今日の臨床サポート

骨髄炎

著者: 河村一郎 大阪国際がんセンター感染症内科

監修: 上原由紀 聖路加国際病院 臨床検査科/感染症科

著者校正/監修レビュー済:2021/11/24
患者向け説明資料

概要・推奨   

  1. 骨髄炎とは、細菌などが骨髄に感染したことにより起きる感染症である。血行性のほか、外傷や周囲の組織などから直接感染することがある。
  1. 診断は病歴、身体診察、検査所見(培養、画像検査など)に基づく臨床診断である。なかでも、培養検査(血液培養、骨生検の培養など)による原因菌の同定は、診断と治療の両面で重要である。
  1. 起因菌の評価には、骨生検の培養の結果が最も信頼度が高い。また、骨生検組織の培養による検出菌とその周囲の組織など骨以外の検出菌は必ずしも一致しないことが知られているため、周囲の組織の培養結果を信頼して治療を開始してはいけない(推奨度2
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
河村一郎 : 特に申告事項無し[2021年]
監修:上原由紀 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、部分的な修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 骨髄炎とは、骨の生理的・解剖的特徴により抗菌薬による治癒が難しい疾患の1つである。長期間の抗菌薬治療を必要とするため、骨生検を含め原因菌特定のための努力は惜しんではならない。
  1. 骨髄炎には、3つの感染経路があり、血行性感染、隣接する骨・軟部組織感染からの波及、および、外傷や手術に伴う微生物の直接侵入に分かれる。
  1. 血行性感染の場合は単一菌、それ以外の感染経路では複数菌によることが多い。いずれの経路においても最も検出頻度の高い原因菌は、黄色ブドウ球菌である。
  1. 好発部位は脊椎(成人>小児)、長骨(小児>成人)である。
問診・診察のポイント  
  1. 骨髄炎のリスク因子を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Benjamin A Lipsky, Anthony R Berendt, H Gunner Deery, John M Embil, Warren S Joseph, Adolf W Karchmer, Jack L LeFrock, Daniel P Lew, Jon T Mader, Carl Norden, James S Tan, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2004 Oct 1;39(7):885-910. doi: 10.1086/424846. Epub 2004 Sep 10.
Abstract/Text
PMID 15472838  Clin Infect Dis. 2004 Oct 1;39(7):885-910. doi: 10.1086・・・
著者: Sonia Butalia, Valerie A Palda, Robert J Sargeant, Allan S Detsky, Ophyr Mourad
雑誌名: JAMA. 2008 Feb 20;299(7):806-13. doi: 10.1001/jama.299.7.806.
Abstract/Text CONTEXT: Osteomyelitis of the lower extremity is a commonly encountered problem in patients with diabetes and is an important cause of amputation and admission to the hospital. The diagnosis of lower limb osteomyelitis in patients with diabetes remains a challenge.
OBJECTIVE: To determine the accuracy of historical features, physical examination, and laboratory and basic radiographic testing. We searched for systematic reviews of magnetic resonance imaging (MRI) in the diagnosis of lower extremity osteomyelitis in patients with diabetes to compare its performance with the reference standard.
DATA SOURCES: MEDLINE search of English-language articles published between 1966 and March 2007 related to osteomyelitis in patients with diabetes. Additional articles were identified through a hand search of references from retrieved articles, previous reviews, and polling experts.
STUDY SELECTION: Original studies were selected if they (1) described historical features, physical examination, laboratory investigations, or plain radiograph in the diagnosis of lower extremity osteomyelitis in patients with diabetes mellitus, (2) data could be extracted to construct 2 x 2 tables or had reported operating characteristics of the diagnostic measure, and (3) the diagnostic test was compared with a reference standard. Of 279 articles retrieved, 21 form the basis of this review. Data from a single high-quality meta-analysis were used to summarize the diagnostic characteristics of MRI in osteomyelitis.
DATA EXTRACTION: Two authors independently assigned each study a quality grade using previously published criteria and abstracted operating characteristic data using a standardized instrument.
DATA SYNTHESIS: The gold standard for diagnosis is bone biopsy. No studies were identified that addressed the utility of the history in the diagnosis of osteomyelitis. An ulcer area larger than 2 cm2 (positive likelihood ratio [LR], 7.2; 95% confidence interval [CI], 1.1-49; negative LR, 0.48; 95% CI, 0.31-0.76) and a positive "probe-to-bone" test result (summary positive LR, 6.4; 95% CI, 3.6-11; negative LR, 0.39; 95% CI, 0.20-0.76) were the best clinical findings. A erythrocyte sedimentation rate of more than 70 mm/h increases the probability of a diagnosis of osteomyelitis (summary LR, 11; 95% CI, 1.6-79). An abnormal plain radiograph doubles the odds of osteomyelitis (summary LR, 2.3; 95% CI, 1.6-3.3). A positive MRI result increases the likelihood of osteomyelitis (summary LR, 3.8; 95% CI, 2.5-5.8). However, a normal MRI result makes osteomyelitis much less likely (summary LR, 0.14; 95% CI, 0.08-0.26). The overall accuracy (ie, the weighted average of the sensitivity and specificity) of the MRI is 89% (95% CI, 83.0%-94.5%).
CONCLUSIONS: An ulcer area larger than 2 cm2, a positive probe-to-bone test result, an erythrocyte sedimentation rate of more than 70 mm/h, and an abnormal plain radiograph result are helpful in diagnosing the presence of lower extremity osteomyelitis in patients with diabetes. A negative MRI result makes the diagnosis much less likely when all of these findings are absent. No single historical feature or physical examination reliably excludes osteomyelitis. The diagnostic utility of a combination of findings is unknown.

PMID 18285592  JAMA. 2008 Feb 20;299(7):806-13. doi: 10.1001/jama.299.・・・
著者: M L Grayson, G W Gibbons, K Balogh, E Levin, A W Karchmer
雑誌名: JAMA. 1995 Mar 1;273(9):721-3.
Abstract/Text OBJECTIVE: To assess a bedside technique for diagnosing osteomyelitis.
DESIGN: We prospectively assessed infected pedal ulcers for detectable bone by probing with a sterile, blunt, stainless steel probe. We then examined the relationship between detection of bone and the presence or absence of osteomyelitis that was defined histopathologically and/or clinically.
SETTING: A tertiary care center.
PATIENTS: Seventy-five hospitalized diabetic patients with a total of 76 infected foot ulcers were studied.
RESULTS: Osteomyelitis was diagnosed in 50 instances (66%) and was excluded in 26 instances. Bone was detected by probing in 33 of 50 ulcers with contiguous osteomyelitis; in contrast, bone was probed in only four of 26 ulcers without contiguous osteomyelitis (P < .001). Bone detected on probing was visible in only three instances. Palpating bone on probing the pedal ulcer had a sensitivity of 66% for osteomyelitis, a specificity of 85%, a positive predictive value of 89%, and a negative predictive value of 56%.
CONCLUSIONS: Palpation of bone in the depths of infected pedal ulcers in patients with diabetes is strongly correlated with the presence of underlying osteomyelitis. If bone is palpated on probing, specialized roentgenographic and radionuclide tests to diagnose osteomyelitis are unnecessary. Probing for bone should be included in the initial assessment of all diabetic patients with infected pedal ulcers.

PMID 7853630  JAMA. 1995 Mar 1;273(9):721-3.
著者: Andres F Zuluaga, Wilson Galvis, Juan G Saldarriaga, Maria Agudelo, Beatriz E Salazar, Omar Vesga
雑誌名: Arch Intern Med. 2006 Jan 9;166(1):95-100. doi: 10.1001/archinte.166.1.95.
Abstract/Text BACKGROUND: Although bone specimens were established 25 years ago as the gold standard for etiologic diagnosis of chronic osteomyelitis, recent studies suggest that nonbone specimens are as accurate as bone to identify the causative agent. We examined concordance rates between cultures from nonbone and bone specimens in 100 patients.
METHODS: Prospective study conducted at Hospital Universitario San Vicente de Paul, a 750-bed university-based hospital located in Medellín, Colombia. We included patients with chronic osteomyelitis who had been free of antibiotic therapy for at least 48 hours, excluding those with diabetic foot and decubitus ulcers. At least 1 nonbone and 1 bone specimen were taken from each individual and subjected to complete microbiologic analysis.
RESULTS: Bone cultures allowed agent identification in 94% of cases, including anaerobic bacteria in 14%. Cultures of nonbone and bone specimens gave identical results in 30% of patients, with slightly better concordance in chronic osteomyelitis caused by Staphylococcus aureus (42%) than by all other bacterial species (22%). However, statistical concordance determined by the Cohen kappa statistic was less than 0 (-0.0092+/-0.0324), indicating that the observed concordance was no better than that expected by chance alone (P>.99).
CONCLUSIONS: Appropriate diagnosis and therapy of chronic osteomyelitis require microbiologic cultures of the infected bone. Nonbone specimens are not valid for this purpose.

PMID 16401816  Arch Intern Med. 2006 Jan 9;166(1):95-100. doi: 10.1001・・・
著者: Andrés F Zuluaga, Wilson Galvis, Fabián Jaimes, Omar Vesga
雑誌名: BMC Infect Dis. 2002 May 16;2:8. Epub 2002 May 16.
Abstract/Text BACKGROUND: Prognosis of chronic osteomyelitis depends heavily on proper identification and treatment of the bone-infecting organism. Current knowledge on selecting the best specimen for culture is confusing, and many consider that non-bone specimens are suitable to replace bone cultures. This paper compares the microbiology of non-bone specimens with bone cultures, taking the last as the diagnostic gold standard.
METHODS: Retrospective observational analysis of 50 patients with bacterial chronic osteomyelitis in a 750-bed University-based hospital.
RESULTS: Concordance between both specimens for all etiologic agents was 28%, for Staphylococcus aureus 38%, and for organisms other than S. aureus 19%. The culture of non-bone specimens to identify the causative organisms in chronic osteomyelitis produced 52% false negatives and 36% false positives when compared against bone cultures.
CONCLUSIONS: Diagnosis and therapy of chronic osteomyelitis cannot be guided by cultures of non-bone specimens because their microbiology is substantially different to the microbiology of the bone.

