Osteomyelitis Management

Aka: Osteomyelitis Management, Cierny-Mader Staging System

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II. Staging: Cierny-Mader Staging System

  1. Anatomic Type
    1. Stage 1: Medullary Osteomyelitis
    2. Stage 2: Superficial Osteomyelitis
    3. Stage 3: Localized Osteomyelitis
    4. Stage 4: Diffuse Osteomyelitis
  2. Physiologic Type
    1. Class A: Normal Immune System response and healthy vascular system
    2. Class B-L: Compromised locally
      1. Arteritis
      2. Lymphedema
      3. Radiation Fibrosis
      4. Tissue scarring
      5. Vascular Compromise (e.g. Peripheral Arterial Disease, Critical Limb Ischemia)
      6. Venous Stasis
    3. Class B-S: Compromised systemically
      1. Alcohol Abuse
      2. Age extremes (young children, elderly)
      3. Chronic Hypoxia
      4. Corticosteroid Use
      5. Diabetes Mellitus
      6. Immunodeficiency
      7. Malignancy
      8. Malnutrition
      9. Liver Failure
      10. Renal Failure
      11. Tobacco Abuse
    4. Class C: Not a surgical candidate
      1. Treatment is more harmful than disease
      2. Palliative management is indicated
  3. References
    1. Marais (2015) J Orthop 12(4): 184-92 +PMID: 26566317 [PubMed]

III. Management: General

  1. If possible, delay antibiotics until bone culture and sensitivity are available
  2. Indications for empiric immediate antibiotics (prior to biopsy, culture results)
    1. Hospitalized patients at risk of MRSA
    2. Severe Sepsis
    3. Epidural Abscess
    4. Neurologic involvement
  3. Bone biopsy and surgical Debridement
    1. Indications
      1. Indicated in most cases of Chronic Osteomyelitis and contiguous infection
      2. Underlying orthopedic hardware
      3. Necrotic bone
    2. Protocol
      1. Bone stabilization is performed at time of Debridement
      2. Consider antibiotic-loaded collagen sponge placement
        1. Van Vugt (2008) J Bone Joint Surg Am 100(24): 2153-61 [PubMed]
    3. Efficacy
      1. Decreases hospital stays, antibiotic therapy duration and prevents complications
      2. Shih (2005) J Trauma 58(1): 83-7 [PubMed]
  4. Once obtaining surgical bone culture-based antibiotic sensitivities, oral antibiotics are as effective as parenteral
    1. Rombach (2019) N Engl J Med 380(5):425-36 [PubMed]
  5. Additional Measures
    1. Hyperbaric Oxygen Therapy
      1. Savvidou (2018) Orthopedics 41(4): 193-9 [PubMed]

IV. Management: Acute (Hematogenous Spread)

  1. Protocol
    1. Total antibiotic duration: 4 to 6 weeks (up to 3-6 months for prosthetic hip or knee)
      1. Parenteral antibiotics for first 1-2 weeks
      2. Oral antibiotics for remainder of course
    2. Obtain cultures before starting empiric antibiotics
    3. Revise antibiotic coverage upon culture results
  2. First-line antibiotics (choose 2)
    1. Antibiotic 1: Vancomycin
      1. Vancomycin substitutes: Linezolid, Daptomycin, Trimethoprim-Sulfamethoxazole or if sensitive, Clindamycin
      2. Cefazolin or Nafcillin may be considered instead in non-life threatening infecton if low MRSA risk (<10%)
    2. Antibiotic 2: Cephalosporin (Ceftriaxone, Ceftazidime, Cefepime, Cefotaxime)
      1. Cephalosporin substitutes: Aztreonam, or if over age 15 years, Ciprofloxacin or Levofloxacin
  3. Additional coverage in special circumstances
    1. Sickle Cell Anemia (include Salmonella coverage)
      1. Add Fluoroquinolone (not in children)
    2. IV Drug Abuse or Hemodialysis patient
      1. Add Ciprofloxacin
  4. Other specific management (based on cultures)
    1. Candida Albicans
      1. Surprisingly, most often occurs in immunocompetent patients
      2. Most common sites are Vertebrae in adults, the femur in children
      3. Surgical Debridement and hardware removal is typical
      4. Treated with Antifungals for 6-12 months
        1. IV for First 2 weeks: Echinocandin (e.g. Caspofungin), Fluconazole or Amphotericin B
        2. Next: Fluconazole for 6-12 months
      5. Gamaletsou (2012) Clin Infect Dis 55(10):1338-51 +PMID:22911646 [PubMed]

