Osteomyelitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected sepsis

1st line – follow local sepsis protocol

ACUTE

suspected acute peripheral osteomyelitis

low MRSA prevalence

1st line – antibiotic therapy

Back

1st line –

antibiotic therapy

Peripheral osteomyelitis usually occurs in the major long bones (e.g., femur, tibia, humerus), but can occur in small bones too. An acute presentation has a history of <2 weeks.[6] For a patient with diabetes and suspected osteomyelitis in a foot, see the patient group suspected osteomyelitis in diabetic foot below.

Establish the aetiology of infection and classify the disease to plan individual treatment. Follow local antibiotic protocols.

Base initial antibiotic choice on the most likely causative organism, which depends on:

The patient’s age
Immunisation history
Local organism prevalence and their sensitivities
Comorbidities
Local protocols.

Select appropriate care setting

Admit any patient who is systemically unwell to hospital for intravenous antibiotic therapy.

If your patient is well, you can arrange for intravenous antibiotic therapy to be given through an ambulatory care pathway, depending on local resources.

Admit any child with acute osteomyelitis to hospital for intravenous antibiotic therapy, unless there are exceptional circumstances.[6]

Adults

If the patient is unwell, give intravenous flucloxacillin within 1 hour of reaching hospital. If the patient has a penicillin allergy, give intravenous vancomycin.

If the patient is systemically well, wait for results of the culture before giving targeted intravenous antibiotic therapy.

Take account of antibiotic susceptibilities demonstrated in organism cultures.[6]

Switch to appropriate oral antibiotic therapy when clinically indicated. Narrow the antibiotic regimen in line with microbiological culture and sensitivity results, or PCR results.

The optimal duration of antimicrobial therapy is not certain.[63] In practice, continue antibiotic treatment for about 6 weeks in total.

Antibiotics are usually sufficient to treat acute bone infection (i.e., surgical procedures are usually unnecessary) if all of the following exist for any particular patient:

The diagnosis is made within a few days of symptom onset
No dead bone or abscesses are present on imaging
Rapid response is seen to systemic antibiotic treatment
There is no associated septic arthritis.

If any diagnosis is delayed, dead bone or abscesses are present, response to antibiotics is slow, or a septic arthritis is associated with the osteomyelitis, additional treatment, such as drainage or surgery, will often be required.

Children

For children aged 3 months to 5 years, give an intravenous cephalosporin such as cefazolin or cefuroxime.[6] In UK practice, ceftriaxone is considered a better option for methicillin-sensitive Staphylococcus aureus (MSSA) than cefuroxime.

First-generation cephalosporins (e.g., cefazolin) may be suboptimal if the osteomyelitis is caused by Streptococcus pneumoniae or Haemophilus influenzae type b in unvaccinated children.[6]
While second-generation cephalosporins (e.g., cefuroxime) and third-generation cephalosporins (e.g., ceftriaxone) demonstrate better coverage for S pneumoniae and H influenzae, they may be inferior to first-generation cephalosporins (or flucloxacillin) for osteomyelitis caused by S aureus.[6] In the UK, it is generally accepted that ceftriaxone provides adequate cover against MSSA.
Alternative options include amoxicillin/clavulanate, ceftriaxone, an antistaphylococcal penicillin (e.g., flucloxacillin), or clindamycin (for non-Kingella species). An antistaphylococcal penicillin is not effective against Kingella kingae.[6]

For children aged ≥5 years, give an intravenous antistaphylococcal penicillin, or cefazolin.[6]

When risk factors for atypical organisms are present (e.g., sickle cell disease), consider ceftriaxone with or without an antistaphylococcal penicillin or clindamycin.[6]

Consider switching from intravenous to oral antibiotics after 2 to 4 days when the child:[6]

Has been afebrile for 24 to 48 hours
Shows clinical improvement with reduced pain, inflammation, and improved mobility
Has a C-reactive protein (CRP) level that has decreased by at least 30% of the highest value.

See the European Society For Paediatric Infectious Diseases guideline on bone and joint infections for the antibiotics most appropriate for organisms that have been identified by PCR.[6] However, if the organism has been identified by culture, and sensitivity to antibiotics has been determined, narrow antibiotics accordingly.

Treat uncomplicated acute osteomyelitis in children with antibiotics for at least 3 to 4 weeks.