PMID 12015818  BMC Infect Dis. 2002 May 16;2:8. Epub 2002 May 16.
著者: Eric Senneville, Hugues Melliez, Eric Beltrand, Laurence Legout, Michel Valette, Marie Cazaubiel, Muriel Cordonnier, Michèle Caillaux, Yazdan Yazdanpanah, Yves Mouton
雑誌名: Clin Infect Dis. 2006 Jan 1;42(1):57-62. doi: 10.1086/498112. Epub 2005 Nov 21.
Abstract/Text BACKGROUND: We assessed the diagnostic value of swab cultures by comparing them with corresponding cultures of percutaneous bone biopsy specimens for patients with diabetic foot osteomyelitis.
METHODS: The medical charts of patients with foot osteomyelitis who underwent a surgical percutaneous bone biopsy between January 1996 and June 2004 in a single diabetic foot clinic were reviewed. Seventy-six patients with 81 episodes of foot osteomyelitis who had positive results of culture of bone biopsy specimens and who had received no antibiotic therapy for at least 4 weeks before biopsy constituted the study population.
RESULTS: Pathogens isolated from bone samples were predominantly staphylococci (52%) and gram-negative bacilli (18.4%). The distributions of microorganisms in bone and swab cultures were similar, except for coagulase-negative staphylococci, which were more prevalent in bone samples (P < .001). The results for cultures of concomitant foot ulcer swabs were available for 69 of 76 patients. The results of bone and swab cultures were identical for 12 (17.4%) of 69 patients, and bone bacteria were isolated from the corresponding swab culture in 21 (30.4%) of 69 patients. The concordance between the results of cultures of swab and of bone biopsy specimens was 42.8% for Staphylococcus aureus, 28.5% for gram-negative bacilli, and 25.8% for streptococci. The overall concordance for all isolates was 22.5%. No adverse events--such as worsening peripheral vascular disease, fracture, or biopsy-induced bone infection--were observed, but 1 patient experienced an episode of acute Charcot osteoarthropathy 4 weeks after bone biopsy was performed.
CONCLUSIONS: These results suggest that superficial swab cultures do not reliably identify bone bacteria. Percutaneous bone biopsy seems to be safe for patients with diabetic foot osteomyelitis.

PMID 16323092  Clin Infect Dis. 2006 Jan 1;42(1):57-62. doi: 10.1086/4・・・
著者: C R Perry, R L Pearson, G A Miller
雑誌名: J Bone Joint Surg Am. 1991 Jun;73(5):745-9.
Abstract/Text The pathogens that were identified on cultures of material obtained by swabbing of the superficial aspect of the wound and needle biopsy were compared with those that were isolated from material that was obtained at débridement from sixty patients who had post-traumatic or postoperative osteomyelitis. The cultures of material that was obtained by superficial swabbing of the wound and needle biopsy were inadequate for prediction of the presence of aerobic organisms. Moreover, the failure to isolate anaerobes from the material obtained by needle biopsy did not rule out the presence of anaerobic organisms. Therefore, tissue for culture of aerobic and anaerobic organisms must be obtained during operative débridement in order to identify all pathogenic organisms. Fungi were isolated from the material obtained by biopsy in two patients. In addition, histological examination of the tissue obtained at biopsy led to the diagnosis of epidermoid carcinoma in two patients in whom this diagnosis had not been suspected before biopsy. Cultures were negative for mycobacteria in all patients. An additional ten patients who had a tibial non-union and latent osteomyelitis were studied. In nine of them, cultures of material obtained by needle biopsy showed no growth. Six of these nine patients had an exacerbation of the osteomyelitis after intramedullary nailing for the non-union. Therefore, the absence of growth of organisms from tissue obtained at needle biopsy does not rule out the possibility that osteomyelitis may be reactivated after intramedullary nailing with reaming.

PMID 2045400  J Bone Joint Surg Am. 1991 Jun;73(5):745-9.
著者: Thomas Gross, Achim H Kaim, Pietro Regazzoni, Andreas F Widmer
雑誌名: J Trauma. 2002 Jun;52(6):1210-9.
Abstract/Text
PMID 12045656  J Trauma. 2002 Jun;52(6):1210-9.
著者: P A Mackowiak, S R Jones, J W Smith
雑誌名: JAMA. 1978 Jun 30;239(26):2772-5.
Abstract/Text Sinus-tract cultures were compared with cultures of operative specimens from 40 patients with chronic osteomyelitis. Thirty-five patients (87.5%) had a single pathogen isolated from their operative specimens. Only 44% of the sinus-tract cultures contained the operative pathogen. Isolation of Staphyloccus aureus from sinus tracts correlated with the presence of S aureus in the operative specimen. However, less than half of the sinus-tract cultures obtained from patients with S aureus osteomyelitis contained this organism. Isolation of bacteria other than S aureus from sinus tracts had a low likelihood of predicting the pathogen isolated from bone. A presumptive diagnosis of S aureus osteomyelitis is justified if S aureus is isolated from an associated sinus tract. A bacteriologic diagnosis of chronic osteomyelitis based on isolation of common pathogens other than S aureus from sinus tracts must be verified by an appropriate operative culture.

PMID 349185  JAMA. 1978 Jun 30;239(26):2772-5.
著者: Eric Senneville, Hélène Morant, Dominique Descamps, Sophie Dekeyser, Eric Beltrand, Bruno Singer, Michèle Caillaux, Arnaud Boulogne, Laurence Legout, Xavier Lemaire, Christine Lemaire, Yazdan Yazdanpanah
雑誌名: Clin Infect Dis. 2009 Apr 1;48(7):888-93. doi: 10.1086/597263.
Abstract/Text BACKGROUND: Needle puncture has been suggested as a method for identifying bacteria in the bones in patients with diabetes with osteomyelitis of the foot. However, no studies have compared needle puncture with concomitant transcutaneous bone biopsy, which is the current standard recommended in international guidelines.
METHODS: We conducted a prospective study in 2 French diabetes foot clinics. Transcutaneous bone biopsy specimens, needle puncture specimens, and swab samples were collected on the same day for each patient.
RESULTS: Overall, 31 patients were included in the study from July 2006 through February 2008. Twenty-one bone biopsy specimens (67.7%), 18 needle puncture specimens (58%), and 30 swab samples (96.7%) had positive culture results. Staphylococcus aureus was the most common type of bacteria that grew from bone samples, followed by Proteus mirabilis and Morganella morganii. The mean number of bacteria types per positive sample were 1.35, 1.32, and 2.51 for bone biopsy specimens, needle puncture specimens, and swab samples, respectively. Among the 20 patients with positive bone biopsy specimens (69%), 13 had positive needle puncture samples. Overall, the correlation between microbiological results was 23.9%, with S. aureus showing the strongest correlation (46.7%). Results of cultures of bone biopsy and needle puncture specimens were identical for 10 (32.3%) of 31 patients. Bone bacteria were isolated from the needle punctures in 7 (33.3%) of the 21 patients who had positive bone biopsy specimen culture results. If the results of cultures of needle puncture specimens alone had been considered, 5 patients (16.1%) would have received unnecessary treatment, and 8 patients (38.1%) who had positive bone culture results would not have been treated at all.
CONCLUSIONS: Our results suggest that needle punctures, compared with transcutaneous bone biopsies, do not identify bone bacteria reliably in patients with diabetes who have low-grade infection of the foot and suspected osteomyelitis.

PMID 19228109  Clin Infect Dis. 2009 Apr 1;48(7):888-93. doi: 10.1086/・・・
著者: Irene G Sia, Elie F Berbari
雑誌名: Best Pract Res Clin Rheumatol. 2006 Dec;20(6):1065-81. doi: 10.1016/j.berh.2006.08.014.
Abstract/Text Osteomyelitis can result from hematogenous or contiguous microbial seeding of the bone. Staphylococcus aureus is the most common infecting microorganism. Although any bone can potentially develop osteomyelitis, long-bone, vertebral, and foot osteomyelitis account for the majority of cases. Confirmatory diagnosis of osteomyelitis often depends on the results of a bone biopsy and bone cultures. Radiologic and laboratory studies are often helpful in leading to the diagnosis, determining the extent of the disease, and following up selected patients with osteomyelitis. Optimal therapy for osteomyelitis requires the collaboration of a multidisciplinary team of physicians. Debridement is often needed in contiguous osteomyelitis, whereas acute hematogenous and vertebral osteomyelitis can often be treated with a prolonged course of antimicrobial therapy.

PMID 17127197  Best Pract Res Clin Rheumatol. 2006 Dec;20(6):1065-81. ・・・
著者: Ercole Concia, Napoleone Prandini, Leo Massari, Franco Ghisellini, Vincenzo Consoli, Francesco Menichetti, Elena Lazzeri
雑誌名: Nucl Med Commun. 2006 Aug;27(8):645-60.
Abstract/Text Bone infections represent a diagnostic or therapeutic challenge for the infectivologist, orthopaedic surgeon, radiologist and nuclear medicine physician. Staphylococcus aureus is the major bacterium responsible for bone infections although Mycobacterium tuberculosis is emerging as an infectious agent in Italy because of immigration from Africa and Asia. Osteomyelitis requires long and expensive antibiotic treatment, including rifampicin administered parenterally for several weeks and the use of antimicrobial-impregnated cement in prosthesis substitution. Sometimes it is necessary to carry out surgical debridement of a necrotic bone or the consolidation of compromised bones and joint prosthesis implants. Radiographs and bone cultures are mainstays for the diagnosis of bone infections but are often useless in the lengthy management of these patients. Diagnosis of skeletal infections still includes conventional radiography but magnetic resonance imaging is essential in haematogenous and spinal infections. Bone scans are still useful in acute osteomyelitis whereas scintigraphy using labelled white blood cells is preferred in infections of peripheral bone segments or joint prosthesis. In the axial skeleton a combination of an agent for detecting inflammation ((67)Ga citrate) and a metabolic agent ((99m)Tc-methylene diphosphonate) enables an infection and an area of increased metabolic activity to be distinguished. [(18)F]Fluorodeoxyglucose positron emission tomography, where available, has a significant impact in the study of infections using radionuclides: high-resolution tomographic images represent an effective alternative to gallium in the assessment of inflammation of spine lesions but a comparison with morphological examinations (computed tomography or magnetic resonance imaging) is essential.

