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

Johan Andrianasolo (1, 2) , Tristan Ferry (3, 1, 2) , Fabien Boucher (2, 4) , Joseph Chateau (2) , Hristo Shipkov (2, 4) , Fatiha Daoud (1, 2) , Evelyne Braun (1, 2) , Claire Triffault-Fillit (1, 2) , Thomas Perpoint (1, 2) , Frédéric Laurent (3, 2, 5) , Alain-Ali Mojallal (2, 4) , Christian Chidiac (1, 2, 3) , Florent Valour (3, 1, 2) , Lyon Bji Study Group

1 Service de Maladies Infectieuses et Tropicales [Hôpital de la Croix-Rousse - HCL]
2 Centre interrégional de référence Rhône-Alpes - Auvergne des infections ostéo-articulaires complexes
3 StaPath - Pathogénie des Staphylocoques – Staphylococcal Pathogenesis
4 Service Chirurgie Plast Esthétique et Reconstructrice
5 Laboratoire de bactériologie

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.

Mots clés: Antimicrobial therapy; Bacteriology; Chronic osteomyelitis; Debridement; Flap coverage; Negative pressure therapy; Pressure ulcer

Domaines: Immunologie; Bactériologie; Virologie

Johan Andrianasolo, Tristan Ferry, Fabien Boucher, Joseph Chateau, Hristo Shipkov, et al.. Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy. BMC Infectious Diseases, 2018, 18 (1), pp.166. ⟨10.1186/s12879-018-3076-y⟩. ⟨hal-01917824⟩