What is the treatment for chronic osteomyelitis (infection of the bone)?

From the Guidelines

The treatment of chronic osteomyelitis requires a multidisciplinary approach combining surgical debridement and prolonged antibiotic therapy, with a recommended duration of at least 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone. Surgical intervention is essential and involves thorough debridement of all infected and necrotic bone and soft tissue, followed by appropriate wound management which may include local antibiotic delivery systems like antibiotic-impregnated beads or cement spacers 1. After obtaining deep tissue cultures during surgery, empiric antibiotic therapy should be initiated, typically with broad-spectrum coverage such as vancomycin (15-20 mg/kg IV every 12 hours) plus ceftriaxone (2g IV daily) or piperacillin-tazobactam (4.5g IV every 6-8 hours) 1. Once culture results are available, therapy should be narrowed to target the specific pathogen. For MSSA, nafcillin or oxacillin (2g IV every 4 hours) is preferred; for MRSA, vancomycin, daptomycin (6-8 mg/kg IV daily), or linezolid (600mg IV/PO twice daily) are options 1. Gram-negative infections may require fluoroquinolones like ciprofloxacin (750mg PO twice daily) or third-generation cephalosporins. Some key points to consider in the treatment of chronic osteomyelitis include:

• The importance of surgical debridement and drainage of associated soft-tissue abscesses 1
• The use of antibiotic therapy, with a recommended duration of at least 6 weeks for patients who do not undergo resection of infected bone 1
• The need for regular monitoring of inflammatory markers (ESR, CRP) to assess treatment response 1
• The importance of nutritional support for healing
• The potential use of hyperbaric oxygen therapy as an adjunct in refractory cases
• The need for long-term suppressive antibiotics in cases where complete surgical debridement is not possible. It is also important to consider the following factors when treating osteomyelitis:
• The anatomic site of infection
• The local vascular supply
• The extent of both soft tissue and bone destruction
• The presence of any systemic signs of infection
• The patient’s preferences for treatment. Overall, the treatment of chronic osteomyelitis requires a comprehensive approach that takes into account the individual patient's needs and circumstances, and involves a combination of surgical and medical therapies.

From the Research

Treatment Options for Chronic Osteomyelitis

• Chronic osteomyelitis is a difficult to treat infection of the bone, which requires a combined medical and surgical approach and often persists intermittently for years, with relapses and failures 2.
• The optimal type, route of administration, and duration of antibiotic treatment remain controversial, and the emergence of multi-drug resistant organisms poses major therapeutic challenges 2.
• Identification of the causative agent and subsequent targeted antibiotic treatment has a major impact on patients' outcome 2.

Antibiotic Regimens

• Antibiotic classes used in the treatment of osteomyelitis include penicillins, beta-lactamase inhibitors, cephalosporins, other beta-lactams (aztreonam and imipenem), vancomycin, clindamycin, rifampin, aminoglycosides, fluoroquinolones, trimethoprim-sulfamethoxazole, metronidazole, and new investigational agents including teicoplanin, quinupristin/dalfopristin, and oxazolidinones 3.
• Traditional treatments have used operative procedures followed by 4 to 6 weeks of parenteral antibiotics 3.
• Oral antibiotics are available that achieve adequate levels in bone, and there are now more published studies of oral than parenteral antibiotic therapy for patients with chronic osteomyelitis 4.

Route of Administration

• Limited evidence suggests that the method of antibiotic administration (oral versus parenteral) does not affect the rate of disease remission if the bacteria are sensitive to the antibiotic used 5, 6.
• Oral therapy avoids risks associated with intravenous catheters and is generally less expensive, making it a reasonable choice for osteomyelitis caused by susceptible organisms 4.

Duration of Treatment

• The optimal duration of therapy for chronic osteomyelitis remains uncertain 4.
• There is no evidence that antibiotic therapy for >4-6 weeks improves outcomes compared with shorter regimens 4.
• Defining the optimal route and duration of antibiotic therapy and the role of surgical debridement in treating chronic osteomyelitis are important, unmet needs 4.

Adverse Events

• Antibiotic treatment for osteomyelitis was associated with moderate or severe adverse events in 4.8% of patients allocated oral antibiotics and 15.5% patients allocated parenteral antibiotics 5.
• Superinfection occurred in participants of both groups (5/66 in the oral group versus 4/58 in the parenteral group) 6.