PMID 16829765  Nucl Med Commun. 2006 Aug;27(8):645-60.
著者: Lew Daniel P DP, Waldvogel Francis A FA
雑誌名: Lancet. 2004 Jul 24-30;364(9431):369-79. doi: 10.1016/S0140-6736(04)16727-5.
Abstract/Text Bone and joint infections are painful for patients and frustrating for both them and their doctors. The high success rates of antimicrobial therapy in most infectious diseases have not yet been achieved in bone and joint infections owing to the physiological and anatomical characteristics of bone. The key to successful management is early diagnosis, including bone sampling for microbiological and pathological examination to allow targeted and long-lasting antimicrobial therapy. The various types of osteomyelitis require differing medical and surgical therapeutic strategies. These types include, in order of decreasing frequency: osteomyelitis secondary to a contiguous focus of infection (after trauma, surgery, or insertion of a joint prosthesis); that secondary to vascular insufficiency (in diabetic foot infections); or that of haematogenous origin. Chronic osteomyelitis is associated with avascular necrosis of bone and formation of sequestrum (dead bone), and surgical debridement is necessary for cure in addition to antibiotic therapy. By contrast, acute osteomyelitis can respond to antibiotics alone. Generally, a multidisciplinary approach is required for success, involving expertise in orthopaedic surgery, infectious diseases, and plastic surgery, as well as vascular surgery, particularly for complex cases with soft-tissue loss.

PMID 15276398  Lancet. 2004 Jul 24-30;364(9431):369-79. doi: 10.1016/S・・・
著者: Carlos Pineda, Rolando Espinosa, Angelica Pena
雑誌名: Semin Plast Surg. 2009 May;23(2):80-9. doi: 10.1055/s-0029-1214160.
Abstract/Text The diagnostic imaging of osteomyelitis can require the combination of diverse imaging techniques for an accurate diagnosis. Conventional radiography should always be the first imaging modality to start with, as it provides an overview of the anatomy and the pathologic conditions of the bone and soft tissues of the region of interest. Sonography is most useful in the diagnosis of fluid collections, periosteal involvement, and surrounding soft tissue abnormalities and may provide guidance for diagnostic or therapeutic aspiration, drainage, or tissue biopsy. Computed tomography scan can be a useful method to detect early osseous erosion and to document the presence of sequestrum, foreign body, or gas formation but generally is less sensitive than other modalities for the detection of bone infection. Magnetic resonance imaging is the most sensitive and most specific imaging modality for the detection of osteomyelitis and provides superb anatomic detail and more accurate information of the extent of the infectious process and soft tissues involved. Nuclear medicine imaging is particularly useful in identifying multifocal osseous involvement.

PMID 20567730  Semin Plast Surg. 2009 May;23(2):80-9. doi: 10.1055/s-0・・・
著者: Carlos Pineda, Angélica Vargas, Alfonso Vargas Rodríguez
雑誌名: Infect Dis Clin North Am. 2006 Dec;20(4):789-825. doi: 10.1016/j.idc.2006.09.009.
Abstract/Text Osteomyelitis frequently requires more than one imaging technique for an accurate diagnosis. Conventional radiography still remains the first imaging modality. MRI and nuclear medicine are the most sensitive and specific methods for the detection of osteomyelitis. MRI provides more accurate information regarding the extent of the infectious process. Ultrasound represents a noninvasive method to evaluate the involved soft tissues and cortical bone and may provide guidance for diagnostic or therapeutic aspiration, drainage, or tissue biopsy. CT scan can be a useful method to detect early osseous erosion and to document the presence of sequestra. PET and SPECT are highly accurate techniques for the evaluation of chronic osteomyelitis, allowing differentiation from soft tissue infection.

PMID 17118291  Infect Dis Clin North Am. 2006 Dec;20(4):789-825. doi: ・・・
著者: Alok Kapoor, Stephanie Page, Michael Lavalley, Daniel R Gale, David T Felson
雑誌名: Arch Intern Med. 2007 Jan 22;167(2):125-32. doi: 10.1001/archinte.167.2.125.
Abstract/Text BACKGROUND: Uncertainty exists regarding the optimal workup of patients with suspected osteomyelitis of the foot, many of whom have diabetes mellitus. We conducted a meta-analysis to determine the diagnostic test performance of magnetic resonance imaging (MRI) for osteomyelitis of the foot and compared this performance with that of technetium Tc 99m bone scanning, plain radiography, and white blood cell studies.
METHODS: We searched MEDLINE (from 1966 to week 3 of June 2006) and EMBASE (from 1980 to week 3 of June 2006) for English-language studies in which adults suspected of having osteomyelitis of the foot or ankle were evaluated by MRI. We then extracted data using a standard form derived from the Cochrane Methods Group. To summarize the performance of diagnostic tests, we used the summary receiver operating characteristic curve analysis, which relies on the calculation of the diagnostic odds ratio (DOR). We also examined subsets of studies defined by the presence or absence of particular design flaws or populations.
RESULTS: Sixteen studies met inclusion criteria. In all studies combined, the DOR for MRI was 42.1 (95% confidence interval, 14.8-119.9), and the specificity at a 90% sensitivity cut point was 82.5%. The DOR did not vary greatly among subsets of studies. In studies in which a direct comparison could be made with other technologies, the DOR for MRI was consistently better than that for bone scanning (7 studies-149.9 vs 3.6), plain radiography (9 studies-81.5 vs 3.3), and white blood cell studies (3 studies-120.3 vs 3.4).
CONCLUSIONS: We found that MRI performs well in the diagnosis of osteomyelitis of the foot and ankle and can be used to rule in or rule out the diagnosis. Magnetic resonance imaging performance was markedly superior to that of technetium Tc 99m bone scanning, plain radiography, and white blood cell studies.

PMID 17242312  Arch Intern Med. 2007 Jan 22;167(2):125-32. doi: 10.100・・・
著者: Termaat M F MF, Raijmakers P G H M PG, Scholten H J HJ, Bakker F C FC, Patka P P, Haarman H J T M HJ
雑誌名: J Bone Joint Surg Am. 2005 Nov;87(11):2464-71. doi: 10.2106/JBJS.D.02691.
Abstract/Text BACKGROUND: A variety of diagnostic imaging techniques is available for excluding or confirming chronic osteomyelitis. Until now, an evidence-based algorithmic model for choosing the most suitable imaging technique has been lacking. The objective of this study was to determine the accuracy of current imaging modalities in the diagnosis of chronic osteomyelitis.
METHODS: A systematic review and meta-analysis of the literature was conducted with a comprehensive search of the MEDLINE, EMBASE, and Current Contents databases to identify clinical studies on chronic osteomyelitis that evaluated diagnostic imaging modalities. The value of each imaging technique was studied by determining its sensitivity and specificity compared with the results of histological analysis, findings on culture, and clinical follow-up of more than six months.
RESULTS: A total of twenty-three clinical studies in which the accuracy was described for radiography (two studies), magnetic resonance imaging (five), computed tomography (one), bone scintigraphy (seven), leukocyte scintigraphy (thirteen), gallium scintigraphy (one), combined bone and leukocyte scintigraphy (six), combined bone and gallium scintigraphy (three), and fluorodeoxyglucose positron emission tomography (four) were included in the review. No meta-analysis was performed with respect to computed tomography, gallium scintigraphy, and radiography. Pooled sensitivity demonstrated that fluorodeoxyglucose positron emission tomography was the most sensitive technique, with a sensitivity of 96% (95% confidence interval, 88% to 99%) compared with 82% (95% confidence interval, 70% to 89%) for bone scintigraphy, 61% (95% confidence interval, 43% to 76%) for leukocyte scintigraphy, 78% (95% confidence interval, 72% to 83%) for combined bone and leukocyte scintigraphy, and 84% (95% confidence interval, 69% to 92%) for magnetic resonance imaging. Pooled specificity demonstrated that bone scintigraphy had the lowest specificity, with a specificity of 25% (95% confidence interval, 16% to 36%) compared with 60% (95% confidence interval, 38% to 78%) for magnetic resonance imaging, 77% (95% confidence interval, 63% to 87%) for leukocyte scintigraphy, 84% (95% confidence interval, 75% to 90%) for combined bone and leukocyte scintigraphy, and 91% (95% confidence interval, 81% to 95%) for fluorodeoxyglucose positron emission tomography. The sensitivity of leukocyte scintigraphy in detecting chronic osteomyelitis in the peripheral skeleton was 84% (95% confidence interval, 72% to 91%) compared with 21% (95% confidence interval, 11% to 38%) for its detection of chronic osteomyelitis in the axial skeleton. The specificity of leukocyte scintigraphy in the axial skeleton was 60% (95% confidence interval, 39% to 78%) compared with 80% (95% confidence interval, 61% to 91%) for the peripheral skeleton.
CONCLUSIONS: Fluorodeoxyglucose positron emission tomography has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis. Leukocyte scintigraphy has an appropriate diagnostic accuracy in the peripheral skeleton, but fluorodeoxyglucose positron emission tomography is superior for detecting chronic osteomyelitis in the axial skeleton.

PMID 16264122  J Bone Joint Surg Am. 2005 Nov;87(11):2464-71. doi: 10.・・・
著者: Alan D Tice, Pamela A Hoaglund, David A Shoultz
雑誌名: Am J Med. 2003 Jun 15;114(9):723-8.
Abstract/Text PURPOSE: To examine the effects of diabetes, vascular disease, age, and antimicrobial therapy on clinical outcomes, including amputation rates, in patients with osteomyelitis treated in the outpatient setting.
METHODS: We performed a retrospective chart review of patients treated with intravenous antimicrobial therapy for osteomyelitis at an outpatient infectious diseases practice. All patients were followed for at least 6 months.
RESULTS: Four hundred and fifty-four patients qualified for inclusion, with follow-up information available for up to 10 years. One hundred and thirty-nine patients (31%) had recurrences and 27 (6%) had amputations. Of the recurrences, 108 (78%) occurred within 6 months and 132 (95%) within 1 year. In univariate analyses, peripheral vascular disease, diabetes, and the combination were all associated with the risk of recurrence; age (>70 years) was not. For osteomyelitis due to Staphylococcus aureus, the relative risk of recurrence, using a Cox regression model, was 0.8 for ceftriaxone (95% confidence interval [CI]: 0.4 to 1.5; P = 0.53), 1.1 for cefazolin (95% CI: 0.5 to 2.2; P = 0.80), and 2.5 for vancomycin (95% CI: 1.1 to 5.6; P = 0.04), as compared with the use of a penicillinase-resistant penicillin.
CONCLUSION: Diabetes and peripheral vascular disease are important factors in determining the prognosis of patients with osteomyelitis, but age is not. Almost all recurrences of osteomyelitis occur within 1 year. Recurrence rates with osteomyelitis associated with S. aureus appear to be higher with the use of vancomycin, whereas ceftriaxone and cefazolin appear to be similar to penicillinase-resistant penicillins.

