J Bone Jt Infect 2017; 2(3):149-153. doi:10.7150/jbji.20002
Epidemiological, Clinical and Microbiological Characteristics of Patients with Post-Traumatic Osteomyelitis of Limb Fractures in Southwest China: A Hospital-Based Study
1. Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China;
2. Joint Orthopaedic Research Center of Zunyi Medical University & University of Rochester Medical Center, Zunyi 563000, China;
3. Department of Orthopedics, Affiliated Hospital of Zunyi Medical College, Zunyi 563000, China;
4. Department of Orthopedics, The Second Affiliated Hospital of Central South University, Changsha 410011, China;
5. Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester NY 14642 USA;
6. Department of Orthopedics, Virginia Commonwealth University, Richmond, VA 23298 USA.
Peng J, Ren Y, He W, Li Z, Yang J, Liu Y, Zheng Z, Kates SL, Schwarz EM, Xie C, Xu Y. Epidemiological, Clinical and Microbiological Characteristics of Patients with Post-Traumatic Osteomyelitis of Limb Fractures in Southwest China: A Hospital-Based Study. J Bone Jt Infect 2017; 2(3):149-153. doi:10.7150/jbji.20002. Available from http://www.jbji.net/v02p0149.htm
Objective To determine the epidemiological, clinical and microbiological characteristics, of patients with post-traumatic osteomyelitis of extremity fractures, and provide evidence-based guidelines for early diagnosis and treatment, including empiric antibiotic therapy.
Methods Human subject research was performed using institutional review board approved protocols. A retrospective chart review was conducted on 5,368 patients diagnosed with extremity traumatic fractures from January 1, 2012 to December 31, 2015, to identify osteomyelitis patients. Records from the Microbiology Department were reviewed, and patients with a positive wound culture, or bone biopsy culture, were selected for the study. Microbial suceptability was determined by the M-100-S22 protocol (Clinical & Laboratory Standards Institute® (CLSI) 2012 USA). Additional clinical information, including data on patients' baseline epidemiological, clinical, and microbiological records was collected from all available charts, and reviewed using a designed protocol.
Results 84 (1.56%) patients were diagnosed with osteomyelitis based on a positive culture result. The most prevalent comorbidities in these patients were compartment syndrome, diabetes and hypertension. The most commonly involved infected site was the tibia-fibula (47.62%). 66 (78.57%) of these cases were monomicrobial, and 18 cases (21.43%) were polymicrobial. The infections were predominantly caused by Gram-positive bacteria (56, 53.85%). The most common Gram-positive bacteria were Staphylococcus aureus (39 cases, 37.50%) and S. epidermidis (6 cases, 5.77%), which were sensitive to ampicillin, synercid/ dalfopristin, linezolid, tigecycline, macrodantin, and vancomycin. S. aureus was the most common pathogen in both monomicrobial and polymicrobial cases. All 17 cases of MRSA infection were sensitive to Imezolid, ampicillin, synercid/ dalfopristin, linezolid, tigecycline, furadantin, piperacillin/yaz, rifampicin, and vancomycin, respectively. The most common Gram-negative bacteria were E. coli (16 cases, 15.38%) and Enterobacter cloacae (11 cases, 10.58%), which were sensitive to thienamycin.
Conclusions In this study, the overall rate of post-traumatic osteomyelitis of limb fractures (1.56%) is lower than the national average rate (2.6-7.8%), for major medical centers in China. The main medical comorbidities were compartment syndrome, diabetes mellitus and hypertension. The most common infection was monomicrobial in lower extremities. S. aureus was the most common pathogen, which presented in 39 (37.50%) cases, and 17 of these (43.59%) were caused by MRSA. These findings can guide empiric antibiotic therapy in Southwest China for osteomyelitis in patients with traumatic limb fractures.
Keywords: Osteomyelitis, Limb fracture, Methicillin-resistant Staphylococcus aureus (MRSA), Antibiotic resistance, Regional characteristics.
Osteomyelitis is a bacterial infection of the bone or bone marrow often resulting in hospital admission. Osteomyelitis may result from contiguous spread of infection from adjacent soft tissues and joints, hematogenous seeding, or direct inoculation of bacteria into the bone as a result of trauma or surgery.
