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Ergashev Vali Alimovich, Senior Researcher of the Department of Hygiene of Water and Soil of the Research Institute of Sanitary, Hygiene and Professional diseases of Ministry of Health, Uzbekistan
E-mail: dildor-22@bk.ru
COMPARATIVE CHARACTER OF OSTEOMYELITIS' MICROBIAL LANDSCAPES STUDIED DEPENDING ON AGE OF PATIENTS, FORMS AND CAUSES OF THE DISEASE
Abstract: The goal of the study was to compare the microbial landscape of osteomyelitis relate to patient's age and to the forms and causes of the disease in hot climatic condition of Uzbekistan. We found that, regardless of age, for patients with osteomyelitis the gram-positive cocci were cropped more often, in both: monoculture and association of microorganisms. There observed the significant differences between the inoculated strains as a result of the acute or chronic forms of osteomyelitis. The spectrum of etiological agents in the chronic osteomyelitis was more manifold than in the case of acute osteomyelitis. For the posttraumatic osteomyelitis, the sowing of the gram-positive and the gram-negative microorganisms was practically independent of the age of patient.
Keywords: osteomyelitis, sick children and adults, microbial landscape, the forms and causes of the disease.
Along with the treatment and prevention of osteomyelitis' complications, there is an essential importance to identify etiologic agents of the disease.
In literature we found that in 15.9-30.4% of cases the acute osteomyelitis transferred to the chronic forms, and in 1.6-22.4% of cases, the osteomyelitis is developed after surgery in to musculoskeletal system of organism [1; 2].
In the studies of several authors we found the causative agents of osteomyelitis were the coagulase-positive and the coagulase-negative staphylococci, enterobacteria, pseudomonas, anaerobic microorganisms, Candida fungi, etc. [4; 5; 6; 7; 8].
By the numerous studies of osteomyelitis, it was recognized the relationship the etiological agents of osteomyelitis with its different forms and stages, with the duration of persistence on the bone's pathological process and on tactics of treatment [9, 10, 11].
In the present, a comparative study a microbial landscape of pathogens of the acute and the chronic osteomyelitis in relation of the age of the patients, the form and cause of the diseases should be carry out. The study of some taxonomic features of the inoculated strains and determination of main criteria of microbiological aspects of osteomyelitis' formation and development processes should be solved too.
In the connection with foregoing, in our study we have performed one comparative analysis of osteomyelitis'microbial landscape in depending on patient'sage and on the forms and causes of the disease in the semi-arid climate of Uzbekistan.
Materials and methods. We have been examined the 448 patients with the acute (n = 53) and with the chronic (n = 395) osteomyelitis. From these patients, there were the children (up to 15 years of 68 (15.2 ± 1.7%) and 380 (84.8 ± 1.7%) were adult's patients. The chronic osteomyelitis in adult' patients were diagnosed more often than the acute osteomyelitis osteomyelitis: 92.1 ± 1.4% (n = 350) and 7.9 ± 1.4% (n = 30), respectively. The children's patients had also the same tendency: with the chronic - 66.2 ± 5.7% (n = 45) and with acute osteomyelitis - 33.8 ± 5.7% (n = 23), respectively.
Of the total treated population were female patients: 124 person (27.7 ± 2.1%) and 324 people (72.3 ± 2.1%) were male'patients. Among the adults, there were the 329 patient (86.6 ± 1.7%) from rural area of Uzbekistan and 51 person (13.4 ± 1.7%) were the urban residents. For the children'patients there were 91.2 ± 3.4% (n = 62) from rural area and 8.8 ± 3.4% (n = 6) from urban area. The age' distribution of patients was as followings: 0-6 years - 13 patients (2.9 ± 0.8%); 7-14 years old - 55 patients (12.2 ± 1.5%); 15-18 years old - 72 patients (16.1 ± 1.7%); 19-29 years old - 103 patients (23.0 ± ± 2.0%); 30-39 years old - 75 patients (16.8 ± 1.8%); 40-49 years old - 85 patients (19.0 ± 1.9%); 50-59 years old - 32 patients (7.1 ± ± 1.2%); 60 years old and older - 13 patients (2.9 ± 0.8%).
