*2.4.2. Treatment*

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

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

Measures for prevention of osteomyelitis are in fact those that were mentioned in Section 2.3.1 for prevention of pressure ulcer and skin and soft tissue infection. The main preventive measures are pressure relief, regular change of position, and frequent observation of the skin

Pulmonary complications in SCI patients are important, as they may be life threatening. Pneumonia, pulmonary infarction, pulmonary thromboembolism, chest injury, and atelectasis are the most frequent and important complications in these patients. Pneumonia is one of the most important pulmonary complications. It may have developed shortly after spinal cord injury, during hospitalization or even in rehabilitation periods. The risk of pneumonia is greater in post-injury period. In this phase, the patients usually do not have effective cough. If the phrenic and intercostal nerves have been damaged, the respiration cycle may be influenced and the patients may be prone to pneumonia [48]. After intubation and mechanical ventilation, ventilator-associated pneumonia (VAP) may develop. VAP is in fact the occurrence of pneumonia in patients with mechanical ventilation, occurring more than 48 h after endotracheal intubation [49]. VAP is the most frequent nosocomial infection in patients with mechanical ventilation and is associated with longer intensive care unit stay, longer duration

Pneumonia is diagnosed by signs and symptoms of respiratory infection and according to criteria for diagnosis of nosocomial pneumonia and VAP. By endotracheal culture, the causative organism is found and an antibiotic is chosen according to the result of culture. The most common organisms are *Pseudomonas aeruginosa*, *Klebsiella pneumonia*, *Acinetobacter baumannii* [50],

diagnosis of osteomyelitis in SCI patients with pressure sores [45].

treatment are chosen according to the results of culture.

of mechanical ventilation, and high morbidity and mortality [4].

*2.3.2. Treatment*

98 Essentials of Spinal Cord Injury Medicine

*2.3.3. Prevention*

**2.4. Pneumonia**

*2.4.1. Diagnosis*

over bony prominences.

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