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Classification of Infectionaccording to Severity

E E G LAUTENBACHDivision of OrthopaedicsFaculty of Health SciencesAugust 2008

CIERNY CLASSIFICATION

University of Texas staging system for adultosteomyelitis

Anatomic Type I• Medullary osteomyelitis• Superficial osteomyelitis• Localised osteomyelitis• Diffuse osteomyelitis

CIERNY CLASSIFICATION

Physiological Class

A host – Good immune system and delivery

B1 host – Compromised locally

BS host – Compromised systemically

C host – Requires suppression or no treatment. Minimal disability.

Treatment worse than disease. Not candidate for surgery.

Clinical stage = type + class

LAUTENBACH CLASSIFICATION OF MUSCULO SKELETAL INFECTION

• A. CLINICAL• B. LABORATORY

• C. RADIOLOGICAL

LAUTENBACH CLASSIFICATION OF INTENSITY OF ACUTE INFECTION

Grade 1 Acute Fulminating

Grade 2 Sub-AcuteGrade 3 a) Insiduous onset

b) Acute exacerbation of chronic

LAUTENBACH CLASSIFICATION OF INTENSITY OF CHRONIC INFECTION

Grade 4 OverwhelmingGrade 5 Diffuse inflammation

Grade 6 Low grade extensiveGrade 7 Localised infection

Grade 8 Non infective pathology

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CLINICAL FEATURES

Grade 1 – Acute Fulminating

• Pyrexia• Inflammation

• Calor, dolor, rubor• tumor, functio liso

Grade 2 – Sub-Acute

• Settling acute infection• Apyrexial - not toxic• Minor oedema

• Mild or no discharge

Grade 3 – Acute Infection

• 3a) Insiduous onset without pyrexia and minor inflammation

• 3b) Chronic infection with acute exacerbation of pain, inflammation, oedema and discharge

Joint movement often suddenly restricted

Grade 4 - Overwhelming

• Large necrotic lesions• Copious Discharge (>10ml)• Poor Containment (scarring)

• Oedema• Cahexia - Protein Deficiency

• Procalcitonin Elevated

X-ray Grade 4

• Bone destruction > • sclerosis and callus formation

Grade 5 – Extensive and Inflamed

• Extensive lesion• Red, Swollen Glands• Low-grade pyrexia

• Moderate containment• More than 5 ml pus per day

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Xray Grade 5

• Irregular Periosteal Reaction• Cavitation• Sclerosis

• Perhaps sequestra

Grade 6 – Extensive without Inflammation

• Extensive lesion (whole bone)• Good containment of infection• Warm, indurated, established sinus with

• moderate discharge 2 ml + per day• Membranous periosteal reaction

X-Ray Grade 6

• Membranous periosteal reaction• Sclerosis, cavities, obliterated medulla

Grade 7 – Localised Lesion

• Warm not inflamed or indurated• Pinhole sinus with spotting• Internal barriers with free passage to

exterior

• Compatible with good health

Skin Thermometer X-Ray Grade 7

• X-Ray well contained• Sclerosis with normal bone beyond• Periosteal reaction = fuzzy cortex

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Grade 8 – Non-Infective Lesion

• Tumours, RSD, Haematoma, aseptic loosening

• Non infective inflammatory disease• Completely resolved infection

• Soft mature scar normal texture

NB A sinus is not a sine qua non for infection.

Most infections have no sinus

A draining sinus can be quite compatible with excellent health

MONITORING THE PROGRESSOF INFECTION

EEG Lautenbach

University of the WitwatersrandJohannesburg April 2005.

OBJECTIVES

•Establish :

•diagnosis

•Duration of therapy

•Safety for implantation

•Classify clinical trials

•Medico-legal disputes

ANAEMIA OF CHRONIC INFECTIONAetiology

• RBC turnover

• Iron retention in RES

• Malabsorbtion of dietary iron

• Renal haemopoietin

• Marrow activity

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ANAEMIA OF CHRONIC INFECTIONEffects

• Iron, ferritin

• Hypochromia, microcytosis

• Anisocytosis, anisochromia, basophilia

• Protein (transferrin-carrier)

• Result – smaller, paler, fewer red blood cells

WHITE CELLS IN CHRONIC INFECTION

• Neutrophil leucocytosis

• Lymphocytosis

• Thrombocytosis

• Toxic granulation

• Shift to left

PROTEIN DISTURBANCE IN INFECTION

C-reactive protein

Sedimentation rate

Plasma viscosity

Mucoproteins

Rouleaux formation

Transferrin (iron carrier)

IRON PROFILE

Serum Iron

Transferrin

Iron Binding Cap.

