Chronic Osteomyelitis: Time for a Paradigm Shift in Delivery of Care?

Chronic osteomyelitis: is it time for a paradigm shift in our delivery of care? Dr Tony Berendt Consultant Physician Bone Infection Unit Nuffield Orthopaedic Centre Oxford University© byHospitals author NHS Trust

nd ESCMID22 OnlineECCMID, LectureLondon, 2012 Library Declaration of interests

• No commercial interests • I am a medical manager as well as a practising clinician • I have worked on a multi-disciplinary unit for the management of bone and joint infection for over 15 years

ESCMID Online Lecture Library Bone Infection Unit, NOC, OUH

3rd Oxford Bone Infection Conference,ESCMID Oxford,Online Lecture March Library 2013

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ESCMID Online Lecture Library The challenge • 44 yr old male • History of paraplegia, illicit drug dependency in past • Previous pressure sores treated and reconstructed • Recurrent ulceration and episodes of sepsis including proven E coli bacteremia • Readmitted with sepsis; massive pressure sores with pelvic osteomyelitis • Low albumin, BMI low, malnourished • Diazepam dependency© by author • “Difficult” patient

ESCMID Online Lecture Library PATIENT DIAGNOSIS

5 47 female Osteomyelitis of coccyx & sacrum & multiple intra- abdominal collections + wound/drain site dehiscence. PMH: Ulcerative colitis, badly controlled Type 1 diabetic, Diabetic neuropathy, depression. L foot charcot joint. Sub-total colectomy- ileostomy. Parastomal hernia. Grade 4 sacral pressure sore. 6 73 male Failed 2 stage elsewhere and 3 repeat first stage debridements, referred on 3 months iv. Rx 7 64 male Recurrent E coli bacteraemias, R native hip now Girdlestone, persistent bacteraemias, ? ongoing pelvic or L hip involvement 8 69 male Multiple revised© by R TKR author elsewhere, further 2 stage in progress, confusion, fractured and revised spacer, wound still leaking 9 25 female Infected spinal metalware on suppression, breakthrough ESCMIDinfection Online now Stenotrophomonas, Lecture Library previous ESBL E coli 10 67 male Infected R Girdlestone (done elsewhere), CVA, schizophrenia, asthma, risk of falls. Benign essential tremor. VRE, recurrent seromas 11 38 male Pedicle flap to chronic sacral ulcer 18.1.12 transferred to ITU with respiratory failure. PMH: RTA, tetraplegic, asthma, PE 2008, C6 cord transaction. Bilateral girdlestones. 12 68 female L5 Discitis, has leg ulcers on L leg and R heel has dry sore PMH: Chronic ETOH, Leg ulcers both legs, lymphodoema, PVD, cirrhosis and varices 13 67 female Native R knee joint MSSA septic arthritis and bacteraemia, recurrent bacteraemia post treatment and aggressive destruction of L hip now Girdlestone © by author 15 36 female Excision osteomyelitis left tibia. PMH: Type 1DM, hiatus hernis CKD, asthma, hyperthyroidism (previous thyroidectomy for Graves) ESCMID Online Lecture Library 16 52 male RO infected plate L knee and gastroc flap (20/2/12) 1 6

17 61 male L total femoral replacement for sarcoma, 2 stage revision for infection, breakthrough infection after 2 years suppression, history of on table cardiac arrest and hypoxic brain injury. Sinuses at each end of femur 18 47 male Excision of Infected Bone L Femur + Local Flap 22/2/12. Ex IVDU still on Methadone 19 71 male Infected bilateral Girdlestones of hips. Pericarditis PMH-bilateral lymphadenectomy 2002, iliac abscess 2009, septic arthritis© hips,by Caauthor penis 20 39 male Infected grade 4 pressure sore. For 3 day assessment from Exeter PMH: paraplegia secondary to RTA 1991, OM R femur and ESCMIDR hip, Online anaemia, Prev Lecture alcohol addiction. Library 21 67 male MRSA Spinal abscess not for surgery, 2 : NIDDM, Schizophrenia, 1 23 46 male Osteomyelitis Pelvis-for assessment 1 grade 4 and 1 grade 2 pressure sore right buttock, BKA (1999) following burst femoral artery, T12 paraplegia following fall, 2 metal rods spine 1988, L hip joint removal 1998, Allergy to penicillin 24 47 female Excision Osteomyelitis Lt calcaneum + free flap 27/2/12, peri-op ITU transfer due to bronchial plugging Allergic to penicillin 25 73 female 2 stage revision© L TKR,by authorlymphoedema of leg, bowel Ca – in remission, coronary stent. VRE

