From the Guidelines
High output drainage following osteomyelitis surgery should be managed with a comprehensive approach focusing on wound care, fluid balance, and infection control, prioritizing the use of negative pressure wound therapy (wound VAC) and antimicrobial therapy based on culture results, as supported by recent guidelines 1.
Key Considerations
- Assess drainage volume, color, and consistency to determine if it's within expected limits for the surgical site.
- Use appropriate absorbent dressings such as calcium alginates or hydrofiber dressings, changing them as needed to prevent maceration of surrounding tissue.
- Negative pressure wound therapy (wound VAC) at 75-125 mmHg continuous pressure can be particularly effective for controlling high output and promoting healing.
- Maintain fluid and electrolyte balance by monitoring intake and output, replacing losses with appropriate IV fluids (typically normal saline or lactated Ringer's), and checking electrolytes regularly, especially if output exceeds 200 mL/day.
Antimicrobial Therapy
- Continue antimicrobial therapy based on culture results, typically with antibiotics like vancomycin (15-20 mg/kg IV q12h), ceftriaxone (2g IV daily), or piperacillin-tazobactam (4.5g IV q6h) for 4-6 weeks total, as suggested by recent studies 1.
- The choice of an antimicrobial agent for treating osteomyelitis should optimally be based on the results of a bone culture, especially because of the need for long-duration therapy 1.
Nutritional Support and Wound Assessment
- Nutritional support is crucial, with increased protein intake (1.5-2 g/kg/day) and caloric supplementation to support wound healing.
- Regular wound assessment by the surgical team is essential to evaluate for complications such as dehiscence or persistent infection, as emphasized in recent guidelines 1.
Surgical Intervention
- Surgical resection of infected bone has long been the standard treatment of osteomyelitis, but recent evidence suggests that in properly selected patients, antibiotic therapy alone can be as effective as surgery regarding the remission of DFO and need for amputation 1.
- The decision to perform surgical intervention should be based on individual patient factors, including the presence of concomitant soft tissue infection, ischaemia, and the patient's overall health status, as discussed in recent studies 1.
From the Research
Management of High Output Following Osteomyelitis Surgery
- High output following osteomyelitis surgery can be managed through a combination of surgical debridement, antimicrobial therapy, and negative pressure wound therapy 2, 3, 4.
- Surgical debridement is often necessary to remove necrotic material and promote healing 5, 3.
- Antimicrobial therapy should be tailored to the specific causative organism and may involve the use of intravenous or oral antibiotics 5, 6.
- Negative pressure wound therapy has been shown to be effective in reducing the need for repeated surgical interventions and promoting wound closure 2, 4.
- The use of vancomycin-loaded calcium sulfate beads has also been shown to be effective in treating acute hematogenous osteomyelitis, particularly in pediatric patients 4.
- Localized delivery of antibiotics, such as vancomycin, may help to reduce the need for prolonged administration of post-operative parenteral antibiotics 4.
Treatment Options
- Surgical debridement followed by negative pressure wound therapy 2, 4
- Antimicrobial therapy with intravenous or oral antibiotics 5, 6
- Use of vancomycin-loaded calcium sulfate beads 4
- Negative pressure instillation therapy with polyvinyl alcohol foam and polyhexanide antiseptic solution 2
Key Considerations
- The optimal duration of antibiotic therapy is not certain, but continuing parenteral antimicrobial therapy for at least six weeks from the last debridement is recommended 5.
- The use of maggot therapy may be considered in earlier stages of treatment for complicated necrotic wounds 5.
- Diabetes mellitus and cardiovascular disease increase the overall risk of acute and chronic osteomyelitis 3.