Iron Saturation

Ferritin

INTERPRETATION OF PROCALCITONIN (PCT)TEST RESULTS

S-PCT (ng/ml) INTERPRETATION

< 0.5 Systemic bacterial infection unlikely

0.5 – 2 Local infection possible. Severe sepsis

or septic shock unlikely.

2 – 10 Systemic(bacterial or fungal) infection

likely.

�10 Severe bacterial infection with systemic

inflammation probable(sepsis with organfailure and possible shock).

NOTE: PCT DETECTABLE WITHIN 6 HOURS OF ONSET.

PCT HAS A HALF-LIFE OF 24 HOURS

Jan 1982 to Dec 1988 (7 years)

1191 Patients

1874 incl. changed grades

3170 records

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Grades of Infection

Acute

1. Fulminating

2. Subacute

3. Insidious

6/3 Acute on chronic

7/3 exacerbation

Grades of Infection

Chronic

4. Overwhelming

5. Inflammation

6. Diffuse

7. Localised

8. Not Infected

GROUP 4 – OVERWHELMING

Large necrotic lesions

Copious pus (> 20 ml/day)

Toxin producing bacteria

Impaired immunity

Cahexia

Poor containment (scarring)

Bone destruction > sclerosisand callus formation

GROUP 5 – EXTENSIVE + INFLAMMATION

Extensive lesion

Red, Swollen Glands

Low-grade pyrexia

Moderate containment

Moderate pus (> 5 ml/day)

Florid periosteal reaction

GROUP 6 – EXTENSIVE NOT INFLAMED

Extensive lesion (whole bone)

Warm, indurated, sinusmild pus (>2 ml/day)

Good containment of lesion

Membranous periosteal reaction

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GROUP 7 – LOCALISED LESION

Local Warmth

No induration

Pinhole with spot

Well contained lesion

Sclerotic border - normal bone beyond

Periosteal reaction: none/irregular or fuzzy cortex

GROUP 8 - NOT INFECTED

Tumours, Reflex Sympathetic Dystrophy

Haematoma, Aseptic loosening

Non infective inflammatory disease

Haemoglobin

normal 14 - 18.5 (g/dl)

Grade Median Above 14

4 12.8 23%

5 13.6 42%

6 14.4 62%

7 15.1 77%

8 15.3 81%

White Cell Count

normal 4 - 11.5 (1E)

Grade Median Under 11

4 9.3 77%

5 8.9 82%

6 8.6 87%

7 8 93%

8 7.9 81%

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Sedimentation Rate

Normal 1 - 10 or 20 (mm/hr)

Grade Median Under 10 Under 20

4 50 15% 15%

5 36 16% 30%

6 18 32% 56%

7 8 66% 89%

8 6 79% 94%

Serum Iron

normal 11 - 30 (umol/ml)

Grade Median Over 11

4 7 33%

5 9 31%

6 11 49%

7 14 72%

8 16 82%

Iron Saturation

normal 15 - 50%

Grade Median Above 15

4 16.7 50%

5 15.6 54%

6 19 71%

7 23.6 84%

8 26.7 90%

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Transferrin

normal 2 - 3.8 (g/l)

Grade Median Above 2

4 2 50%

5 2.4 74%

6 2.6 83%

7 2.8 93%

8 2.8 92%

Ferritin

normal 17 - 230 (ng/ml)