ESCMID Online Lecture Library Osteomyelitis: a historical disease

“My sins sicken me like pus in my bones Help me Jesus, Lamb of God, for I am sinking in deepest slime”

Therapeutic nihilism © by author Ineffective ESCMID Onlinetreatment Lecture Library Clinical manifestations

• Diabetic foot • Other decubiti, mainly pelvic or femoral • Long bone • Vertebral • Sternal post sternotomy • Skull base • Osteochondritis of foot • Mandible © by author • Osteitis pubis

ESCMID Online Lecture Library What we know

• Pathogenesis • Pathophysiology of the chronic osteomyelitic lesion • Diagnosis and treatment can be difficult • Good outcomes are possible…..

ESCMID Online Lecture Library Pathogenesis • Access of pathogen • Haematogenous • Contiguous focus • Contiguous infection as site of entry to bone • Chronic soft tissue loss as cause • Pathogen factors • Adhesins • Toxins • Agents leading to bone resorption • Host response • Inflammation • Bone resorption © by author • Bone death

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ESCMID Online Lecture Library Pathogenesis (Host factors) • Trauma • Surgery • Injecting drug users • Dialysis or transplant patients • Immunocompromised • Immunosuppression • HIV • Sickle • Cancer • Chemotherapy © by author • Radiotherapy • Elderly and debilitated • Paraplegic and neuropathic ESCMID Online Lecture Library Pathophysiology of the chronic osteomyelitic lesion (1) • Chronic infection • Biofilm formation • Chronic inflammation • Pus • Bony compromise • Lysis • Fracture • Cavities and surgical dead spaces • Bone death © by author • Sequestrum • New bone formation • Sclerosis • InvolucrumESCMID Online Lecture Library Pathophysiology of the chronic osteomyelitic lesion (2)

• Soft tissue compromise • Chronic wounds • Sinus formation • Abnormal tissue planes and adhesions • Scarring • Local hypoxia © by author

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ESCMID Online Lecture Library Diagnosis

• Lack of criterion standards • Use tests according to evidence • Experience valuable in grey areas • Regular interaction between clinicians and those who provide diagnostic tests for learning

ESCMID Online Lecture Library Diagnosis • Blood tests • Inflammatory markers • Bone related markers • Laboratory • Culture • Molecular

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Colonisers ESCMIDPathogens Online Lecture Library Diagnosis • Blood tests • Inflammatory markers • Bone related markers • Laboratory • Culture • Molecular • Imaging • Ultrasound • Plain film • Isotope scans © by author • Cross sectional • CT • MRI • ESCMIDPET/SPECT Online Lecture Library

Treatment is often challenging • Antibiotic selection, route and duration • Wide variety of pathogens (Sheehy et al, 2010, J. Infect 60:338) • Staphylococci (32% of all Staph aureus) • Enterobacteriaceae • Pseudomonas • Anaerobes • Salmonella • TB • NTM • Brucella • fungi • Others © by author • Culture negative (28%) • MDROs • Allergies and intolerances • OPAT,ESCMID iv vs oral, locally Online-delivered Lecture Library

Treatment is often challenging

• Surgical expertise • Orthopaedic • Plastic • Vascular • Medical optimisation • Physiological optimisation (nutrition, organ failure) • Revascularisation • Offloading • HBO • Psychological support © by author • Rehabilitation

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ESCMID Online Lecture Library Joint (and bone) destruction

ESCMID Online Lecture Library What do we offer, and patients get?

