……….. www.Vitals.com

 Dr. George Cierny is an orthopaedic surgeon .  He has 36 years as a doctor and is based out of REOrthopaedics located at 7910 Frost Street; Ste 120, San Diego, CA.   Dr. Cierny is affilitated with a 4-star hospital, has received a fellowship, and attended a 4-star medical school.  Dr. George Cierny has additional knowledge and expertise in areas of bone transplantation, bone marrow inflammation (osteomyelitis), fracture fixation, tibial fractures, musculoskeletal tumors, un-united fractures and Methods of Ilizarov.  He has 126 research publications.   His overall average patient rating is four out of four stars, with an overall rating of “Excellent”.  You may also find the doctor’s name written as Dr. George Cierny III, MD.

Meet Eric Wickre (the original, Alaskan Viking Cowboy), treated at our center December 2008 for Stage IA osteomyelitis of his left tibia, a con-sequence of an open fracture suffered in 1981.   His (and others’) entire medical case portfolio will be posted  at http://www.osteomyelitis.com/html/news.html#featured-case .  After successful treatment at our treatment center in  San Diego, Eric is now back to his rough-and-ready cowboy ways, having just been selected to be one of 1000 motorcyclists from around the globe to compete in The Hoka Hey Motorcycle Challenge —– also known as the “Iditarod of Harley Davidson, 2010”.

CLICK TO ENLARGE

The Challenge is a grueling, 7,000 mile race from Key West, FL to the Kenai Peninsula, Alaska where “winner takes all” …one half million dollarsin Alaskan gold!  It starts June 20th and ends in Homer, AK on July 4th.  The secret route will initially head 1,000 miles into Mississippi. There, riders will get a map for the next leg of the ride: traveling the back roads, highways and byways; enduring hail storms, heat waves and scorpions; sleeping along side their bikes every night for the entire journey.

Join us as we follow Eric’s epic journey through the Americas on  OSTEOMYELITIS  BLOG.                                           Good luck, Eric!!

George Cierny, MD; REOrthopaedics in San Diego

In acute pediatric osteomyelitis  and osteomyelitis of the spine (verbetral osteomyelitis; sacroiliitis) in all ages,  surgery is not always necessary to affect cure.  In other forms of acute osteomyelitis  (infection following open fracture; surgical site infections following trauma or reconstructive surgery) and nearly all forms of the chronic disease, treatment will have to combine various aspects of surgery (with antibiotics) to result in cure .
The treatment of a refractory (chronic) osteomyelitis is governed by its pathophysiolgy —– it is a ‘biofilm disease’.    Unlike the mobile (planktonic), environmentally sensitive microbes found in an acute infection, chronic wound pathogens are sessile and resilient, transformed into colony-forming units by environmental triggers (quorum-sensing) and the successful attachment to ‘unprotected’ surfaces within the wound (inert materials; non-viable tissues or organisms, etc.).    Thereafter, individual cells become colony-forming units that mature (2-4 weeks) to secrete and maintain a mucopolysaccharide “slime” that protects them from host defenses and the penetration of most antimicrobial agents .   To cure this biofilm infection, a LIVE, CLEAN WOUND is paramount: the biofilm-colony its attachment surfaces must be completely excised.

The type of surgery will depend on the duration of the infection (acute or chronic), the contents of the wound (extent of necrosis; substrate surfaces), the anatomic site, the health and well-being (impairment) of the host, and the experience of the healthcare team.

However, surgery, as a form of treatment, is not available to everyone. Patients who are very ill may not be able to endure the extensive surgery and recovery. In these cases, doctors may use antibiotics for long periods in an attempt to suppress (rather than cure) the infection.  Then, if the infection persists and, again, threatens the patient’s well-being, lesser morbid procedures, such as amputation of all or part of an infected limb, may be necessary.  

Surgical treatment options  – Drain the infected area: Opening up the area around the infected bone allows the surgeon to drain any pus or fluid that has accumulated in response to the infection.  This is usually applied in the acute setting to decrease strain on host defenses and amplify the effects of antibiotics.  Remove the attached, biofilm-colony:  In a procedure called debridement, the surgeon removes the diseased bone and tissue. In some cases, foreign objects, such as surgical plates or screws, used in previous surgeries, may also be removed. Restore the bone and soft-tissue envelope: Your surgeon may fill any empty space left by the debridement procedure with a piece of bone or other tissue, such as skin or muscle, from another part of your body. Sometimes temporary fillers containing antibiotics (antibiotic depots) are placed in the space until the infection is cured and the patient is healthy enough to undergo a definitive reconstruction. Bone grafts and tissue flaps help the body recruit new blood vessels into the site and form new bone.  Protect against instability: Immediately following debridement, the surgeon may use an external fixatation device (external fixator) to hold and protect the bone from further injury.  This method limits the amount of implanted, foreign material (metal) in the still-contaminated wound by attaching thin wires or pins (that pass through the limb) to a frame positioned around the limb (outside the skin).  The fixator can be the only method used throughout treatment or, after a course of local antibiotic therapy, replaced with internal methods of fixation such as metal plates, rods or screws.

