What is the treatment for osteomyelitis?

Treatment of Osteomyelitis

Osteomyelitis requires a multidisciplinary approach involving orthopedic surgeons, infectious disease specialists, and interventional radiologists, with treatment typically consisting of appropriate antibiotic therapy for 4-6 weeks combined with surgical debridement in most cases. 1

Diagnosis

• Bone biopsy is the gold standard for diagnosis and should be performed by a properly trained physician (orthopedic surgeon, podiatrist, or interventional radiologist) under fluoroscopic or CT guidance when possible 2, 1
• MRI is the most accurate imaging study for defining bone infection when diagnosis remains uncertain 1, 3
• Obtain 2-3 bone specimens when possible, sending at least one for culture and another for histological analysis 2
• Cultures of bone specimens provide more accurate microbiologic data than soft tissue specimens for guiding antibiotic therapy 2, 1

Treatment Approach

Antibiotic Therapy

• Base selection of antibiotics on bone culture results rather than soft tissue cultures 1, 4
• Initial parenteral therapy followed by oral antibiotics with good bioavailability is recommended 1, 5
• Duration of antibiotic therapy depends on surgical approach:
  • 2-14 days if infected bone is completely removed surgically 1, 4
  • 4-6 weeks for non-surgical management or incomplete surgical debridement 1, 5, 4
• Oral antibiotics with good bone penetration include fluoroquinolones, rifampin, clindamycin, linezolid, and trimethoprim-sulfamethoxazole 4

Surgical Management

• Surgical intervention should be strongly considered in cases with:
  • Substantial bone necrosis or exposed joint
  • Functionally compromised limb
  • Presence of resistant pathogens
  • Limb with uncorrectable ischemia
  • Patient preference for surgical treatment 1, 4
• Surgical options include:
  • Debridement of infected and necrotic bone
  • Resection of infected bone
  • Amputation when necessary
  • Antibiotic-impregnated beads, sponges, or cement in selected cases 4, 6
• Patients who undergo surgical treatment have significantly fewer relapses compared to those treated with antibiotics alone 7

Special Considerations

Non-surgical Management

Non-surgical management with antibiotics alone might be considered in specific situations:

• No acceptable surgical target (radical cure would cause unacceptable functional loss)
• Patient has limb ischemia caused by unreconstructable vascular disease
• Infection confined to forefoot with minimal soft tissue loss
• Surgical management carries excessive risk 2, 1, 4
• Published reports on nonsurgical treatment with prolonged antibiotics have reported clinical success in approximately 65%-80% of cases 2

Diabetic Foot Osteomyelitis

• Diabetic foot osteomyelitis typically involves the forefoot and develops by contiguous spread from overlying soft tissue 5
• Medical management with antibiotics alone may be appropriate when infection is confined to the forefoot 5
• The Infectious Diseases Society of America recommends 4-6 weeks of antibiotic therapy for osteomyelitis without surgical resection 5

Pelvic Osteomyelitis in Pressure Injuries

• For pelvic osteomyelitis following surgical debridement and flap reconstruction, 6 weeks of antibiotic therapy is recommended 2
• Oral antibiotic therapy may be adequate for treatment of osteomyelitis in a subset of patients 2
• No systemic antibiotics are needed for pelvic osteomyelitis without evidence of soft tissue infection and no plans for debridement and flap reconstruction 2

Common Pitfalls to Avoid

• Relying on soft tissue cultures rather than bone cultures to guide antibiotic therapy 1, 4
• Continuing the same antibiotic regimen that previously failed 4
• Inadequate surgical debridement of necrotic bone 4, 6
• Not addressing vascular insufficiency which limits antibiotic delivery 1, 4
• Inadequate duration of therapy increases risk of treatment failure and recurrence 5

When Treatment Fails

When initial therapy fails, consider:

• Whether the original diagnosis was correct
• If there is residual necrotic or infected bone that should be resected
• If the selected antibiotic regimen covered the causative organisms and achieved adequate bone levels
• Whether non-infectious complications are the real cause of the problem 1, 4