|N-ACETYLCYSTEINE is a special form of amino acid cysteine found in egg whites, red pepper or garlic. NAC is widely used in Europe for sinus and lung support. Several clinical studies have found that NAC is highly effective \ . It thins out mucus, draining it out of sinuses and the lungs . NAC protects your cells through its antioxidant activity .*
|QUERCETIN is a flavonoid present in apples, citrus fruits and strawberries. It is the secret behind the saying “An apple a day keeps the doctor away”. Quercetin has amazing anti-inflammatory and immune-supporting effects. All these activities are caused by the strong antioxidant action of quercetin. Studies have shown improved respiratory function for people who consume plenty of apples . . It not only reduces inflammation ,but also helps compensate for the negative effects of pollution. *
|BUTTERBUR is a plant that grows in northern parts of Europe and Russia. For many centuries, it has been used as an herbal remedy for respiratory health maintenance. A clinical study showed that Butterbur helps improve lung ventilation . *
Enhancing Healthcare Team Outcomes
Osteomyelitis is a complicated infection to treat. In most cases, management involves a multifaceted, interprofessional approach, including the primary care provider, radiologist, surgeons , a podiatrist, an infectious disease specialist, pharmacist, nurse wound care team, and sometimes a plastic surgeon, a pain specialist or interventional radiologist. The primary care provider often plays a vital role in the initial diagnosis and coordination of care across these medical and surgical specialties.
The therapeutic approach to management is guided sometimes by the site of infection and the presence of vascular insufficiency. Minimally invasive CT or fluoroscopically guided aspiration of the disc space for microbiological and histopathological testing is recommended for the diagnosis of suspected NVO if clinical, imaging and other laboratory data suggest osteomyelitis in the absence of positive blood cultures with an organism known to cause osteomyelitis . However, in patients with suspected subacute NVO and strongly positive Brucella serology or those with suspected NVO based on available clinical, radiological, laboratory data and positive blood cultures involving an organism known to cause osteomyelitis, image-guided aspiration biopsy is not recommended. A 6-week course of parenteral antibiotics is reserved for cases with neurological complications or failure of medical therapy.
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Which Individuals Are Of Greater Risk Of Developing Osteomyelitis
The pathogenesis of osteomyelitis includes three processes which in turn dictates who develops this infection. Those individuals who are at greater risk of developing osteomyelitis are:
- patients with polyneuropathy and/or peripheral arterial disease develop skin ulcers which become infected with subsequent extension to adjacent bone. Other infections can extend to adjacent bone .
- patients undergoing surgery or suffering trauma that extends to the bone .
- patients with S. aureus bacteremia are at unique risk for developing vertebral osteomyelitis or seeding of implanted prosthetic joints with subsequent paraprosthesis bone infection. Bacteremia due to other organisms can seed these sites as well but does so less frequently than that due to S. aureus .
Beware: there are other diseases that can mimic osteomyelitis:
Osteomyelitis is a common term for bacterial bone and marrow infection with structural deformation of bone, although nonbacterial and non-infectious inflammation of bones and adherent structures exist. Mimics of bone infection include: SAPHO syndrome is a rare immunologic disorder that results in synovitis, acne, pustulosis, hyperostosis, and osteitis. Other immunologic diseases, such as chronic recurrent multifocal osteomyelitis, palmoplantar pustulosis, charcot foot or idiopathic bone marrow oedema can also present with non-infectious osteomyelitis.
Oral Antibiotics For Infective Endocarditis: Time To Switch
Paul G. Auwaerter, MD
This is Paul Auwaerter with Medscape Infectious Diseases, speaking from the Johns Hopkins School of Medicine.
I’ve taken care of patients for more than 30 years in this area at Johns Hopkins Hospital, where endocarditis is a fairly common request for consultation. Trainees and faculty are often faced with difficult decisions in patients who may not be great candidates for the traditional 4-6 weeks of intravenous antibiotic therapy, whether it’s because they are threatening to leave against medical advice, they don’t have the financial wherewithal for home-based therapy, or they have substance abuse issues that would affect the likelihood of success if they were to have an IV line in place. Ethical issues aside, I’ve always been amazed at the number of patients who did not receive full courses of therapy, yet they don’t seem to come back with repeat bouts of endocarditis.
From a biological perspective, a well-absorbed oral antibiotic should be equivalent to an IV antibiotic, but we all know that there are issues on either side which can be argued. So I think it’s with some interest that one of the most robust studies examining whether oral therapy may be helpful was the POET study, which didn’t really look at stem-to-stern oral therapy, but rather at partial oral antibiotic therapy of endocarditis.
Medscape Infectious Diseases Â© 2018 WebMD, LLC
Switching To Oral Antibiotics Early For Bone And Joint Infections Gave Similar Results To Continuing Intravenous Therapy
This is a plain English summary of an original research article
For adults with bone or joint infection, many of whom had metal implants, beginning six weeks of oral antibiotics within seven days of intravenous treatment, was no worse than a regimen delivered wholly intravenously . After one year, around 14% of both groups still had an infection, showing the difficulty of treatment, irrespective of the route of administration.
Although current practice suggests antibiotics should be given IV for bone and joint infections, for at least six weeks, this large NIHR-funded UK trial challenges this assumption. Participants were randomised to oral antibiotics seven days after initial surgical or IV antibiotic treatment.
Using oral antibiotics has the potential to reduce complications and give patients greater freedom while undergoing treatment, and costs less. This study strengthens evidence from an existing Cochrane review of smaller diverse trials, and may potentially lead to a shift in practice.
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