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Old 11-23-2003, 08:38 PM   #1
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Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Hi - I have been reading this board and sometimes try to help with a reply. I see that Bruce and PandaGirl have knowledge and experience and so I pose some questions to you both in hopes you may be able to help. In fact, if there are adequate facilities for me to send a second/third opinion culture to grow that you might recommend. I have had osteomyelitis of the maxilla - dr. beleives infection has been gone for a good 8 months. I have horrible pain sometimes and all the time just very uncomfortable or worse. This all started with the placement of a porcelain veneer, then a root canal with abx (antibiotics), then an apico with abx, then an extraction with abx, then finally a debridement with abx, then another debridement and bone extraction, iv abx for streptococci, anaerobic pathogens, (don't have complete list, will tomorrow evening), cleocin 3x day 6oo mg each, then added fortaz two iv pushes day - cannot remember dosage. This is what had me starting to feel better. I was on iv for 11 weeks. I started to feel better. 3 phase bone scan showed no infection, all blood tests were back to normal. Is there a time to how long one should stay on abx? Or perhaps there is a general rule of thumb? Anyhow, it's a year since; I am currently diving at the Hyperbaric Chambers for 20 dives with 9 completed. I will then have abx beads implanted at localized site. - doxycyclin I believe, how do I know this is what I will need? Dr. will send the culture out to the lab. What are some precautions I should see are met with this? Time limits, length of time to grow, growing normal flora for an extra long time since it is oral in nature - is it true some bugs should not be found in the oral cavity? Then I will have another PICC line already installed in this fighting maching I am trying to be, ready to take on the onslaught of more abx. I will obviously see what the culture reads and change abx accordingly. Is there a time frame you know of on how long to keep a PICC line? I will then continue with an additional 10-20 dives for deep bone penetration of the sequestra and bacteria with the abx.

ANY info you offer is indeed appreciated! I have been searching and reading and learning things I didn't want to ever know about. Oddly, if I wasn't ill, in need of getting better fast to start a family, and wasn't as old as I am - I would become an ID doctor. It's FASCINATING> just wish I wasn't being cultured

 
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Old 11-24-2003, 10:36 PM   #2
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

I'll try to answer some of your questions.
Quote:
Originally Posted by tryingtofeelgood
[COLOR=Sienna][SIZE=2][FONT=Verdana] Is there a time to how long one should stay on abx?
Yes, and this is totally dependent on what one is being treated for....some treatments for things like uncomplicated urinary tract infections can be for 7 days, while treating something like tuberculosis could be for 9 months! It all depends on which bug you're infected with, and at what site. Osteomyelitis is often a type of infection which requires a long course of antibiotics to totally ward off the infection. Usually, osteomyelitis only needs like 4-6 weeks of treatment with Abx, but depending on the site in the body, and its resistance to the treatment, the therapy MAY go on for months.
Quote:
doxycyclin I believe, how do I know this is what I will need?
Well, presumably, when they took biopsies of the bone, they cultured the bacteria and searched for which antibiotics the bug was sensitive to (this is called a culture and sensitivity test). Doxycycline is very good at treating intracellular pathogens like chlamydia, and rickettsia, but it is also known to be good for things like anerobes which are often what cause infections involving the oral cavity.
Quote:
is it true some bugs should not be found in the oral cavity?
Yes...normally, the bugs found in the oral cavity are anaerobes (i.e. they are poisoned by oxygen), and you also get the famous Streptococcus viridans (which is infamous for causing bacterial endocarditis).
Quote:
Is there a time frame you know of on how long to keep a PICC line?
Depending on what the line is for, as long as it's not for cancer chemotherapy (which have specialized PICC lines), the PICC line shouldn't be in for more than a few months at the most....at least that's what we go by at our center here in London, Canada.

 
Old 11-25-2003, 12:42 PM   #3
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

First of all, another culture might be misleading, because you have already been given antibiotics and their are a variety of anaerobic bacteria usually found in the upper rerspiratory tract that are difficult to grow in a culture. So you have to assume you have a mixed anaerobic infection. I avoid using the words "normal flora", because these same bacteria wouldn't usually cause infections od the mouth, however, they could play a part in gum diseaAE.

For a serious infection like yours, it is important to get the highest blood/tissue levels as possible. The best is iv, the next best is im, and with oral drugs the blood/tissue level of the antibiotic is much lower than iv or im injections.

You can find just about any bacteria in the throat and the presence of the usual flora protects you from infection. After taking antibiotics, it is a sure thing you will see yeast in your throat, and may or may not cause an infection. If you had dianetes or HIV a yeast infection is likely.