“Isolated islands of excellence in a sea of indifference, nihilism and fragmented care”

Berendt, ECCMID, 2012

ESCMID Online Lecture Library Modern healthcare’s “perfect storm”

• Demographics (patient and workforce) • Patient and societal expectations • EconomicESCMID downturn and Online inflating costsLecture Library • New commissioning relationships and structures High quality care • Safety – At all points in the pathway • Effectiveness • Evidence based care • Outcomes • Technical • Patient-reported • Cost effective • Patient experience • Staff beliefs, attitudes, knowledge and skills • Access to services © by author • Environment and facilities • Partnership and empowerment

ESCMID Online Lecture Library How will we get there? Vision • Multi-disciplinary model of care • Patient involvement and empowerment • Evidence based care • Clinical networks and specialist centres • Consensus definitions and multi-centre studies • Strong attention to outcomes and governance

ESCMID Online Lecture Library How will we get there? Strategy

• Start now • Set clinical standards and audit them • Consider power of networks including ESCMID • Influencing • Commissioners • Colleagues • Patients and public

ESCMID Online Lecture Library Is it possible?

• Yes • Examples

ESCMID Online Lecture Library What’s the diagnosis? It is well recognised that patients require special support when affected by xxx. Because of the rarity of xxx, most patients and non- specialist clinicians will have no background knowledge of the condition. This can lead to a sense of frustration and isolation for the patient. The problem is not helped by fragmented information and few reliable information sources. There are also specific long-term healthcare support issues that must be addressed. xxx surgery is frequently disabling or disfiguring, and although fewer patients face amputation than in the past they require lifetime access to support services with specific expertise. Some centres have established key workers, usually clinical nurse© specialists, by author and patient support groups. Improving outcomes for people with sarcoma, NICE 2006, http://www.nice.org.uk/nicemedia/live/10903/28934/28934.pESCMID Online Lecture Library df Features of this disease

• Usually progressive without treatment • Serious, with risk of death • May be painful • Systemic illness, weight loss • Major psychological issues • Needs complex treatment including medical and surgical and a range of other treatments exist • Imperfect evidence base© by author • Prospect that treatment may fail, tendency to relapse

ESCMID Online Lecture Library NICE on MDTs • Sarcoma: “All patients with a confirmed diagnosis of bone or soft tissue sarcoma (except children with certain soft tissue sarcomas) should have their care supervised by or in conjunction with a sarcoma multidisciplinary team (MDT)”. • Breast cancer: “People who develop local recurrence, regional recurrence and/or distant metastatic disease have their treatment and care discussed by the multidisciplinary team” • Chronic heart failure: “People with chronic heart failure are cared for by© a bymultidisciplinary author heart failure team led by a specialist and consisting of professionals with appropriate competencies from primary and secondary care, and are given a single pointESCMID of contact for Online the team” Lecture Library NICE on MDTs • Colorectal cancer: “Discuss the risk of local recurrence, short-term and long-term morbidity and late effects with the patient after discussion in the multidisciplinary team” • Diabetes: “People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours” © by author

ESCMID Online Lecture Library Benefits of teams

• Dividing and covering the work • Spreading the load • Improving communication • Accessing necessary skills • Reducing risks of making human factors errors • Offering challenge and support

ESCMID Online Lecture Library Problems with teams

• They are made up of people…..

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ESCMID Online Lecture Library Human factors

• Attention • Memory constraints • Automaticity • Situation awareness • Heuristics (ways of thinking and learning) • Pattern matching not careful reasoning • Do what has worked before • Confirmation bias • Availability © by author • Selectivity • Frequency gambling

ESCMID Online Lecture Library Building high performing teams • Aware, distributed leadership • Healthy conflict • Commitment to common goal and to continuous work to achieve and maintain it • Accountability • Delivery (attention to results) • Empathy • Respect © by author • Value and support team members • Serious thought and reflection ESCMID Online Lecture Library In conclusion

• MDTs widely used to improve quality and governance • BJI needs to adopt not just the concept but the rigour • Composition and attendance • Documentation • Standards • Outcome measures • Team building and team functioning • Treating a difficult condition with a challenging prognosis is no excuse© for by lack author of discipline

ESCMID Online Lecture Library Conclusions (2)

• Establishment of a network with centres of excellence and extended MDTs, supporting the general hospitals • Clear definitions of treatment and referral thresholds and standards • Consensus definitions allowing better classification, aggregation of data and comparision between methods and centres • “We are the change we seek”… © by author

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