In children who respond well, early transition from intravenous to oral therapy (after 3 days to 1 week) may be as effective as longer courses of intravenous treatment.[70][71] Signs suggestive of clinical improvement include:[6]

Apyrexia
Increased mobility
Decreased inflammation
Decreased pain
Decreasing CRP.

Complicated or high-risk infections may need longer intravenous and oral antibiotic therapy.[6]

These regimens are examples only; follow local antibiotic protocols.

Primary options

Adults

flucloxacillin: 1-2 g intravenously every 6-8 hours

Children

cefazolin: 25-100 mg/kg/day intravenously given in 2-4 divided doses

Children

cefuroxime: 20 mg/kg intravenously every 8 hours (maximum 750 mg/dose), may increase to 50-60 mg/kg every 6-8 hours in severe infections (maximum 1500 mg/dose)

Children

flucloxacillin: 50 mg/kg intravenously every 6 hours, maximum 2000 mg/dose

Secondary options

Adults

vancomycin: 15-20 mg/kg intravenously every 8-12 hours, maximum 2000 mg/dose

Children

ceftriaxone: 50-100 mg/kg intravenously every 24 hours, maximum 4000 mg/day

Children

amoxicillin/clavulanate: 30 mg/kg intravenously every 8 hours, maximum 1200 mg/dose

Children

clindamycin: 3.75 to 10 mg/kg intravenously every 6 hours, maximum 1200 mg/dose

Children

ceftriaxone: 50-100 mg/kg intravenously every 24 hours, maximum 4000 mg/day

-- AND --

flucloxacillin: 50 mg/kg intravenously every 6 hours, maximum 2000 mg/dose

clindamycin: 3.75 to 10 mg/kg intravenously every 6 hours, maximum 1200 mg/dose

Consider – Pseudomonas antibiotic cover

Back

Consider –

Pseudomonas antibiotic cover

Additional treatment recommended for SOME patients in selected patient group

Walking barefoot may predispose children, particularly, but not exclusively, to osteomyelitis from penetrating injury. Pseudomonas can also be waterborne.

In UK practice, use piperacillin/tazobactam in the first instance if you suspect infection with Pseudomonas.

If the patient is allergic to penicillin, use a fluoroquinolone such as ciprofloxacin (consider safety issues - see Drug safety alert below).[6]

These regimens are examples only; follow local antibiotic protocols.

Drug safety alert: Restrictions on the use of fluoroquinolone antibiotics

In November 2018, the European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.

As a consequence of this review, the EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only. Furthermore, it recommends that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Coadministration of a fluoroquinolone and a corticosteroid should be avoided.[67] The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) supports these recommendations.[68]

Primary options

piperacillin/tazobactam: children: 90 mg/kg intravenously every 6-8 hours, maximum 4.5 g/dose; adults: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections

Secondary options

ciprofloxacin: children: 10 mg/kg intravenously every 8 hours, maximum 400 mg/dose; adults: 400 mg intravenously every 8-12 hours

Plus – supportive care

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Offer pain relief to all patients as required. Start with paracetamol or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen, with an opioid such as morphine for breakthrough pain relief. If regular use of morphine is required, switch to a slow-release oral formulation. In practice, severe pain usually suggests there is a collection (abscess) that needs to be drained.

Elevate and immobilise the limb for comfort if necessary.

Look out for deep vein thrombosis particularly with S aureus osteomyelitis.[6][66] Refer to a haematologist and follow local protocols. See our topic Deep vein thrombosis.

Address any comorbidities. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.

Consider referral to other specialist teams, such as:

The haematology team for a patient with sickle cell disease
The diabetes inpatient specialist team for a patient with diabetes mellitus but who does not have a diabetic foot problem.

Primary options

paracetamol: children: consult specialist for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults: 15 mg/kg (maximum 1000 mg/dose) intravenously every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

Secondary options

morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Consider – surgery

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Consider –

surgery

Additional treatment recommended for SOME patients in selected patient group

A rapid response to antibiotic therapy is usually expected, but if the limb deteriorates or imaging suggests progressive bone destruction, discuss choice of antibiotics with microbiology and consider surgery to prevent progression to chronic osteomyelitis.

Although acute osteomyelitis often responds to antibiotics alone if it can be treated promptly and aggressively, once dead bone or a biofilm has become established, antibiotics alone cannot cure the infection and thorough surgical debridement is required. See chronic osteomyelitis section below.

