Orthopedics Book


Osteomyelitis Management

Aka: Osteomyelitis Management
  1. See Also
    1. Osteomyelitis
    2. Osteomyelitis Causes
    3. Vertebral Osteomyelitis
  2. Management: General
    1. If possible, delay antibiotics until bone culture and sensitivity are available
    2. Bone biopsy and surgical debridement
  3. 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. Age under 4 months
      1. Nafcillin or Oxacillin (or Vancomycin) and
      2. Cefotaxime or Ceftriaxone
    3. Age 4 months to 21 years
      1. Nafcillin or Oxacillin (or Vancomycin or Clindamycin)
      2. Add Cefotaxime or Ceftriaxone for Gram Stain with G-
    4. Age over 21 years
      1. Nafcillin or Oxacillin or Cefazolin (or Vancomycin)
  4. Management: Acute Osteomyelitis Special Circumstances
    1. Sickle Cell Anemia
      1. Fluoroquinolone (not in children) or
      2. Cefotaxime or Ceftriaxone
    2. IV Drug Abuse or Hemodialysis patient
      1. Nafcillin (or Vancomycin) and Ciprofloxacin
  5. Management: Contiguous Osteomyelitis
    1. No Vascular Insufficiency
      1. Post-op ORIF Fracture
        1. Nafcillin and Ciprofloxacin or
        2. Vancomycin with Cefotaxime or Ceftriaxone
      2. Post-op Sternotomy
        1. Vancomycin and Rifampin
      3. Post-nail puncture of foot via tennis shoe
        1. Ceftazidime or Cefepime (or Ciprofloxacin)
    2. Vascular Insufficiency
      1. Mild (Outpatient Management)
        1. Augmentin
      2. Severe (Inpatient Management)
        1. Imipenem or meropenem or
        2. Timentin or Zosyn or
        3. Unasyn or
        4. Trovafloxacin
  6. 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
  7. Management: Osteomyelitis due to Staphylococcus aureus
    1. Methicillin sensitive Staphylococcus aureus
      1. First-line: Nafcillin, Cefazolin
      2. Alternative: Clindamycin, Quinolone with Rifampin
    2. Methicillin Resistant Staphylococcus Aureus
      1. First-line: Vancomycin
      2. Alternative: Linezolid, Daptomycin, Trimethoprim Sulfamethoxazole, Minocycline
  8. References
    1. Gilbert (2001) Sanford Guide Antimicrobial, p. 2-3
    2. Bamberger (2005) Am Fam Physician 72:2471-81 [PubMed]
    3. Boutin (1998) Orthop Clin North Am 29:41-66 [PubMed]
    4. Carek (2001) Am Fam Physician 63(12):2413-20 [PubMed]
    5. Hatzenbuehler (2011) Am Fam Physician 84(9): 1027-33 [PubMed]
    6. Lew (1997) N Engl J Med 336:999-1007 [PubMed]
    7. Lipsky (1997) Clin Infect Dis 25:1318-26 [PubMed]

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