PMID 12829198  Am J Med. 2003 Jun 15;114(9):723-8.
著者: Perlroth Joshua J, Kuo Melissa M, Tan Jennifer J, Bayer Arnold S AS, Miller Loren G LG
雑誌名: Arch Intern Med. 2008 Apr 28;168(8):805-19. doi: 10.1001/archinte.168.8.805.
Abstract/Text BACKGROUND: Staphylococcus aureus causes severe life-threatening infections and has become increasingly common, particularly methicillin-resistant strains. Rifampin is often used as adjunctive therapy to treat S aureus infections, but there have been no systematic investigations examining the usefulness of such an approach.
METHODS: A systematic review of the literature to identify in vitro, animal, and human investigations that compared single antibiotics alone and in combination with rifampin therapy against S aureus.
RESULTS: The methods of in vitro studies varied substantially among investigations. The effect of rifampin therapy was often inconsistent, it did not necessarily correlate with in vivo investigations, and findings seemed heavily dependent on the method used. In addition, the quality of data reporting in these investigations was often suboptimal. Animal studies tended to show a microbiologic benefit of adjunctive rifampin use, particularly in osteomyelitis and infected foreign body infection models; however, many studies failed to show a benefit of adjunctive therapy. Few human studies have addressed the role of adjunctive rifampin therapy. Adjunctive therapy seems most promising for the treatment of osteomyelitis and prosthetic device-related infections, although studies were typically underpowered and benefits were not always seen.
CONCLUSIONS: In vitro results of interactions between rifampin and other antibiotics are method dependent and often do not correlate with in vivo findings. Adjunctive rifampin use seems promising in the treatment of clinical hardware infections or osteomyelitis, but more definitive data are lacking. Given the increasing incidence of S aureus infections, further adequately powered investigations are needed.

PMID 18443255  Arch Intern Med. 2008 Apr 28;168(8):805-19. doi: 10.100・・・
著者: Norden C W CW, Bryant R R, Palmer D D, Montgomerie J Z JZ, Wheat J J
雑誌名: South Med J. 1986 Aug;79(8):947-51.
Abstract/Text A controlled trial of treatment of chronic osteomyelitis caused by Staphylococcus aureus compared nafcillin alone with nafcillin plus rifampin for a six-week period. Treatment was well tolerated, the only adverse effect being mild neutropenia in four of 18 patients; no toxicity was observed from rifampin. Eight of ten patients in the combined treatment group had a favorable clinical response (with follow-up of two to four years) as compared to four of eight in the nafcillin group (P = .2). Despite the failure to show a statistically significant advantage of rifampin plus nafcillin, we conclude that the combination, along with appropriate surgery, should be considered for patients with chronic staphylococcal osteomyelitis.

PMID 3526570  South Med J. 1986 Aug;79(8):947-51.
著者: Van der Auwera P P, Klastersky J J, Thys J P JP, Meunier-Carpentier F F, Legrand J C JC
雑誌名: Antimicrob Agents Chemother. 1985 Oct;28(4):467-72.
Abstract/Text A total of 101 patients with proven Staphylococcus aureus infection were included in a double-blind, placebo-controlled study; this study compared oxacillin (12 g/day, intravenously) or vancomycin (2 g/day, intravenously) plus rifampin (1,200 mg/day, orally) with oxacillin or vancomycin plus placebo. We evaluated 65 patients. Of the patients tested, 33 received oxacillin plus rifampin (13 bacteremias), and 32 received oxacillin plus placebo (16 bacteremias). Clinical cure was achieved in 61% of the patients treated with oxacillin plus rifampin and in 56% of the patients treated with oxacillin plus placebo. Improvement was noted in 27 and 25%, respectively, and failure occurred in 9 and 18%, respectively. These differences were not statistically significant. Bacteriological failure occurred in 3 and 28%, respectively (P less than 0.05). None of the failures within the rifampin-treated group was associated with the emergence of a rifampin-resistant mutant. The rates of superinfection were similar in both groups. The geometric means of the serum bactericidal activity after 1, 6, and 11 h were, respectively, 22, 17, and 9 after treatment with oxacillin plus rifampin and 25, 3.4, and 2.3 after treatment with oxacillin plus placebo. It was suggested that the addition of rifampin to oxacillin or vancomycin might only be beneficial to severely ill patients.

PMID 3907494  Antimicrob Agents Chemother. 1985 Oct;28(4):467-72.
著者: Priest David H DH, Peacock James E JE Jr
雑誌名: South Med J. 2005 Sep;98(9):854-62.
Abstract/Text OBJECTIVE: Staphylococcus aureus is the most common cause of hematogenous vertebral osteomyelitis in adults. To better define clinical features and therapeutic outcomes, the charts of 40 adult patients with S aureus hematogenous vertebral osteomyelitis were retrospectively reviewed.
METHODS: Retrospective chart review using standardized data collection form.
RESULTS: S aureus hematogenous vertebral osteomyelitis commonly occurred in the settings of recent invasive procedures (55% of patients), insulin use (28%), and hemodialysis (20%). Ten percent of patients had S aureus bacteremia or vascular catheter infection within the preceding 6 months. Median time from first symptom to diagnosis was 51.3 days. A portal of entry for S aureus was identified in 13 patients (32.5%); intravenous catheters were the likely origin in 9 of those 13 patients. Concurrent endocarditis was present in 4 patients. Forty-eight percent of patients had neurologic abnormalities and 60% of patients had an epidural, paraspinous, or psoas abscess demonstrated by neuroimaging. S aureus was isolated through fine-needle aspiration in 17 of 23 patients (74%) and from blood cultures in 23 of 34 patients (68%). Infection was due to methicillin-susceptible S aureus in 67.5% of patients. All patients received intravenous antibiotics for a mean duration of 58.6 days; 36 of 40 (90%) also received concomitant rifampin. Twenty-seven percent and 12.5% of patients underwent surgical debridement and CT-guided drainage of abscesses, respectively. After intravenous therapy, 19 of 30 eligible patients received oral continuation treatment. The mean duration of total antibiotic therapy was 142.2 days.
CONCLUSIONS: Cure of infection was achieved in 83% (24/29) of evaluable patients, but 50% of those achieving cure still had infection-related sequelae. Intravenous antibiotic therapy for at least 8 weeks was the only clinical factor associated with cure (P = 0.05, two-tailed Fisher exact test).

PMID 16217976  South Med J. 2005 Sep;98(9):854-62.
著者: Livorsi Daniel J DJ, Daver Naval G NG, Atmar Robert L RL, Shelburne Samuel A SA, White A Clinton AC Jr, Musher Daniel M DM
雑誌名: J Infect. 2008 Aug;57(2):128-31. doi: 10.1016/j.jinf.2008.04.012. Epub 2008 Jun 17.
Abstract/Text OBJECTIVES: Hematogenous vertebral osteomyelitis is caused predominantly by Staphylococcus aureus. The rise in incidence of methicillin-resistant S. aureus (MRSA) has complicated the treatment of this infection. Our objective was to evaluate therapeutic outcomes for S. aureus vertebral osteomyelitis in a setting of high MRSA prevalence.
METHODS: We conducted a retrospective chart review of all patients who presented with S. aureus vertebral osteomyelitis over a 7-year period at 2 tertiary care hospitals in Houston, TX, USA.
RESULTS: Thirty-five patients were identified who received > or =2-week course of parenteral antibiotics and had a follow-up period of at least 12 months post-therapy. MRSA was responsible for 20 (57%) cases. Mean duration of total antibiotic therapy was 61.4 days. The overall relapse rate was 14%. At 12 months post-therapy, 86% patients were cured. The one factor significantly associated with relapse was presence of undrained abscesses (p=0.04).
CONCLUSIONS: When the mean duration of effective antibiotic therapy was 60 days, cure rates for S. aureus vertebral osteomyelitis exceeded 80%. Drainage of all associated abscesses correlated with a significantly higher rate of cure.

PMID 18562009  J Infect. 2008 Aug;57(2):128-31. doi: 10.1016/j.jinf.20・・・
著者: Liu Catherine C, Bayer Arnold A, Cosgrove Sara E SE, Daum Robert S RS, Fridkin Scott K SK, Gorwitz Rachel J RJ, Kaplan Sheldon L SL, Karchmer Adolf W AW, Levine Donald P DP, Murray Barbara E BE, J Rybak Michael M, Talan David A DA, Chambers Henry F HF
雑誌名: Clin Infect Dis. 2011 Feb 1;52(3):285-92. doi: 10.1093/cid/cir034.
Abstract/Text Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.

PMID 21217178  Clin Infect Dis. 2011 Feb 1;52(3):285-92. doi: 10.1093/・・・
著者: Carragee E J EJ, Kim D D, van der Vlugt T T, Vittum D D
雑誌名: Spine (Phila Pa 1976). 1997 Sep 15;22(18):2089-93.
Abstract/Text STUDY DESIGN: Retrospective chart review of 44 cases.
OBJECTIVE: To describe the clinical usage of the erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis.
SUMMARY OF BACKGROUND DATA: The erythrocyte sedimentation rate is often used to determine the efficacy and duration of treatment in pyogenic vertebral osteomyelitis. Although consensus and anecdotal reports support this notion, no detailed review of the erythrocyte sedimentation rate response in conservative treatment of pyogenic vertebral osteomyelitis has been made, to date.
METHODS: For 44 patients with pyogenic vertebral osteomyelitis who had erythrocyte sedimentation rate testing at or before the time of diagnosis and at least twice during the next month, the clinical findings and results of the erythrocyte sedimentation rate testing were reviewed.
RESULTS: Of 18 cases with no significant fall in the erythrocyte sedimentation rate during the first month, 9 (50%) failed conservative treatment. Conversely, of the 26 cases with a good erythrocyte sedimentation rate response during the first month, three (12%) were clinical failures. However, a rapid decline of the erythrocyte sedimentation rate (> 50% in the first month) is rarely seen in treatment failure. In addition, approximately 2 weeks after antibiotic treatment, 19 of 32 were actually higher than at the time of diagnosis, but went on to clinical cure without surgery. The erythrocyte sedimentation rate, in combination with the patient's age and immune status, predicted the success of antibiotic treatment, in most cases. The erythrocyte sedimentation rate response alone during the first month was not a clear predictor of success.
CONCLUSIONS: Although the erythrocyte sedimentation rate does correlate well with response to treatment as a general rule, care must be taken in interpretation of a persistently elevated or even rising erythrocyte sedimentation rate as an isolated clinical finding.

