**2.3. Osteomyelitis**

with rapid healing but stay in low level in ulcers with poor healing. So plasma fibronectin level may predict the speed of healing of pressure ulcers [27]. The SCI patients may also suffer from other soft tissue infection rather than pressure ulcers including fungal infections and

Diagnosis of pressure ulcers is clinical. The ulcer smear and culture can be useful for recognizing the causative organism and determining the antibiotic sensitivity. *Staphylococcus aureus*, *Pseudomonas aeruginosa*, *Proteus mirabilis*, and *Enterococcus faecalis* are the most common organ-

Offloading is the cornerstone of treatment of pressure ulcers. Ultrasound (low-frequency and nonthermal) may have a therapeutic role in intact skin ulcers. If the ulcer is superficial, foam dressing and collagenase may be used. For deep pressure ulcers, usually debridement and surgical intervention is needed. Osteomyelitis beneath the ulcer is so important and should be considered in treatment of deep ulcers [23]. In SCI patients, flap surgery may be needed to cover the place of debridement [25]. In Schryvers's study on large number of SCI patients with pressure ulcers during 20 years, a large number of patients needed surgical intervention. Pelvic area ulcers were the most common (468 of 598 pressure ulcers), of which 431 (92%) were treated surgically. Fasciocutaneous or cutaneous flaps, muscle or musculocutaneous flaps and primary closures were the most common surgical intervention. During the ulcer management, some bone intervention is unavoidable [29]. Medical honey has a substantial efficacy on wound management and control of infection of pressure ulcer, as shown by low

Electric stimulation therapy (EST) accelerates pressure ulcer healing in SCI patients. Pressure ulcer healing is determined by decrease in wound size and improvement in wound appearance after 3 months of treatment with EST [31]. Use of ultraviolet light C (light wavelength 200–290 nm) may be effective in treatment. It can be because of its potency in killing antibiotic-resistant microorganisms. *Staphylococcus aureus*, methicillin-resistant *Staphylococcus aureus* (MRSA) and *Pseudomonas aeruginosa* that may be resident on superficial layer of wound may be killed by ultraviolet light C [32]. Maggot therapy may also be used a subsidiary way to treat wound ulcer. Live blowfly larvae in wound dressings accelerate wound healing by increasing debridement. They can debride necrotic tissue within 1 week that is so rapid in nonsurgical wound management. It is safe, simple, and inexpensive, and it seems that it has no complications, so it can be used for treatment of pressure ulcers in SCI patients [33].

Pressure ulcers certainly have a great influence on daily activity and life of SCI patients [34]. The best position and the turning frequency are not clear, but avoiding the 90° lateral position is recommended. This position will bring about high pressure over the trochanters with

bacterial growth, decreased wound size, and improved healing stage [30].

seborrheic dermatitis [28].

96 Essentials of Spinal Cord Injury Medicine

isms causing pressure ulcers [24].

*2.2.1. Diagnosis*

*2.2.2. Treatment*

*2.2.3. Prevention*

One of the complications of spinal cord injury is osteomyelitis. Osteomyelitis may develop by extension of infection from pressure ulcers [38]. After spinal fixation surgery, osteomyelitis may be developed, as a complication of surgery. Osteomyelitis increases the treatment cost and may lead to other complications [39].

#### *2.3.1. Diagnosis*

There are several diagnostic methods for diagnosis of osteomyelitis in SCI patients.

Bone biopsy is the gold standard, and magnetic resonance imaging (MRI) is usually used as a sensitive and specific modality. Several organisms are known as causative agents. The most common isolated organisms are *Staphylococcus aureus*, Peptostreptococcus, and Bacteroides. Coagulasenegative staphylococci, group B Streptococcus, Proteus, and group milleri Streptococcus may also be isolated as less common agents. The diagnosis of pelvic osteomyelitis is difficult and may need multiple bone biopsies. At least three bone samples may be necessary to detect the pathogen and exclusion of contamination. In one study, sensitivity of MRI for diagnosis of pelvic pressure ulcer osteomyelitis was 94% and specificity was 22% [40].

