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INFECTION
dr. Ronald V Munthe SpOT
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Is a condition in which pathogenic
organism multiply and spread within the body tissues
Infection
Classical sign : Kalor, Rubor, Dolor, Tumor, O!
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Directly "ndirectly
Stab #ound, operation,open $racture
%lood stream &hematogen'(ose, mouth, bo#el, )* tract
+cute yogenic"n$ection
Chronic )ranulomatouReaction
Sub-acute hase
us&de$unct leucocytes, dead bacteria
tissue debris'
)ranuloma&lymphocyte, macrophage
giant cell'
type o$ in aderthe site o$ in$ectionthe host response
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Host susceptibility
Local Factor :• Trauma• Poor circulation• Sensiblity /• !oreign body &0'• Chronic bone or
1oint disease
Systemic factor • Malnutrition• Diabetes• Imunitas /• Debility
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cute 2aematogenous Osteomyeliti
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Common in children
+dults #ith special conditiondiabetes, immunocompromised, malnutrition, drug user
ost-traumatic e enthaematomes, 3uid collection
+cute 2aematogenous Osteomyelitis
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)ram 0 )ram -
Staphylococcus +ureus
Streptococcus yogenes
Streptococcus neumonia
2aemophylus "n3uen4a
5. Coli
seudomonas +erogenosa
roteus Miriabilis
%acteroides !ragilis
+cute 2aematogenous Osteomyelitis
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"n3ammation
Resolution or"ntractable chronicity
Suppuration
(ecrosis
(e# %one !ormation
Characteristic attern
+cute 2aematogenous Osteomyelitis
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Vascular congestione6udation o$ 3uid leucocyte in7ltration
+"(
intra-osseus pressure
"n3ammation
+cute 2aematogenous Osteomyelitis
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Suppuration
+cute 2aematogenous Osteomyelitis
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Suppuration
+cute 2aematogenous Osteomyelitis
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intra-osseus pressure eriosteal Strippingascular stasis, thrombosis due to pus
Compromise blood supply
%one death
%acterial to6ins
0
se8uestra
(ecrosis
+cute 2aematogenous Osteomyelitis
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Stripped periosteum Deep layer ne# bone $ormation
"n olucrum
5nclose the in$ected bone9 se8uestra
(e# %one !ormation
+cute 2aematogenous Osteomyelitis
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Patogenesis (4)• Setelah 1 minggu terja i ne!rosis tulang
Se"uester#• Setelah $ minggu terbentu! tulang baru
ari periosteum yang terang!at in%olucrum#
• Pus mencari jalan !eluar membuat lubangyang isebut cloaca&fistel
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2 O li i
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2ealing
Remodelling
+ntibiotics 9 "ntraosseus decompression
(ormal bone contour
Resolution or"ntractable Chronicity
+cute 2aematogenous Osteomyelitis
2 O li i
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Clinical !eatures
Re$use to use a ected limb
oo;S#elling
2yperaemiaus discharge
!eel
!ebris!luctuation
ain
Mo e
Not appear in early antibiotocs treatment
Tachicardia Tenderness
ymphadenopati2istory o$ in$ection
+cute 2aematogenous Osteomyelitis
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Diagnostic "maging
Di gnostic
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Diagnostic"maging
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Diagnostic"maging
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Diagnostic
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USG Detect 3uid collection
Radioscintigraphy "ncreased acti ity in both phase
MRI & CTSensiti e
Di erentiateSo$t tissue in$ection 9 Osteomyelit
Sensiti e but not spesi7cBBmTc-2D
)a-citrate or === ln
Diagnostic"maging
Diagnostic
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Diagnostic"maging
Diagnostic
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Diagnostic"maging
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The most certain #ay to con7rmthe clinical diagnosis
is to aspirate pus $romthe metaphyseal subperiostealabscess or the ad1acent 1oint
us -
%acteroidal e6amination9
+ntibiotics sensiti ity
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aboratory
