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Original Research (Original Article) 


Mubark H. alsharari et al, 2020;4(2):331–337.

International Journal of Medicine in Developing Countries

Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia

Mubark H. Alsharari1*, Ahmed E. Taha2,3, Sager H. Alruwaili4, Omar I. Almadhi5, Abdulaziz A. Alanazi1, Basil R. Alanazi1, Nawaf A. Almndil1

Correspondence to: Mubark H. Alsharari

*MBBS Student, College of Medicine, Jouf University, Al-Jouf, Saudi Arabia.

Email: Mubark509 [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 11 December 2019 | Accepted: 04 January 2020


ABSTRACT

Background:

Osteomyelitis (OM), a serious but rare condition, is a bone infection with bone marrow inflammation. It is difficult-to-cure infection with a high rate of relapse despite adequate treatment. Mostly, Staphylococcus aureus bacteria are the causative organisms of OM. The infection could reach the bone from an adjacent open fracture or surgery wound or may spread through the blood from a distant body part to reach the bone. Thus, the aim of this study was to study the awareness level of OM among the adult population in Sakaka city of Al-Jouf, Saudi Arabia and to determine the relationship between socio-demographic data and level of awareness of OM.


Methodology:

It was a questionnaire-based cross-sectional study conducted in Sakaka city of Al-Jouf, Saudi Arabia on 420 adults. A pre-tested questionnaire was used for data collection. The questionnaire included questions about the socio-demographic factors and awareness of the adults about OM.


Results:

Many adult males and females had an incomplete awareness of OM. However, those who were aware and their most common source of information about OM were from doctors or health care providers (20%).


Conclusion:

More educational programs should be campaigned to improve knowledge about this serious disease.


Key words:

Bone, bone marrow, osteomyelitis, Saudi Arabia, Staphylococcus aureus.


Introduction

Osteomyelitis (OM) is one among the oldest recorded diseases with descriptions back to the time of Hippocrates (460-370 BC). The terms like “abscesses in medulla,” “necrosis,” and “a boil of bone marrow” were used to describe the infection till Nelaton introduced the term OM in 1844. Mortality rates from this serious infection remained high (33%) till the discovery of antibiotics in 1940 that dramatically modified the treatment and prognosis of OM [1]. OM is a progressive infection mostly caused by Staphylococcus aureus bacteria. Staphylococcus aureus is a worldwide leading cause of human community-acquired and nosocomial infections ranging from minor skin infections and bone infections to fatal sepsis, necrotizing pneumonia, and deaths [2].

OM results in inflammatory destruction, necrosis, and bone neoformation, which might progress to a chronic stage. The term acute OM is used clinically when bone infection develops within two weeks of an initial infection, injury, or the onset of an underlying disease. Chronic OM is often defined as OM that has been present for more than two months [3]. The disease affects both children and adults. In children, long bones are most frequently affected, whereas in adults the vertebrae and the pelvis bones are the common sites. Certain behaviors and conditions weaken the immune system ultimately increases the person’s susceptibility to OM including diabetes (most OM cases stem from diabetes), HIV, sickle cell anemia, rheumatoid arthritis, alcoholism, intravenous drug abuse, long-term steroids, poor blood supply, hemodialysis, and recent bone injury or surgery including hip and knee replacements [4].

OM is categorized based on the infection mechanism into hematogenous or secondary to a contiguous infection. Hematogenous OM happens more commonly in children than in adults. Contiguous OM tends to occur in younger people in the setting of trauma and related surgery, whereas in older adults secondary to ulcers and infected total joint arthroplasties [5]. Hematogenous OM is typically mono-microbial, whereas contiguous OM could be either poly-microbial or mono-microbial. Staphylococcus aureus, coagulase-negative staphylococci, and aerobic gram-negative bacilli are the common causative organisms of OM. Other organisms include streptococci, anaerobes, enterococci, mycobacteria, and fungi [1,6].

