RISK FACTORS: Diabetes mellitus, Sickle cell disease, Other conditions which predispose to bone infarcts, IV drug use, Hemodialysis, Local trauma, Open fractures, Presence of prosthetic orthopedic implant, Vascular insufficiency
GENERAL MEASURES Symptomatic treatment of pain
SURGICAL MEASURES
β’ Surgical drainage and removal of necrotic tissues are of utmost importance to effect cure
β’ In patients with vascular insuffi ciency or severe gangrenous infection, amputation may be the only effective
treatment
β’ Revascularization may be an option for some patients
ACTIVITY Bedrest and immobilization of the involved bone and joint
DIET No restriction
PATIENT EDUCATION Stress need for longterm treatment and follow up
DRUG(S) OF CHOICE
These are essentially empiric choices; recommendations based on data from a small number of studies.
Antimicrobial agent/agents based on susceptibility testing and known clinical effi cacy. The duration of therapy for acute osteomyelitis should be at least 4-6 weeks. In chronic osteomyelitis, longer duration of therapy may be needed.
β’ Staphylococcus aureus and coagulase negative staphylococcus: nafcillin 2 g IV q4-6h. Vancomycin 1 g
q12h for methicillin resistant Staph.
β’ Streptococcus spp.: penicillin G 2-4 million units q4h IV
β’ Enteric gram negative bacilli and Pseudomonas aeruginosa: piperacillin 4 g q4-6h IV, plus aminoglycoside
β’ Mixed aerobic/anaerobic infection (diabetic foot, bite wound): beta-lactamase inhibitor combination (ticarcillin-clavulanate 3.1 g q6h IV; ampicillin-sulbactam 3 g q6h IV); piperacillin-tazobactam 3.375 g q6h IV
ALTERNATIVE DRUGS
β’ Staphylococcus aureus and coagulase negative staphylococcus: clindamycin 600 mg IV q6h, nafcillin 2
g q4h, or cefazolin 1 g q8h IV, or vancomycin 1 g q12h or linezolid (Zyvox) 600 mg po bid or IV bid
β’ Streptococcus spp.: penicillin G 2 million units q4h, cefazolin 1 g q8h IV, or clindamycin 600 mg q6h IV
β’ Enteric gram negative bacilli and Pseudomonas aeruginosa: ceftazidime 1 g q8h IV or ciprofl oxacin [or other
quinolone] 750 mg q12h orally.
β’ Mixed aerobic/anaerobic infection (diabetic foot, bite wound): clindamycin plus third generation cephalosporin or quinolone
β’ Home therapy often used - consider a simplifi ed antibiotic regimen for outpatient use or oral therapy
β’ Some published studies recommend use of hyperbaric oxygen (HBO), but none are randomized, controlled
trials
PATIENT MONITORING Blood level of antimicrobial agents, serum antibacterial titers, sedimentation rate, repeat plain x-ray, CT or MRI to confirm healing
PREVENTION/AVOIDANCE Avoid further stress and weight bearing until healing
POSSIBLE COMPLICATIONS
β’ Abscess formation
β’ Bacteremia
β’ Fracture
β’ Loosening of the prosthetic implant
β’ Postoperative infection
EXPECTED COURSE/PROGNOSIS
β’ Cure of osteomyelitis with medical treatment is notoriously unpredictable especially when not accompanied
by surgical debridement
β’ In patients with acute hematogenous osteomyelitis, the prognosis is usually good even without surgery. Cure
takes about 6 weeks. X-ray improvement may take 3-6 months.
β’ The prognosis is improved if all infected bone has been removed