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Ehite cell count
C-Reacti e rotein
5SR
%lood Culture 0
aboratory
Di ti l Di
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Di erential Diagnose
Cellulitis
Streptococcal (ecroti4ing Myositis
+cute Suppurati e +rthritis
+cute Rheumatism
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Treatment
"$ osteomyelitis is suspected on clinical
grounds,blood and 3uid samples should be ta;enand then
treatment started immediately #ithout
#aiting$or 7nal con7rmation o$ the diagnosis
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Treatment Principles• Pro%i e analgesia ' lui Therapy• est affecte part (imobilisasi)•
I entify organism an gi%e antibiotic• Pus e%acuation an necrotic tissue• Stabili*e bone if it has fracture
Treatment
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Treatment
Surgical Drainage
Supporti e Treatment
Splintage
+ntibiotic Therapy
Treatment
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Supporti e Treatment
eat e t
+nalgesic
Septicaemia 9 !e er Dehydration
Treatment
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+ntibiotic Therapy
the prompt administrationo$ antibiotics is so ital, that treatment
should not a#ait the result
Ta;e the ‘best guest’
patientFs age, general state o$ resistance, renal $unction,degree o$ to6aemia and pre ious history o$ allergy
Must be ta;en into account
Treatment
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+ntibiotic Therapy
+dultsStaphylococcal
3uclo6acillin 9 $usidic acid
" . V &=-> #ee;s'
Oral &G- #ee;s'
Children2aemophylus
" . V
Oral
Cephalosporin&ce$uro6ime H ce$ota6ime'
+mo6ycla
Treatment
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Surgical Drainage
i$ the clinical $eatures do notimpro e #ithin G hours o$ starting treatment, or
e en
be$ore that i$ there are signs o$ deep pus &s#elling,oedema, 3uctuation', and most certainly i$ pus is
aspirated,the abscess should be drained by open operation
under general anaesthesiai$ there is an e6tensi e intramedullary abscess drainage can be better achie edby cutting a small #indo# in the corte6
Complication
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p
Metastatic "n$ection
Suppurati e +rthritis
+ltered %one )ro#th
Chronic Osteomyelitis
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Sub-+cute 2aematogenous
Osteomyelitis
presumably due tothe organism being less irulent orthe patient more resistant &or both'
Sub-+cute 2aematogenous Osteomyelitis
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Typically there is a #ell-de7ned ca ity incancellous bone, containing glairy seropurulent
3uid
The surrounding bone trabeculae are o$tenthic;ened
The ca ity is lined by granulation tissuecontaining a
mi6ture o$ acute and chronic in3ammatory
cells
Sub-+cute 2aematogenous Osteomyelitis
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May ha e a limp and o$ten there isslight s#elling , muscle #asting and local
tenderness.
The temperature is usually normal and there is littleto
suggest an in$ection.
Clinical !eaturesain near one o$ the larger 1oints
$or se eral #ee;s or e en months
Sub-+cute 2aematogenous Osteomyelitis
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The typical radiographic lesion is a circumscribed,round or o al Ica ityJ =-> cm in diameter,
most o$ten it is seenin the tibial or $emoral metaphysis
Sometimes the Fca ityF is surrounded by ahalo o$ sclerosis, the classic
Brodie'sabscess
The radioisotope scan sho#s
mar;edly increased acti ity
"ma g ing
Sub-+cute 2aematogenous Osteomyelitis
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Sub-+cute 2aematogenous Osteomyelitis
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%iopsy is a gold standard $or diagnosis
The clinical and 6-ray appearancesmay resemble those
o$ an osteoid osteoma
"$ 3uid is encountered,it should be sent $or bacteriological culture
Sub-+cute 2aematogenous Osteomyelitis
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immobili4ation and antibiotics&3uclo6acillin and $usidic acid' $or #ee;s usually result in healing
Curettage is also indicatedi$ the 6-ray sho#s that there is no
healinga$ter conser ati e treatment
Conser ati e
Treatment
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Chronic Osteomyelitis
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Chronic Osteomyelitis
