Do steroids mask infection

I had a total knee replacement on 25th Nov. Took 10 mgs of Pred (double dose re Sick Day rules).

On 24th Dec got infection in scar - stitch abcess for which I got antibiotics from MIU. Saw Ortho surgeon a few days later who told me to stop taking antibiotics because they would mask bacterial infection in leg. Things seemed to calm down at surface but pain and swelling caused concern. Returned to different ortho who thought things were ok. Blood tests showed CRP at 12. When I mentioned steroids would bring CRP down he disagreed. Have appointment on Friday but today redness and soreness has returned to original site. I am concerned there is a bacterial infection in my leg which the 10mgs of Pred is masking. Is this possible? Should I go to A n E which was the advise first ortho gave me after telling me to stop antibiotics?

I reduced to 9mgs of Pred yesterday.

Had stayed on 10 mgs because husband became seriously Ill and nearly died during 72 hours from 16th Dec and then infection.

Just appreciate your wisdom please.

[SnazzyD]

Hello, Pred will tend to dampen down the inflammatory response that would take place to combat the infection. Signs of infection may therefore be less obvious. I’m not sure of the doctor’s logic of stopping the antibiotics, if there’s an infection the antibiotics ‘mask’ it by killing the microbes causing the infection. I wonder if they mean they want the infection to fully show itself by removing the antibiotic if they are not sure if there really is an infection. It strikes me as a non expert that that is a bit of a gamble, especially if you are on an immunosuppressant, albeit not a high dose, with no emergency prescription ready or clear guidance.

I’ve seen many stitch abscesses in my time. If it is one being caused by a stitch still in there (a dissolving stitch refusing to go), it’ll keep happening until that stitch either dissolves or is removed. I’ve had a couple and ended up finding it myself and removing it but I don’t recommend it; I was lucky because they were relatively near the surface. Sometimes the body walls the stitch off as it’s a foreign body and it doesn’t dissolve. The body attacks it which causes an inflammatory response that isn’t necessarily from a microbe and not a primary infection. However, you can get chronic irritation or tissue death in the local area that produces pus even and doesn’t go away. Infection can creep in.

Are there any signs of problems anywhere else in the leg other than locally to the problem area that may suggest it is not isolated?

On an aside I do have to have a grumble and it doesn’t detract from the impossible job so many medical people have. We know the NHS is on it’s knees for various reasons, but I am getting fed up of doctors acting like everything is normal and just follow their old approach. This is, go to A&E or use a GP service which for many is impenetrable or isn’t personal or quick enough. I and my family have been told this a handful of times in the last couple of months too. I think they need to think more like we are on the frontier and either do belt and braces care, give proper empowering guidance and information to avoid further need of services or stop telling patients off when they take matters into their own hands. This is very evident in the increase in the number of people resorting to getting help here because they want a quick opinion before entering the fray or any opinion at all. Do your best consultants to address the problem now, act like the system is overwhelmed and not hedge your bets assuming the safety net is there if you get it wrong or something changes, especially when it comes to Pred dosing.

[Hidden in reply to SnazzyD]

Thank you so much for your reply. It is so helpful. Yes, I believe the ortho wanted to see what would develop having come off the antibiotics. He said the type of bacterial infection likely to follow surgery would not be combated by the antibiotics I had been given.Your explanation regarding a stitch which doesn't dissolve sounds like an accurate assessment of what is happening. There is no evidence of infection anywhere else in the knee or surrounds. Don't fancy searching for stitch tho!!! You are very brave.

I have telephoned the ortho department and left a message asking for their advise.

Thank you so much for taking time to reply.

Really appreciate it.

And I totally agree with your comments regardinv acting as tho everything is normal. I also have found the lack of joined up communication between depts really tricky. I have written in to orthopaedic surgeon and endocrinologist cooying both letters to both departments in the hope of continuity of care!!!!!

Thank you once again. Will post outcome.

[SnazzyD in reply to Hidden]

That sounds like a better rationale. What antibiotics were they?

How wide is the area of inflammation and is there a bit of pus?

