Bone and joint infections caused by P aeruginosa may result as complications of surgery, in particular the implantation of joint prostheses, or pelvic or genitourinary surgery, in association with intravenous (IV) drug abuse, trauma resulting in open fractures such as motor vehicle or farm related accidents, complicated UTIs, diabetic foot ulcers, or puncture wounds of the foot. P aeruginosa has a predilection to infect fibrocartilaginous structures. P aeruginosa prosthetic joint infections may occur as a result of contamination during implantation, aspiration, or injection of the joint with corticosteroids.
In addition, P aeruginosa prosthetic joint infections may occur as a result of repeated surgical manipulation of the joint, joint revision, or reimplantation of the prosthesis. Polymicrobial osteomyelitis with P aeruginosa and other microorganisms is commonly associated with farm or motor vehicle accidents when open fractures become contaminated with water, soil, or vegetative materials. Vertebral osteomyelitis occurs in IV drug abusers or as a complication of UTI or genitourinary surgery. The lumbosacral spine is principally involved, although cervical involvement occurs in IV drug abusers. Sternoarticular pyarthrosis may occur in IV drug abusers or occasionally as a complication of infective endocarditis. Infection of the symphysis pubis may occur after pelvic or genitourinary surgery and must be differentiated from nonpyogenic osteitis pubis.
Puncture wound infections of the foot occur at all ages and have a particular association with punctures through rubber-soled sneakers. These infections occur as a result of the growth of P aeruginosa in the moist inner sole layer of the shoes, and puncture wounds through the shoe inoculate P aeruginosa directly into the bones of the foot and surrounding soft tissue.
Chronic osteomyelitis may occur as a result of contiguous infection following trauma, surgery, or as a complication of diabetic foot ulcers due to direct inoculation or local expansion of the organism. These infections tend to be indolent with pain and decreased range of movement in the absence of fever or leukocytosis. An elevated erythrocyte sedimentation rate, abnormalities on CT scanning or MRI or a positive radionuclide scan suggest the diagnosis, but confirmation requires demonstration of the organism on a Gram stain and recovery of P aeruginosa from cultures. Puncture wounds of the foot may be more acute in presentation, and typically the initial pain after the injury resolves and recurs a few days later with pain and swelling over the site of inoculation. Osteomyelitis of any of the bones of the foot may result.
Effective treatment requires antimicrobial therapy combined with surgical debridement. Successful treatment of P aeruginosa prosthetic joint infection requires resection of the prosthesis and other foreign material together with debridement and antimicrobial therapy.