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us
Se8uestra
Vascular Tissue
Sclerotic +rea
Sequestra & oreign implant act as substrate !or bacterial adhesion
Chronic Osteomyelitis
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The patient presents becausepain, pyre6ia, redness andtenderness ha e recurred
&a F3areF' or #ith a discharging sinus
Clinical !eatures
Chronic Osteomyelitis
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During acute 3ares the 5SR and blood #hite cell count
may be increased , these non-speci7c signs arehelp$ul
in assessing the progress o$ bone in$ectionbut they are not diagnostic
+ntistaphylococcal antibody titres may be
ele ateda aluable sign in the diagnosis o$ hiddenin$ections and in trac;ing progress to reco ery
"aboratory
Chronic Osteomyelitis
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Treatment
+ntibioticsSeldom eradicate by antibiotics alone
Stop the spreading
Control the acute 3ares
Choice depends on bacteriological studies
Capable o$ penetrating sclerotic bone
(on-to6ic #ith long-term use
Chronic Osteomyelitis
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Treatment
ocal Treatment
Sinus dressing
Colostomy paste
"ncission 9 Drainage $or acute abcess
Chronic Osteomyelitis
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Treatment
OperationSigni7cant symptomsClear e idence o$ a se8uestrumor dead bone
+ll in$ected so$t tissue andall dead or de itali4ed bone
56cised
Dead material can be identi7ed by the preoperati e in1ectiono$ sulphan blue #hich stains all li ing tissues
green , lea ing dead material unstained
Chronic Osteomyelitis
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Treatment
Chronic Osteomyelitis
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Treatment
apineau Techni8ue!ill completely the dead space le$t a$ter e6cision o$ necrotictissue #ithli ing or potentially li ing material
Cancellous bone gra$t&autogenous'
+ntobiotic
0
!ibrin sealant
Muscle-3ap trans$er
Split s;in gra$t
ost Traumatic Osteomyelitis
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ost Traumatic Osteomyelitis
Staph. +ureus
The combination o$ tissue in1ury, ascular damage, oedema, haematoma, dead $ragments and
an open path#ay to the atmosphere
#ommon in adults
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e%erish an e%elops pain ans+elling o%er the $racture site , the +oun is
inflame
an there may be a seropurulent ischarge
Treatment : debridement, antibiotics, delayedwound closure
ost Operati e Osteomyelitis
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ost Operati e Osteomyelitis
The true incidence is probably around L
considerably greater in the elderly, the obese, those #ith diabetes or other chronicdiseases, patients #ith sic;le-cell disease, )aucherFs disease orleu;aemia, patients on corticosteroid or immunosuppressi e
therapy, and patients #ho ha e hadmultiple pre ious operations at the same site
Organisms may be introduced directly into the#ound $rom the atmosphere, the instruments,
The patient or the surgeon
mi6ture o$ pathogenic bacteria$Staph, aureus, Proteus, E. coli, Pseudomonas%
&='so$t-tissue damage&>'haematoma $ormation
&G'%one death
ost Operati e Osteomyelitis
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!oreign implant is both a predisposing$actor and an important element in its persistence.
%acteria as #ell as human tissue cells ha e an
a nity $or molecules on the sur$ace o$ the implant.%oth compete $or occupancy o$ the same sur$ace -the tissue cells by adaptation and integration , the
bacteria by adhesion and coloni4ation
Fthe race $or the sur$aceF$ ristina, ())%
5arly"ntermediate
ate
p y
ost Operati e Osteomyelitis
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Septic arthritis• Septic arthritis- terja i a!ibat osteomielitis
pa a tulang metaphysis yang terleta! intracapsular
• Septic arthritis juga terja i a!ibat ino!ulasiba!teri langsung !e alam sen i ,misalnya trauma tembus !e alam sen i
atau infe!si menembus jaringan lempengepiphysis
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Septic arthritis
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Septic arthritis• Infe!si ba!teri yang menyerang jaringan
syno%ium an ruang & !apsul sen i yangmenga!ibat!an ber!umpulnya rea!si sel.sel PM/ an ilepas!annya en*ymproteoliti!