If you are considering surgery, seek advice from orthopaedics.

Practical tip

Note that tuberculous osteomyelitis usually does not require surgical intervention.

Ensure drainage of fluid collections, if present, by radiological guidance or surgery.

For adults who may require surgery, consult a specialist orthopaedic surgeon.

For children with osteomyelitis, consider surgery in the following situations:[6]

Persistent or recurring fever after 3 to 4 days
Periosteal abscess with persistent fever and raised CRP
Sequestration
MRSA or Panton-Valentine leukocidin (PVL)-positive S aureus
Chronic osteomyelitis
Prosthetic material.

Seek paediatric orthopaedic advice.

Practical tip

Note that necrotising features, multifocal osteomyelitis, and recurrence may be caused by PVL-producing S aureus and is associated with serious risk. The British Society for Antimicrobial Chemotherapy (BSAC) makes antibiotic recommendations for this rare aetiology.[56][69]

high MRSA prevalence

1st line – antibiotic therapy

Back

1st line –

antibiotic therapy

Establish the aetiology of infection and classify the disease to plan individual treatment. If the prevalence of MRSA in the community is high, or your patient is known to have had MRSA in the past, ensure that the initial empirical antibiotics cover for MRSA. Follow local antibiotic protocols.

When deciding on the empirical regimen, also take into account:

The patient’s age
Immunisation history
Local organism prevalence and their sensitivities
Comorbidities
Local protocols.

Select appropriate care setting

Admit any patient who is systemically unwell to hospital for intravenous antibiotic therapy.

If your patient is well, you can arrange for intravenous antibiotic therapy to be given through an ambulatory care pathway, depending on local resources.

Admit any child with acute osteomyelitis to hospital for intravenous antibiotic therapy, unless there are exceptional circumstances.[6]

Adults

If the patient is unwell, give intravenous vancomycin within 1 hour of reaching hospital.

Teicoplanin and linezolid are reasonable alternatives if the patient cannot tolerate vancomycin, or if vancomycin is contraindicated.

If the patient is systemically well, wait for results of the culture before giving targeted intravenous antibiotic therapy.

Take account of antibiotic susceptibilities demonstrated in organism cultures.[6]

Switch to appropriate oral antibiotic therapy when clinically indicated. Narrow the antibiotic regimen in line with microbiological culture and sensitivity results, or PCR results.

The optimal duration of antimicrobial therapy is not certain.[63] In practice, continue antibiotic treatment for about 6 weeks in total.

Antibiotics are usually sufficient to treat acute bone infection (i.e., surgical procedures are usually unnecessary) if all of the following exist for any particular patient:

The diagnosis is made within a few days of symptom onset
No dead bone or abscesses are present on imaging
Rapid response is seen to systemic antibiotic treatment
There is no associated septic arthritis.

Children

For children aged <2 years, if the prevalence of MRSA is >10% to 15% in the community, add clindamycin to the empirical regimen as indicated for low MRSA prevalence in the patient group above.[6] If, however, the prevalence of clindamycin resistance in MRSA is ≥10%, prescribe vancomycin or linezolid.[6]

For children aged ≥2 years, if the prevalence of MRSA is >10% to 15% in the community, give clindamycin alone, as long as the prevalence of clindamycin resistance in MRSA is <10%.[6]

Rifampicin or an antistaphylococcal beta-lactam (e.g., amoxicillin/clavulanate) may be added depending on patient and prevalence factors.
If there is a high rate of MRSA and there is severe infection, a high rate of clindamycin resistance (≥10%), or initial treatment failure, give vancomycin or teicoplanin. Rifampicin may be added; however, there is little evidence to support this.

Always consider adding a beta-lactam until MRSA is confirmed to be the causative organism.

When risk factors for atypical organisms are present (e.g., sickle cell disease), consider ceftriaxone with or without an antistaphylococcal penicillin or clindamycin.[6]

Consider switching from intravenous to oral antibiotics after 2 to 4 days when the child:[6]

Has been afebrile for 24 to 48 hours
Shows clinical improvement with reduced pain, inflammation, and improved mobility
Has a C-reactive protein (CRP) level that has decreased by at least 30% of the highest value.

See the European Society For Paediatric Infectious Diseases guideline on bone and joint infections for the antibiotics most appropriate for organisms that have been identified by PCR.[6] However if the organism has been identified by culture, and sensitivity to antibiotics has been determined, narrow antibiotics accordingly.