PMID 9322319  Spine (Phila Pa 1976). 1997 Sep 15;22(18):2089-93.
著者: Palestro Christopher J CJ, Love Charito C, Miller Theodore T TT
雑誌名: Best Pract Res Clin Rheumatol. 2006 Dec;20(6):1197-218. doi: 10.1016/j.berh.2006.08.009.
Abstract/Text Imaging procedures are routinely used to evaluate patients suspected of having musculoskeletal infection. Radiographs should be performed whenever musculoskeletal infection is suspected. Even when not diagnostic, radiographs are useful. They provide an anatomic overview of the region of interest, including pre-existing conditions that could influence the selection and interpretation of subsequent procedures. Magnetic resonance imaging (MRI) is sensitive, provides superb anatomic detail, does not use ionizing radiation, and is rapidly completed. This technique is especially valuable for septic arthritis, spinal osteomyelitis, and diabetic foot infections. Among the radionuclide procedures, three-phase bone imaging is readily available, and very accurate in unviolated bone. Labeled leukocyte imaging should be used in cases of 'complicating osteomyelitis' such as prosthetic joint infections. This test is also useful in unsuspected diabetic pedal osteomyelitis and the neuropathic joint. Gallium imaging is a useful adjunct to MIR in spinal infection. 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) will likely play an important role, especially in the evaluation of spinal infection.

PMID 17127204  Best Pract Res Clin Rheumatol. 2006 Dec;20(6):1197-218.・・・
著者: Guhlmann A A, Brecht-Krauss D D, Suger G G, Glatting G G, Kotzerke J J, Kinzl L L, Reske S N SN
雑誌名: Radiology. 1998 Mar;206(3):749-54.
Abstract/Text PURPOSE: To evaluate use of positron emission tomography (PET) with 2-(fluorine-18) fluoro-2-deoxy-D-glucose (FDG) in detection of chronic osteomyelitis.
MATERIALS AND METHODS: Thirty-one patients suspected to have chronic osteomyelitis in the peripheral (n = 21) or central (n = 10) skeleton were evaluated prospectively with FDG PET. Analysis of the receiver operating characteristic curve was performed. The final diagnosis was made by means of bacteriologic culture of surgical specimens and histopathologic analysis.
RESULTS: FDG PET allowed identification of 17 of 18 patients with osteomyelitis and 12 of 13 without osteomyelitis. There was one false-positive and one equivocal result. The area under the ROC curve was 0.96 for all patients, 1.00 for patients suspected to have osteomyelitis in the peripheral skeleton, and 0.88 for patients suspected to have osteomyelitis in the central skeleton. The overall accuracy of FDG PET was 97% with a high degree of interobserver concordance (kappa = 0.93). The overall sensitivity and specificity were 100% and 92%, respectively.
CONCLUSION: FDG PET enables noninvasive detection and demonstration of the extent of chronic osteomyelitis with a high degree of accuracy. Especially in the central skeleton within active bone marrow, FDG PET is highly accurate and shows great promise in diagnosis of chronic osteomyelitis.

PMID 9494496  Radiology. 1998 Mar;206(3):749-54.
著者: Schmitz A A, Risse J H JH, Grünwald F F, Gassel F F, Biersack H J HJ, Schmitt O O
雑誌名: Eur Spine J. 2001 Dec;10(6):534-9.
Abstract/Text Nuclear medicine procedures can be helpful in diagnosing spine infections. The purpose of the study was to evaluate the findings of positron emission tomography with fluorine-18 fluorodeoxyglucose (FGD-PET) in the detection of spondylodiscitis. We performed FDG-PET in 16 patients with suspected spondylodiscitis. All the patients were operated and underwent histopathological examination. The FDG-PET findings were graded and evaluated by two independent nuclear medicine physicians. Of the 16 patients, 12 had a histopathologically confirmed spondylodiscitis. In all these 12 patients, FDG-PET was true-positive. In the four patients without spondylodiscitis, FDG-PET showed three true-negative and one false-positive result. In spondylodiscitis, the mean standard uptake value (SUV) of FDG was 7.5 (SD+/-3.8). The PET scans depicted the paravertebral soft tissue involvement in cases of spondylodiscitis. Our first results showed that FDG-PET is a very sensitive imaging procedure in the detection of spondylodiscitis. Compared to other nuclear medicine procedures, PET enables a rapid imaging with acceptable radiation dose and high spatial resolution.

PMID 11806396  Eur Spine J. 2001 Dec;10(6):534-9.
著者: Keidar Zohar Z, Militianu Daniela D, Melamed Eyal E, Bar-Shalom Rachel R, Israel Ora O
雑誌名: J Nucl Med. 2005 Mar;46(3):444-9.
Abstract/Text UNLABELLED: Osteomyelitis complicates up to one third of diabetic foot infections, is often due to direct contamination from a soft-tissue lesion, and represents a clinical challenge. Early diagnosis is important since antibiotic therapy can be curative and may prevent amputation. The present study assessed the role of PET/CT using 18F-FDG for the diagnosis of diabetic foot osteomyelitis.
METHODS: Fourteen diabetic patients (10 men and 4 women; age range, 29-70 y) with 18 clinically suspected sites of infection underwent PET/CT after the injection of 185-370 MBq of 18F-FDG for suspected osteomyelitis complicating diabetic foot disease. PET, CT, and hybrid images were independently evaluated for the diagnosis and localization of an infectious process. Additional data provided by PET/CT for localization of infection in the bone or soft tissues were recorded. The final diagnosis was based on histopathologic findings and bacteriologic assays obtained at surgery or at clinical and imaging follow-up.
RESULTS: PET detected 14 foci of increased 18F-FDG uptake suspected as infection in 10 patients. PET/CT correctly localized 8 foci in 4 patients to bone, indicating osteomyelitis. PET/CT correctly excluded osteomyelitis in 5 foci in 5 patients, with the abnormal 18F-FDG uptake limited to infected soft tissues only. One site of mildly increased focal 18F-FDG uptake was localized by PET/CT to diabetic osteoarthropathy changes demonstrated on CT. Four patients showed no abnormally increased 18F-FDG uptake and no further evidence of an infectious process on clinical and imaging follow-up.
CONCLUSION: 18F-FDG PET can be used for diagnosis of diabetes-related infection. The precise anatomic localization of increased 18F-FDG uptake provided by PET/CT enables accurate differentiation between osteomyelitis and soft-tissue infection.

PMID 15750157  J Nucl Med. 2005 Mar;46(3):444-9.
著者: Basu Sandip S, Chryssikos Timothy T, Houseni Mohamed M, Scot Malay D D, Shah Jagruti J, Zhuang Hongming H, Alavi Abass A
雑誌名: Nucl Med Commun. 2007 Jun;28(6):465-72. doi: 10.1097/MNM.0b013e328174447f.
Abstract/Text BACKGROUND: This paper is based on the results from an ongoing prospective trial designed to investigate the usefulness of FDG PET in the complicated diabetic foot.
AIM: To investigate the potential utility of FDG PET imaging in the setting of acute neuropathic osteoarthropathy (Charcot's foot).
PATIENTS AND METHODS: A total of 63 patients, in four groups, were evaluated. The groups were: (A) 17 patients with a clinical diagnosis of Charcot's neuroarthropathy (11 men, six women; mean age: 59.4+/-8.6 years); (B) 21 patients with uncomplicated diabetic foot (16 men, five women; mean age: 63+/-10 years); (C) 20 non-diabetic patients with normal lower extremities (12 men, eight women; mean age 54+/-19 years); and (D) five patients with proven osteomyelitis secondary to complicated diabetic foot (three men, two women; mean age: 61.2+/-13.9 years). Five patients in group A had foot ulcer and intermediate to high degree of suspicion for superimposed osteomyelitis. Each subject underwent FDG PET imaging of the lower extremities in addition to MRI and the findings were compared with the final diagnostic outcome based on histopathology and clinical follow-up. The images were examined visually for focal abnormalities. Regions of interest were assigned to the sites of abnormal FDG uptake for calculating maximum standardized uptake value (SUVmax). Two important clinical decision-making issues were explored: (1) whether FDG PET shows a definitive uptake pattern in Charcot's neuroarthropathy and if so whether that could be utilized to differentiate it from other complicated forms of diabetic foot like osteomyelitis and cellulitis, which is frequently a diagnostic challenge in this clinical setting; and (2) how accurate FDG PET is in detection soft tissue infection in patients with Charcot's foot. These issues were examined by utilizing FDG PET findings along with MRI results in the same patient.
RESULTS: We observed a low degree of diffuse FDG uptake in the Charcot's joints. This was clearly distinguishable from the normal joints. The SUVmax in the Charcot's lesions varied from 0.7 to 2.4 (mean, 1.3+/-0.4) while those of midfoot of the normal control subjects and the uncomplicated diabetic foot ranged from 0.2 to 0.7 (mean 0.42+/-0.12) and from 0.2 to 0.8 (mean 0.5+/-0.16), respectively. The only patient with Charcot's foot with superimposed osteomyelitis had an SUVmax of 6.5. The SUVmax of the sites of osteomyelitis as a complication of diabetic foot was 2.9-6.2 (mean: 4.38+/-1.39). Unifactorial analysis of variance test yielded a statistical significance in the SUVmax between the four groups (P<0.01). The SUVmax between the normal control groups and the uncomplicated diabetic foot was not statistically significant by the Student's t-test (P>0.05). In the setting of concomitant foot ulcer FDG PET accurately ruled out osteomyelitis. Overall sensitivity and accuracy of FDG PET in the diagnosis of Charcot's foot was 100 and 93.8%, respectively; and for MRI were 76.9 and 75%, respectively. FDG PET showed foci of abnormally enhanced uptake in the soft tissue which was suggestive of inflammation in seven cases (43.75%) which were proven pathologically to be secondary to infection. In only two of these cases the features of soft tissue infection were noted on the magnetic resonance images.
CONCLUSION: The results support a valuable role of FDG PET in the setting of Charcot's neuroarthropathy by reliably differentiating it from osteomyelitis both in general and when foot ulcer is present.

