Osteomyelitis

Last updated: March 23, 2022

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Osteomyelitis is an infection of the bone; it occurs following hematogenous (seeded from a remote source) or exogenous (expansion from nearby tissue) spread of pathogens, most commonly Staphylococcus aureus. Individuals are at increased risk of osteomyelitis following trauma, placement of surgical implants or hardware, or if they are immunosuppressed or have poor tissue perfusion. Osteomyelitis can be either acute or chronic and manifests with signs of local inflammation, including swelling, pain, redness, and warmth. Systemic signs, such as fever and chills, are more common in acute infection. Diagnosis is supported via laboratory tests, imaging, and/or biopsy. In most cases, antibiotic therapy should be delayed until culture results are obtained, so as to better tailor treatment. Empiric antibiotic therapy for osteomyelitis is reserved for patients with signs of sepsis or rapidly progressing infections. Surgery may be necessary to remove necrotic bone, abscesses, infected foreign bodies, or fistulae. Osteomyelitis in adults often assumes a chronic course and requires prolonged treatment, whereas children typically make a quick and full recovery.

The diagnosis and management of vertebral osteomyelitis are described in “Spinal infections.”

  • Osteitis: a general term for inflammation of the bone
  • Osteomyelitis: infection of the bone

Epidemiological data refers to the US, unless otherwise specified.

Routes of infection [3]

  • Hematogenous osteomyelitis: (endogenous osteomyelitis): caused by hematogenous dissemination of a pathogen
  • Exogenous osteomyelitis: caused by a spread of bacteria (typically multiple pathogens) from the surrounding environment [4]
    • Posttraumatic: infection following deep injury (penetrating injury, open fractures, severe soft tissue injury)
    • Contiguous: spread of infection from adjacent tissue

Risk factors for osteomyelitis [5]

Pathogens

Most common pathogens causing osteomyelitis [5]
Pathogens Commonly affected groups
Staphylococcus aureus (most common cause)
  • Children and adults
  • Individuals that recreationally use IV drugs [6]
  • Patients with vertebral lesions
  • Patients with prosthetics [7]
  • Diabetic patients with foot ulcers and pressure ulcers
Staphylococcus epidermidis
  • Patients with prosthetics
Streptococci
Pseudomonas aeruginosa
  • Persons who inject drugs [6]
  • Plantar puncture wounds (especially if wearing rubber-soled footwear)
Enterobacteriaceae Salmonella
Klebsiella
  • Patients with UTIs
Mycobacterium tuberculosis
Pasteurella multocida
  • Bites from dogs and cats
Fungi (e.g., Candida)

Acute osteomyelitis and subacute osteomyelitis [5]

  • Onset: within days or weeks; associated with acute bone inflammation
  • Duration: < 2 weeks (acute) or 2–6 weeks (subacute) [3][8]
  • Symptoms: pain at the site of infection; in patients with peripheral neuropathy the pain may be mild or absent
  • Possible localized findings: : point tenderness, swelling, redness, warmth
  • Possible systemic findings: : malaise, fever, chills

Features of underlying disease (e.g., peripheral neuropathy, signs of peripheral arterial disease) may be seen in both acute and chronic osteomyelitis.

Chronic osteomyelitis

  • Onset: develops slowly (over months or years) following acute infection
  • Associated with: avascular bone necrosis and sequestrum formation (necrotic bone fragment that has become detached from the original bone) [9]
  • Duration: typically > 6 weeks
  • Symptoms: recurrent pain lasting weeks to months, maybe cyclical [3]
  • Possible localized findings
    • Swelling, redness
    • Deformity
    • Impaired healing of overlying wounds
    • Local sinus tract formation, perhaps draining pus
    • Positive probe-to-bone test [10]
  • Systemic findings: typically absent; may include low-grade fever, malaise

A positive probe-to-bone test is strongly suggestive of osteomyelitis, especially in diabetic patients with risk factors for osteomyelitis. [10][11]

The symptoms of chronic osteomyelitis may be subtle and the diagnosis may only become apparent when late complications occur (e.g., pathological fracture, loosening of implants). [12]

The following recommendations are for nonvertebral osteomyelitis; diagnostics for vertebral osteomyelitis are detailed separately in “Spinal infections.”

Approach [5][10]

In stable patients, defer antibiotics until blood cultures and/or bone biopsy have been taken. Do not delay antibiotic administration in patients with signs of sepsis.

Laboratory studies [10]

Imaging

Routine imaging [10][13][14]

X-ray is the recommended initial imaging modality because it is inexpensive and can rule out differential diagnoses; however, it may miss acute osteomyelitis as findings are typically visible only 10–14 days after symptom onset. [10][13]

Imaging in special circumstances [15]

Bone biopsy [10][14]

Bone biopsy with cultures is the confirmatory test for osteomyelitis and should be performed unless there are characteristic imaging features of osteomyelitis and positive blood cultures.

The differential diagnoses listed here are not exhaustive.

The following recommendations are for the treatment of nonvertebral osteomyelitis. For treatment of vertebral osteomyelitis, see “Treatment of spinal infections.”

Approach

Acute hematogenous osteomyelitis can typically be treated with antibiotic therapy alone. Management of acute osteomyelitis due to contiguous spread and chronic osteomyelitis usually requires surgical debridement of infected tissue. [18][21]

Antibiotic therapy [5][18][21]

When indicated, obtain a bone biopsy preferably before administering antibiotic therapy to maximize diagnostic yield. [17]

Empiric antibiotic therapy for osteomyelitis

Avoid giving vancomycin with piperacillin-tazobactam; while the combination provides cover against both S. aureus and Pseudomonas, it has a high risk of nephrotoxicity. [22]

Pathogen-directed antibiotics

Pathogen-directed antibiotic therapy for osteomyelitis [5][10][18][21]
Pathogen First-line Alternative
Staphylococcus spp. Methicillin-susceptible S. aureus (MSSA)
Methicillin-resistant S. aureus (MRSA) [24]
Enterococcus spp. Penicillin-susceptible
Penicillin-resistant
Enterobacteriaceae Quinolone-sensitive
Quinolone-resistant
Pseudomonas aeruginosa
Beta-hemolytic streptococci
Anaerobes
  • Consider adding rifampin in patients with retained surgical hardware/foreign bodies. [18]

Supportive therapy [21]

Surgery [21][25]

  • Manage patient factors that may have impacted healing prior to surgery (e.g., anemia, poor nutrition).
  • The decision for surgery should be made in consultation with infectious disease specialists.
  • The choice of procedure depends on site of infection, presence of hardware, and patient factors (e.g., comorbidities).
  • Continue antibiotic therapy after surgery, even if bone has been successfully debrided.
Potential surgical interventions in osteomyelitis [10][21]
Surgical intervention
Chronic osteomyelitis
Acute osteomyelitis refractory to antibiotic treatment
Infected prosthetic joint or foreign body
Posttraumatic osteomyelitis
  • Debridement of grossly infected wounds
  • Removal of surgical hardware may be required.
Overlying abscess
Poor wound healing or limb ischemia

Brodie abscess

We list the most important complications. The selection is not exhaustive.

Osteomyelitis in children [10][19][27]

Overview [10]

Clinical features [28]

Diagnostics

Treatment [10][19]

Maintain a high index of suspicion for osteomyelitis in children; delayed diagnosis and treatment can have detrimental effects on bone development, affecting growth and causing severe long-term impairment.

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