Patients with acute OM generally present a gradual onset of symptoms over many days. The patient is typically presented with acute unpleasant pain with or without movement. In addition to pain, patients typically experience some local findings (tenderness, warmth, erythroderma, and swelling) and general symptoms (fever and rigors) [7]. Patients with chronic OM might present with pain, erythema, or swelling, typically in association with a draining sinus tract. The identification of chronic OM would be significantly difficult once prosthetic material, extensive skin or soft tissue ulceration, or ischemic changes due to vascular insufficiency are present [8]. On the other hand, diabetic patients with chronic OM are presented with cutaneous ulcers, which frequently develop before the development of OM. The common complications of OM are bone fractures, amyloidosis, sepsis, or endocarditis [9].

The diagnosis of OM is classically suspected depending on symptoms. Medical imaging, blood tests, or bone biopsy then confirm the condition. Often, definite diagnosis of OM depends on the radiologic results showing a lytic center with a sclerosis ring [10]. Culture of samples obtained from a bone biopsy is required to detect the causative pathogen [11]. Other sampling methods as surface swabs or needle puncture are easier to perform but are less reliable [12]. Aggressive surgery along with adequate antimicrobial therapy is mandatory for the cure of OM [13]. Surgery plays a key role, especially in chronic OM. The surgical treatment is needed for debridement of the necrotic bones and soft tissues together with the antimicrobial therapy for eradication of the infection. Usually, a combination of antibiotics is necessary to avoid bacterial resistance. Cases suffering from poor blood flow might need amputation [14].

The antibiotic therapy should depend on culture and sensitivity results. If culture and sensitivity results are not available, broad spectrum empiric antibiotic should be administered [15]. In the case of OM caused by gram-negative organisms, fluoroquinolones are prescribed as they have high bone penetration [16]. OM due to methicillin susceptible S. aureus is often treated with parenteral therapy [17,18]. The most effective antibiotic against Methicillin-resistant S. aureus (MRSA) is Vancomycin (VA) [19]. However, for treatment of MRSA with reduced susceptibility to VA, including Vancomycin-resistant S. aureus (VRSA), teicoplanin or an effective combination therapy could be given. In the case of poly-microbial OM due to MRSA and gram-negative bacilli, the concomitant use of VA and ß-lactam antibiotics should be avoided to avoid emergence of VRSA [20,21]. Extended antibiotic treatment without surgery could be curative in hematogenous and vertebral OM, especially in children [22]. Thus, this study was done with an aim to study the awareness level of OM among adult population in Sakaka city of Al-Jouf, Saudi Arabia and to determine the relationship between socio-demographic data and the level of awareness of OM.


Subject and Methods

It was a questionnaire-based cross-sectional study conducted in Sakaka city of Al-Jouf, Saudi Arabia among 420 adults both Saudi and non-Saudi males and females. A pre-tested questionnaire was used for data collection. The questionnaire included questions about the socio-demographic factors and awareness of the adults about OM. The co-investigators visited Al-Jouf plaza and Al-Hassoun market centers to recruit participants. Al-Jouf plaza was visited 3 days per week (Friday, Monday, and Wednesday), and Al-Hassoun center was also visited 3 days per week (Sunday, Tuesday, and Thursday). The days were changed across the centers in the next week. The participants were selected by the simple random sampling procedure. Individuals who agreed to answer the questionnaire were included in the study. The sample size was calculated on a guesstimate that 50% of the population would be aware of OM. Online (Roasoft) sample size calculator (http://www.raosoft.com/samplesize.html) is used with a margin of error 5%, response distribution 50%, confidence level 95%, and 250,000 adults in Sakaka, Al-Jouf, Saudi Arabia. Children who are mentally ill persons and adults who did not agree to answer the questionnaire were excluded from the study. Data were coded, entered, and analyzed using the Statistical Package for Social Science version 22.


Results

The present study included 420 adults, and the majority of the participants were males (62.4%), whereas females were 158 (37.6%) only. Individuals with an age range of 18–25 years old were more dominant (52.4%), followed by those in the age range of 26–35 years (18.6%), then 36–45 and ≥46 years old (15.7%) and (13.3%), respectively. The majority of the participants were married (48.6%), whereas there were 196 (46.7%) singles, 10 (2.4%) divorced, and 10 (2.4%) widowed participants. Saudi individuals were the most dominant (91.4%), whereas non-Saudi individuals were 36 (8.6%) only. The most of the participants (71.9%) had bachelor’s degree, followed by those with the secondary level education (16.2%), intermediate (7.1%), and other (4.8%). There were 178 (42.4%) students, 138 (32.9%) employees, and 104 (24.8%) unemployed participants (Table 1).

