Bone and prosthetic infections

Red flags

Consider urgent referral for patients with the following:

Evidence of septicaemia/bacteraemia
Septic arthritis
Cellulitis
Bone infection with associated valvular heart disease or new heart murmur
Suspected mycobacterial, gonococcal infection

Information that may lead to more urgent categorisation

Presence of sequestrum on Xray (refer orthopaedics)
Non response or relapse after prolonged antibiotic use

Refer to Orthopaedics in the following situations:

Infection related to recent surgery (within 2 yrs)
If osteomyelitis with sequestrum present

Any other bone/prosthetic related infection refer to Infectious Diseases.

Other important information for referring practitioners

Important general advice

If suspected septic arthritis DO NOT commence antibiotic treatment unless blood cultures and joint fluid has already been collected for microscopy and culture. If not confident in the collection of these specimens refer to the Emergency Department.

Lifestyle changes

Encourage healthy nutrition
- Weight reduction especially in the case of weight bearing prostheses
Reduce alcohol intake if excessive

Medical management

All cases of osteomyelitis should be referred for specialised advice and management
If the causative organism can be found commencement of an appropriate antibiotic can be done in Primary Care. Do not commence antibiotics without first
- Collect blood cultures (two sets from separate sites)
- Joint aspiration fluid for microscopy and culture
Likely infecting organisms in bone infections are
- Staphylococcus aureus (most common)
- Streptococcal species
- Other organisms may occur in particular settings
As staph aureus infections are the most common in adults it may be appropriate, once blood cultures and culture of any sinus discharge/synovial fluid have been performed to commence on an anti-staphylococcal antibiotic such as
- Flucloxacillin/dicloxacillin
- Clindamycin
- Co-Trimoxazole
- Cephalexin
- If in any doubt discuss with ID specialist
If recent surgery especially prosthetic joint replacement consider referral to orthopaedic or contact original surgeon for advice prior to commencing antibiotics
If no recent surgery and no sequestrum present refer to Infectious Diseases
If patient may be suitable for treatment in primary care consider contacting Infectious diseases for advice
Optimise co-morbid chronic diseases e.g. diabetes
Screen for immunocompromised host

Referral requirements

A referral may be rejected without the following information.

Essential referral information

Reason for referral
Presence of any Red Flags
Duration and nature of symptoms (fever, pain, swelling , inflammation)
Location of suspected infection
History of recent surgery (joint replacement or trauma). Include hospital discharge letter if available
Treatments trialled with duration and reasons for failure
Drug history and allergies
- History of iv drug use or alcoholism
List relevant co-morbidities
- Immunosuppression
- Diabetes
Examination details (include severity of inflammation, any discharge, sinus etc)
- Any vascular insufficiency
Investigations
- FBC, ESR, CRP, E/LFT
- Plain Xray of affected area (any periostitis, osteopenia, loosening of prosthesis)
- Microscopy and culture of any discharge or aspirate collected
- Blood cultures (two sets collected from separate sites)

Additional referral information (useful for processing the referral)

Mycobacterial culture of any discharge
Isotope bone scan or Indium-111- labelled white cell scan
MRI (may not be possible if ferrous metal prosthesis)

Out of catchment!

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

Clinical Modifiers (where relevant)

Impact on employment
Impact on education
Impact on home
Impact on activities of daily living
Impact on ability to care for others
Impact on personal frailty or safety
Identifies as Aboriginal and/or Torres Strait Islander

Reason for Referral (essential)

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can’t order, or the patient can’t afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Clinical Information (essential)

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use