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Infe!si sen i• Septic arthritis• Septic bursitis• Infe!si pa a pasien pasca total Hip & !nee
replacement
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a!tor pre isposisi
• Peny sen i !ronis• Trauma• heumatio arthritis• Diabetes melitus• Terapi steroi• 0agal ginjal•
eganasan• Drug abuse
• i+ayat aspirasisen i & inje!si
• 0angguan &
insufisiensi %ascular• i+ayat infe!si sen i
sebelumnya
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Sen i pre ile!si
• 2utut 3 5• Hip $65• 7ahu 11 5• Si!u 185• 9rist : 5• ;n!le < 5
• Pre ile!si pa a ana! =
Paling sering sen i
lutut : 5Panggul $ 5
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uman penyebab• Staphylococcus aureus• Strepticoccus sp• 0ram negatif• Pnoumococcus
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uman penyebab
;na! i ba+ah $ th =Haemophylus influensa
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Tes iagnosti!
2ab =• 2eu!osit• 2>D ? $6
• ultur arah
(') 3 5
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Pemeri!saan ra iologi• Soft tissue = beng!a!• >ffusi cairan sensi
• @T scan
•
7one scan Tc ::
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Prinsip terapi• Menghambat multipli!asi !uman g
antibioti!• Drainage abses superiosteal ( bila su ah
terbentu! )
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Penatala!sanaan• ultur resistensi• ;ntibioti! intra %ena = $. 4 minggu• Aperasi rainage
Tuberculosis
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Tuberculosis(Tuberculosis Asteomyelitis)
• 7a!teri = Micobacterium Tuberculosa – Humanus roplet infection paru.paru – 7o%inus susu usus (jarang)
• Pathologyocus primer !ompleB primer (lesi paru '07 se!itar) ba!teri bisa orman i 07
bertahun.tahun#• Penyebaran Se!un er
7ila aya tahan tubuh ren ah T7@ milier iparu$&meningitis#
Penyebaran Tertier (1)
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Penyebaran Tertier (1)• Penyebaran i luar paru.paru terja i bertahun.tahun
setelah serangan pertama pre ile!si i %ertebralbo y an sen i syno%ial besar (panggul an lutut)#• 7a!teri bisa ari epiphyse !e syno%ial atau ari
syno%ial !e epiphyse atau bersamaan, oleh !arena
men apat nutrisi melalui pembuluh arah yangsama#
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Penyebaran Tertier ($)• Penyebaran tertier terja i bila aya tahan tubuh
menurun (nutrisi, penya!it !ronis)#• 7a!teri T7@ juga bisa menyerang iaphyse
phalanB (tuberculous actylitis)#• 7a!teri T7@ membentu! granuloma
!umpulan epitheloi an multi nucleate giantcell yg mengelilingi jaringan ne!rosis, isertailymphocyte pa a tepinya#
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0ejala linis• Pembeng!a!an an nyeri sen i
ter apat gangguan gera!#• 7erat ba an menurun#• /ight cry#
Spon ilitis T7@
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p @• Cmumnya aerah
thoracolumbal#• Penyebaran melalui
7atson s PleBus ari %ena
para%ertebral#
• 7a!teri umumnya menyerang
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a!te u u ya e ye a gbagian anterior %ertebral bo y osteoporosis an Se"uester
granulasi T7@ memenuhiperiosteum Para%ertebral ;bses ligamen longitu inalanterior an posterior oleh!arena iscus inter%ertebralisrelati%e !ebal, ma!a !erusa!anterja i pa a sta ium a!hir hasila!hir terja i !yphosis oleh !arena!olaps ari bagian anterior
%ertebral bo y 0ibus
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0ejala linis
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j• ;namnesa•
Pembuluh arah = 7S>mening!at, ifferentialcount, P@ T7@#
• E.ray• M I
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Therapy• ;nti T7@ $ 8H8>8 16 $H$• Apen operation fusi engan & tanpa
instrumen#
ompli!asi
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p• Pott s paraplegia•
Aleh !arena =1# Te!anan eBtra ural(pus, s"uester)
$# Penyebaran langsung
!e spinal cor
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