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Management of encephalitis may consist of the followingl2,

• Anti-infective agents

• Intracranial pressure management

• Mechanical ventilation, with or without tracheostomy (as

indicated)

• Sedation

INFEcnOUS DISEASES

629

• i.v. fluid and electrolyte replacement

• Nasogasrric rube feedings

Musculoskclctal lnfcctions

Osteomyelitis is an acute infection of the bone that can occur from

direct or indirect invasion by a pathogen. Direct invasion is also

referred to as exogenous or acule contagious osteomyelitis and can

occur any time there is an open wound in the body. Indirect invasion

is also referred to as endogenous or acute hematogenous osteomyelitis

and usually occurs from the spread of systemic infection. Both of

these types can potentially progress to subacute and chronic osteomyelitis. Acute osteolllyelitis typically refers to an infection of less than I month's duration, whereas chrollic osteomyelitis refers to infection

that last longer than 4 weeks' time.39.'0

Acute c01ltag;olts osteomyelitis is an extension of the concurrent

infection in adjacent soft tissues to the bony area. Trauma resulting in

compound fractures and tissue infections is a common example. Prolonged orthopedic surgery, wound drainage, and chronic illnesses, such as diabetes or alcoholism, also predispose patients to acute contagious osteomyelitis.40.41

Awte helllatogel/olls osteomyelitis is a blood-borne infection that

generally results from S. allrellS infection (80%)' and occurs mostly in

infants, children (in the metaphysis of growing long bones), or

patients undergoing long-term i.v. therapy, hyperalimentation, hemodialysis, or corticosteroid or antibiotic therapy. Patients who are malnourished, obese, or diabetic, or who have chronic joint disease, are also susceptible to acute hematogenous osteomyelitis.J9,4o

Clinical presentation of both types of acute osteomyelitis includes

(1) delayed onset of pain, (2) tenderness, (3) swelling, and (4) warmth

in the affected area. Fever is present with hemarogenous osteomyelitis. The general treatment course for acute osteomyelitis is early and aggressive admini tration of the appropriate antibiotics to prevent or

limit bone destrllction.I.JI .39,4o

Chronic osteomyelitis is an extension of the acute cases discussed

above. It results in marked bone destruction, draining sinus tracts,

pain, deformity, and the potential of limb loss. Chronic osteomyelitis

can also result from infected surgical prostheses or infected fractures.

Debridement of dense formations (sequestra) may be a necessary

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AClIrE CARE HANDBOOK FOR PHYSICAL THERAPISfS

adjunct to the antibiotic therapy. If the infection has spread to the surrounding soft tissue and skin regions, then grafting, after debridement, may be necessary. Good results have also been shown with hyperbaric oxygen therapy for chronic osteomyelitisJ9.40

Clinical Tip

Clarify weight-bearing orders with the physician when

performing gait training with patients who have any form

of osteomyelitis. Both upper and lower extremities can be

involved; therefore, choosing the appropriate assistive

device is essential to preventing pathologic fracture.

Skin Infections

Cellulitis, or erysipelas, is an infection of the dermis and the subcutaneous tissue that can remain localized or be disseminared into the bloodstream, resulting in bacteremia (rare). Cellulitis occurs most

commonly on the face, neck, and legs.

Groups A and G Streptococcus and S. aureus are the usual causative

agents for cellulitis and generally gain entry into the skin layers when

there are open wounds (surgical or ulcers). Patients who are at most

risk for developing cellulitis include those who are postsurgical and

immunocompromised from chronic diseases or medical treatment.

The primary manifestations of cellulitis are fever with an abrupt

onset of hot, stinging, and itchy skin and painful, red, thickened lesions

that have firm, raised palpable borders in the affected areas. Identifying

the causative agent is often difficult through blood cultures; therefore,

localized cultures, if possible in open wounds, may be more sensitive in

helping to delineate the appropriate antibiotic treatment.41-4J

Gastrointestinal Infections

Gastroenteritis is a global term used for the inflammation of the

digestive tract that is typically a result of infection. The primary cause

of gastroenteritis is viral infection from rota virus, adenovirus, astrovirus, calicivirus, and small round-structured viruses. Gastroenteritis can also occur from bacterial infection from E. coli, Shigella (which

causes bacterial dysentery), Clostridium difficile, and Salmollella.