Treat uncomplicated acute osteomyelitis in children with antibiotics for at least 3 to 4 weeks.

Apyrexia
Increased mobility
Decreased inflammation
Decreased pain
Decreasing CRP.

Complicated or high-risk infections may need longer intravenous and oral antibiotic therapy.[6]

Practical tip

Note that necrotising features, multifocal osteomyelitis, and recurrence may be caused by Panton-Valentine leukocidin (PVL)- producing Staphylococcus aureus and is associated with serious risk. The British Society for Antimicrobial Chemotherapy (BSAC) makes antibiotic recommendations for this rare aetiology.[56][69]

These regimens are examples only; follow local antibiotic protocols.

Primary options

Adults

vancomycin: 15-20 mg/kg intravenously every 8-12 hours, maximum 2000 mg/dose

Children

clindamycin: 3.75 to 10 mg/kg intravenously every 6 hours, maximum 1200 mg/dose

Children

clindamycin: 3.75 to 10 mg/kg intravenously every 6 hours, maximum 1200 mg/dose

-- AND --

rifampicin: 10 mg/kg intravenously every 12 hours, maximum 600 mg/dose

amoxicillin/clavulanate: 30 mg/kg intravenously every 8 hours, maximum 1200 mg/dose

Secondary options

Adults

teicoplanin: 6 mg/kg intravenously every 12 hours for 3 doses, followed by 6 mg/kg every 24 hours

Adults

linezolid: 600 mg intravenously every 12 hours

Children

vancomycin: 10-15 mg/kg intravenously every 6 hours, maximum 2000 mg/dose

Children

linezolid: 10 mg/kg intravenously every 8 hours, maximum 600 mg/dose

Children

teicoplanin: 12 mg/kg intravenously every 12 hours for 3-5 doses, followed by 12 mg/kg every 24 hours

Children

vancomycin: 10-15 mg/kg intravenously every 6 hours, maximum 2000 mg/dose

teicoplanin: 12 mg/kg intravenously every 12 hours for 3-5 doses, followed by 12 mg/kg every 24 hours

-- AND --

rifampicin: 10 mg/kg intravenously every 12 hours, maximum 600 mg/dose

Consider – Pseudomonas antibiotic cover

Back

Consider –

Pseudomonas antibiotic cover

Additional treatment recommended for SOME patients in selected patient group

Walking barefoot may predispose children, particularly, but not exclusively, to osteomyelitis from penetrating injury. Pseudomonas can also be waterborne.

In UK practice, use piperacillin/tazobactam in the first instance if you suspect infection with Pseudomonas.

If the patient is allergic to penicillin, use a fluoroquinolone such as ciprofloxacin (consider safety issues - see Drug safety alert below).[6]

These regimens are examples only; follow local antibiotic protocols.

Drug safety alert: Restrictions on the use of fluoroquinolone antibiotics

Primary options

piperacillin/tazobactam: children: 90 mg/kg intravenously every 6-8 hours, maximum 4.5 g/dose; adults: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections

Secondary options

ciprofloxacin: children: 10 mg/kg intravenously every 8 hours, maximum 400 mg/dose; adults: 400 mg intravenously every 8-12 hours

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Elevate and immobilise the limb for comfort if necessary.

Look out for deep vein thrombosis particularly with S aureus osteomyelitis.[6][66] Refer to a haematologist and follow local protocols. See our topic Deep vein thrombosis.

Address any comorbidities. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.

Consider referral to other specialist teams, such as:

The haematology team for a patient with sickle cell disease
The diabetes inpatient specialist team for a patient with diabetes mellitus but who does not have a diabetic foot problem.

Primary options

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

Secondary options

Consider – surgery

suspected acute native vertebral osteomyelitis

1st line – referral to infectious disease specialist and spine surgeon

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Address any comorbidities. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.

Consider referral to other specialist teams, such as:

The haematology team for a patient with sickle cell disease
The diabetes inpatient specialist team for a patient with diabetes mellitus but who does not have a diabetic foot problem.

Primary options

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

Secondary options

Plus – antibiotic therapy

Back

Plus –

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

After taking blood for culture, immediately give empirical antibiotic therapy to a patient with progressive or severe neurological symptoms.[7]

If your patient does not have progressive neurological symptoms, delay starting antibiotics until microbiology cultures and sensitivity results are available to guide pathogen-targeted antibiotic therapy.[7]

Select appropriate care setting

Admit any patient who is systemically unwell to hospital for intravenous antibiotic therapy.