However, Huang's study demonstrates that MRI is a sensitive method for diagnosis of osteomyelitis in SCI population. MRI can be used to demonstrate the extension of infection and to guide limited surgical resection and preserve viable tissue [41]. Pelvic pressure ulcers that accompany osteomyelitis may show cortical erosion and bone marrow edema in MRI [42]. In SCI patients, abscesses, fluid collections, and sinus tracts can be detected by MRI [43]. For diagnosis of osteomyelitis, gallium scan and plain pelvis X-ray may be used. Negative bone scan can rule out osteomyelitis. However, chronic ulcers usually accompany osteomyelitis. Delayed healing or recurrence of pressure ulcers has no clear association with osteomyelitis [44]. Computerized tomography and Technetium-99 m bone scans are not usually used for diagnosis of osteomyelitis in SCI patients with pressure sores [45].

*Serratia marcescens* [51] and methicillin-resistant *Staphylococcus aureus* [52]. Chest radiograph accompanied by clinical and laboratory findings are required for diagnosis of patients with

Infectious Complications after Spinal Cord Injury http://dx.doi.org/10.5772/intechopen.72783 99

Antibiotics are chosen according to endotracheal secretion culture. For empirical treatment, combination antibiotic therapy is necessary. In this combination, an anti-pseudomonas agent (that is usually effective on other gram negative organisms) such as imipenem, meropenem, piperacillin-tazobactam or cefepime in addition to an aminoglycoside or a quinolone is used. For coverage of Methicillin-resistant *Staphylococcus aureus (*MRSA*),* vancomycin is usually added to this combination. For a special situation such as multidrug-resistant Acinetobacter or Pseudomona, the appropriate antibiotic (like colistin) is elected according to culture. The rising rates of antimicrobial resistance have led to the routine empiric administration of

One important risk factor for developing pneumonia is retained secretion. So, pulmonary toilet is important in these patients. Appropriate positioning and cough assistance can be useful for clearing retained secretions. Sometimes early intubation may be necessary to prevent secretion retaining by frequent suctioning [48]. Using effective oral care with antiseptics is associated with the reduction of the incidence of ventilator-associated pneumonia. Oral care solutions have been widely used to prevent ventilator-associated pneumonia [49]. Routine cleaning and disinfection of ventilators can play an important role in VAP prevention and

Blood stream infection secondary to urinary tract infections, pneumonia, pressure ulcers [48], catheter-related bloodstream infections [54], and infections at other sites may occur in SCI patients. Meningitis may occur after penetrating injuries or as a result of CSF leakage at the time of injury or subsequent to surgery [48]. Epidural abscess and subdural empyema can be developed with the same mechanisms. Ventilator-associated tracheobronchitis (VAT) is an infective complication of mechanical ventilation and is a part of the spectrum of ventilator-

Infectious diseases after spinal cord injury are important and should be considered in patients with fever and other signs and symptoms of infections. Appropriate approach, diagnosis, and treatment and surgical interventions, if needed, can be lifesaving and can decrease mortality

broad-spectrum antibiotics even when bacterial infection is not documented [52].

suspected VAP [53].

*2.4.2. Treatment*

*2.4.3. Prevention*

management approach [53].

associated respiratory infections [55].

**2.5. Other infections**

**3. Conclusion**

and morbidity.

#### *2.3.2. Treatment*

Treatment of osteomyelitis is composed of two parts: surgical management and medical treatment. Surgical approach is in fact debridement and in some patients, muscle flap. Medical therapy is in fact antibiotic therapy and wound care. Hyperbaric oxygen may be used in refractory osteomyelitis [46]. Treatment of osteomyelitis is prolonged and so, expensive. Using surgical debridement can shorten the duration of antibiotic therapy for osteomyelitis in SCI patients. In SCI patients with bony prominence osteomyelitis, surgical debridement and flap coverage of the sore can influence the outcome of antibiotic treatment [47]. Antibiotics for treatment are chosen according to the results of culture.