The fact that you are still feeling pain, sugests you still have and infection, and drainage and debridement of the infected bone and tissue is an important part of the treatment. I can't give you a precise date when you are curerd, but expect a few more weeks of treatment.

Cleocin is an excellent anaerobic drug, doxycycline is just as oral drug asnd cleocin could be given iv or im.

Here are some combination drugs which act together (synergistic effect): Cefoxitin, probenecid ( not an antibiotic), and doxycycline. Rocephin and doxycycline. Two newer anaerobic drugs are Floxin and Levaquin


Bruce

 
Old 11-25-2003, 01:54 PM   #4
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

I have some thoughts. I am not a doctor, but if your infection as serious as it seems, I would suggest either cefoxitin or cleocin IV for at least four weeks,
Both drugs can cover for staph and the blood levels would be high as you can get.

Antibiotic beads would be a topical treatment and would not sustain an effective tissue level.

If you are at home, take your temp in the AM and PM.

Bruce

 
Old 11-25-2003, 02:10 PM   #5
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Quote:
Originally Posted by Bruce
.

For a serious infection like yours, it is important to get the highest blood/tissue levels as possible. The best is iv, the next best is im, and with oral drugs the blood/tissue level of the antibiotic is much lower than iv or im injections.

Bruce
hey Bruce....something we were learning as of late. The whole idea of "tissue levels" that has been pushed by drug companies is actually falling out of favour. Because the tissues are always in equilibrium with the blood (save for a couple of special areas in the body), it's actually the blood levels that matter, and not the tissue levels (which goes in contradiction to what has been thought for years about antibiotics) One of the clinicians that was teaching us is the regional infection control clincian for SW Ontario, and he gives this talk all over Canada re: this subject.

You're very knowledgeable in infectious diseases...have you heard about what I'm talking about?

 
Old 11-25-2003, 02:17 PM   #6
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Quote:
Originally Posted by Bruce
I have some thoughts. I am not a doctor, but if your infection as serious as it seems, I would suggest either cefoxitin or cleocin IV for at least four weeks,
Both drugs can cover for staph and the blood levels would be high as you can get.

Antibiotic beads would be a topical treatment and would not sustain an effective tissue level.

If you are at home, take your temp in the AM and PM.

Bruce
Another thing...for these chronic infections, I agree that clinda could be given. Usually for anaerobic infections that are "north of the diaphragm", they often just try out a penicillin without clavulante first (south of the diaphragm they'll add in clavulante). After this, they might actually try a cephalosporin like you said, but also possibly an amp/gent combo (assuming there's no renal issues). You were talking about cefoxitin, I think that's an awesome choice, but if a cephalosporin was going to be used, I think they'd be more apt to use a third generation, rather than a second in this case--something like ceftazidime or cefotaxime.

The thing is, I only really know these treatments by which drug is used because we had a patient in our dialysis ward who had a similar presentation.....I'm wondering though...in terms of likely bugs for this condition, what would you say they are?

 
Old 11-25-2003, 02:58 PM   #7
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Actually, i don't usually mention tisssue levels, but was just trying to make myself understood, I havn't heard any specific information about tissue levels, but have always assumed blood and tissue levels were about the same. Just common sense i guess.

Nothing would suprise me about what drug reps would do or say. They used to drive me crazy. They would do anything to promote their drug. It's a ethical problem that is easy to fsll into it. Beware of the free doughnuts.

Bruce

 
Old 11-25-2003, 03:20 PM   #8
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

The docs will probably go the way you said (2nd and 3rd) generation cephlosporins because they think these drugs are more effective(new and improved), but even though cefoxitin is an old drug i have seen studies showing it was more effective against anaerobes. They will go with the new, more expensive drugs regardless what we say.

If we rreally wanted to pick the most effective and cheapest drug for the upper body i would go with good old penicillin, but few doctors would use it. Law suite?

Lets see how many anaerobes in the throat: fusiform bacilli, spirochetes (Borellia), anaerobic strep, Bacteroides, Actinomyces. I have probably left out a few.

Bruce

 
Old 11-26-2003, 07:48 AM   #9
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

I too have osteomyelitis of the maxilla. Because I had been on numerous antibiotics, by the time my bone was cultured they couldn't get a good read on what was in there.

I was on IV cleocin for 6 weeks and then IV penicillin for another 5 weeks. I can't seem to get rid of the infection.

Please, what are the best ways to do cultures. I keep hearing about a fifteen minute rule for some bacteria to get to the lab. What other good antibiotic choices are there for infection that didn't respond to cleocin and penicillin?

This is so painful, and so scary.

Thanks

 
Old 11-27-2003, 07:29 AM   #10
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Obtaining an anaerobic culture requires good technique. The lab should be notified when the culture is collected and a lab tech should be present to take the specimen to the lab as soon as possible.