Table 1. Socio-demographic characteristics of the participants.

Characteristics N (n = 420) Percentage (%)
Age
18–25 220 52.4
26–35 78 18.6
36–46 66 15.7
More than 46 56 13.3
Gender
Female 158 37.6
Male 262 62.4
Nationality
Non-Saudi 36 8.6
Saudi 384 91.4
Marital status
Single 196 46.7
Married 204 48.6
Divorced 10 2.4
Widowed 10 2.4
Educational level
Other 20 4.8
Intermediate 30 7.1
Secondary 68 16.2
Bachelor 302 71.9
Occupation
Student 178 42.4
Employed 138 32.9
Unemployed 104 24.8

In addition, when awareness level of the participants was assessed, almost 209 (49.8%) individuals had not heard about OM, whereas 211 (50.2%) individuals had heard about it. Moreover, there were 140 (33.3%) individuals who did not know the exact answer to the question of “What is OM?” Almost, 112 (26.6%) individuals said that it is an autoimmune disease, 82 (19.5%) said that it is a nutritional disease, 58 (13.8%) said that it is an infectious disease, and 28 (6.7%) said that it is a congenital disease. Furthermore, when the level of awareness of preventive strategies of the OM was assessed among the participants, there were only 32 (7.6%) individuals who said that OM is a not preventable disease; however, 210 individuals (50.0%) said that it was preventable. On the other hand, there were 178 (42.4%) who did not know the answer. Besides, when the level of awareness of the treatment of OM was assessed, approximately, 272 (64.8%) individuals were aware that it is a treatable disease, whereas only 14 (3.3%) individuals were not aware. On the other hand, there were 134 (31.9%) who did not know whether it is treatable or not (Table 2).

Table 2. Awareness of the adult population about osteomyelitis.

Variables N (n = 420) Percentage (%)
Have you ever heard of osteomyelitis?
Yes 211 50.2
No 209 49.8
Osteomyelitis is?
Autoimmune disease 112 26.7
Congenital disease 28 6.7
A disease due to infection 58 13.8
Nutritional disease 82 19.5
I don’t know 140 33.3
Osteomyelitis is a preventable disease?
Yes 210 50
No 32 7.6
I don’t know 178 42.4
Osteomyelitis is a treatable disease?
Yes 272 64.8
No 14 3.3
I don’t know 134 31.9
The ideal way to treat osteomyelitis is?
Surgery 8 1.9
Taking antibiotic course 78 18.6
Both antibiotics and surgery 120 28.6
Change diet 82 19.5

The most common source of individuals’ information about OM was from doctors or health care providers (20.0%), then internet or online resources (14.7%), other different sources (13.3%), and 81 (38.5%) individuals did not use any sources to get information about OM (Figure 1).

When the general awareness of the participants was assessed about the causes of OM, most of the participants (24.76%) were not aware of the causes. According to their responses, causes were hereditary, fractures, diabetic foot, or trauma. Furthermore, some of the participants believed that bleeding disorders, poor diet, septicemia, and tonsillitis were the causes of OM (Figure 2).

Regarding the knowledge about signs and symptoms of OM, 142 (33.81%) participants answered “swelling, redness, and fever” and 136 (32.38%) participants responded “pain in the bone.” On the other hand, there were 78 (18.57%) participants who were not aware about the signs and symptoms (Figure 3).

When the relationship of awareness level was analyzed in association with educational level, it was found that out of a total of 71.9% of participants whose education level was bachelor’s degree, 62% were aware of OM, whereas 38% were not aware of OM. Participants whose education level was secondary, the majority of them (68%) had heard about OM and only 32% had not heard about OM. Details are shown in Figure 4.

Figure 1. Sources of information about osteomyelitis.

Figure 2. Awareness level of the participants about the causes of OM.