Osteomyelitis was caused: in adults in 66.3 ± 2.4% (n = 252) cases because of the posttraumatic osteomyelitis, in 25.0 ± 2.2% (n = 95) cases due to the hematogenous character and in causes of 7.9 ± 1.4% (n = 30) the reason of the disease was not established. For children, these indexes were differed significantly from the adults and consisted of 41.2 ± 6.0% (n = 28), 42.6 ± 6.0% (n = 29) and 16.2 ± ± 4.5% (n = 11), respectively.
The pathological processes were more often localized on the femur, on the shin's bones, on the humerus, and on the foot's bones. This trend was stable in regardless of patient' age. As for all adults, in 73.2% of cases, as for children in 74.9% of cases, the pathological processes were located mainly into the femur and shin's bones. For children, opposed to adults, osteomyelitis were not diagnosed in to the knee, in to the pelvis and into the clavicle.
All patients, which were diagnosed, osteomyelitis was been verified by clinical, clinical, instrumental, bacteriological and other laboratory methods for ICD-10 [1997].
All of observed patients have been hospitalized in 20072015 years, located in the Khorezm region's multiprofile medical Center of Uzbekistan.
Identification and differentiation of inoculated strains ofpatho-gens were carried out according to Bergey's Manual Systematic Bacteriology [3].
Section 3. Medical science
Seeding of biological material (i. e., pus from the pathological focus) was performed according to Gold used an appropriate nutrient media; causative agents were considered to be the etiologically significant at the culture concentration of 104-105 colony forming units in 1 milliliter (CFU/ml).
A statistical analysis was carried using the traditional medicinal methods ofvarians. During of the organizing and conducting experiments, principles of evidence-based medicine were used.
Results and discussion. The obtained results all of 448 examined patients indicated that in 28 patients (24 adults and 4 children) there was not observed a growth ofpathogens on the nutrient media - "negative bacteriological result". However, result of other of 420 patients was reported as "positive bacteriological result", in which there were inoculated of477 strains ofbacteria: 270 strains in
the monoculture's form (mono) and 207 strains in the association's form (asso) of microorganisms.
The comparative indexes of the pathogen's microbial landscape in depending on the seeded strains displayed in (Table 1.) as following: the gram-positive cocci (29.5 ± 5.2%) were basically inoculated as monoculture (mono) for child, but its number was not significantly differing from number of the gram-negative bacteria (25.6 ± 4.9%). But, the similar indexes for adults were differed significantly from each other: 36.4 ± 2.4% and 20.6 ± 2.0% (P < 0.05), respectively for gram-positive and gram-negative.
The microorganism's association (asso) manifested the following results: for children the ratio of gram-positive cocci to gramnegative bacteria was 1.2:1 (23.1 ± 4.8% vs 19.3 ± 4.5%), for adults this ratio compiled 0.8:1 (16.9 ± 1.9% vs. 21.1 ± 2.0%).
