What are the symptoms and treatment options for Osteomyelitis (infection of the bone)?

From the Guidelines

Osteomyelitis treatment should prioritize surgical debridement and drainage of associated soft-tissue abscesses, along with antibiotic therapy, to minimize morbidity, mortality, and improve quality of life. The optimal route of administration of antibiotic therapy has not been established, but parenteral, oral, or initial parenteral therapy followed by oral therapy may be used depending on individual patient circumstances 1. Antibiotics available for parenteral administration include IV vancomycin and daptomycin, while some options with parenteral and oral routes of administration include TMP-SMX, linezolid, and clindamycin 1.

Some key factors to consider when treating osteomyelitis include the anatomic site of infection, local vascular supply, extent of soft tissue and bone destruction, presence of systemic signs of infection, and patient preferences for treatment 1. The choice of an antimicrobial agent should optimally be based on the results of a bone culture, especially because of the need for long-duration therapy 1. If empiric therapy is necessary, the regimen should usually cover S. aureus as it is the most common pathogen.

The duration of antibiotic therapy is also crucial, with a minimum 8-week course recommended for MRSA osteomyelitis 1. Some experts suggest an additional 1–3 months of oral rifampin-based combination therapy for chronic infection or if debridement is not performed 1. Magnetic resonance imaging (MRI) with gadolinium is the imaging modality of choice for detecting early osteomyelitis and associated soft-tissue disease, and erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level may be helpful to guide response to therapy 1.

In cases where surgical treatment is necessary, factors such as the presence of substantial bone necrosis or exposed joint, functional nonsalvageability of the foot, or high risk for antibiotic-related problems may favor surgical intervention 1. On the other hand, medical treatment may be preferred in patients who are medically unstable for surgery, have poor postoperative mechanics of the foot, or have a strong preference to avoid surgery 1.

Overall, the treatment of osteomyelitis requires a comprehensive approach that takes into account the individual patient's circumstances, the severity of the infection, and the potential risks and benefits of different treatment options. Surgical debridement and antibiotic therapy should be prioritized to minimize morbidity, mortality, and improve quality of life, with careful consideration of the patient's overall health status, preferences, and potential complications 1.

Key considerations for treatment include:

• Surgical debridement and drainage of associated soft-tissue abscesses
• Antibiotic therapy with parenteral, oral, or initial parenteral therapy followed by oral therapy
• Choice of antimicrobial agent based on bone culture results or empiric coverage of S. aureus
• Duration of antibiotic therapy, with a minimum 8-week course recommended for MRSA osteomyelitis
• Imaging modalities such as MRI with gadolinium and laboratory tests like ESR and CRP to guide response to therapy
• Consideration of patient preferences, overall health status, and potential complications when deciding between medical and surgical treatment.

From the Research

Osteomyelitis Symptoms

• Osteomyelitis is an infection-related inflammatory disease of the bones 2
• The disease can be acute or chronic, with chronic osteomyelitis being difficult to treat and often persisting intermittently for years, with relapses and failures 3

Osteomyelitis Treatment

• The main course of treatment should be antibiotics, which should be chosen depending on the findings of the culture and the characteristics of each patient 2
• Bony debridement surgery is frequently required, and in high-risk patients or those with severe illness, additional surgical intervention can be necessary 2
• Identification of the causative agent and subsequent targeted antibiotic treatment has a major impact on patients' outcome 3
• Antibiotics such as ceftriaxone, rifampicin, vancomycin, levofloxacin, and linezolid have been shown to be effective against osteomyelitis, but the optimal type, route of administration, and duration of antibiotic treatment remain controversial 3, 4, 5
• Oral β-lactams may be a safe option for certain adult patients with Methicillin-Susceptible Staphylococcus aureus (MSSA) vertebral osteomyelitis, but further evaluation is needed 6

Challenges in Osteomyelitis Treatment

• The emergence of multi-drug resistant organisms poses major therapeutic challenges 3
• S. aureus can adapt phenotypically during intracellular infection of osteocytes, adopting a reversible quiescent state that is protected against antibiotics, even at high concentrations 5
• The optimal duration of antibiotic treatment is unclear, and long-term follow-up of patients treated for osteomyelitis outcome has not been done in sufficient detail to be certain of the comparative results of different antimicrobials 4