The best way to collect a specimen is for the doctor to aspirate a few drops with a syringe and cap the needle.

In the lab, a small amount of broth culture media can be aspirated into the syringe, because the amount of specimen will be small.

The lab should inoculate anaerobic media with and without antibiotics plus sheep blood.

The culture plates should be placed in anaerobic biobags and incubated for 48 hours beforer opening the bags.

Some large hospitals may have more sophisticated hardware to handle anaerobes.

Surgical treatment by removing or scraping the infected site is an important part of the treatment.

It is doubtful as this time, your culture will grow anything significant.

IV cleocin and IV penicillin are excellent choices. Another choice is IV metronidazole. Ceftriaxone, a 3rd generation cephlosporin could be an alternative, but cleocin and penicillin should work, it just takes a long time and a lot of patience.

Bruce

 
Old 11-27-2003, 09:01 AM   #11
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

This might be helpful. One of the anaerobes that cause infections around the facial area (46%) are the Fusobacteria. They are penicillin resistent. They are found in the oral cavity where they can cause, along with other bacteria, peridontal disease. Cleocin or metronidazole should work.

Bruce

 
Old 11-28-2003, 03:01 AM   #12
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Bruce, thank you so much for your suggestions.

I did have surgery, with a large area of bone removed. It is still filling in with new bone. My doctor has had to remove some bone and tissue since then. I wonder if I wasn't on the IV antibiotics long enough.

This is a very frustrating disease.

Thanks again.

 
Old 11-28-2003, 06:13 AM   #13
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Jojo, take your tempt twice a day (AM and PM). If you temp. is elavated that could be an indication you still have an infection.

Treating osteomylitis is difficult and is a serious infection. The problem is any dead tissue reduces oxygen to the site and promotes the growth of anaerobes.

It must be very frustrating for you.

Bruce

 
Old 11-30-2003, 05:11 PM   #14
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Quote:
Originally Posted by Bruce
Jojo, take your tempt twice a day (AM and PM). If you temp. is elavated that could be an indication you still have an infection.

Treating osteomylitis is difficult and is a serious infection. The problem is any dead tissue reduces oxygen to the site and promotes the growth of anaerobes.

It must be very frustrating for you.

Bruce
Bruce, I thank you from the bottom of my heart for your knowledge and time. This is a serious problem. It has been for me for almost 2 years now. It's life threatening in that it can make you crazy from the pain and loss of quality of life. Anyhow, I am working on getting better. I am currently in HBO for 20 dives and soon to have another debridement/cultures/sensitivities done with PICC line awaiting I am giving this thing one last good fight. Then I don't know what happens. It's a horrible disease process and I believe it has started to effect the rest of my body with aches and pains. I have a chronic illness now that my brain is acting upon by changing firing patterns and that just thrills me endlessly - not. I do try and stay positive as I believe this is what also kills the little buggers, but man is that a hard task at times. I just thought this was an 18th century disease - this should not be happening now. I believe the diagnosis time is crucial and it's rarely caught early. Perhaps putting live maggots in the site would be beneficial - they can eat the bad all up. I actually read this was therapy for someone in 1932. oi!

thanks again and I will be MORE than grateful if you will allow me to discuss with you my test results for your opinions. I quite need the more the merrier at this point in time!

Is there a site online that I might be able to access to talk about this with pathologists? I do have my own, but again, the more the merrier - and I speak with doctors and patients alike, online and offline. Ya know, anything to get me back

in kindness and health,
Randi

 
Old 11-30-2003, 05:15 PM   #15
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Re: Osteomyelitis of the Maxilla <Bruce & PandaGirl>

Quote:
Originally Posted by jojocm
Bruce, thank you so much for your suggestions.

I did have surgery, with a large area of bone removed. It is still filling in with new bone. My doctor has had to remove some bone and tissue since then. I wonder if I wasn't on the IV antibiotics long enough.

This is a very frustrating disease.

Thanks again.
JoJo! Long time no see. I thought you would be well and about by now. I am sorry you are still having difficulties (It's Me Randi ) remember me?? Back from the day of CindyLouWho and Clouda on the dental pages. Goodness. In any event, aren't you in PA? Did you have cultures/sensitivities done? Bone culture results where what from the removed bone? This is the KEY to our wellness! Also, did you have the dead space replaced with anything? Cannot take a lot of bone and not replace it with something for a bit/ were you implanted with antibiotic beads and have you done any Hyperbaric Oxygen dives? I am still here and hope with your knowledge and your doctors, you will be able to get better! I hope we all do.

 
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