Table 1. - Comparative indexes of pathogen's microbial landscape of osteomyelitis depend on the inoculated strains,%
Pathogens Monoculture, 270 strains Association of m/o, 207 strains
Child Adults Child Adults
S.aureus 19,2 ± 4,5 22,3 ± 2,1 12,8 ± 3,8 6,8 ± 1,3
S.epidermidis 5,1 ± 2,5 9,0 ± 1,4 10,3 ± 3,4 6,3 ± 1,2
S.saprophyticus 1,3 ± 1,2 1,0 ± 0,5 1,3 ± 1,2 2,3 ± 0,8
Enterococcus spp 2,6 ± 1,8 1,8 ± 0,7 0 0,5 ± 0,4
S.hemolyticus 0 1,0 ± 0,5 0 0,5 ± 0,4
S.pyogenes 0 1,3 ± 0,6 0 0,5 ± 0,4
Gram «+» cocci, total 28,2 ± 5,1 36,4 ± 2,4 24,4 ± 4,9 16,9 ± 1,9
E.coli 7,7 ± 3,0 7,3 ± 1,3 6,4 ± 2,8 8,3 ± 1,4
Proteus spp 2,6 ± 1,8 1,0 ± 0,5 5,1 ± 2,5 2,8 ± 0,8
Klebsiella spp 3,8 ± 4,7 4,5 ± 1,0 2,6 ± 1,8 1,0 ± 0,5
Enterobacter spp 0 1,0 ± 0,5 2,6 ± 1,8 1,8 ± 0,7
P.aeruginosa 11,5 ± 3,6 6,8 ± 1,3 2,6 ± 1,8 7.2 ± 1,3
Gram «-» bacteria, total 25,6 ± 4,9 20,6 ± 2,0 19,3 ± 4,5 21,1 ± 2,0
Bacteroides spp 0 0 0 2,7 ± 0,8
Candida spp 0 0 2,6 ± 1,8 2,5 ± 0,8
Sum of strains 53,9 ± 5,6 56,9 ± 2,5 46,2 ± 5,6 43,1 ± 2,5
Note: m/o - microorganisms; percentages were calculated with respect to total number of strains (n = 477)
25 20 15 10 5 0
19,2
-6,4
2,6
Child-mnnn --•--S.aureus
222
3
i,8
9
7,3
9
/1 A — -
---♦ -1
Adults-mnnn
-A—S.epidermidis
5,1
Child-assn *— E.cnli
3
6,3
2,8
6,8
Adults-assn Proteus spp
Figure 1. Comparative parameters of main pathogens of osteomyelitis inoculated in the form of monoculture (mono) and in the association (asso) for children and adults,%
In the form of monoculture, regardless of age, the most cropped strains were S.aureus, P.aeruginosa, E.coli, S.epidermidis and Klebsiella spp. In the fact, that for adults some microorganisms (S.hemolyticus, S.pyogenes, Enterobacter spp), which were sown as a causative agents, were not found in children. A resembling result was obtained from the cropping of the association (asso) of microorganisms.
Accordingly our results, for both: children and adults with osteomyelitis, gram-positive cocci were inoculated more often, as in the form of monoculture, as well in form microorganism's association. While, children did not indicate a significant difference between mono and association cultures, for adults these indexes were significantly different (P < 0.05).
As a result of this study following features were established: for child were not cropped as monoculture: S.hemolyticus, S.pyogenes, Enterobacter spp, Bacteroides spp and Candida spp, and as association: Enterococcus spp.
For children the P.aeruginosa in 1.7 times more seeded as monoculture's form than as association form, while for adults P.aeruginosa was more inoculated in the association's form. As the pathogen 'agent in the form of monoculture, were not cropped the
Table 2. - Comparative indexes of pathogen's microbial
Bacteroides spp and Candida spp, however, these species were identified in the association forms.
All of mentioned above, is shown in Fig. 1, where are presented the comparative parameters of inoculation of main osteomyelitis' pathogens for children and adults.
The next phase of our study was a comparative analyses of the etiological agents subjectioned to the form of the disease - acute and chronic osteomyelitis (Table 2).
According to inoculated pathogens, there were noticeable differences between the acute and the chronic osteomyelitis, as well as due to age of patients. We have found for the child with both: the acute and the chronic osteomyelitis there was no significant differences in cropping of the gram-positive cocci between two osteomyelitis, while for adults there was great significant difference between acute and chronic forms: the pacients with the chronic osteomyelitis were obsreved in 7.6-fold favor more than with acute osteomyelitis.
For children there was no significant differences between acute and chronic forms in the cropping of S.aureus, but for adults this difference was significant: patients with the chronic osteomyelitis were inoculated by S.aureus in 7.3 times more than patients with acute one.
