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Infectious causes of bone and joint pain in travellers and migrants
Sarah Logan
ID consultant at HTD
22.7.15
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Risk factors
• Ethnicity • Vitamin D • Occupation • Immunocompromise • Sickle Cell disease • Vaccination • Surgery/risk factor
for bactereamia
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Where have they been?
• Chikungunya
TB- MDRTB
Typhoid Meliodosis XDR Gram negatives Group A strep/rheumatic fever MRSA
Brucella
HIV Parvovirus Rubella
Gonococcal Reiters- chlamydia
salmonella shigella yersinia
Borrelia/ Lyme
Coxiella
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Mr H.S
• 33 year old Punjabi♂
• UK for 2 years working in a restaurant
• attended GP after a fall on the bus
• Back pain with night sweats 5/52 ?
• ° Weight loss or loss of appetite
• o/e- tender over thoracic spine
• What would you do?
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gibbus
haematogenous, lymphatic or contiguous spread
Tuberculosis of the spine
myelopathy usually due to arachnoiditis/vasculitis rather than direct pressure?
5% of TB notifications in UK
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Management
• Transferred to neurosurgical centre • Aspirate- AFB’s seen, sent for culture • Treatment:conventional quadruple anti-TB
regimen i.e rifampicin 600mg isoniazid 300mg pyrazinamide 2g ethambutol 15mg/kg • Steroids due to spinal cord compression
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Call from the lab
• Day 14- Looks like M.TB • Genetic test for resistance also +ve • Likely to be rifampicin and isoniazid resistant
• MDRTB (later confirmed on culture) • Switched to IV amikacin, pyrazinamide,
ethambutol, moxifloxacin, cycloserine • Amikacin delivered via OPAT • Tolerated regimen, left with no neurological
deficit, still on oral treatment when I last saw.
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TB spine management in West
London
• Retrospective case notes review
• Pts located from London TB Register & local hospital records
• All patients diagnosed 2000-2008
• Old radiology, paper and computerised records all reviewed where available
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Patient demographics • 118 patients • 57% male • Median age 35 years • 94% born overseas • Mean UK residency at diagnosis was 10 years (range 0-42yrs) • 83% presented with pain • Median symptom duration was 4 months (range <1-48 months) • 63% had sought medical advice with symptoms prior to
episode when diagnosed
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Back Pain Red Flags
• Onset age < 20 or > 55 years
• Non-mechanical pain (unrelated to time or activity)
• Thoracic pain • Previous history of carcinoma, steroids, • HIV • Feeling unwell • Weight loss • Widespread neurological symptoms • Structural spinal deformity
BMJ 2006;332:1430-1434 (17 June), doi:10.1136/bj.332.755.1430
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Ealing Red Flags
• Any age
• From Asian Subcontinent or Africa
• History of weight loss / night sweats / Loss of Appetite
• No history of trauma or very minor
• Past history of tuberculosis
• Immunosuppression
• On examination- any deformity of the spine/ visible abscess, Bony tenderness
• Investigations: raised ESR (irrespective of spine X-rays)
• Repeat attendances
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Mr OA • 65 yrs man, swelling of left
hand for 18 months
Dudub
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Differential?
• Monoarthritis of Left wrist – Non infectious
– Brucella
– TB
• Other cause of swelling , not in joint – TB
– Non tuberculous mycobacteria
– Fungal mycetoma
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Management
Diagnostic investigation?
• Biopsy of collection
• Micro- AFB’s seen
• GeneXpert- M.TB, RPOB negative
• Commenced on first line therapy, RHZE
• Culture at 18 days- Fully sensitive Mycobacterium tuberculosis.
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Rev I
• 65yr Nigerian man
• Sickle Cell Disease
• Prostate Ca- surveillance
• TRUS BX in Lagos
• Attends GP 5 weeks later- painful lump on arm
• Night sweats
• What do you do?
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Investigations
CRP 3.9 WCC 3.1
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Referred to ortho
• Diagnostic bone biopsy
–ESBL E.coli (multi drug resistant)
• Extensive debridement and reaming of bone
• Prolonged course of intravenous ertapenem via OPAT.
• Vac dressing to wound
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• 8 weeks of IV ertapenem
• Wound healed
• No further night sweats
• Pain better
• Repeat MRI….
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Mrs IT
• Nigerian midwife
• Commutes between Port Harcourt and Willesden
• Redo R TKR on 30.1.15
• Off to see family in Nigeria
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Attends GP on return
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• Well, walking around
• Swabs- MC+S- no growth
• Course of flucloxacillin
• Course of erythromycin
• Referred back to ortho
• Normal bloods
• What do you think they said?
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Surely can’t be in joint?
• Superficial exploration of tissue down to fascia
• 6 samples sent
• 3/6- Mycobacterium fortuitum
• Commenced on
– IV amikacin- via OPAT
– Po ciprofloxacin
– Po co-trimoxazole
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Are we winning?
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10.7.15
• Returns to theatre for first part of 2 stage revision
• Sinus extends into joint
• Cement spacer inserted with amikacin
• Oral Linezolid and Co-trimoxazole
• Cultures in the lab…….
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Outpatient parenteral antimicrobial therapy
Patient needs IVAB
Home
Self/ carer/ partner
Nurse
Outpatients Hospital
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Why ‘do’ OPAT?
35
–Reduced length of stay (admission avoidance)
–Increased inpatient capacity
–Significant cost savings
–Reduce risk of HCAI
–Improve patient choice and satisfaction
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How the service at UCLH
operates
• The OPAT week
– Weekly nurse clinic and Dr clinic
– Virtual ward round
– Seeing new ward referrals (Dr and nurse)
– Telephone liasion with community teams (nurse)
– Teaching self administration
– Adhoc appts in addition incl weekends
36
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The team
The team
– Clinical Nurse Specialists
– Consultants- ID and Micro
– SpR
– Pharmacist
– Administrative support
– Vascular access team
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OPAT episodes by site of infection
0
5
10
15
20
25
30
35
40
Bon
e & jo
int
Gen
ito-u
rinar
ySSTI
Bac
tera
emia
Car
diov
ascu
lar
Pulm
onar
y
Intra
-abd
ominal
CNS
ENT
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Bone & joint infections
Prosthetic joint
infection
32%
Osteomyelitis - non
vertebral
30%
Osteomyelitis -
vertebral with
metalwork
14%
Osteomyelitis - NON-
vertebral with
metalwork
11%
Discitis
5%
Septic arthritis
5%
Osteomyelitis -
vertebral
3%
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4
1
1
2
1
5
2
3
2
6
1
8
2 1
1
2
2
1
2
5
45
+
1 each from Bath, Cambs, Beds,
WestSussex
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October 2012- January 2015
• 230 patients
• 251 episodes of care
• On IVAb’s for 9 days (range 1-175)
• Median Age 53 (IQR 34-82)
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Outcomes
• Clinical outcomes- disease specific
• Service outcomes
– Bed days saved
– Hospital acquired complications
• Patient satisfaction
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Conclusions
• Travel and migration affect the spectrum of Bone and Joint infections we see in UK
• What/who/where/when/why
• Increasing need for OPAT to manage a range of infections