急性血源性骨髓炎全身与局部抗生素治疗体会及重症病例分析

目的:总结急性血源性骨髓炎尤其是重症患者治疗中全身及局部抗生素应用的经验、方法及临床疗效。方法:回顾性分析空军军医大学第二附属医院2016年11月至2019年4月收治的12例急性血源性骨髓炎患者,其中3例为合并肺脓肿的重症败血症患者。对患者首先进行经验性全身抗生素治疗,并进行细菌学分析,然后根据药敏结果进行系统抗生素调整,采用万古霉素负载的硫酸钙/磷酸钙复合物进行局部抗生素缓释治疗,分析治疗前后实验室指标变化、局部影像学变化。结果:细菌学培养显示金黄色葡萄球菌10例,人葡萄球菌1例,阴沟肠杆菌1例;平均随访56.6周;治疗后患者白细胞(WBC)、中性粒细胞百分比(NEUT%)、红细胞沉降率(ESR)、高敏C反应蛋白(hs-CRP)等指标均恢复到正常范围内;影像学显示患者病灶处骨重建及新骨形成良好,无感染复发迹象;12例患者中成功治愈11例,治愈率91.7%;1例转为慢性骨髓炎,二期手术后痊愈;其中3例骨髓炎合并重症败血症、肺脓肿患者经系统抗生素及外科治疗,全部治愈。结论:急性血源性骨髓炎的致病菌主要为甲氧西林敏感金黄色葡萄球菌(MSSA),其治疗要在早诊断的前提下,率先经验性应用抗生素,然后根据药敏结果合理选择足量敏感抗生素。苯唑西林在3例合并败血症、肺脓肿的重症患者治疗中起到了关键作用,同时局部采用硫磷复合物负载万古霉素进行治疗,既可以实现局部抗感染作用,又可以促进新骨形成,有效控制全身感染、消除败血症,临床疗效满意。

Application of Systemic and Local Antibiotics in the Treatment of Acute Haematogenous Osteomyelitis and Analysis of Severe Cases

Objective: To summarize the experience, methods and clinical effects of systemic and local antibiotics in the treatment of acute hematopoietic osteomyelitis, especially in severe cases. Methods: A retrospective analysis was performed on 12 cases of acute hematopoietic osteomyelitis who were treated in the second hospital affiliated to Air Force Military Medical University(AFMU)during November 2016 to April 2019, among which 3 cases were with severe sepsis complicated with pulmonary abscess. The patients were firstly treated with empiric systemic antibiotics, followed by bacteriological analysis. Then systemic antibiotics were adjusted according to the results of microbial culture and drug sensitivity. Calcium sulfate/calcium phosphate complex loaded with vancomycin was applied for local release of antibiotics. The outcome of laboratory and radiological examination before and after treatment were analyzed. Results:Bacteriological culture showed 10 cases of staphylococcus aureus, 1 case of human staphylococcus and 1 case of enterobacter cloacae.The mean follow-up was 56.6 weeks. White blood cell(WBC), neutrophil(NEUT%), erythrocyte sedimentation rate(ESR), high sensitivity c-reactive protein(hs-CRP) and other indicators all returned to normal range after treatment. Radiological examination showed a successful bone reconstruction with good osteogenesis and no infection recurrence. 11 out of the 12 patients were treated successfully,with a cure rate of 91.7 %. 1 patient developed chronic osteomyelitis and recovered after the second stage of operation, among which 3 patients with osteomyelitis accompanied by sepsis and pulmonary abscess were cured by systematic antibiotics and surgical treatment successfully. Conclusions: Methicillin Sensitive Staphylococcus Aureus(MSSA) is the most common pathogen for acute haematopoietic osteomyelitis. Treatment should be based on early diagnosis. Firstly, we should use antibiotics empirically, and then choose sensitive antibiotics according to the results of drug sensitivity. Oxacillin plays a significant role in the treatment of 3 severe cases with sepsis and pulmonary abscess. Meanwhile, calcium sulfate/calcium phosphate composite loaded with vancomycin not only achieve local anti-infection effect, but promote the formation of new bone. The treatment effectively eliminate infection, control sepsis and pulmonary abscess with satisfactory clinical efficacy.