I’m not suggesting you go for a dig! You do need to have seen a few. However, a common issue is that the stitch dissolves but the knot doesn’t. I’ve had a couple of wounds where there was a small focus of apparent infection and I’ve given it a light squeeze and the knot has popped out. I had four on a mastectomy wound, a couple on an appendix wound and one on a knee wound. I’ve only done that when the issue is very localised and the rest of the wound is fine. An in-growing hair can to it too.

[Hidden in reply to SnazzyD]

Thanks so much. I will take a closer look and see if knot is obvious. I am sure you are right and this is what it is.

The area of inflammation is a bit bigger than a 50p and there is no pus.

You have been so helpful, SnazzyD. Really appreciate your posts. Thank you.

[PMRpro Ambassador in reply to Hidden]

That seems a large area to me ...

[PMRpro Ambassador]

I wouldn't have said abx MASK infection - prevent it maybe. And he's contradicting himself - if it is the wrong abx then it won't work and you will see the infection, As for the rest - I agree 100% with Snazzy. The NHS isn't functioning as normal and nipping to the GP or the ED really isn't a realistic option.

The GP practice, in person and ask to see a nurse? They are often a lot better at wound care.

[Hidden in reply to PMRpro]

Thanks, PMRpro. One cannot help feeling bemused and insecure with all that’s going on. My surgery is hard fast regarding boundaries of care between them and the hospital. I will try them tho and see what they say.

Thanks for your response.

[PMRpro Ambassador in reply to Hidden]

Mmm - possibly. But wound care after discharge usually falls to the nurse.

[SnazzyD in reply to PMRpro]

I’ve not known many doctors who ‘do’ wounds and the ups and downs of wound healing other than decide on appropriate antibiotics or surgically intervene eg a haematoma removal. I usually had to tell the GP what to do. Surgeons were usually used to recent post op wounds or wounds that were going seriously wrong.

[PMRpro Ambassador in reply to SnazzyD]

Quite!

[Pugchick]

A bit of explanation. The orthopod probably advised discontinuing antibiotics so that she could determine if the infection is superficial (eg stitch abscess, which sounds like your case) or deep (ie around the prosthesis/within the joint).

It doesn't sound like this in your case, but an antibiotic can partially suppress deep infection, esp around a joint prosthesis or in bone, making it harder to diagnose. At this early stage, further surgery may give the best prospect of clearing deep infection, rather than let it grumble on and become established.

I think a GP Practice nurse would be a good adversary if there is a troublesome stitch in there, as advised by PMRPro. Sometimes the GPs will expect a level of post-op care from the surgical unit, though, so you may have been given a leaflet from the unit stating who to contact with a post-op problem?

[Hidden in reply to Pugchick]

Thank you. All very helpful. Contacted GP surgery to see practise nurse. Put thru to dr who I sent pic to. She rang orthopaedic dept and I am currently in A n E waiting to be assessed by ortho team! I do think you have the picture, Pugchick. Thanks to all because it has reassured me. Here's hoping right course of action now chosen here. Feeling sure its a troublesome stitch which needs out. Thanks again.

[Broseley]

I can only speak from experience with my cat, who was on long term steroids for a pituitary tumour. He became incontinent and didn't seem to know when he needed to wee. So he would wee all over you if you picked him up. The vet was puzzled, so I did some research and found a paper that said steroids can mask infection so asked her to test his urine. He did have a nasty infection. Antibiotics worked, and the incontinence stopped, but once he finished the course it came back.So it seems that the antibiotics didn't quite clear the infection, whether that means it was "masked" by them or the steroids I don't know, but it may explain why you were taken off them - so they can see exactly the nature of your infection.

[Hidden in reply to Broseley]

Thank you, Broseley. After 4.5 hours in A n E dr sent me home. No antibiotics. Going back on Friday am and they suggested if anything needs to be done then I should not be full of antibiotics.

Just hoping I get clarity and this lingering thing gets sorted once and for all.

[Broseley in reply to Hidden]

Let's hope so. It does sound like it's inflamed and therefore infected. Is it hot as well? If you don't get anywhere with the ED Drs maybe try Manuka honey on it.

[Bramble2000]

The steroids will mask inflammation, that you can see and also in blood test results

[Hidden in reply to Bramble2000]

So what to do?

[Bramble2000 in reply to Hidden]

I don’t know but your Drs should