If your patient is well, you can arrange for intravenous antibiotic therapy to be given through an ambulatory care pathway, depending on local resources.

Admit any child with acute osteomyelitis to hospital for intravenous antibiotic therapy, unless there are exceptional circumstances.[6]

Adults

Give an empirical antibiotic regimen that covers staphylococci (including MRSA), streptococci, and gram-negative bacilli.[7]

Vancomycin plus a third- or fourth-generation cephalosporin (e.g., ceftriaxone) is an example of a suitable regimen.[7]
For patients with an allergy or intolerance, give daptomycin plus a fluoroquinolone such as ciprofloxacin (consider safety issues - see Drug safety alert below).[7]

These regimens are based on Infectious Diseases Society of America (IDSA) guidance.[7] Note that UK regimens may be narrower spectrum due to less resistance; consult local protocols because no national guidance for native vertebral osteomyelitis has been published.

Drug safety alert: Restrictions on the use of fluoroquinolone antibiotics

Do not prescribe empirical antifungal and antimycobacterial therapy in most situations.[7]

Children

For children with spondylodiscitis or vertebral osteomyelitis, seek advice from microbiology on empirical antibiotic regimens and doses.

Pathogen-targeted therapy

Narrow the antibiotic regimen according to culture and sensitivity results when they become available. Detailed guidance on regimens is available from the IDSA.[7]

Give a total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy.[7]

When the aetiological agent is Brucella, culture may be difficult and results slow to obtain, as the organism is intracellular and the number of circulating bacteria is usually low.[105] Therefore, targeted antibiotic therapy may need to be started when PCR results are available and infection has been confirmed, regardless of whether culture and sensitivity results are available. Follow local antibiotic protocols or seek advice from microbiology on choice of antibiotic regimen in endemic areas. Give antibiotics for Brucella infection for 3 months.[7] See our Brucellosis topic for more information. Seek evaluation by a spine surgeon and an infectious disease specialist in nonendemic areas.[7]

These regimens are examples only; follow local antibiotic protocols.

Primary options

vancomycin: adults: 15-20 mg/kg intravenously every 8-12 hours, maximum 2000 mg/dose

and

ceftriaxone: adults: 2 g intravenously every 24 hours

Secondary options

daptomycin: adults: 4-6 mg/kg intravenously every 24 hours

and

ciprofloxacin: adults: 400 mg intravenously every 8-12 hours

Consider – surgery

suspected acute osteomyelitis in diabetic foot

1st line – referral to multidisciplinary foot care team

Plus – antibiotic therapy

Back

Plus –

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Start empirical antibiotic therapy for a patient with a suspected diabetic foot infection as soon as possible.[26]

When choosing an empirical antibiotic regimen for suspected osteomyelitis in a patient with a diabetic foot problem, take into account:[26]

The risk of developing complications
Previous microbiological results
Previous antibiotic use
Patient preferences.

Practical tip

In practice, see your local treatment protocol and discuss the patient with the multidisciplinary foot care service and/or microbiology in order to start an appropriate antibiotic regimen.

Select appropriate care setting

Admit any patient who is systemically unwell to hospital for intravenous antibiotic therapy.

Most patients need admission to ensure strict glucose control.

Admit any child with acute osteomyelitis to hospital for intravenous antibiotic therapy, unless there are exceptional circumstances.[6]

Adults

The UK National Institute for Health and Care Excellence (NICE) recommends giving one of the following intravenous antibiotic regimens for 48 hours in an adult aged ≥18 years with suspected osteomyelitis (moderate to severe diabetic foot problem):[26]

Flucloxacillin with or without gentamicin and/or metronidazole
Amoxicillin/clavulanate with or without gentamicin
Ceftriaxone plus metronidazole.

In patients with a penicillin allergy, prescribe trimethoprim/sulfamethoxazole with or without gentamicin and/or metronidazole.[26]

Review intravenous antibiotics at 48 hours and consider switching to oral antibiotics if possible.

Children

Diabetic foot infections are uncommon in children. Seek specialist advice when prescribing antibiotics for a suspected diabetic foot infection in children and young people aged <18 years.[26]

Pathogen-targeted therapy

When microbiological results are available, review and change the antibiotic accordingly, using a narrow-spectrum antibiotic, if appropriate.[26]

Treat osteomyelitis in a patient with a diabetic foot problem for 6 weeks.[26]

Review the need for continued antibiotics regularly.[26]

These regimens are examples only; follow local antibiotic protocols.