landscape of osteomyelitis relay on disease' forms,%
Pathogens Acute osteomyelitis Chronic osteomyelitis
Child, n = 23 Adults, n = 30 Child, n = 45 Adults, n = 350
S.aureus 18,0 ± 4,4 3,5 ± 0,9 14,1 ± 3,5 25,6 ± 2,2
S.epidermidis 3,8 ± 4,7 0,8 ± 0,4 11,6 ± 3,6 14,5 ± 1,8
S.saprophyticus 0 0,3 ± 0,2 2,6 ± 1,8 3,0 ± 0,9
Enterococcus spp 0 0,3 ± 0,2 2,6 ± 1,8 2,0 ± 0,7
S.hemolyticus 0 0,5 ± 0,3 0 1,0 ± 0,5
S.pyogenes 0 0,8 ± 0,4 0 1,0 ± 0,5
Gram «+» cocci, total 21,8 ± 4,7 6,2 ± 1,2 30,9 ± 5,2 47,1 ± 2,5
E.coli 3,8 ± 4,7 1,5 ± 0,6 10,3 ± 3,4 14,1 ± 1,7
Proteus spp 2,6 ± 1,8 0,3 ± 0,2 5,1 ± 2,5 3,5 ± 0,9
Klebsiella spp 0 0 6,4 ± 2,8 5,5 ± 1,1
Enterobacter spp 0 0,3 ± 0,2 2,6 ± 1,8 2,5 ± 0,8
P.aeruginosa 0 0 14,1 ± 3,5 14,0 ± 1,7
Gram «-» cocci, total 6,4 ± 2,8 2,1 ± 0,7 38,5 ± 5,5 39,6 ± 2,4
Bacteroides spp 0 1,0 ± 0,5 0 1,8 ± 0,7
Candida spp 0 0 2,6 ± 1,8 2,5 ± 0,8
Sum of strains 28,2 ± 5,1 9,0 ± 1,4 71,8 ± 5,1 91,0 ± 1,4
Have not been sow 1 0 3 24
Note: percentages were calculated with respect to total number of strains (n = 477)
For child with the acute osteomyelitis, there was not identified the 9 pathogens of the 13 seeded, for adults was not identified the 3 out of 13 cropped pathogens; as for the chronic osteomilitis: were not cropped the 3 of the 13 studied pathogens from child'patients, but all studied pathogens were inoculated in adult's patients. In the case of the acute osteomyelitis the Klebsiella spp, P. aeruginosa and
Candida spp were not identified regardless of patient's age, but in the case of the chronic form the Klebsiella spp, P. aeruginosa and Candida spp seeding as the etiologic agents.
The obtained results is in Fig. 2, in which shown the comparative parameters of seeding of pathogen's groups relate to the forms of osteomyelitis.
Section З. Medical science
91
1GG 8G 6G 4G 2Û G
21,8
Child AO
39,6
6,2 Adults AO
Total strains Gram bact
Gram cocci
Child ChrO
13 Gram cncci
Adults ChrO
FH Gram bact В Tntal strains
Figure 2. Comparative rates of inoculated pathogen' groups of osteomyelitis relay on the acute and chronic forms of the disease,% (AO -acute and ChrO- chronic osteomyelitis)
Thus, there were significant differences between the microbial landscape depending on the forms of osteomyelitis: the acute and the chronic, and between the adult and children patients with these forms of disease. It was remarkable, the spectrum of studied etiologic agents of the chronic osteomyelitis was much wider and greater than of studied agents in acute osteomyelitis.
As a next step of our study, we have conducted the comparative analysis of microbial landscape of osteomyelitis' causative agents of depending on the causes of the onset of the disease In the future, we conducted a comparative analysis of the microbial landscape of osteomyelitis'agents regarding of onset causes of disease (Table 3).
