Zusammenfassung
Wegen der vielfältigen klinischen Präsentation der Osteomyelitis werden diese Patienten von Ärzten verschiedenster Fachrichtungen gesehen. Verschiedene Klassifikationen spiegeln die Konzepte zur Diagnostik und Therapie der Osteomyelitis wider. Ursprünglich wurde die Osteomyelitis nur in eine akute und eine chronische eingeteilt. Die klassische Einteilung nach Waldvogel berücksichtigt die Pathogenese. Nach Wagner wird beim diabetischen Fuß der fließende Übergang von der Weichteilinfektion zur Osteomyelitis und zur Gangrän beschrieben. Die Einteilung nach Cierny-Mader nützt v. a. der Therapie durch den Traumatologen/Orthopäden. Das Erregerspektrum ist abhängig von Art der Osteomyelitis, geographischer Epidemiologie, Patientenalter, Komorbidität, mikrobiologischer Technik und Infektionsdauer. S. aureus spielt bei jeder Form die wichtigste Rolle. Bei Bildung von Biofilm und „small-colony variants“ neigt der Keim zu Persistenz und Rezidiv. Die Antibiotikaresistenz nimmt seit 20 Jahren zu. Nicht nur die In-vitro-Resistenz, sondern auch die Wirkung der Antibiotika auf nichtwachsende und adhärierende Keime bei Implantatinfektionen sind wichtig. Zur optimalen Antibiotikatherapie sollte immer der Keimnachweis versucht werden.
Abstract
The clinical presentation of osteomyelitis is multifarious. Therefore, patients are diagnosed and treated by various specialists with many different concepts of optimal management. Originally, only the acute and the chronic presentations were differentiated. The classification of Waldvogel, which is based on pathogenetic mechanisms, is more sophisticated. Diabetic foot is classified according to Wagner, who takes into account the continuous progression from sore to ulcer to osteomyelitis to gangrene. The staging according to Cierny-Mader is the most useful for the therapeutic management by surgeons. The spectrum of microorganisms is variable according to the type of osteomyelitis, epidemiology, age of the patient, co-morbidity, microbiological technique (culture, PCR), and duration of the infection. S. aureus is the leading pathogen in each type of osteomyelitis. Over the past 20 years, antimicrobial resistance has become an increasing problem. In case of osteomyelitis, standard susceptibility testing can be inaccurate. In case of device-related infection or in any type of chronic osteomyelitis, antimicrobial agents must be efficacious on stationary-phase and adhering microorganisms. Microbiologic culture and susceptibility testing should always be performed, in order to optimize the antimicrobial therapy.
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Zimmerli, W., Flückiger, U. Verlaufsformen und Mikrobiologie der bakteriellen Osteomyelitis. Orthopäde 33, 267–272 (2004). https://doi.org/10.1007/s00132-003-0604-1
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DOI: https://doi.org/10.1007/s00132-003-0604-1