V. Management: Contiguous Osteomyelitis

  1. No Vascular Insufficiency
    1. Bacterial causes
      1. Staphylococcus aureus
      2. Coagulase Negative Staphylococcus
      3. Gram Negative Rods
      4. Streptococcus
      5. Pseudomonas aeruginosa
    2. Empiric antibiotics (only in acutely ill patients, otherwise wait for culture results)
      1. Vancomycin (or Linezolid) AND
      2. Cephalosporin (Ceftazidime or Cefepime)
      3. Consider adding Rifampin
        1. Prosthetic joint
        2. Spinal implant
    3. Antibiotics after culture identifies Bacteria
      1. Methicillin sensitive Staphylococcus aureus
        1. First-line: Nafcillin, Oxacillin, Cefazolin
      2. Methicillin Resistant Staphylococcus Aureus
        1. First-line: Vancomycin
        2. Alternative: Linezolid, Rifampin, Daptomycin
      3. Streptococcus Species
        1. First-Line: Penicillin G
        2. Alternatives: Ceftriaxone, Clindamycin
      4. Quinolone-Resistant Enterobacteriaceae
        1. First-Line: Ticarcillin/Clavulanate (Timentin), Piperacillin/Tazobactam (Zosyn)
        2. Alternatives: Ceftriaxone
      5. Quinolone-Sensitive Enterobacteriaceae
        1. First-Line: Fluoroquinolone (e.g. Ciprofloxacin, Levofloxacin)
        2. Alternatives: Ceftriaxone
      6. Pseudomonas aeruginosa
        1. First-Line: Ciprofloxacin AND Cefepime or Piperacillin/Tazobactam (Zosyn)
        2. Alternative: Imipenem/Cilastin (Primaxin) AND Aminoglycoside
      7. Anaerobic Bacteria
        1. First-Line: Clindamycin, Ticarcillin/Clavulanate (Timentin)
        2. Alternative: Cefotetan (Cefotan), Metronidazole (Flagyl)
    4. Antibiotic course
      1. Duration if no hardware: 6-8 weeks
      2. Duration if hardware: 3-6 months (or until hardware removed)
  2. Vascular Insufficiency (Peripheral Arterial Disease or Diabetes Mellitus with Neuropathy)
    1. See Diabetic Foot Infection
    2. See Diabetic Foot Osteomyelitis
    3. Antibiotics for 6 weeks based on bone culture and sensitivity
    4. Empiric antibiotics (only in acutely ill patients, otherwise wait for culture results)
      1. Vancomycin AND Ertapenem (or Moxifloxacin)
    5. Other measures
      1. Consider revascularization

VI. Management: Chronic Osteomyelitis

  1. Avoid Empiric antibiotics unless acute exacerbation
    1. Treat acute exacerbation as Acute Osteomyelitis
  2. Base management on culture and sensitivity
    1. Bone biopsy culture and sensitivity (preferred)
    2. Soft-tissue culture and sensitivity
  3. Antibiotic duration for 2 to 6 weeks
  4. Surgical Debridement with
    1. Careful and complete Debridement is critical
    2. Dead-space management
      1. Local myoplasty
      2. Free-tissue transfers
      3. Antibiotic impregnated beads

VII. References

  1. (2019) Sanford Guide, accessed on IOS 10/26/2019
  2. Bamberger (2005) Am Fam Physician 72:2471-81 [PubMed]
  3. Boutin (1998) Orthop Clin North Am 29:41-66 [PubMed]
  4. Bury (2021) Am Fam Physician 104(4): 395-402 [PubMed]
  5. Carek (2001) Am Fam Physician 63(12):2413-20 [PubMed]
  6. Hatzenbuehler (2011) Am Fam Physician 84(9): 1027-33 [PubMed]
  7. Lew (1997) N Engl J Med 336:999-1007 [PubMed]
  8. Lipsky (1997) Clin Infect Dis 25:1318-26 [PubMed]

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