There has been a remarkable increase in osteomyelitis in the USA between 1969 and 2009 for reasons that remain unclear, but could comprise a variety of host, pathogen and environmental factors. To date, little is known about changes in the epidemiological and clinical findings of osteoarticular infections over long periods of time. Conceivably, there may have been major changes in the microbiology, types of osteoarticular infections, and the characteristics of patients at risk. For example, the widespread use of medical devices in orthopaedic surgery and increased life expectancy of the population are all factors related to the increased rates of some osteoarticular infections[3, 4]. Also, the emergence of multidrug-resistant microorganisms (e.g. methicillin-resistant Staphylococcus aureus, MRSA) in hospitals and other healthcare institutions has been associated with increased rates of bacterial infections caused by difficult-to-treat pathogens[5, 6]. An increasing incidence of infections has also been related to the improvement of identification methods of microorganism.
To our knowledge, there are no comprehensive studies describing the entire spectrum of osteomyelitis in Southwest China. Thus, our objective was to examine the epidemiological, clinical and microbiological characteristics of osteomyelitis in a hospital that serveing for mainjority of this area over a four-year period from January 1, 2012 to December 31, 2015.
Materials and Methods
This study was a hospital-based investigation conducted at Affiliated Hospital of Zunyi Medical College, China, which was an investigational site participating in the AO Trauma Clinical Priority Program (AOCPP). The Ethics Committee of Affiliated Hospital of Zunyi Medical College approved all the human subject research.
We retrospectively reviewed the records of patients from January 1, 2012 to December 31, 2015, to identify osteomyelitis patients in search of patients with positive wound culture or bone biopsy culture. 84 patients were indentified with confirmed bacterial bone infections and were included in the study. Bacterial susceptibility data was determined by the M-100-S22 protocol (Clinical & Laboratory Standards Institute® (CLSI) 2012 USA. The information collected from patients with osteomyelitis included the patients' baseline characteristics, clinical presentation, and microbiological records.
We identified 84 patients (58 open fracture cases and 26 closed fracture cases) with post-traumatic osteomyelitis of limb fractures. There were 69 males and 15 females, and the mean age was 43 years (range, 16-72 years).
The medical comorbidities in patients with osteomyelitis are presented in Table 1. There were 10 identified comorbidities in 84 patients, including compartment syndrome, diabetes, hypertension, hepatic dysfunction, craniocerebral trauma, closed thoracic trauma, osteoporosis, hyperuricemia, hypoproteinemia, and hyperkalemia. The most frequent accompanying conditions were compartment syndrome (4, 18.18%), diabetes (4, 18.18%) and hypertension (3, 13.64%).
Medical comorbidities in patients with osteomyelitis
|Osteofascial compartment syndrome||4|
|Closed thoracic trauma||2|
The Distribution and percentage of affected sites
|Infection site||Single infection (%)||Mixed infection (%)||Total (%)|
|Tibia and Fibula||32 (38.10)||8 (9.52)**||40 (47.62)|
|Femur||13 (15.48)||7 (8.33)**||20 (23.81)|
|Radius and Ulna||9 (10.71)||2(2.38)**||11 (13.10)|
|Humerus||5 (5.95)||—||5 (5.95)|
|Patella||5 (5.95)||—||5 (5.95)|
|Calcaneus||2 (2.38)||1 (1.19)**||3 (3.57)|
|Total (%)||66 (78.57)||18 (21.43)||84 (100.00)|
Notes: The superscript ** are mix infection cases which the detail is listed in table 4 Mix infection: Sites and pathogenic bacteria.
The distribution and percentage of affected sites of the 84 patients with osteomyelitis are shown in Table 2. 66 (78.57%) cases were monomicrobial, and 18 (21.43%) cases were polymicrobial. The most commonly involved site was the tibia-fibula (40, 47.62%), including monomicrobial (32, 38.10%) and polymicrobial (8, 9.52%), femur (20, 23.81%) and radius-ulna (11, 13.10%).
According to the proportion and cases of Gram-positive/negative bacteria (Table 3), there were 104 strains in 84 patients; 56 (53.85%) strains were Gram-positive bacteria and 48 (46.15%) were Gram-negative bacteria. The most prevalent Gram-positive bacteria were S. aureus (39, 37.50%) and S. epidermidis (6, 5.77%), and E. coli (16 cases, 15.38%) and Enterobacter cloacae (11 cases, 10.58%) were the most commonly identified Gram-negative bacteria. Overall, S. aureus was the most common pathogen in both monomicrobial (31, 46.97%) and polymicrobial (8, 44.44%) cases, and the breakdown of the 39 strains included MRSA (17, 43.59%) and MSSA (22, 56.41%). The mixed mix infection and pathogenic bacteria are listed in table 4. The S. aureus and S. epidermidis strains were sensitive to ampicillin, synercid/ dalfopristin, linezolid, tigecycline, macrodantin, and vancomycin, respectively (Table 5). All 17 cases of MRSA infection were sensitive to Imezolid, ampicillin, synercid/ dalfopristin, linezolid, tigecycline, furadantin, piperacillin/yaz, rifampicin, and vancomycin, respectively (Table 6). E. coli and E. cloacae presented as the main Gram-negative bacteria, and were all sensitive to thienamycin (Table 7).
The proportion and cases of the Gram-positive/negative bacteria
|Pathogenic bacteria||Isolate||Proportion (%)|
|Staphylococcus aureus **||39||37.5|
|Enterococcus avium **||2||1.92|
|Streptococcus milleri **||1||0.96|
|Staphylococcus aureus subspecies**||1||0.96|
|Enterococcus faecalis **||5||4.81|
|Klebsiella oxytoca **||1||0.96|
Note: The superscript ** are mix infection cases which the detail is listed in table 4 Mix infection: Sites and pathogenic bacteria.
Mix infection: Sites and pathogenic bacteria
|Sites||Case No.||Pathogenic bacteria|
|Tibia and Fibula (44.4%)||1||S.aureus||Klebsiella pneumoniae|
|3||S.aureus||Streptococcus epidermidis||S. Hominic|
|5||S.aureus subspecies||Psiudomonas aeruginoso|
|7||Enterobacter cloacae||Baumann acinetobacter|
|8||Enterobacter cloacae||Klebsiella oxytoca|
|Femur (38.9%)||9||S.aureus||Baumann acinetobacter|
|10||S.aureus||Escherichia coli||Baumann acinetobacter|
|11||S. epidermidis||Enterococcus faecali|
|12||Enterococcus avium||Escherichia coli|
|13||Enterococcus faecalis||Enterobacter cloacae|
|14||Eschrichia coli||Baumann acinetobacter|
|15||Eschrichia coli||Baumann acinetobacter|
|Radius and Ulnar (11.1%)||16||S.aureus||Enterobacter cloacae|
|Calcaneus (5.60%)||18||Enterococcus faecalis||Escherichia coli|
The rate of drug resistance of the main Gram-positive bacteria
|Antibiotics||S.aureus (n=39)||S. epidermidis (n=6)|
|Cases (n)||Drug resistance rate (%)||Cases (n)||Drug resistance rate (%)|
To the end of understating the incidence and clinical aspects of post-traumatic osteomyelitis in Southwest China, and deriving an empirical antibiotic regimen, we conducted a retrospective analysis of this population. The results showed that the overall rate of post-traumatic osteomyelitis of limb fractures (1.56%) seen at the Affiliated Hospital of Zunyi Medical College is lower than the national average rate (2.6-7.8%) for major medical centers in China. This may be associated with our strict screening criteria. The majority of patients with osteomyelitis were young males, and 58 (69.05%) with open fractures. The most commonly involved site was the tibia-fibula (40, 47.62%), which may be related to the fact that these fractures are usually caused by direct trauma, and many of them are open fracture cases. Additionally, open fracture wounds are often contaminated, have long exposure times, and suffer from major soft tissue defects. At the same time, some patients have comorbidities that may delay wound healing, such as compartment syndrome, and diabetes,. These factors markedly increase the risk of infection[10, 11].
Two decades ago, Gram-negative bacteria were the main pathogens responsible for osteomyelitis in China. Since then, S. aureus has become the most prevalent bacteria in nosocomial infections. In this study, we found that the detection rates of MSSA and MRSA were 69.64%, 43.59%, respectively, which compares with the Chinese national average of 59.1% and 57.8%. There are regional characteristics for osteomyelitis; in the Southwest region of China, the main strains of MRSA were ST239-III-t30, ST239-037 and ST5-II-t002. In addition, we identified ST5-II, ST59-IV (a community acquired strain) and unique ST2582-III-t030 strains.
The rate of drug resistance of Staphylococcus aureus
|Cases||Drug resistance rate (%)||Cases||Drug resistance rate (%)|
The rate of drug resistance of the main Gram-negative bacteria
|Antibiotics||E. coli (n=16)||Enterobacter cloacae (n=11)|
|Cases||Drug resistance rate (%)||Cases||Drug resistance rate (%)|
Although multidrug resistance is a major healthcare problem, our research found that all 39 S. aureus strains detected were succeptible to imezolid, ampicillin /sulbactam, synercid/dalfopristin, linezolid, tigecycline, furadantin, piperacillin/tazo, and vancomycin. Additionally, all MRSA strains were sensitive to imezolid, ampicillin, synercid/ dalfopristin, linezolid, tigecycline, furadantin, piperacillin/tazo, rifampicin, and vancomycin. MSSA strains were sensitive to imezolid, ampicillin, synercid/ dalfopristin, amoxicillin/clavulanic acid, linezolid, tigecycline, cefoxitin, cefazolin, thiomycin, oxacillin, piperacillin/tazo, and vancomycin. Interestingly, this result differs from the drug-resistant bacteria spectrum observed in other regions in China. Additionally, while we identified common strains (ST 239, ST5, and ST59), we also found osteomyelitis patients infected with ST2582-III-t30, which appears to be unique in Southwest of China.
There are several notable limitations to this study. This is a retrospective study and the size of sample is relatively small. We were not able to save fresh specimens to extract DNA, RNA or protein to complete gene sequencing in order to screen for gene mutation and to confirm the level of protein expression. In addition, our results only represent the osteomyelitis cases seen in Zunyi and its surrounding area. Thus, a large multi-center prospective study would be required to identify determine patient outcomes and to offer a broader assessment of osteomyelitis in Southwest China.
The overall rate of post-traumatic osteomyelitis of limb fractures in Zunyi is lower than the national average of major medical centers in China. The regional characteristics from an epidemiological, clinical and microbiological characteristics are shown by this study. These results can provide guidance for the early diagnosis and treatment including empiric antibiotic therapy for osteomyelitis.
This work was supported by the National Natural Science Foundation of China (81260280, 81572179), AOTrauma Research (CPP Bone Infection) and NIH P30 AR069655, Guizhou Provential Foundation of Science and Technology (2010-2182).
The authors have declared that no competing interest exists.
1. Lew DP, Waldvogel FA. Osteomyelitis. Lancet. 2004;364:369-79
2. Kremers HM, Nwojo ME, Ransom JE. et al. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am. 2015;97:837-45
3. Lora-Tamayo J, Euba G, Narvaez JA. et al. Changing trends in the epidemiology of pyogenic vertebral osteomyelitis: the impact of cases with no microbiologic diagnosis. Semin Arthritis Rheum. 2011;41:247-55
4. Kurtz S, Mowat F, Ong K. et al. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005;87:1487-97
5. Gasch O, Ayats J, Angeles Dominguez M. et al. Epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection: secular trends over 19 years at a university hospital. Medicine (Baltimore). 2011;90:319-27
6. Lye DC, Earnest A, Ling ML. et al. The impact of multidrug resistance in healthcare-associated and nosocomial Gram-negative bacteraemia on mortality and length of stay: cohort study. Clin Microbiol Infect. 2012;18:502-8
7. Walter G, Vernier M, Pinelli PO. et al. Bone and joint infections due to anaerobic bacteria: an analysis of 61 cases and review of the literature. Eur J Clin Microbiol Infect Dis. 2014;33:1355-64
8. Liu Y. Orthopaedic postoperative infection risk factor and anti-infection treatment. Clinical Medication Journal. 2015:53-58
9. Lin SY, Lin CL, Tseng CH. et al. The association between chronic osteomyelitis and increased risk of diabetes mellitus: a population-based cohort study. Eur J Clin Microbiol Infect Dis. 2014;33:1647-52
10. Korol E, Johnston K, Waser N. et al. A systematic review of risk factors associated with surgical site infections among surgical patients. PLoS One. 2013;8:e83743
11. Parkkinen M, Madanat R, Lindahl J. et al. Risk Factors for Deep Infection Following Plate Fixation of Proximal Tibial Fractures. J Bone Joint Surg Am. 2016;98:1292-7
12. Jiang N, Ma YF, Jiang Y. et al. Clinical Characteristics and Treatment of Extremity Chronic Osteomyelitis in Southern China: A Retrospective Analysis of 394 Consecutive Patients. Medicine (Baltimore). 2015;94:e1874
13. Guo Y, Zhu DM, Hu FP. et al. CHINET 2010 Surveillance and analysis of bacterial resistance in Staphylococcus spp. in China. Chin J Ifect Chemother. 2013;13:86-92
14. Ren YL, Peng JC, Li ZD. et al. Regional characteristics of bacteria infections and antibiotic resistance in postoperative traumatic limb fractures. Chinese Journal of Orthopaedic Trauma. 2016;18:226-232
Corresponding authors: Xu Youjia, Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China. Email: xuyoujiacom.cn Chao Xie, Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester NY 14642 USA. Email: chao_xierochester.edu