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Osteomyelitis

MagazineJuly 2002 (Vol. 13 Issue 4)Osteomyelitis

Q Could you suggest an alternative to the antibiotic flucloxacillin? I was alarmed to read in WDDTY that it can create liver damage, particularly in the elderly (I am 69), if taken for more than two weeks

Q Could you suggest an alternative to the antibiotic flucloxacillin? I was alarmed to read in WDDTY that it can create liver damage, particularly in the elderly (I am 69), if taken for more than two weeks.


In 1997, I was diagnosed with osteomyelitis in three thoracic vertebrae, and was prescribed a five-month course of amoxycillin and flucloxacillin.


When it recurred three years later, I had a three-month course of the same antibiotics. I am now convinced it has flared up for a third time and am waiting for a bone scan to confirm this. In view of the numerous X-rays, bone and MRI (magnetic resonance imaging) scans I've had during the past six years, do you think it advisable to forego this and move straight onto antibiotics? If so, which one? - NB, via e-mail


A Osteomyelitis, as you know, is an infection of the bone - in your case, of the spine. Often, it follows some sort of trauma - surgery or fractures - joint disease or sickle-cell anaemia. With chronic cases of this condition, you can predict its onset by a general feeling of chronic fatigue and malaise, fever and pain.


The usual first-line orthodox treatment is antibiotics, surgery (to clean out the infection and scrape away or remove diseased bone or dead tissue) and, on rare occasions, bone grafts.


In chronic osteomyelitis, some doctors recommend surgery plus four to six weeks of intravenous antibiotics, plus local antibiotics (beads, spacers or coated implants, which deliver a steady stream of antibiotic to the offending infection) (J Clin Orthop, 1999; March: 47-65).


There are several possible reasons why your osteomyelitis keeps returning. You haven't told us whether it followed an operation but, if so, it could be the presence of foreign or dead matter at the site of the infection.


You could also have a condition that compromises your ability to heal, such as diabetes, steroid use, smoking or a nutritional deficiency. It could also be that the bacteria causing your condition (usually Staphylococcus aureus, S. epidermidis or Pseudomonas aeruginosa) are resistant to the heavy-duty antibiotics your doctor has prescribed. In one study of seven patients with methicillin-resistant S. aureus (MRSA), five had bacterial organisms in addition to MRSA (Clin Orthop, 1985; Sept: 231-9).


It may not be necessary for you to undergo the entire battery of tests your doctor wishes to give you all over again. According to Dr Randall King, program director of the Department of Emergency Medicine at Saint Vincent Mercy Medical Center in Ohio, only two of four criteria are necessary to diagnose osteomyelitis: a positive lab test of bone tissue or blood culture; a positive finding of infected tissue taken from the affected bone; the presence of physical symptoms like local tenderness of the bone and swelling of the tissue overlying it; and a positive test on radiological imaging, such as X-ray or MRI (eMed J, 2002; 3: www. emedicine.com/EMERG/topic).


Ask your doctor if you can take two laboratory tests and a careful physical examination rather than the radiological testing all over again.


Both the antibiotics your doctor has prescribed are penicillin derivatives. The usual rationale in treating osteomyelitis is to blast away at the highly resistant S. aureus with a combination antibiotic, so if one doesn't work, two (particularly one that is new and exotic) just might do the job. Naturally, you increase your potential for side-effects the more drugs you take together.


As you rightly say, flucloxacillin may cause liver damage and, with prolonged courses, the manufacturer (SmithKline Beecham Pharmaceuticals) recommends that your kidney and liver function be monitored regularly. Cases of hepatitis and cholestatic jaundice have also been reported with this drug. More worryingly, these side-effects can appear up to two months after your treatment has ended and carry on for many months.


These liver or kidney problems may be fatal, but usually only in patients who have an underlying disease.


Amoxycillin, on the other hand, is a common-or-garden penicillin used to treat ear, sinus and bladder infections and is also a first-line treatment for osteomyelitis. It is often prescribed in combination with another drug.


On rare occasions, amoxycillin can cause jaundice, hepatitis, or blood disorders such as leukopenia (low white blood cells) or thrombocytopenia (low blood platelets). But, overall, this is an older and better-tolerated drug.


If you have to take antibiotics for any reason, a good rule of thumb is to opt for the oldest, simplest variety with the longest track record of safety.


As amoxycillin itself is indicated for osteomyelitis, you could ask your doctor to let you take this drug on its own - once he has isolated the offending bug and determined whether it will respond to this antibiotic.

Another typical antibiotic used for S. aureus-resistant osteomyelitis is vancomycin (Clin Orthop, 1985; Sept: 231-9), but this drug can also cause kidney failure or hearing loss.


Whichever drug you use and whenever you embark on this type of prolonged treatment, your doctor should regularly monitor you with liver and kidney function tests.


As antibiotics have failed to cure your problem in the past, you may wish to take a different tack altogether, and investigate hyperbaric oxygen (HBO) therapy. In this treatment, you are given 100 per cent oxygen at two to three times the normal atmospheric pressure in a special chamber.


Delivering this additional pressurised oxygen increases the amount of oxygen in the blood and, thus, the amount available to the tissues which, in turn, promotes healing and your body's ability to fight infection.


HBO helps to inhibit the growth of many microorganisms and increases the ability of your immune system's leukocytes to kill the offending microorganisms. No study has shown any side-effects (Orthop Clin North Am, 1991; 22: 467-71).


This alternative treatment is fast gaining acceptance even among orthodox medical practitioners for a number of conditions, particularly wound healing. It has been used in a variety of medical centres in America to heal cases of gangrene and slow-to-heal wounds, burns, abscesses particularly inside the skull, diabetic ulcers, skin grafts that aren't 'taking' properly, exceptional anaemia, burns due to radiotherapy and postoperative infections as well as osteomyelitis (S Afr J Surg, 2001; 39: 117; Undersea Hyperb Med, 1997; 24: 175-9; Clin Podiatr Med Surg, 1990; 7: 483-92; J Invest Surg, 1989; 2: 409-21; Neurosurgery, 2002; 50: 287-95). HBO is routinely used at the University of Texas Medical Branch in Galveston to treat patients with osteomyelitis.


The usual procedure is one session per day for one and a half to three hours at two to three atmospheres of 100 per cent oxygen (Clin Orthop, 1999; March: 47-65). Although this is usually used as an adjunct to antibiotic therapy, you may wish to investigate whether it is effective on its own or with a simple antibiotic like amoxycillin. Its effectiveness on its own has only been attempted in certain animal trials and, although it worked well, such results may not apply to humans. Also, the effect was more pronounced when antibiotics were used together with the HBO therapy (Undersea Hyperb Med, 1999; 26: 169-74).


HBO has been found to be effective in chronic cases of osteomyelitis, particularly those with resistant S. aureus. In one study of five patients with seven episodes of infection, five of the seven infections cleared after a regime of antibiotics plus HBO (Clin Orthop, 1985; Nov: 231-9). In another, larger study of 70 patients with refractory (difficult to treat) osteomyelitis who underwent surgery or received antibiotics and HBO, all were improved and 63 per cent remained cured (Postgrad Med, 1977; 61: 70-6).


You might also wish to investigate ozone therapy, which can also kill bacteria, particularly in necrotic bone. This has been used successfully in animals with osteomyelitis although, again, such results may not apply to humans (Eur Arch Otorhinolaryngol, 1999; 256: 153-7). See WDDTY vol 11 no 11 for a list of practitioners who offer oxygen therapy in the UK.


A tax on the sweet

Arava

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