PMID 17460537  Nucl Med Commun. 2007 Jun;28(6):465-72. doi: 10.1097/MN・・・
著者: Werner Zimmerli
雑誌名: N Engl J Med. 2010 Mar 18;362(11):1022-9. doi: 10.1056/NEJMcp0910753.
Abstract/Text
PMID 20237348  N Engl J Med. 2010 Mar 18;362(11):1022-9. doi: 10.1056/・・・
著者: J C Kosmidis, V Corbett, A J Cole, R G Finch, J E Barker, A M Geddes
雑誌名: Br J Clin Pract. 1973 Aug;27(8):315-8.
Abstract/Text
PMID 4586639  Br J Clin Pract. 1973 Aug;27(8):315-8.
著者: Feigin R D RD, Pickering L K LK, Anderson D D, Keeney R E RE, Shackleford P G PG
雑誌名: Pediatrics. 1975 Feb;55(2):213-23.
Abstract/Text Forty-eight children, 1 month to 14 years of age, including 11 patients with untreated acute osteomyelitis, 8 with pretreated acute osteomyelitis, 12 with septic arthritis, and 11 with cellulitis or soft tissue abscess, were treated with clindamycin. Staphylococcus aureus was isolated from the blood, synovial fluid, bone, or soft tissues of 27 of these individuals while group A, beta-hemolytic streptococci or Clostridia were isolated from 9 patients. Clindamycin was provided intravenously until patients were afebrile for three days followed by orally administered clindamycin for one week in patients with cellulitis to as long as six months in patients with chronic osteomyelitis. Clinical and bacteriologic responses to treatment generally were excellent, most likely reflecting the excellent serum and tissue concentrations of clindamycin which were achieved. Serum concentrations of clindamycin following intravenous infusion at 20 to 30 mg/kg/day in three divided doses were 8- to 32-fold in excess of the minimal inhibitory concentrations of all organisms isolated in this study. Bone and synovial fluid concentrations of clindamycin were 60% to 85% of the serum concentrations measured concomitantly. Clindamycin provides an effective alternative treatment of osteomyelitis and septic arthritis in children who are sensitive to penicillin.

PMID 1118208  Pediatrics. 1975 Feb;55(2):213-23.
著者: R G Finch, I Phillips
雑誌名: J Antimicrob Chemother. 1975 Sep;1(3):297-303.
Abstract/Text
PMID 1102515  J Antimicrob Chemother. 1975 Sep;1(3):297-303.
著者: A M Geddes, N S Dwyer, A P Ball, R S Amos
雑誌名: J Antimicrob Chemother. 1977 Sep;3(5):501-7.
Abstract/Text
PMID 332683  J Antimicrob Chemother. 1977 Sep;3(5):501-7.
著者: Rodriguez W W, Ross S S, Khan W W, McKay D D, Moskowitz P P
雑誌名: Am J Dis Child. 1977 Oct;131(10):1088-93.
Abstract/Text Clindamycin phosphate was used in the treatment of 29 children with osteomyelitis of whom 25 had an acute and four a chronic type of infection. The usual dose was 50 mg/kg/day intravenously for approximately three weeks followed by oral clindamycin palmitate at home in a dose of 30 mg/kg/day for an additional six weeks. Staphylococcus aureus was isolated in 22 of 29 cases: 96% of strains were penicillin resistant. The clinical and bacteriologic results in the present series were good to excellent. There was prompt clinical and bacteriologic response shortly after initiation of clindamycin therapy. Good bone penetration of the drug was observed. Long-term evaluation revealed satisfactory clinical and roentgenographic progress in all patients. No diarrhea or manifestations of enterocolitis appeared in any patient in spite of high doses of the drug for intervals up to nine weeks.

PMID 910760  Am J Dis Child. 1977 Oct;131(10):1088-93.
著者: Kaplan S L SL, Mason E O EO Jr, Feigin R D RD
雑誌名: South Med J. 1982 Feb;75(2):138-42.
Abstract/Text The treatment of osteomyelitis due to Staphylococcus aureus was evaluated by randomized trial in 12 children who received clindamycin and 13 children who received nafcillin or methicillin. In the nafcillin/methicillin group, the mean duration of intravenous (IV) therapy was 27 days (range 14 to 38 days) plus 3.7 weeks (range 0 to 8 weeks) of oral therapy with dicloxacillin. In the clindamycin group, the mean duration of IV therapy was 5.8 days (range three to ten days) plus 4.7 weeks (range three to nine weeks) of oral therapy with clindamycin. The geometric means (GMs) of peak serum bactericidal titers for IV therapy were 45 (range 16 to 256) and seven (2 to 256) for nafcillin/methicillin and clindamycin respectively. The GMs of peak serum inhibitory and bactericidal titers for oral therapy with clindamycin were 99 (range 16 to 512) and four (range 1 to 128) and were generally within one dilution of the IV titer. The outcome of therapy was excellent for ten children in the nafcillin/methicillin group and for 11 children in the clindamycin group. In the clindamycin group, the outcome did not correlate with achieving a peak bactericidal titer of greater than 1:8. Clindamycin administered IV until the patient is afebrile for three consecutive days and then orally for approximately four weeks is an alternative to nafcillin/methicillin in the therapy of S aureus osteomyelitis in children.

PMID 7036354  South Med J. 1982 Feb;75(2):138-42.
著者: Calhoun Jason H JH, Manring M M MM
雑誌名: Infect Dis Clin North Am. 2005 Dec;19(4):765-86. doi: 10.1016/j.idc.2005.07.009.
Abstract/Text Adult osteomyelitis remains difficult to treat, with considerable morbidity and costs to the health care system. Bacteria reach bone through the bloodstream, from a contiguous focus of infection, from penetrating trauma, or from operative intervention. Bone necrosis begins early, limiting the possibility of eradicating the pathogens, and leading to a chronic condition. Appropriate treatment includes culture-directed antibiotic therapy and operative debridement of all necrotic bone and soft tissue. Treatment often involves a combination of antibiotics. Operative treatment is often staged and includes debridement, dead space management, soft tissue coverage, restoration of blood supply, and stabilization. Clinicians and patients must share a clear understanding of the goals of treatment and the difficulties that may persist after the initial course of therapy or surgical intervention. Chronic pain and recurrence of infection still remain possible even when the acute symptoms of adult osteomyelitis have resolved.

PMID 16297731  Infect Dis Clin North Am. 2005 Dec;19(4):765-86. doi: 1・・・
著者: C W Norden, D R Dickens
雑誌名: J Infect Dis. 1973 May;127(5):525-8.
Abstract/Text
PMID 4698640  J Infect Dis. 1973 May;127(5):525-8.
著者: Roblot F F, Besnier J M JM, Juhel L L, Vidal C C, Ragot S S, Bastides F F, Le Moal G G, Godet C C, Mulleman D D, Azaïs I I, Becq-Giraudon B B, Choutet P P
雑誌名: Semin Arthritis Rheum. 2007 Apr;36(5):269-77. doi: 10.1016/j.semarthrit.2006.09.004. Epub 2007 Jan 3.
Abstract/Text OBJECTIVES: To compare the risk of relapse of vertebral osteomyelitis (VO), according to the duration of antibiotic therapy (< or =6 weeks versus >6 weeks).
METHODS: We performed a 10-year retrospective study to assess the risk of VO relapse and to verify that this risk was not enhanced in patients who received 6 weeks of antibiotic therapy (Group 1) as compared with those who received a longer treatment (Group 2). VO was diagnosed based on clinical manifestations, magnetic resonance imaging and/or computed tomography findings, and isolation of a pyogenic organism in blood cultures and/or a discovertebral biopsy. Relapse was diagnosed based on isolation of the same organism in blood cultures and/or a discovertebral biopsy. Outcome was evaluated 6 months post-treatment and in December 2004.
RESULTS: Group 1 included 36 patients (mean age, 58 +/- 15 years) and Group 2 included 84 patients (mean age, 67 +/- 15 years) (P = 0.003). Clinical data and microorganisms were comparable in the 2 groups. In the first 6 months, 6 (5%) patients died (Group 1, n = 2; Group 2, n = 4), and 5 (4%) in Group 2 relapsed, 2 with recurrent VO and 3 with recurrent bacteremia. In 2004, 91 patients were evaluated (mean follow-up, 40.6 +/- 31 months): 77 (85%) were cured, 13 (14%) died (Group 1, n = 3; Group 2, n = 10), 1 had VO due to a different microorganism (Group 2), and no long-term relapses occurred.
CONCLUSION: Our results suggest that antibiotic therapy of VO could be safely shortened to 6 weeks without enhancing the risk of relapse.

PMID 17207522  Semin Arthritis Rheum. 2007 Apr;36(5):269-77. doi: 10.1・・・
著者: Kowalski Todd J TJ, Berbari Elie F EF, Huddleston Paul M PM, Steckelberg James M JM, Mandrekar Jayawant N JN, Osmon Douglas R DR
雑誌名: Clin Infect Dis. 2007 Apr 1;44(7):913-20. doi: 10.1086/512194. Epub 2007 Feb 14.
Abstract/Text BACKGROUND: Spinal implant infections provide unique diagnostic and therapeutic challenges.
METHODS: We conducted a retrospective cohort study to evaluate risk factors for treatment failure in patients with early- and late-onset spinal implant infections at the Mayo Clinic (Rochester, MN) during 1994-2002.
RESULTS: We identified 30 patients with early-onset spinal implant infection and 51 patients with late-onset spinal implant infection. Twenty-eight of 30 patients with early-onset infection were treated with debridement, implant retention, and antimicrobial therapy. The estimated 2-year cumulative probability of survival free of treatment failure for patients with early-onset infection was 71% (95% confidence interval [CI], 51%-85%). Thirty-two of 51 patients with late-onset infection were treated with implant removal. Their estimated 2-year cumulative probability of survival free of treatment failure was 84% (95% CI, 66%-93%). For patients with early-onset infections, receiving oral antimicrobial suppression therapy was associated with increased cumulative probability of survival (hazard ratio, 0.2; 95% CI, 0.1-0.7). For patients with late-onset infections, implant removal was associated with increased cumulative probability of survival (hazard ratio, 0.3; 95% CI, 0.1-0.7).
CONCLUSIONS: Early-onset spinal implant infections are successfully treated with debridement, implant retention, and parenteral followed by oral suppressive antimicrobial therapy. Implant removal is associated with successful outcomes in late-onset infections.