Primary options

flucloxacillin: adults: 1-2 g intravenously every 6 hours; 1 g orally four times daily

-- AND --

gentamicin: adults: 5-7 mg/kg intravenously every 24 hours

and/or

metronidazole: adults: 500 mg intravenously every 8 hours; 400 mg orally three times daily

amoxicillin/clavulanate: adults: 1.2 g intravenously every 8 hours; 500/125 mg orally three times daily

and

gentamicin: adults: 5-7 mg/kg intravenously every 24 hours

ceftriaxone: adults: 2 g intravenously every 24 hours

and

metronidazole: adults: 500 mg intravenously every 8 hours; 400 mg orally three times daily

Secondary options

trimethoprim/sulfamethoxazole: adults: 160/800 mg intravenously every 12 hours, may increase to 240/1200 mg every 12 hours in severe infections; 160/800 mg orally twice daily

-- AND --

gentamicin: adults: 5-7 mg/kg intravenously every 24 hours

and/or

metronidazole: adults: 500 mg intravenously every 8 hours; 400 mg orally three times daily

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Show drug information for a patient with no comorbidities

Primary options

flucloxacillin

-- AND --

gentamicin

and/or

metronidazole

amoxicillin/clavulanate

and

gentamicin

ceftriaxone

and

metronidazole

Secondary options

trimethoprim/sulfamethoxazole

-- AND --

gentamicin

and/or

metronidazole

Consider – MRSA antibiotic cover

Consider – Pseudomonas antibiotic cover

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Consider –

Pseudomonas antibiotic cover

Additional treatment recommended for SOME patients in selected patient group

If you suspect Pseudomonas infection, add in:[26]

Piperacillin/tazobactam
Clindamycin plus ciprofloxacin (consider safety issues - see Drug safety alert below) and/or gentamicin, if the patient has a penicillin allergy.

Drug safety alert: Restrictions on the use of fluoroquinolone antibiotics

For confirmed Pseudomonas infection, be guided by culture and sensitivities results.

Seek specialist advice when prescribing antibiotics for a suspected diabetic foot infection in children and young people aged <18 years.

These regimens are examples only; follow local antibiotic protocols.

Primary options

piperacillin/tazobactam: adults: 4.5 g intravenously every 8 hours, may increase to 4.5 g every 6 hours in severe infections

Secondary options

clindamycin: adults: 600-2700 mg/day intravenously given in 2-4 divided doses, may increase to 1200 mg every 6 hours in life-threatening infections; 150-450 mg orally four times daily

-- AND --

ciprofloxacin: adults: 400 mg intravenously every 8-12 hours; 500 mg orally twice daily

and/or

gentamicin: adults: 5-7 mg/kg intravenously every 24 hours

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Admit the patient for strict glucose control. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.

Address any comorbidities.

Immobilise the limb for comfort if necessary.

Look out for deep vein thrombosis, particularly with Staphylococcus aureus osteomyelitis.[6][66] Follow local protocols. See our topic Deep vein thrombosis.

Primary options

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

Secondary options

Consider – surgery

ONGOING

chronic osteomyelitis

1st line – referral to specialist team

Back

1st line –

referral to specialist team

Once there is dead bone or a biofilm has become established, the osteomyelitis can be considered chronic. Chronic osteomyelitis usually has a history of >3 months.[6] Antibiotics alone cannot cure the infection and thorough surgical debridement is required for full cure.

Consider where the patient should receive their treatment and discuss this with them.

In practice, treat a patient with an acute exacerbation of chronic osteomyelitis in the same way as you would treat a patient with a purely acute presentation, but refer them to the team that usually supervises their care.

Discuss admission of a patient with an acute exacerbation of chronic osteomyelitis with the team that usually provides their care.

Owing to the many and varied comorbidities present in class B patients under the Cierny-Mader classification (patients with comorbidities that directly reduce the likelihood of wound healing, reduce the efficacy of drug treatment, or increase the risks of surgery) and the particular surgical techniques required to tackle complex infections, these patients should be seen in a specialist bone infection centre.

