Early Results of Adjuvant Topical Treatment of Recurrent Osteomyelitis with Absorbable Antibiotic Carriers
Early Results of Adjuvant Topical Treatment of Recurrent Osteomyelitis with Absorbable Antibiotic Carriers
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DOI：
10.1055/s-0042-112228
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发表时间：
2017-02-01
影响因子：
1
通讯作者：
Hoffmann, R.
中科院分区：
文献类型：
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作者：
Gramlich, Y.;Walter, G.;Hoffmann, R.
背景肌肉骨骼感染的治疗主要包括根治性手术清创和全身应用抗生素。额外的局部抗生素疗法尚未普遍确立，也缺乏有效的循证证据。尽管如此，由于大多数专门部门不愿放弃这一选择，因此有多种实用的方法。已建立的聚甲基丙烯酸甲酯(PMMA)载体系统具有许多实际缺点。这导致了可吸收载体系统的使用增加，以硫酸钙为基础的载体系统取得了特别令人鼓舞的结果。在这篇文章中，我们介绍了我们在骨髓炎治疗中的经验。材料与方法2014年2月至2015年5月，93例复发性骨髓炎患者接受了以硫酸钙为基础的局部可吸收抗生素载体治疗。这些患者曾遭受骨髓炎复发的痛苦，这些骨髓炎通过一次植入PMMA链和全身抗生素治疗失败。治疗算法包括根治性清创，然后植入商业PMMA链。如果没有观察到感染缓解，则手术移除链条，并用可吸收的载体系统和根据耐药图选择的抗生素替换。按Cierny和Mader分型，I型10例，II型5例，III型55例，IV型23例。平均随访11个月。两个载体系统Osteoset(注册商标)和Herafill(注册商标)分别从美国田纳西州阿灵顿的Wright Medical Technology Inc.和德国Wehheim的Heraeus Medical GmbH购买。这些药物被用作妥布霉素和庆大霉素的供应品。在Osteoset的情况下，也可以添加额外的任意的、水溶性的抗生素。结果临床表现以股骨(36%)和胫骨(29%)为主。最常用的抗生素是万古霉素(38%)和妥布霉素(38%)，其次是庆大霉素(17%)、头孢曲松(4%)、磷霉素(2%)和粘菌素(1%)。抗生素的系统给药是平行进行的，根据耐药图。在所有患者中，85%的患者获得了缓解。耐甲氧西林金黄色葡萄球菌(MRSA；62%)和铜绿假单胞菌(43%)感染的缓解率明显较低。细菌谱以金黄色葡萄球菌(28%)、表皮葡萄球菌(22%)、铜绿假单胞菌(7%)、粪肠球菌(5%)为主，其次为大肠埃希菌和催产克雷伯菌(4%)。结论以可吸收载体系统为基础的局部辅助抗生素治疗骨髓炎是一种便捷的推广治疗方法。复发感染的缓解率为85%，这鼓励了许多患者使用替代疗法。我们开发了一种治疗骨髓炎的算法，包括使用不同成分的局部抗生素和可吸收的载体。我们报告了复发性骨髓炎患者在用不可吸收的抗生素链局部治疗无效后成功治疗的早期结果。
Background Treatment of musculoskeletal infections principally consists of radical surgical debridement and systemic administration of antibiotics. Additional local antibiotic therapy is not yet generally established, and lacks evidence-based proof of efficacy. Nonetheless, there are a variety of practical approaches, as most specialised departments are unwilling to forego this option. The established polymethylmetacrylate (PMMA) carrier system has a number of practical disadvantages. This has led to the increased use of absorbable carrier systems, and those based on calcium sulphate have given particularly encouraging results. In this article, we present our experience with this procedure in the treatment of osteomyelitis. There is currently no standard procedure or algorithm for the use of local antibiotic carriers in the treatment of recurrent osteomyelitis.Material and Methods Between February 2014 and May 2015, a total of 93 patients were treated with an absorbable carrier of topical antibiotics based on calcium sulphate. These patients had suffered from a recurrence of osteomyelitis that had been unsuccessfully treated by the primary implantation of a PMMA chain and systemic antibiotics. The treatment algorithm consisted of radical debridement, followed by implantation of a commercial PMMA chain. If no remission of the infection was observed, the chains were surgically removed and replaced with an absorbable carrier system and antibiotics chosen in accordance with the resistogram. Pursuant to the classification of Cierny and Mader, 10 patients were classified as type I, 5 as type II, 55 as type III and 23 as type IV. The mean follow-up period was 11 months. Two carrier systems, Osteoset((R)) and Herafill((R)), were purchased from Wright Medical Technology Inc., Arlington, TN, USA and Heraeus Medical GmbH, Wehrheim, Germany, respectively. These were used as supplied for tobramycin and gentamycin. In the case of Osteoset, it was also possible to add an additional arbitrary, water-soluble antibiotic. Systemic administration of antibiotics was carried out in parallel in accordance with the resistogram.Results The most common clinical entities were femoral (36%) and tibial (29%) osteitis. Vancomycin (38%) and tobramycin (38%) were the most frequently used topical antibiotics, followed by gentamycin (17%), ceftriaxone (4%), fosfomycin (2%) and colistin (1%). Systemic administration of antibiotics was carried out in parallel, in accordance with the resistogram. In 85% of all patients, remission was achieved. Infections with methicillin-resistant Staphylococcus aureus (MRSA; 62%) and Pseudomonas aeruginosa (43%) showed significantly poorer remission rates. The bacterial spectrum was primarily composed of Staphylococcus aureus (28%), Staphylococcus epidermidis (22%), Pseudomonas aeruginosa (7%) and Enterococcus faecalis (5%), as well as Escherichia coli and Klebsiella oxytoca (4%).Conclusion Topical adjuvant antibiotic therapy based on an absorbable carrier system offers an expedient extension of the treatment of osteomyelitis. The remission rate of 85% for recurrent infections encouraged the use of a therapeutic alternative for many patients. We developed an algorithm for the treatment of osteomyelitis, which includes the application of local antibiotics with different compositions and absorbable carriers. We present early results of successful treatment of patients with recurrent osteomyelitis, after futile topical therapy with non-absorbable antibiotic chains.