Figure 3. Awareness level of the participants about the sign and symptoms of OM

Besides, when the relationship of educational level in association with awareness of treatment of OM was assessed, it was analyzed that awareness level of the treatment of OM was directly proportional to the educational level (Figure 5).

Figure 4. Relationship of awareness level of OM in association with educational level.

Figure 5. Relationship of awareness level of the treatment of OM in association with educational level.

Furthermore, when the relationship of occupational level in association with awareness of OM was assessed, it was analyzed that employed individuals (69.57%) were mostly aware of OM when compared to students (55.06 %) and unemployed (55.77%) participants (Figure 6).


Discussion

There were 50.2% of participants who claimed that they had heard about OM from health care providers or internet mainly. On the other hand, 49.8% of participants said that they did not hear about it. There were 33.3% individuals who were not exactly aware of OM, in addition those who were aware did not gave the correct answer. Therefore, it was found that the participants who claimed that they had heard about the disease actually did not have a clear idea about what the disease actually is. OM is a progressive infection resulting in inflammatory destruction, necrosis, and bone neoformation that might progress to a chronic persistent stage with sequestrum (detached dead bone) formation [23,24]. When the causes of the disease were assessed, it was found that 24.76% of participants did not know the causes. According to the responses, the most common causes were hereditary, fractures, diabetic foot, and trauma. Some of the participants believed that bleeding disorders, poor diet, septicemia, and tonsillitis were the causes of OM, whereas, in reality, OM could be categorized into two main subgroups according to the source of the infection; the first is the hematogenous OM in which there is bacterial seeding from a remote source in patients (mainly intravenous drug abusers and children) with infectious disease elsewhere in the body, such as urinary tract infection, pneumonia, or an abscessed tooth. The second is the direct (contiguous) OM in which there is direct contact of bone with infected tissue because of a trauma or surgical procedure [25].

Figure 6. Relationship of awareness level of OM in association with occupation.

In addition, when the knowledge about signs and symptoms of OM was analyzed, 33.8% of participants answered “swelling, redness, and fever,” 32.4% of participants’ responded “pain in the bone” and 18.6% of them did not know the signs and symptoms. The signs and symptoms of OM can vary greatly [26]. In children, OM most often occurs more quickly and includes fever, chills, irritability, swelling, or redness over the infected bone, drainage of pus, stiffness, and nausea [27]. In people with diabetes, peripheral neuropathy, or peripheral vascular disease, there might be no pain or fever (the only sign might be an area of skin breakdown that is worsening or not healing) [28]. In OM of the spine (vertebral OM) or the spinal discs (discitis), the only symptom may be back pain [29].

OM prevention is not possible but the limitation of its effects is through awareness of risk factors, early prediction, and prompt treatment [3]. There were only 7.6% of individuals who said that OM is not a preventable disease and most of the individuals (50.0%) that OM is preventable.

In addition, when awareness of participants about the treatment of OM was assessed, almost 64.7% reported that it is a treatable disease, whereas 3.3% of individuals reported that it is not treatable. OM is a treatable disease [30] and the majority of the participants had said so. The most of the participants (31.4%) had no idea about how to treat the disease. The majority of the participants (28.5%) responded to both antibiotic and surgery as a treatment strategy, whereas 19.5% suggested change in diet and 18.6% suggested antibiotic course. It was found through researches that the majority of the OM cases respond well to antibiotics and pain medications. If there is an area of localized bacteria or joint infection, it might need to open, wash, and drain it [1416]. Amputation may be indicated for cases suffering from poor blood flow [15].

Regarding the relation between the educational levels and the awareness of OM, it was noticed that when the educational level has increased the awareness of OM and its treatment options also increases. In addition, the awareness of OM was found in employed persons and students.


Conclusion

The majority of the adult males and females in Al-Jouf, Saudi Arabia were unaware of OM or at least had incomplete knowledge about this disease. Thereby, it was recommended that more educational programs should be campaigned to improve knowledge about this fatal disease. Treatment outcomes are generally good if the condition had only been present early, but amputation might be obligatory in cases of high grade with poor blood flow. Thereby, awareness of OM is necessary for early detection and to avoid complications.


