Osteomyelitis is a topic covered in the Washington Manual of Medical Therapeutics.

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General Principles

  • Osteomyelitis is an inflammatory process caused by an infecting organism that can lead to bone destruction. It should be considered when skin or soft tissue infections overlie bone and when localized bone pain accompanies fever or sepsis.
  • See Table 14-2.
    Table 14-2: Treatment of Osteomyelitis
    Etiology of OsteomyelitisOrganismTreatment Considerations
    Acute hematogenous
    • Staphylococcus aureus
    • Antibiotic therapy alone may be sufficient if no foreign body present.
    • S. aureus
    • Gram-negative bacilli
    • Mycobacterium tuberculosis
    • Biopsy off antibiotics (preferred) to guide therapy.
    • Antibiotic therapy alone may be sufficient.
    Associated with a contiguous focus of infection
    • S. aureus
    • Gram-negative bacilli
    • Coagulase-negative staphylococci (surgical site infections)
    • Anaerobes/polymicrobial (infected sacral decubitus ulcers, diabetics)
    • Diabetics and patients with peripheral vascular disease seldom are cured with antibiotics alone. Revascularization, debridement, or amputation is often required.
    • Long-term, suppressive antimicrobial therapy can be used if surgery is not feasible.
    • Hyperbaric oxygen may be a useful adjunct.
    Presence of an orthopedic device
    • S. aureus
    • Coagulase-negative Staphylococcus species
    • Rarely eradicated by antimicrobials alone, and typically requires removal of the device.
    • If removal is impossible, the addition of rifampin 300 mg PO q8-12h is recommended and long-term, suppressive antimicrobial therapy may be needed.
    Associated with hemoglobinopathies
    • S. aureus
    • Salmonella species

    Chronic osteomyelitis
    • Gram-negative pathogens (necrotic sequestrum)
    • S. aureus
    • Surgical removal of sequestrum is recommended in addition to antibiotics.
    Culture-negative osteomyelitis
    • Review above pathogens
    • Empiric therapy should cover S. aureus and all other likely pathogens.

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