Grade Median Under 100 Under 230

4 372 10% 50%

5 215 30% 54%

6 160 36% 64%

7 99 51% 79%

8 89 55% 80%

PERCENTAGE WITH NORMAL VALUES

TEST Grade 7 Grade 8 % Variation

FE %>11 72 82 13

FERRITIN %<100 51 55 8

FERRITIN %<230 79 80 1

HB %>14 77 81 5

ESR %<10 66 79 18

ESR %<20 89 94 5

SATURATION %>15 84 90 7

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MEDIAN VALUES

TEST Grade 7 Grade 8 % Variation

IRON median 14 16 13

FERRITIN median 99 89 -11

HB median 15.1 15.3 1

ESR median 8 6 -29

SATURATION median 23.6 26.7 12

Serum Ferritin : Iron Ratio

Grade

4 53.1

5 23.8

6 14.5

7 7.1

8 5.6 27% Variation

Haemoglobin

Sedimentation

Serum Iron

Iron Saturation

Ferritin

Clinical History

Signs & Symptoms

X-RAY

RED CELL COUNT (g/dl M 4.4-6.0

F 4.2-5.5

HAEMOGLOBIN (g/dl) M 14-18

F 12-16

HAEMATOCRIT (%) M 0.41-0.51

F 0.37-0.49

MEAN CELL VOLUME (l) 82-100

MEAN CELL HB 27-32

MEAN CELL HB CONC (g/dl) 32-36

Grade 1 2 3 4 5 6 7

RBC ± - - ± - -

HB - - ± -

PCV - - ± -

MCV ± - - ± -

MCH ± - - ± -

MCHC - - - ± - -

RED BLOOD CORPUSCLES LEUCOCYTES 4000 – 11000

NEUTROPHILS 2000 - 7800(40-75%)

MONOCYTES 180 – 800(2-10%)

LYMPHOCYTES 1000 – 4000(20-45%)

EOSINOPHILS 0 – 450(0-6%)

BASOPHILS 0 – 200(0-2.5%)

PLATELETS 140 000 – 400 000

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Grade 1 2 3 4 5 6 7

WBC ± ± - -

NEUT ± ± - -

LYMPH - - ± - - -

TOX GRAN - - ± - -

L SHIFT - - ± - -

PLATES - - ± - -

LEUCOCYTES

ABNORMAL CELLS

(size, colour, shape, Basophilia Nuclei)

ROULEAUX FORMATION

ERYTHROCYTE SED RATE

M 0 – 10 mm/hr

F 0 – 15 mm/hr

Grade 1 2 3 4 5 6 7

ABNORMAL ± - - ± - -

ROULEAUX ± - - -

SED RATE ± ± -

ABNORMALITIES OF RED CORPUSCLESIRON PROFILE

SERUM IRON (umol/L) M 14 – 31F 11 – 29

TOTAL IRON (umol/L) M 44 – 72F 44 – 72

SATURATION (%) M 20 – 50F 15 – 20

TRANSFERRIN (g/l) M 2 – 4F 2 – 4

FERRITIN (ng/ml) M 17 – 230F 14 – 150

Grade 1 2 3 4 5 6 7

IRON ± - ±

TIBC - - - - -

SATURATION - - - ±

TRANSFERRIN - - - - -

FERRITIN ± -

IRON STUDIES

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Radiological Features of Osteitis

• The Features pertaining to bone infection will be discussed under the different headings as we deal with them viz.

• Haemotogenous osteomyelitis• Septic Arthritis• Infection of fractures and fracture implants

• Infection around arthroplasties

Radiological Features of Osteitis (cont.)

• In Medico-Legal disputes and research it is often necessary to determine the end point or cure of infection.

Definition of Grades

• 5 – Definite Infection• 4 – Probable Infection• 3 – Equivocal

• 2 – Probable Cure• 1 – Definite Cure

or Absence of Infection

Trabecula normalNegative isotope

Ferritin:Iron Ratioless than 5:1

Nothing1

SclerosisFerritinLocal warmth2

No changeMCV MCHSerum Iron

LymphadenopathyInduration

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PeriostealReaction

AnaemiaInflammationOedema

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Bone lysisSequestrum

NeutrophiliaCRP ESRPlasma Viscosity

PyrexiaExudate

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RadiologicalLaboratoryClinicalGrade

Evaluation of Degree of Infection Scoring

Good Fair Poor

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