PMID 17342641  Clin Infect Dis. 2007 Apr 1;44(7):913-20. doi: 10.1086/・・・
著者: Zimmerli W W, Widmer A F AF, Blatter M M, Frei R R, Ochsner P E PE
雑誌名: JAMA. 1998 May 20;279(19):1537-41.
Abstract/Text CONTEXT: Rifampin-containing regimens are able to cure staphylococcal implant-related infections based on in vitro and in vivo observations. However, this evidence has not been proven by a controlled clinical trial.
OBJECTIVE: To evaluate the clinical efficacy of a rifampin combination in staphylococcal infections associated with stable orthopedic devices.
DESIGN: A randomized, placebo-controlled, double-blind trial conducted from 1992 through 1997.
SETTING: Two infectious disease services in tertiary care centers in collaboration with 5 orthopedic surgeons in Switzerland.
PATIENTS: A total of 33 patients with culture-proven staphylococcal infection associated with stable orthopedic implants and with a short duration of symptoms of infection (exclusion limit <1 year; actual experience 0-21 days).
INTERVENTION: Initial debridement and 2-week intravenous course of flucloxacillin or vancomycin with rifampin or placebo, followed by either ciprofloxacin-rifampin or ciprofloxacin-placebo long-term therapy.
MAIN OUTCOME MEASURES: Cure was defined as (1) lack of clinical signs and symptoms of infection, (2) C-reactive protein level less than 5 mg/L, and (3) absence of radiological signs of loosening or infection at the final follow-up visit at 24 months. Failure was defined as (1) persisting clinical and/or laboratory signs of infection or (2) persisting or new isolation of the initial microorganism.
RESULTS: A total of 18 patients were allocated to ciprofloxacin-rifampin and 15 patients to the ciprofloxacin-placebo combination. Twenty-four patients fully completed the trial with a follow-up of 35 and 33 months. The cure rate was 12 (100%) of 12 in the ciprofloxacin-rifampin group compared with 7 (58%) of 12 in the ciprofloxacin-placebo group (P=.02). Nine of 33 patients dropped out due to adverse events (n=6), noncompliance (n=1), or protocol violation (n=2). Seven of the 9 patients who dropped out were subsequently treated with rifampin combinations, and 5 of them were cured without removal of the device.
CONCLUSION: Among patients with stable implants, short duration of infection, and initial debridement, patients able to tolerate long-term (3-6 months) therapy with rifampin-ciprofloxacin experienced cure of the infection without removal of the implant.

PMID 9605897  JAMA. 1998 May 20;279(19):1537-41.
著者: Dunbar J A T JA, Sandoe J A T JA, Rao A S AS, Crimmins D W DW, Baig W W, Rankine J J JJ
雑誌名: Clin Radiol. 2010 Dec;65(12):974-81. doi: 10.1016/j.crad.2010.03.015. Epub 2010 Jul 7.
Abstract/Text AIM: To describe the magnetic resonance imaging (MRI) appearances in patients with a clinical history suggestive of vertebral osteomyelitis and discitis who underwent MRI very early in their clinical course.
MATERIALS AND METHODS: A retrospective review of the database of spinal infections from a spinal microbiological liaison team was performed over a 2 year period to identify cases with clinical features suggestive of spinal infection and an MRI that did not show features typical of vertebral osteomyelitis and discitis. All patients had positive microbiology and a follow up MRI showing typical features of spinal infection.
RESULTS: In four cases the features typical of spinal infection were not evident at the initial MRI. In three cases there was very subtle endplate oedema associated with disc degeneration, which was interpreted as Modic type I degenerative endplate change. Intravenous antibiotic therapy was continued prior to repeat MRI examinations. The mean time to the repeat examination was 17 days with a range of 8-22 days. The second examinations clearly demonstrated vertebral osteomyelitis and discitis.
CONCLUSION: Although MRI is the imaging method of choice for vertebral osteomyelitis and discitis in the early stages, it may show subtle, non-specific endplate subchondral changes; a repeat examination may be required to show the typical features.

Copyright © 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
PMID 21070900  Clin Radiol. 2010 Dec;65(12):974-81. doi: 10.1016/j.cra・・・
著者: Blumberg H M HM, Rimland D D, Carroll D J DJ, Terry P P, Wachsmuth I K IK
雑誌名: J Infect Dis. 1991 Jun;163(6):1279-85.
Abstract/Text The fluoroquinolones, particularly ciprofloxacin, have been suggested to treat methicillin-resistant Staphylococcus aureus (MRSA) infections and colonization and methicillin-susceptible S. aureus (MSSA) infections. The development of ciprofloxacin resistance in MRSA and MSSA was prospectively evaluated. After 3 months of ciprofloxacin use, high-level resistance (MIC90, 64 micrograms/ml) developed in MRSA and increased at an alarming rate, from none to 79% over a 1-year period. High-level ciprofloxacin resistance also developed in MSSA, increasing to 13.6% over the same period. Antibiograms, phage typing, and plasmid profile analysis suggest that more than one clone of MRSA developed resistance and that ciprofloxacin resistance is not associated with the acquisition of a new plasmid. Most patients had nosocomial acquisition and about one-half had a history of previous ciprofloxacin use. Ciprofloxacin resistance can develop rapidly in S. aureus; thus, ciprofloxacin appears to have limited usefulness in treating staphylococcal infections and colonization, especially those due to MRSA.

PMID 2037793  J Infect Dis. 1991 Jun;163(6):1279-85.
著者: Stein A A, Bataille J F JF, Drancourt M M, Curvale G G, Argenson J N JN, Groulier P P, Raoult D D
雑誌名: Antimicrob Agents Chemother. 1998 Dec;42(12):3086-91.
Abstract/Text We examined the effectiveness and safety of high-dose oral co-trimoxazole (trimethoprim-sulfamethoxazole) for the treatment of orthopedic implants infected with multidrug-resistant Staphylococcus species. The prospective study was conducted between 1989 and 1997 in a university medical center with ambulatory-care services. Patients eligible for the study consisted of those from whom multidrug-resistant Staphylococcus spp. organisms susceptible only to glycopeptides and co-trimoxazole were isolated from their orthopedic implants and for whom there was no contraindication to the treatment. All patients were treated orally with high-dose co-trimoxazole (trimethoprim, 20 mg/kg of body weight/day; sulfamethoxazole, 100 mg/kg/day). Patients with prosthetic hip infections were treated for 6 months, with removal of any unstable prosthesis after 5 months of treatment; patients with prosthetic knee infections were treated for 9 months, with removal of any unstable prosthesis after 6 months of treatment; and patients with infected osteosynthetic devices were treated for 6 months, with removal of the device after 3 months of treatment, if necessary. Monthly clinical evaluations were conducted until the completion of the treatment, and follow-up examinations were conducted regularly for up to 6 years. The overall treatment success rate was 66.7% (26 of 39 patients), with success rates of 62.5% for patients with prosthetic knee infections, 50% for those with prosthetic hip infections, and 78.9% for those with other device infections. Seventeen of the 28 (60.7%) patients who did not have any orthopedic material removed were cured. Eight patients stopped the treatment because of side effects, and one patient was not compliant. In three patients treatment failed because of the appearance of a resistant bacterium. Long-term oral ambulatory treatment with co-trimoxazole appears to be an effective alternative to the conventional medicosurgical treatment of chronic multidrug-resistant Staphylococcus-infected orthopedic implants which includes long-term intravenous antibiotic therapy combined with surgical debridement and removal of foreign material or its subsequent one- or two-stage replacement.

PMID 9835495  Antimicrob Agents Chemother. 1998 Dec;42(12):3086-91.
著者: Goulet J A JA, Pellicci P M PM, Brause B D BD, Salvati E M EM
雑誌名: J Arthroplasty. 1988;3(2):109-16.
Abstract/Text Nineteen periprosthetic infections after total hip arthroplasty were treated with prolonged suppressive antibiotics without removing the components. In 11, antibiotic therapy was monitored with serum bactericidal titers. Eleven had incision and drainage. Indications included patients' refusal of removal or medical contraindications to surgery. Requirements included well-fixed components, highly sensitive organisms, and no systemic sepsis. The follow-up period averaged 4.1 years after treatment. Nine hips showed no deterioration. Seven prostheses failed, five with progressive hip sepsis. Three patients had increasing symptoms without prosthesis removal. Although two-stage reimplantation is preferred, suppressive antibiotics and prosthesis retention can succeed in some patients and may be considered in old, frail patients with an early infection caused by bacteria responsive to oral antibiotic therapy. Suppressive therapy may also be considered for an otherwise compliant patient who refuses removal of an infected prosthesis. The organism must be sensitive to oral antibiotics, and the patient must be tolerant of the antibiotics.

PMID 3397740  J Arthroplasty. 1988;3(2):109-16.
著者: Drancourt M M, Stein A A, Argenson J N JN, Roiron R R, Groulier P P, Raoult D D
雑誌名: J Antimicrob Chemother. 1997 Feb;39(2):235-40.
Abstract/Text Oral therapy of staphylococcal infection of orthopaedic implants with 900 mg/day rifampicin combined with either 1.5 g/day fusidic acid for 5 days followed by 1 g/day thereafter, or 600 mg/day ofloxacin was compared. Patients with an infected hip were treated for 6 months, with removal of any unstable prosthesis after 5 months' treatment and those with an infected knee prosthesis were treated for 9 months, with removal of the prosthesis after 6 months of treatment. Patients with infections of other type of bone implants were treated for 6 months with removal of the implant after 3 months of treatment, if necessary. Cure was defined as the absence of clinical, microbiological and radiological evidence of infection 12 months after completion of treatment. The treatment of 46 of the 52 included in the study was evaluated for safety and that of 42 was assessed for efficacy. Overall treatment was successful for 11 (55%) of 20 patients treated with rifampicin and fusidic acid group and for 11 (50%) of the 22 treated with rifampicin and ofloxacin. Treatment failed in four cases in each treatment group because of persistent infection. One patient given rifampicin and fusidic acid and three patients given rifampicin and ofloxacin failed treatment because of relapse. Superinfection led to failure in the remainder and was due to staphylococci in all but one case in which Acinetobacter calcoaceticus var. anitratus was isolated. There were no side effects related to study treatment. Oral treatment with rifampicin combined with fusidic acid may be a suitable alternative to the combination of rifampicin and ofloxacin for treating implant infections due to Staphylococcus spp. either when the patient is intolerant to quinolones or when the infecting organism is resistant to these drugs.

PMID 9069545  J Antimicrob Chemother. 1997 Feb;39(2):235-40.
著者: Segreti J J, Nelson J A JA, Trenholme G M GM
雑誌名: Clin Infect Dis. 1998 Oct;27(4):711-3.
Abstract/Text Prolonged suppressive antibiotic therapy may be an alternative to removal of infected orthopedic prostheses in some patients. However, the efficacy of prolonged suppressive antibiotics is not well established. We retrospectively reviewed 18 patients with infected orthopedic prostheses who had been treated with prolonged antimicrobial suppression during the last 10 years. Eighteen episodes of infection were identified in these 18 patients. There were nine men and nine women, and the mean age was 66 years (range, 31-83 years). All patients had a functional prosthesis and were treated with surgical debridement, retention of the prosthesis, and administration of intravenous antibiotics for 6-8 weeks, followed by prolonged oral antibiotic suppression. Fifteen of the 18 patients appear to have had a good response and have been able to retain a functional prosthesis. Complications related to antibiotic suppression occurred in 22% but did not necessitate discontinuation of the antibiotic therapy. Prolonged antibiotic suppression is a reasonable alternative to surgery in selected patients with infected orthopedic prostheses.

