社區醫學 ,2,3 1,4 前言 Hippocrates (460 to 370 BC) 1844 Nelaton osteomyelitis (1940) 33% 0-22% [1] 15 % [2] 1-2% [3] 高雄醫學大學附設中和紀念醫院家庭醫學科

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1 ,2,3 1,4 前言 Hippocrates (460 to 370 BC) 1844 Nelaton osteomyelitis (1940) 33% 0-22% [1] 15 % [2] 1-2% [3] 高雄醫學大學附設中和紀念醫院家庭醫學科 2 高雄醫學大學附設中和紀念醫院部 3 高雄醫學大學家庭醫學科 4 高雄醫學大學公共衛生學系 osteomyelitis, bone infection 0.03%-0.04% 病理機轉與分級 20 % ( 34 %) 47 % [4] Staphylococcus aureus, coagulasenegative staphylococci, aerobic gramnegative bacilli streptococci, enterococci, anaerobes, fungi and mycobacteria Lew and 62 家庭醫學與基層醫療 第三期

2 Waldvogel classification Cierny and Mader classification Cierny and Mader [5] 臨床表徵與診斷流程 ( ) ( ) [6] WBC, blood culture, CRP, ESR 2 plain radiography (cortical eroson) (lucency) (periosteal reaction) (sequestrum) ( ) [7] plain radiography Bone scan(technetium-99m scan) MRI Bone scan (radionuclide) osteoblast [8] ( ) CT (computed tomography) Gallium scan [9] 表一 Cinery-Mader staging system for long bone osteomyelitis 解剖位置 Stage 1 Medullary osteomyelitis( 髓質內部 ) (Anatomic type) Stage 2 Superficial osteomyelitis( 傷口底下骨頭表面 ) Stage 3 Localized osteomyelitis ( 全層骨壞死 ) 宿主身體狀況 (Physiological class) 其他影響因素 (Type of Compromise) 資料來源 : 參考資料 5 Stage 4 Class A Class B Class C 全身性 (Systemic) 局部性 (Local) Diffuse osteomyelitis 正常有全身性或局部不良因素宿主身體的狀況比骨髓炎所導致的疾病狀況差營養不良 肝腎衰竭 糖尿病 慢性缺氧 癌症淋巴水腫 靜脈滯留 吸菸 ( 每天大於兩包 ) 血管炎 家庭醫學與基層醫療 第三期 63

3 (percutanous biopsy) bone biopsy swab culture bone biopsy [10] 治療 6 ESR, CRP (hyperbaric oxygen therapy) ( negative pressure wound therapy) 結語 表二常見抗生素使用準則 病原菌抗生素劑量 MSSA Oxacillin 1-2 g Q6H IV Cefazolin 1 g Q6H IV MRSA Vancomycin 30 mg/kg QD or 15 mg/kg Q12H Coagulase-negative staphylococcus Vancomycin 同上 Gram-negative organisms Ciprofloxacin 750 mg PO BID Levofloxacin Ceftazidime Cefepime 750 mg PO QD 2 g Q8H IV 2 g Q8H IV S. aureus, streptococcus 等常見菌種經驗性抗生素 Vancomycin + against G(-) organisms 64 家庭醫學與基層醫療 第三期

4 圖一大腿骨 (femur) 處的骨髓炎, 可以看到死骨形成 ( 粗箭頭 ) 以及孔洞化 ( 細箭頭 ) 的現象 圖二 Bone scan 之放射性核素 (radionuclide) 聚集於病患感染骨髓炎的手指區域 參考資料 1. Costas P, Nikolaos KK, Juan P et al: Prevalenceof complications of open tibial shaft fractures stratified as per the Gustilo-Anderson classification. Injury Int J. Care Injured 2011; 42: Waldvogel FA, Medoff G, Swartz MN: Osteomyelitis: a review of clinical features, 家庭醫學與基層醫療 第三期 65

5 therapeutic considerations and unusual aspects. N Engl J Med 1970; 282: Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J: Infection burden for hip and knee arthroplasty in the United States.JArthroplasty. 2008;23: David R, Barron BJ, Madewell JE: Osteomyelitis, acute and chronic. RadiolClin North Am 1987; 25: Mader JT, Shirtliff M, Calhoun JH: Staging and staging application in osteomyelitis; Clinical Infectious Diseases, 1997; 25: Butalia S, Palda VA, Sargeant RJ, et al: Does this patient with diabetes have osteomyelitis of the lower extremitiy? JAMA 2008; 299: Gold RH, Hawkins RA, Katz RD: Bacterial osteomyelitis: findings on plain radiography, CT, MR, and scintigraphy. AJR Am J Reoentgenol 1991; 157: Schauwecker DS: The scintigraphic diagnosis of osteomyelitis AJR Am J Roentgenol 1992; 158: Pineda C, Vargas A, Rodriguez AV: Imaging of osteomyelitis: current concepts. Infect Dis Clin North Am 2006; 20: Senneville E, Melliez H, Beltrand E, et al: Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: concordance with ulcer swab cultures. Clin Infect Dis 2006; 42: 家庭醫學與基層醫療 第三期