Table 3. - The comparative indexes of pathogen' microbial landscape of osteomyelitis depend on the causative agents of the disease,%
Pathogens Posttraumatic Hematogenous
Child, n = 28 Adults, n = 252 Child, n = 29 Adults, n = 95
S.aureus 20,5 t 4,6 23,1 t 2,1 6,4 t 2,8 5,3 t 1,1
S.epidermidis 11,5 t 3,6 13,5 t 1,7 2,6 t 1,8 1,5 t 0,6
S.saprophyticus 2,6 t 1,8 3,3 t 0,9 0 0
Enterococcus spp 1,3 t 1,2 0 1,3 t 1,2 2,0 t 0,7
S.hemolyticus 0 1,5 t 0,6 0 0
S.pyogenes 0 1,8 t 0,7 0 0
Gram «+» cocci, total 35,9 t 5,4 43,2 t 2,5 10,3 t 3,4 8,8 t 1,4
E.coli 2,6 t 1,8 11,2 t 1,6 9,0 t 3,2 3,0 t 0,9
Proteus spp 2,6 t 1,8 1,0 t 0,5 3,8 t 2,2 2,0 t 0,7
Klebsiella spp 1,3 t 1,2 3,3 t 0,9 5,1 t 2,5 1,3 t 0,6
Enterobacter spp 0 0 2,6 t 1,8 2,8 t 0,8
P.aeruginosa 7,7 t 3,0 9,3 t 1,5 2,6 t 1,8 2,5 t 0,8
Gram «-» bacteria, total 14,1 t 3,9 24,8 t 2,2 23,0 t 4,8 11,6 t 1,6
Bacteroides spp 0 1,5 t 0,6 0 1,0 t 0,5
Candida spp 2,6 t 1,8 2,5 t 0,8 0 0
Sum of strains 52,6 t 5,7 71,9 t 2,3 33,3 t 5,3 21,3 t 2,0
Have not been sow 1 8 3 10
Note: percentages were calculated with respect to total number of strains (n = 477).
As it is known, the causes of osteomyelitis are mainly post traumatic and hematogenous. It was established that both the grampositive cocci and the gram-negative bacteria were more often sown in the post-traumatic cases of osteomyelitis. According with the microbial landscape of osteomyelitis'causative agents, relate to
the cause'agent of the disease there was no reliable differences between the adults and child. Furthermore, the species: S.hemolyticus, S.pyogenes, Enterobacter spp, Bacteroides spp, Candida spp, and in adults Enterococcus spp and Enterobacter spp were not identified for children with the posttraumatic osteomyelitis.
In the cases of the hematogenous osteomyelitis, the diversity of inoculated pathogens was much less, and the percentage of pathogen's detectability was a significantly lower level than in the case of posttraumatic osteomyelitis. The age differences, relate to the cause'agent of osteomyelitis, between the microbial landscape of child and adults were not identified.
So, it was found, that for adults the spectrum of inoculated microorganisms was larger as result of the posttraumatic osteomyelitis than in the case of the hematogenous, but for children this difference was not observed. Also, in the case of the posttraumatic osteomyelitis, the inoculation of gram-positive and gram-negative microorganisms was practically independent on the age of patients. It should be emphasized, that the spectrum of both: posttraumatic and hematogenous pathogens, was greater for adults than for child.
Conclusions
1. It was established for osteomyelitis'patients regardless of their age, gram-positive cocci were cropped more often than gramnegative bacteria, as in monoculture form as well in association form of microorganisms. While, for children did not have observed significant difference between these parameters, conversely, for adults, the number of seeded gram-positive cocci were significantly higher than number of inoculated gram-negative bacteria.
2. The following features were established: for child were not cropped as monoculture: S.hemolyticus, S.pyogenes, Enterobacter spp, Bacteroides spp and Candida spp, and as association: Enterococcus spp. For children the P.aeruginosa in 1.7 times more seeded as monoculture's form than as association form, while for adults P.aeruginosa was more inoculated in the association's form. As the pathogen 'agent in the form of monoculture, were not cropped the Bacteroides spp and Candidas pp, however, these species were identified in the association forms.
3. It was found the significant differences between the inoculated strains depending on the forms of osteomyelitis (acute and chronic). As a result, it was significant difference between adult and child patients rely on these parameters. The spectrum of etiological agents of the chronic osteomyelitis was greater than in the acute osteomyelitis.
4. It was established that in the posttraumatic osteomyelitis the spectrum of cropped strains for adults was more wider than in the hematogenous osteomyelitis, however, for children this difference was not observed. In the posttraumatic osteomyelitis, the cropping of the gram-positive and the gram-negative microorganisms was practically independent of the patient'age. The spectrum of pathogens was diverseforme compare to children in both cases: posttraumatic and hematogenous osteomyelitis.
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