In patients with type IV disease (where there is diffuse involvement of the entire circumference of the bone), in diffuse osteomyelitis, or when there are infected fractures, a multidisciplinary team specialising in bone infection should be involved.

The team should include orthopaedic surgeons, microbiologists, plastic surgeons, and clinical nurse specialists who assist with home intravenous therapy and wound care.
Involve a musculoskeletal radiologist to interpret imaging and perform percutaneous bone biopsies.
There is also a role for a vascular surgeon in a patient with peripheral vascular disease. For example, a patient with a non-union or a foot ulcer may require revascularisation prior to operative intervention to improve outcome.

For any patient with a limb-threatening or life-threatening diabetic foot problem, including a clinical concern that there is a bone infection, liaise with the multidisciplinary foot care service immediately.[26] See the patient group suspected acute osteomyelitis in diabetic foot, above, and our topic Diabetic foot complications for more information.

In a patient with native vertebral osteomyelitis, consult a spine surgeon and an infectious disease physician.

Chronic osteomyelitis in children is rare. When it does occur, discuss the patient with a paediatric orthopaedic surgeon and infectious diseases consultant.

Arrange functional rehabilitation for all patients with chronic osteomyelitis.

Plus – clinical staging and assessment for surgery

Plus – optimise patient’s condition

Consider – antibiotic therapy ± limited surgery

Consider – curative surgery plus intravenous antibiotic therapy

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Consider –

curative surgery plus intravenous antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

Surgery in a patient with chronic osteomyelitis is complex and often warrants technical expertise and multidisciplinary input. Staged reconstruction is sometimes needed. For further details, see the section on Chronic osteomyelitis in the Management Recommendations section of this topic.

Plan the surgical approach using imaging. Plain film x-ray and magnetic resonance imaging (MRI) are particularly useful in accessing the sequestrum and avoiding unnecessary damage to the healthy bone when making a window to enter the medullary canal. MRI is also helpful in identifying localised active disease when the normal morphology of the bone is disrupted.

In general, operative principles include:

Use of a tourniquet wherever possible
Excision of any sinus with an ellipse of skin in the line of the incision
Thorough debridement and excision of all infected tissue
Meticulous microbiological and histological sampling early during the procedure
- Obtaining uncontaminated representative samples to diagnose the causative organism and rule out other potential differentials, such as tumour, is essential.
Dead space management to prevent the formation of haematoma
- Haematoma increases infection recurrence rates.
Stabilisation of the bone, when there is instability or risk of fracture, usually with an external fixator
Attaining immediate soft-tissue coverage with healthy vascularised tissue that can deliver systemic antibiotics.

Once sampling has been completed, antibiotics are given. Initial intravenous antibiotic therapy appropriate to the flora encountered in the hospital’s region must be continued until a definitive regimen is selected based on the intraoperative culture results.

A protocol using a glycopeptide and a carbapenem antibiotic postoperatively in 166 cases of osteomyelitis debridement showed coverage of 96% of all organisms subsequently cultured.[74] This study revealed that one third of organisms cultured were resistant to a penicillin-based empirical antibiotic regimens. The carbapenem is usually stopped after 48 hours' culture if no gram-negative organisms have been cultured at that point.

If the patient does not respond to standard therapy, atypical organisms or fungal infections should be considered.

The optimal duration of antimicrobial therapy after surgery is not certain. If the osteomyelitic bone has been fully resected, a shorter course of antibiotic therapy (2-6 weeks) may be adequate as long as operative wounds are healing without any signs of infection.

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Osteomyelitis

Treatment algorithm

suspected sepsis

follow local sepsis protocol

Practical tip

suspected acute peripheral osteomyelitis

low MRSA prevalence

antibiotic therapy

Select appropriate care setting

Adults

Children

Primary options

Adults

Children

Children

Children

Secondary options

Adults

Children

Children

Children

Children

These drug options and doses relate to a patient with no comorbidities.

Primary options

Adults

Children

Children

Children

Secondary options

Adults

Children

Children

Children

Children

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Adults

Children

Children

Children

Secondary options

Adults

Children

Children

Children

Children

Pseudomonas antibiotic cover

Drug safety alert: Restrictions on the use of fluoroquinolone antibiotics

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

supportive care

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

surgery

Practical tip

Practical tip

high MRSA prevalence

antibiotic therapy

Select appropriate care setting

Adults

Children

Practical tip

Primary options

Adults

Children

Children

Secondary options

Adults