List of Abbreviations

MRSA Methicillin-resistant Staphylococcus aureus
OM Osteomyelitis
VM Vancomycin
VRSA Vancomycin resistant Staphylococcus aureus

Conflict of interest

The authors declared that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent of publication

Informed consent was obtained from all participants.


Ethical approval

Ethical approval for the research was taken from the Local Committee of Bioethics in Jouf University.


Author details

Mubark H. Alsharari1, Ahmed E. Taha2,3, Sager H. Alruwaili4, Omar I. Almadhi5, Abdulaziz A. Alanazi1, Basil R. Alanazi1, Nawaf A. Almndil1

  1. Medical Intern, College of Medicine, Jouf University, Al Jouf, Saudi Arabia.
  2. Assistant professor, Microbiology and Immunology Unit, Department of Pathology, College of Medicine, Jouf University, Aljouf, Saudi Arabia.
  3. Medical Microbiology and Immunology Department, Faculty of Medicine, Mansoura University, Egypt.
  4. Assistant professor, Department of Surgery, Orthopedic Division, College of Medicine, Jouf University, Sakaka, Saudi Arabia.
  5. Medical Student, College of Medicine, Jouf University, Al Jouf, Saudi Arabia.

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How to Cite this Article
Pubmed Style

Alsharari MH, Taha AE, Alruwaili SH, Almadhi OI, Alanazi AA, Alanazi BR, Almndil NA. Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia. IJMDC. 2020; 4(2): 331-337. doi:10.24911/IJMDC.51-1575384341


Web Style

Alsharari MH, Taha AE, Alruwaili SH, Almadhi OI, Alanazi AA, Alanazi BR, Almndil NA. Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia. https://www.ijmdc.com/?mno=76413 [Access: October 15, 2021]. doi:10.24911/IJMDC.51-1575384341


AMA (American Medical Association) Style

Alsharari MH, Taha AE, Alruwaili SH, Almadhi OI, Alanazi AA, Alanazi BR, Almndil NA. Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia. IJMDC. 2020; 4(2): 331-337. doi:10.24911/IJMDC.51-1575384341



Vancouver/ICMJE Style

Alsharari MH, Taha AE, Alruwaili SH, Almadhi OI, Alanazi AA, Alanazi BR, Almndil NA. Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia. IJMDC. (2020), [cited October 15, 2021]; 4(2): 331-337. doi:10.24911/IJMDC.51-1575384341



Harvard Style

Alsharari, M. H., Taha, . A. E., Alruwaili, . S. H., Almadhi, . O. I., Alanazi, . A. A., Alanazi, . B. R. & Almndil, . N. A. (2020) Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia. IJMDC, 4 (2), 331-337. doi:10.24911/IJMDC.51-1575384341



Turabian Style

Alsharari, Mubark H., Ahmed E. Taha, Sager H. Alruwaili, Omar I. Almadhi, Abdulaziz A. Alanazi, Basil R. Alanazi, and Nawaf A. Almndil. 2020. Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (2), 331-337. doi:10.24911/IJMDC.51-1575384341



Chicago Style

Alsharari, Mubark H., Ahmed E. Taha, Sager H. Alruwaili, Omar I. Almadhi, Abdulaziz A. Alanazi, Basil R. Alanazi, and Nawaf A. Almndil. "Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia." International Journal of Medicine in Developing Countries 4 (2020), 331-337. doi:10.24911/IJMDC.51-1575384341



MLA (The Modern Language Association) Style

Alsharari, Mubark H., Ahmed E. Taha, Sager H. Alruwaili, Omar I. Almadhi, Abdulaziz A. Alanazi, Basil R. Alanazi, and Nawaf A. Almndil. "Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia." International Journal of Medicine in Developing Countries 4.2 (2020), 331-337. Print. doi:10.24911/IJMDC.51-1575384341



APA (American Psychological Association) Style

Alsharari, M. H., Taha, . A. E., Alruwaili, . S. H., Almadhi, . O. I., Alanazi, . A. A., Alanazi, . B. R. & Almndil, . N. A. (2020) Awareness of osteomyelitis among adult population in Sakaka city, Al-Jouf, Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (2), 331-337. doi:10.24911/IJMDC.51-1575384341