PMID 9798021  Clin Infect Dis. 1998 Oct;27(4):711-3.
著者: Izawa Kazutaka K
雑誌名: Nihon Rinsho. 2011 Aug;69(8):1413-6.
Abstract/Text As the incidence of tuberculosis in Japan decreases, osteoarticular tuberculosis becomes relatively rare. Therefore, it is often overlooked or misdiagnosed that leads to cryptic aggravation of the disease. On the other hand, because of population aging in Japan, degenerative conditions such as compression vertebral fracture or osteoarthritis should be considered as differential diagnoses of osteoarticular tuberculosis. In addition, we should beware of extra-pulmonary tuberculosis in the patients who undergo biological agent therapy for rheumatoid arthritis that has been advanced drastically in recent years. Surgical treatment for osteoarticular tuberculosis is still an essential part of its treatment in order to achieve early rehabilitation and rapid healing of the lesion.

PMID 21838039  Nihon Rinsho. 2011 Aug;69(8):1413-6.
著者: Takahashi Y Y, Mizuno H H, Go T T, Kawarazaki S S, Shindo T T, Aoki M M, Tamura K K, Wada H H, Hitomi S S
雑誌名: Nihon Kyobu Shikkan Gakkai Zasshi. 1991 Jun;29(6):753-7.
Abstract/Text A 48-year-old male was referred to our division, on the suspicion of lung cancer with bone metastasis. Chest radiography showed a mass shadow and bone scintigram demonstrated multiple scattered regions of increased uptake. However bronchial and bone biopsy specimens revealed granuloma with epithelial cells and giant cells. A diagnosis of tuberculous osteomyelitis was made, and antituberculous therapy was begun. Chest radiography and bone scintigrams one year later showed marked improvement.

PMID 1895593  Nihon Kyobu Shikkan Gakkai Zasshi. 1991 Jun;29(6):753-7・・・
著者: Oshika H H, Abe T T, Hattori N N, Maeda H H, Ogasawara T T, Suzuki M M, Totani Y Y, Senda Y Y
雑誌名: Kekkaku. 1995 Aug;70(8):477-81.
Abstract/Text A 47-year old woman was admitted to our hospital with complaints of headache and right occipital swelling. Brain CT scan showed right occipital bone defect with a sequestrum and soft tissue swelling. T1 weighted MRI enhanced by GD-DTPA revealed several nodules. A right occipital craniotomy was performed. Subcutaneous pus and a well-circumscribed yellowish, firm mass which existed under the bone defect was extirpated. Pathologically, this mass was considered to be a tuberculoma and intracranial nodules were suspected to be cerebral tuberculosis. Anti-tuberculous therapy was started. Since her admission fecal occult blood continued and endoscopic examination with biopsy revealed sigmoid colon cancer. Sigmoidectomy was performed and she has been well during 1 year post-operative follow up. Although tuberculous disease are decreasing in number in our country, we must take into account of the existence of skull tuberculosis.

PMID 7564059  Kekkaku. 1995 Aug;70(8):477-81.
著者: Vohra R R, Kang H S HS, Dogra S S, Saggar R R RR, Sharma R R
雑誌名: J Bone Joint Surg Br. 1997 Jul;79(4):562-6.
Abstract/Text Tuberculous osteomyelitis which does not involve a joint is uncommon and may fail to be diagnosed by an orthopaedic surgeon. We treated 28 lesions of tuberculous osteomyelitis in 25 patients between 1988 and 1995. The duration of symptoms was from two to 39 months, and most of our patients had been treated initially with non-steroidal anti-inflammatory drugs which failed to provide relief. Bone pain which does not promptly respond to analgesic medication is often due to infection or neoplasia. In the early stages, when plain radiographs are normal, MRI or CT may help to localise lesions. On plain radiographs, more advanced lesions may mimic chronic pyogenic osteomyelitis, Brodie's abscess, tumours or granulomatous lesions. Biopsy is mandatory to confirm the diagnosis, and antituberculous drugs are the mainstay of treatment. When operative findings at biopsy have the features of skeletal tuberculosis curettage of the affected bone may promote earlier healing.

PMID 9250739  J Bone Joint Surg Br. 1997 Jul;79(4):562-6.
著者: Johnson Melissa D. MD, Perfect John R. JR
雑誌名: Curr Infect Dis Rep. 2001 Oct;3(5):450-460.
Abstract/Text Osteoarticular complications may occur with a variety of invasive fungal infections, and seem to be increasing with growing use of prosthetic joints and as the immunosuppressed patient population increases. Epidemiology, pathogenesis, presentation, and management strategies differ somewhat among the different fungal species. This review focuses on recent developments in diagnostic and management approaches for patients with osteoarticular mycoses, and outlines specific treatment strategies for the different species.

PMID 11559466  Curr Infect Dis Rep. 2001 Oct;3(5):450-460.
著者: Miller D J DJ, Mejicano G C GC
雑誌名: Clin Infect Dis. 2001 Aug 15;33(4):523-30. doi: 10.1086/322634. Epub 2001 Jul 20.
Abstract/Text Candida species uncommonly cause vertebral osteomyelitis. We present a case of lumbar vertebral osteomyelitis caused by Candida albicans and review 59 cases of candidal vertebral osteomyelitis reported in the literature. The mean age was 50 years, and the lower thoracic or lumbar spine was involved in 95% of patients. Eighty-three percent of patients had back pain for >1 month, 32% presented with fever, and 19% had neurological deficits. The erythrocyte sedimentation rate was elevated in 87% of patients, and blood culture yielded Candida species for 51%. C. albicans was responsible for 62% of cases, Candida tropicalis for 19%, and Candida glabrata for 14%. Risk factors for candidal vertebral osteomyelitis were the presence of a central venous catheter, antibiotic use, immunosuppression, and injection drug use. Medical and surgical therapies were both used, and amphotericin B was the primary antifungal agent. Prognosis was good, with an overall clinical cure rate of 85%.

PMID 11462190  Clin Infect Dis. 2001 Aug 15;33(4):523-30. doi: 10.1086・・・
著者: Malani Preeti N PN, McNeil Shelly A SA, Bradley Suzanne F SF, Kauffman Carol A CA
雑誌名: Clin Infect Dis. 2002 Dec 1;35(11):1316-20. doi: 10.1086/344192. Epub 2002 Nov 7.
Abstract/Text Eleven patients developed deep sternal wound infections due to Candida albicans after undergoing coronary artery bypass grafting (CABG) and were assessed. Six had sternal osteomyelitis, 1 had osteomyelitis and mediastinitis, and 4 had deep wound infections that probably involved bone. Seven patients experienced onset of infection within 28 days of CABG, but 4 experienced onset 48-150 days after CABG. Infections were characterized by a chronic, indolent course requiring prolonged treatment with an antifungal agent. Delay in initiating antifungal therapy was common. All patients were treated with fluconazole, and 1 also received amphotericin B. Six patients underwent incision and drainage, with or without wire removal, and 3 underwent sternectomy with placement of a muscle flap. Of 10 patients for whom follow-up data were available, 7 were cured after initial therapy (median duration of treatment, 6 months), and 3 experienced a relapse and required a second course of fluconazole.

PMID 12439793  Clin Infect Dis. 2002 Dec 1;35(11):1316-20. doi: 10.108・・・
著者: Hendrickx L L, Van Wijngaerden E E, Samson I I, Peetermans W E WE
雑誌名: Clin Infect Dis. 2001 Feb 15;32(4):527-33. doi: 10.1086/318714. Epub 2001 Feb 6.
Abstract/Text The incidence of deep-seated candidal infection is increasing, but candidal vertebral osteomyelitis is still rare. We describe 6 patients recently treated in our hospital. Conservative treatment failed in all. We reviewed the literature and identified 59 additional cases of candidal vertebral osteomyelitis. Candidemia was documented in 61.5% of them. The interval between the diagnosis of candidemia and the onset of symptoms of vertebral osteomyelitis varied widely, from days to >1 year. In patients without documented candidemia, there was a similar interval between the occurrence of risk factors for candidemia (present in 72% of the patients) and the onset of symptoms of vertebral osteomyelitis. Clinical, laboratory, and radiological findings are not specific for candidal spondylodiskitis. Final diagnosis is determined by means of culture of a biopsy specimen from the infected vertebra or disk. Treatment consisted of prolonged antifungal treatment, and it often included surgery. On the basis of our experience (for all 6 patients, initial conservative treatment with only antifungals failed), we recommend consideration of early surgical debridement in combination with prolonged antifungal therapy.

PMID 11181113  Clin Infect Dis. 2001 Feb 15;32(4):527-33. doi: 10.1086・・・
著者: Jensen A G AG, Espersen F F, Skinhøj P P, Frimodt-Møller N N
雑誌名: Arch Intern Med. 1998 Mar 9;158(5):509-17.
Abstract/Text BACKGROUND: The incidence of hematogenous Staphylococcus aureus osteomyelitis of the vertebral column is rapidly increasing and few studies dealing with the diagnosis, treatment, and outcome of this severe disease are available.
METHODS: Based on a nationwide registration, the clinical and bacteriological data were reviewed from 133 cases with a positive blood culture for S aureus and symptoms of vertebral osteomyelitis in Denmark for the period 1980 to 1990.
RESULTS: The 133 cases of vertebral S aureus osteomyelitis reviewed were mainly community-acquired infections (82%) in older patients (median age, 65 years) and often occurred with underlying diseases. Both symptoms and laboratory values were relatively unspecific. Bone scan methods proved to be more optimal for diagnosis of vertebral S aureus osteomyelitis in the early stages compared with conventional radiography that proved a lack of consistency in the formative stages. The infection was mostly (70%) localized in the lower part of the column. The recurrence rate and rate of therapeutic failure depended on the duration and dosage of penicillinase-stable penicillins, respectively. Patients treated with fusidic acid in addition to penicillinase-stable penicillins had a significantly lower recurrence rate. Based on these findings, we recommend treatment with penicillinase-stable penicillins and fusidic acid for a total of 8 weeks, with a daily dosage of penicillinase-stable penicillins higher than 4 g.
CONCLUSIONS: The diagnosis of vertebral S aureus osteomyelitis based on clinical findings is difficult to ascertain. Bone scans are necessary because radiographic methods do not detect disease as early. Treatment with penicillinase-stable penicillins, at least 4 g/d for at least 8 weeks, is recommended.

PMID 9508229  Arch Intern Med. 1998 Mar 9;158(5):509-17.

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(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから