Hospital-Acquired Infections in Orthopedic Patients

Hospital-acquired infection (HAI)

A patient with a comminuted fracture from a car accident developed acute osteomyelitis due to a Staphylococcus aureus infection post-surgery, which progressed to chronic osteomyelitis.
The patient later sought treatment at a medical center, receiving daily infusions of four bottles of vancomycin and undergoing multiple debridement surgeries.
After bone grafting and following medical advice, the patient returned to the hospital several times for inflammation index checks, which all returned normal.
The attending physician informed the patient that further follow-up visits were unnecessary.

Two years later, the patient experienced electric shock-like pain in the cheek and visited the hospital, consulting three dentists.
Each dentist recommended tooth extraction, despite the patient informing them of a history of chronic osteomyelitis and having undergone 13 surgeries, now in recovery.
The dentists assured the patient that tooth extraction, being an invasive procedure, would not trigger a recurrence of chronic osteomyelitis and prescribed antibiotic treatment.
However, several days after the extraction and suturing, the patient developed chronic osteomyelitis in the distal femur of the right leg (redness, swelling, heat).
The patient quickly went to the medical center's emergency department, where blood tests revealed elevated inflammatory markers: WBC 13.5, ESR 62, CRP 260.37.
The patient was admitted that night and treated with vancomycin, later discharged, but returned for debridement surgery to remove necrotic bone.
Subsequently, other physicians diagnosed the patient with trigeminal neuralgia, which was not the gingival inflammation suggested by the dentists.
The patient learned from medical literature that the pain was indeed trigeminal neuralgia, not as the dentists had claimed.
Reports in various newspapers indicated that several individuals experienced unresolved symptoms after tooth extractions, later found to be caused by trigeminal nerve issues.
A minority of dentists misdiagnosed trigeminal neuralgia as gingival inflammation, leading to unnecessary extractions and unresolved problems.

The antibiotics prescribed by the dentists, such as amoxicillin, were suitable for the general population but not for patients with a history of chronic osteomyelitis, necessitating orthopedic consultations that resulted in hospitalization and debridement surgery.
When the patient returned for follow-up, they inquired about the cause of their condition, which was identified as Coagulase-negative Staphylococcus, a pathogenic bacterium responsible for the patient's complications.

The patient sought information at a bookstore and found that literature on microbiology indicated that Methicillin-Resistant Staphylococcus aureus (MRSA) could cause bloodstream infections.
This aligned with the attending physician's writings on osteomyelitis, highlighting the insufficient preoperative preparation by the dentists.
Amoxicillin is ineffective against resistant Staphylococcus aureus.
The use of Augmentin would provide better protection against the risk of hospital-acquired infections.
Resistant Staphylococcus aureus is prevalent in hospitals and clinics, which is why the Ministry of Health and Welfare promotes infection prevention and control in the media and publications.
Do you agree with this statement?

Shenqi Xiaodingdang, 40~49 year old female. Ask Date: 2013/11/14

Dr. Shi Guozheng reply Orthopedics

Infection control within healthcare facilities is essential for every hospital.
The use of antibiotics follows specific clinical guidelines.
If a patient has an implanted device and is undergoing dental surgery, it is advisable to administer prophylactic antibiotics.

Reply Date: 2013/11/14

More Info

Hospital-acquired infections (HAIs) are a significant concern in orthopedic patients, particularly those with a history of complex surgeries and underlying conditions such as chronic osteomyelitis. Your experience highlights the critical nature of infection prevention and management in such cases.
In orthopedic settings, patients are at risk for HAIs due to several factors, including the invasive nature of surgeries, the presence of foreign materials (like implants), and the potential for compromised immune systems. Staphylococcus aureus, particularly methicillin-resistant Staphylococcus aureus (MRSA), is a common pathogen associated with these infections. The risk of developing chronic osteomyelitis, as you experienced, can arise from these infections if they are not adequately managed.

Preventing HAIs involves a multifaceted approach:
1. Preoperative Assessment: A thorough evaluation of the patient's medical history, including previous infections and current medications, is essential. Patients with a history of chronic infections should be closely monitored and may require additional prophylactic measures.

2. Antibiotic Prophylaxis: The choice of antibiotics is crucial. In your case, the use of Amoxicillin may not have been sufficient due to the presence of resistant strains of bacteria. Augmentin, which combines amoxicillin with clavulanate, can provide broader coverage against resistant organisms. It is vital for healthcare providers to tailor antibiotic prophylaxis based on the patient's history and the specific risks associated with the procedure.

3. Surgical Techniques: Employing sterile techniques during surgery, minimizing the duration of the procedure, and using appropriate wound closure methods can significantly reduce the risk of infection.
4. Postoperative Care: Monitoring for signs of infection, such as redness, swelling, and increased pain, is essential. Patients should be educated on these signs and encouraged to report any concerning symptoms promptly.

5. Interdisciplinary Collaboration: In complex cases, collaboration between orthopedic surgeons, infectious disease specialists, and dental professionals is crucial. For instance, your experience with dental procedures following orthopedic surgery underscores the need for clear communication about a patient's medical history and potential risks.

6. Patient Education: Patients should be informed about the signs of infection and the importance of adhering to prescribed antibiotic regimens. Understanding the potential risks associated with procedures, especially for those with a history of infections, can empower patients to seek timely care if complications arise.

Your case also illustrates the importance of accurate diagnosis and treatment. Misdiagnosis, such as attributing your pain to gingival inflammation rather than recognizing it as trigeminal neuralgia, can lead to inappropriate treatments and further complications. It is essential for healthcare providers to consider a patient's complete medical history and to be vigilant in diagnosing and treating infections.

In conclusion, the prevention of HAIs in orthopedic patients requires a comprehensive strategy that includes careful preoperative planning, appropriate antibiotic use, meticulous surgical techniques, and ongoing postoperative monitoring. Your experience serves as a reminder of the complexities involved in managing patients with a history of infections and the necessity for healthcare providers to remain vigilant in preventing and addressing HAIs. The emphasis on infection control measures by health authorities is indeed warranted, given the prevalence of resistant organisms in healthcare settings.

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