Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy

BMC Infect Dis. 2018 Apr 10;18(1):166. doi: 10.1186/s12879-018-3076-y.

Abstract

Background: A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated.

Methods: Adult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis.

Results: Sixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36-63)) were included. Osteomyelitis was mostly polymicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae spp. (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5-10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p = 0.022). An increased prevalence of coagulase negative staphylococci (p = 0.017) and Candida spp. (p = 0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae spp. was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p = 0.005). Treatment duration was as 20 (IQR, 14-27) weeks, including 11 (IQR, 8-15) after reconstruction. After a follow-up of 54 (IQR, 27-102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p = 0.025) and Actinomyces spp. infection (OR, 9.5; p = 0.027).

Conclusions: Pressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. The lack of correlation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment.

Trial registration: ClinicalTrials.gov NCT03010293.

Keywords: Antimicrobial therapy; Bacteriology; Chronic osteomyelitis; Debridement; Flap coverage; Negative pressure therapy; Pressure ulcer.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Anti-Infective Agents / pharmacology
  • Anti-Infective Agents / therapeutic use*
  • Candida / drug effects
  • Candida / isolation & purification
  • Chronic Disease
  • Debridement
  • Enterobacteriaceae / drug effects
  • Enterobacteriaceae / isolation & purification
  • Female
  • Humans
  • Male
  • Middle Aged
  • Osteomyelitis / diagnosis
  • Osteomyelitis / drug therapy*
  • Osteomyelitis / etiology
  • Osteomyelitis / microbiology
  • Pressure Ulcer / complications
  • Pressure Ulcer / diagnosis*
  • Risk Factors
  • Staphylococcus aureus / drug effects
  • Staphylococcus aureus / isolation & purification
  • Surgical Flaps
  • Treatment Failure

Substances

  • Anti-Infective Agents

Associated data

  • ClinicalTrials.gov/NCT03010293