2. Osteomielitis y artritis séptica en pediatría Dra. LAURA ELENA MERINO DEL REAL Hospital Ángeles del Pedregal

3. INTRODUCCIÓN Las infecciones osteoarticulares son una patología infecciosa relativamente infrecuente en la infancia Afectan generalmente a niños pequeños, menores de 5 años. Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

4. OSTEOMIELITISDEFINICIÓN Osteon: hueso; myelos: médula; itis: inflamación. Proceso inflamatorio infeccioso agudo o crónico de la médula ósea y tejido óseo adyacente. Causada por una infección bacteriana o fúngica Menor frecuencia por parásitos o micobacterias. Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

5. Generalidades El 50% de los casos ocurre en los primeros 5 años de vida por la riqueza vascular del hueso Predominio 2:1 en varones En el 30% de los casos existe algún antecedente traumático La fuente de origen es habitualmente hematógena Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

6. GENERALIDADES La sintomatología está habitualmente presente Los huesos más afectados son los largos Los huesos planos se compromenten en el 1 a 4% Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

7. Clasificación según evolución clínica Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

8. Clasificación según mecanismo de introducción Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

9. Clasificación de acuerdo a Etiología microbiana Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

10. Patogenia Fracturas compuestas, desgarros traumáticos extensos y heridas por bala.

11. Factores bacterianos

12. Absceso subperióstico Fractura patológica Secuestro óseo NECROSIS Fístula Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

13. Recién Nacido Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

14. Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

15. Cuadro Clínico Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

16. Diagnóstico Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

17. Diagnóstico microbiológico directo Hemocultivo 60% Positivo en: osteomielitis hematógenas niños Bajo rendimiento en: formas crónicas Osteomielitis isquémica Osteomielitis por contigüidad Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

18. Diagnóstico microbiológico directo Punción/aspiración 60-70% cultivo positivo Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

19. Diagnóstico Biopsia ósea 90% cultivo positivo Recomendable cuando la punción con aguja es negativa. adultos Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

20. DIAGNÓSTICO DIFERENCIAL Artritis supurativa Fiebre reumática Celulitis Esguince Erisipela Escorbuto. Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

21. Tratamiento Precoz QUIRÚRGICO + MÉDICO Antimicrobianos bactericidas Agudas: 4 a 6-8 semanas IV Crónicas: 4 a 8 semanas IV + >2 meses Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

22. ANTIBIÓTICOS Antibioticoterapia.: Penicilina en la droga de elección: dar un 1000000 U c/3 hrs, IM hasta que la temperatura vuelva a lo normal. Continuar con un 1 200 000 U c/ 24 hrs IM por tres semanas Se aconseja combinar el tratamiento anterior con 0.5 gm. de Estreptomicina cada seis horas. Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

23. TRATAMIENTO Alergia a la Penicilina Bacitracina o Vancomicina. La antibioticoterapia definitiva quedará sujeta a los resultados del antibiograma. Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

24. Profilaxis Antiestafilocócica en cirugía de prótesis Cementos con antimicrobianos Silver K., Kemple., Bruyn: "Infections of thebone and joints". Handbook of pediatrics. Cap 22, SixthEdition. LangeMedicalPublications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 ThirdEdition, LangeMedicalPublications 1998.

25. ARTRITIS SEPTICA

26. DEFINICION Infección aguda bacteriana en el espacio articular Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

27. Epidemiología Frecuente en la infancia que en la edad adulta Mayor incidencia de 2 a 6 años Mas frecuente en varones que en mujeres (2:1) Afectan con mayor frecuencia las articulaciones de miembros inferiores. Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

28. FACTORES PREDISPONENTES Traumatismo penetrante Cirugía y/o inyecciones intraarticulares Artritis preexistente Infecciones cutáneas Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

29. ETIOLOGIA S. aureus presenta mayr frecuancia

30. Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

31. PATOGENIA

33. CLINICA 90% de los pacientes presenta: Dolor, Limitación del movimiento y fiebre Las Articulaciones mas frecuentemente afectadas son: Rodilla, cadera y tobillo Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

34. DIAGNOSTICO Historia clínica. Exploración fisica. Análisis del liquido articular Técnicas de imagen: Rx, ECO, TAC, RMN Hemocultivo 50% d los casos positivo Reactantes de fase aguda en sangre: eritro, recuento y distribución leucocitarios. Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

35. ESTUDIO LIQUIDIO SINOVIAL Incluye Cultivo para aerobios y anaerobios Celularidad y glucosa Leucocitos > 100.000/mm3 PMN(75-90%). Glucosa <50% Proteínas elevadas Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

36. Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

37. TRATAMIENTO INTEGRAL QUIRURGICO CLÍNICO Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

38. TRATAMIENTO IDEAL Punción del liquido articular Toma de hemocultivos Con líquido purulento o bacterias en el Gram, iniciar tratamiento parenteral 1 sem y después completarse por VO mínimo 3-4 sem en total. Drenaje articular Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

39. Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

40. TRATAMIENTO QUIRURGICO Punción y lavado articular ARTROSCOPIA: Permite el lavado y aspirado bajo visión. Al inicio o después de punciones seguidas sin resolución ARTROTOMÍA : Artritis Séptica de cadera Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

41. MOVILIZACION PRECOZ Movilización postoperatoria pasiva asistida Nutrición del cartílago Mejora el intercambio hístico de sustratos dentro de la art afectada Evita la lesión articular Favorece la distribución ATB dentro del liq articular Liberación de bridas Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

42. ARTRITIS SEPTICA EN RECIEN NACIDO

43. Ocurre de 1 a 28días después de una venopunción CLINICA Fiebre, aspecto séptico Leucocitosis Poliarticular Artritis gonocócica en el RN cursa con síntomas sistémicos tales como: Fiebre Irritabilidad Rechazo de la alimentación. 1-5 sem despues del nacimiento Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

44. TRATAMIENTP EN RECIÉN NACIDOS Menores de 7 días Cloxacilina 120 mg/kg/día, C/ 6 hr + Cefotaxima 100 mg/kg/día,c/ 12 h, IV De 7 días a 28 días Cloxacilina 100mg/kg/día, c/ 8 hr + Cefotaxima150 mg/kg/día, c/ 8hr, IV. Mayores de 28 días Cloxacilina 100mg/kg/día, C/8 hr + Cefotaxima 200 mg/kg/día, c/6 hr , IV Silver K., Kemple., Bruyn: "Infections of the bone and joints". Handbook of pediatrics. Cap 22, Sixth Edition. Lange Medical Publications. Wilson J.L., McDonald J.J: "Infections of nones and joints" Cap 19 Third Edition, Lange Medical Publications 1998.

45. ¡Gracias! lawishidelreal@hotmail.com