To whom should a patient with osteomyelitis be referred for evaluation and management?

Who to Refer for Osteomyelitis

All patients with osteomyelitis should be managed by a multidisciplinary team including an infectious disease specialist, orthopedic surgeon, and interventional radiologist to optimize outcomes and reduce morbidity and mortality. 1

Core Multidisciplinary Team Members

Infectious Disease Specialist

• Essential for all osteomyelitis cases to guide appropriate antibiotic selection, duration, and monitoring based on culture results and patient-specific factors 1, 2
• Particularly critical for interpreting bone culture results and tailoring antimicrobial therapy to the specific pathogen and susceptibility patterns 3
• Should be consulted early in the diagnostic process, not just after treatment failure 4

Orthopedic Surgeon

• Required for performing surgical debridement, bone resection, and reconstruction procedures that are often necessary for definitive treatment 1
• Essential when substantial bone necrosis is present, exposed joint exists, or the foot appears functionally nonsalvageable 3, 5
• Should evaluate all cases to determine if surgical intervention is indicated, even if ultimately managed medically 2

Interventional Radiologist

• Performs image-guided bone biopsies under fluoroscopic or CT guidance when percutaneous sampling is needed for definitive diagnosis 1, 3
• Critical for obtaining diagnostic specimens when surgical debridement is not immediately planned 4

Specialized Referrals Based on Clinical Context

Diabetic Foot Osteomyelitis

• Podiatrist may perform bone biopsies and surgical procedures, particularly for forefoot involvement 1
• Vascular surgeon for immediate evaluation of peripheral arterial disease, as ischemia limits antibiotic delivery and predicts treatment failure 5
• Urgent vascular consultation needed if significant vascular disease is present to determine timing of revascularization 5

Vertebral Osteomyelitis (Native)

• Spine surgeon consultation recommended for all patients with native vertebral osteomyelitis 4
• Mandatory immediate surgical consultation for patients with neurologic compromise with or without impending sepsis or hemodynamic instability 4
• Required for treatment failure cases showing clinical and radiographic evidence of persistent infection 4

Chronic Non-Bacterial Osteitis (CNO)

• Rheumatologist should lead the multidisciplinary team for CNO cases 4
• In the absence of a rheumatologist, a specialist with expertise in autoinflammatory and bone-related disorders should assume this role 4
• Musculoskeletal imaging experts should be involved for accurate diagnosis and monitoring 4

When to Refer to Expert/Tertiary Centers

Immediate Referral Indications

• All difficult-to-treat patients should be referred to expert centers if not done initially 4
• Patients with treatment failure after 4 weeks showing unchanged or increasing inflammatory markers (ESR, CRP) 4
• Cases with progressive epidural or paraspinal soft tissue infection on follow-up MRI 4
• Presence of necrosis requiring urgent surgical intervention within 24-48 hours 5

Consider Referral for All Cases

• All adult patients with chronic non-bacterial osteitis (CNO) should be considered for referral to an expert center due to rarity and limited evidence 4
• Complex cases requiring prolonged antibiotic therapy (4-6 months) without surgical intervention 3
• Cases with antibiotic-resistant organisms, especially methicillin-resistant Staphylococcus aureus (MRSA) 2

Hub-and-Spoke Model

• Periodic assessments at an expert center may be beneficial for ongoing management, allowing shared care between tertiary centers and local providers 4

Additional Specialist Consultations

Wound Care Specialists

• Important for managing complex soft tissue defects and optimizing healing conditions 6
• Essential for diabetic foot infections with extensive ulceration 4

Rehabilitation Specialists

• Needed for patients requiring prolonged recovery and functional restoration 6
• Critical for optimizing off-loading and preventing recurrence in diabetic foot cases 3

Common Pitfalls to Avoid

• Do not delay specialist referral while attempting empiric management, as early multidisciplinary involvement improves outcomes 1, 2
• Do not rely solely on primary care management for osteomyelitis, as this complex infection requires specialized expertise 6, 7
• Do not wait for treatment failure before involving infectious disease specialists and surgeons—early consultation is essential 4, 2
• Do not overlook vascular assessment in diabetic or peripheral vascular disease patients, as inadequate blood supply guarantees treatment failure 5

Documentation and Communication

• Ensure clear communication between all team members regarding culture results, surgical findings, and treatment plans 1
• Document rationale for surgical versus medical management decisions 3
• Establish follow-up protocols with the multidisciplinary team to monitor for treatment response and potential relapse 4, 2