OSTEOMYELITIS

Osteomyelitis is an inflammatory
process of bone secondary to
infection with subsequent bone
destruction.

The
incidence
of
chronic
osteomyelitis is increasing: Around
20 cases per 100,000 people

Classification

Based on route of infection:

Based on histopathologic findings/duration of the

infection
ACUTE (first episode_ symptoms typically present
within two weeks of disease onset_ no necrosis)
CHRONIC (relapsing _ symptoms may not occur
until six weeks after the onset of infection_ presence
of necrotic bone.

S. aureus is the predominant pathogen seen in all

types of osteomyelitis.
How about susceptibility???

However
Host factors such as age, comorbidities,
medication, route of infection and presence of
foreign devices can influence the spectrum of
infection

Patients with diabetes and/or PVD:

IV drug users:

Pseudomonas aeruginosa and MRSA

Elderly:

Wounds colonized with a mixture of aerobic and anaerobic (polymicrobial)

E-coli secondary to UTI

Individuals with prosthetic implants:

(coagulase-negative staphylococci)

S. aureus

Neonates:

E-coli or group B streptococcus

Sickle cell patients:

Salmonella 67%

Suspected bacteria
H (neonates)

H (Infants-Children)

S. Aureus (MSSA)
Group B strept.
E. Coli
S. aureus

H (adult)

S. Aureus
Gm ve bacilli (E. coli)

C (w/o PVD)

S. Aureus (60%)
Gm ve bacilli (E. coli)
P. Aeruginosa (wounds)
Anaerobes

C (with PVD)

S. aureus (MRSA)
Enterococcus
P. aeruginosa
Enterobacteriaceae
Anaerobes

Signs and symptoms

Fever and chills
Localized pain, tenderness, and soft tissueswelling, decreased

joint range of motion

Neurologic symptoms if spinal cord compression

Laboratory tests

Elevated WBC
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein

Diagnostic tests
Radiographic tests (X-ray)
CT and MRI scans
Radionuclide imaging
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Bone biopsy

histological
exam

Culture

Isolate
pathogen

Presence of
inflammatory
cells

osteonecrosis

Appropriate antibiotic therapy

often requires surgical removal of infected and necrotic tissue
In the absence of culture and susceptibility results information

Use broad-spectrum, empiric antibiotics

Suspected mo
H (neonates<1 S. aureus
mo)
Group B strept.
E. coli
H (Infants, 136 mo)

S. aureus

AB
Nafcillin plus cefotaxime OR
Nafcillin plus an aminoglycoside.
Cefuroxime
Ceftriaxone
Nafcillin plus cefotaxime.

Nafcillin
H (children,>3 S. Aureus
Epidermidis, pyogenes, Cefazolin
years)
Clindamycin
H.influenzae, E. coli

Adults:
Nafcillin, cefazolin, or vancomycin
Choose additional antibiotics according to patient-specific characteristics.

H (adults)

S. aureus
E. coli

vancomycin.
AND
3rd /4th cephalo.

C (w/o PVD) S. aureus

vancomycin.

C (with PVD) S. aureus (MRSA)

Enterococcus
P. aeruginosa
Enterobacteriacea
Anaerobes

Vancomycin +
Piperacillin or imepenem or
meropenem or
(cefipime/ceftazidime or
cipro/levo + clinda or
metronidazole

Patients with sickle cell anemia Ceftriaxone/cefotaxime or ciprofloxacin/levofloxacin

(no studies assessing best empiric therapy)

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Suspected pathogen

MSSA

Antimicrobial agent

Nafcillin or oxacillin.
Cefazolin (1st gen.)

MRSA (ped.)

Clindamycin

MRSA (adult) MIC 2mcg/ml

Vancomycin

VRSA (MIC>2 mcg/ml)

Linezolid

Daptomycin adults only

Enterococcus spp.
Amp sensitive
Amp-resist.
VME

Ampicillin.
Vancomycin.
Linezolid or daptomycin.

Antimicrobial agent
Streptococcus

Penicillin G.

Entero-bacteriaceae

3rd or 4th gen. cephalo.

Piperacillin/tazobactam
Carbapenemes.
Cipro, levo, moxi adults

P. aeruginosa

Piperacillin/tazobactam.
Cefotaxime, Ceftazidime, Cefipime.
Cipro, levofloxacin,
Imepenem/cilastatin
Meropenem

Anaerobes

Clindamycin
Metronidazole

Acute osteomyelitis: 46 weeks

IV(1-2 weeks) in/outpatient
Then complete with oral therapy.
Chronic osteomyelitis: 68 weeks of
parenteral therapy and 312 months of oral
therapy

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a. Debridement and retention of prosthesis (DAIR) or

one-stage exchange of prosthesis
i. Staphylococcal: Pathogen-specific intravenous therapy plus rifampin 300450mg
twice daily for 26 weeks, followed by rifampin plus ciprofloxacin or levofloxacin
for 3 months (hip, elbow, shoulder, ankle prosthesis) or 6 months (knee prosthesis)
Indefinite chronic oral antimicrobial suppression may follow the above regimen.
ii. Non-staphylococcal: Pathogen-specific intravenous (or highly bioavailable oral)
therapy for 46 weeks, followed by indefinite oral suppression therapy

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b. Resection of prosthesis with/without planned

reimplantation or amputation
i. Pathogen-specific intravenous (or highly bioavailable oral)
therapy for 46 weeks

ii. Only 2448 hours of antibiotic therapy after amputation if

all infected tissue is removed and there is no concomitant
sepsis syndrome or bacteremia.

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Adherence

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21

Infectious Diseases Society of America. Diagnosis

and management of prosthetic joint infection:
clinical practice guidelines by the Infectious
Diseases Society of America. Clin Infect Dis
2013;56:e1-e25
Pharmacotherapy: Principles and Practice. Third
edition

ACCP Updates in Therapeutics 2014:

Pharmacotherapy Preparatory Review and
Recertification Course

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