PREVENTING HOSPITAL ACQUIRED INFECTIONS:   The translation of basic epidemiologic evidence into successful prevention has led to several successes in hospital-acquired infection prevention research over the past decade.  First is the use of alcohol-based hand rubs in clinical practice.

I.  Hand Hygiene:  Before the past decade, the major method of decontamination of the hands was the use of soap and water. The limitations of this procedure included the time it took to do, the number of sinks and the location of sinks in the hospital defined the optimal adherence to policy, and repeat use of detergents can be very irritating to the skin.

In 2002, the Centers for Disease Control and Prevention [CDC] through the Healthcare and Infection Control Practices Advisory Committee firmly established alcohol-based hand rubs at the center of hand hygiene practices, recommending them for routine decontamination of hands in all clinical situations except when the hands are visibly soiled.    Application of the rub takes seconds, the compounds are non-irritating and the dispensers are small, inexpensive and accessible wherever needed.  By 2008 84% of all US hospitals surveyed indicated that they had adopted alcohol-based hand rub and number of studies have shown dramatic increases in adherence to hand hygiene.  - Mody L, et al; Adoption of Alcohol-Based Handrub by United States Hospitals: a National Survey. Infect Control Hosp Epidemiol., 2008; 29:1177-1180.

II. Central Line catheter infections:  In the 2000s, there were 2 separate reports of large collaborative regional demonstration projects that focused on improved implementation of existing recommendations to prevent central line-associated blood stream infections (CLABSI) among patients in intensive care units (ICUs), first in southwestern Pennsylvania (2005) and then in Michigan (2006). Both studies demonstrated ~70% reductions in CLABSI rates across a wide variety of facility and ICU types, suggesting that the preventable fraction of these infections was perhaps much larger than we had originally thought.  The protocol was a 5-step process:  1) hand hygiene by the person inserting the device.  2) maximal barrier precautions.  3) chlorhexidine gluconate for antisepsis applied to the site of the insertion.  4) avoidance of femoral central line insertion.  5) removal of the central line as soon as possible /when no longer needed.

The results of these 2 studies have changed expectations of CLABSI prevention programs. The earlier single-center reports were viewed by many as somehow aberrant, the result of special circumstances and/or resources that could exist only in those particular, reporting facilities. These regional studies demonstrated that better implementation of existing recommendations can have a major impact across a wide spectrum of hospital settings —– dramatic success was possible, and not just under special circumstances.

III. DECOLONIZATION OF PATIENTS: Another innovative advance is the role of “source control” in preventing infection, particularly with the use of chlorhexidine bathing of patients. Based on data suggesting that colonization of a patient’s skin is an important source of spread for epidemiologic imported bacteria, it was hypothesized that daily bathing with a skin antiseptic (chlorhexidine gluconate) would decrease the burden of the patient’s skin contamination, indirectly decrease contamination in the environment, decrease transmission by healthcare worker, and play a role in decreased transmission of resistant pathogens and the incidence of both surgical site infections and CLABSI.  Today, data strongly suggest that daily chlorhexidine bathing can significantly reduce contamination of the patient’s skin, the environment, and healthcare workers’ hands, and an impact on methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) acquisition has been documented.  - Barta R, Cooper BS, Whitely C, Patel AK, Wyncoll D, Edgeworth JD.  Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit. Clin Infect Dis. 2010;50:210-217.

Discussion: One area of controversy is the role of active surveillance, or what the value is of actively screening patients for MRSA.  . Most of the studies done in the past were typically small, single-institution studies, and often with quasi-experimental, pre- vs post- design. The results from those studies leave the conclusions open to interpretation and raise the issues of potential confounding or bias. With that said, even more rigorously done, recent studies have come to different conclusions.   Clearly, more work needs to be done.  - Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008;299:1149-1157. CONCLUSION: A universal, rapid MRSA admission screening strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection. – Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148:409-418.  CONCLUSION: The introduction of universal admission surveillance for MRSA was associated with a large reduction in MRSA disease during admission and 30 days after discharge.

IV. Catheter-Associated Urinary Tract Infections:  Wald and colleagues  looked at catheter-associated UTIs [urinary tract infections] — morbidity and mortality associated with the device.  There is good evidence that getting the catheter out by postoperative day 2 makes a real difference. – Wald HL, Ma A, Bratzler DW, Kramer AM. Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data. Arch Surg. 2008;143:551-557.