Treatment algorithm

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 acute peripheral osteomyelitis: low MRSA prevalence

1st line – empiric antibiotic therapy

Back
INITIAL
|
suspected acute peripheral osteomyelitis: low MRSA prevalence
|
adults
1st line – 

empiric antibiotic therapy

Peripheral osteomyelitis usually occurs in the major long bones (e.g., femur, tibia, humerus), but can occur in other bones too.[12] An acute presentation has a history of <2 weeks.[12]​ For a patient with diabetes and suspected osteomyelitis in a foot, see the patient group "suspected acute osteomyelitis in diabetic foot," below.

Any patient who is systemically unwell should be admitted to the hospital for intravenous antibiotic therapy.

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Local sepsis protocols should be followed. See Sepsis in adults.

Blood cultures should be considered in patients with fever suspected of having peripheral bone infection.[1] If blood cultures are indicated, samples should be taken before commencing antibiotics.[1]

Initial antibiotic choice is based on the most likely causative organism, which in turn depends on the patient's age, immunization history, comorbidities, the prevalence of organisms in the community, and antimicrobial sensitivities.

In adults with suspected acute peripheral osteomyelitis in areas of low MRSA prevalence (<10%), empiric therapy options include vancomycin plus a third- or fourth-generation cephalosporin (e.g., ceftriaxone, cefepime). If the patient has a penicillin allergy, vancomycin plus a fluoroquinolone (e.g., ciprofloxacin) may be considered.[99]

If Pseudomonas is suspected, an empiric antibiotic regimen that covers Pseudomonas should be chosen. Hematogenous osteomyelitis caused by Pseudomonas aeruginosa and other Pseudomonas species occurs most often in people who inject drugs.[9]P aeruginosa is the most common bacterial cause of calcaneal osteomyelitis in patients who develop this infection after stepping on nails while wearing sneakers.[9]​​ A local infectious disease specialist should be consulted about suitable options.

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[102]​ Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[103][104]

Intravenous therapy should be switched to appropriate oral antibiotic therapy when clinically indicated. Once the organism is identified by culture or polymerase chain reaction (PCR), and sensitivity to antibiotics is determined, antibiotic therapy should be narrowed accordingly.

The optimal duration of antimicrobial therapy is not certain.[57]​​ Response to antibiotic treatment is typically rapid. However, if the affected limb deteriorates or imaging suggests progressive bone destruction, choice of antibiotics should be discussed with microbiology. Surgery should be considered to prevent progression to chronic osteomyelitis.

Examples of antibiotic regimens are provided here; however, local protocols should be followed.

Primary options

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

More

-- AND --

ceftriaxone: 1-2 g intravenously every 24 hours

or

cefepime: 1-2 g intravenously every 8-12 hours

Secondary options

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

More

and

ciprofloxacin: 400 mg intravenously every 8-12 hours

Plus – supportive care

Back
INITIAL
|
suspected acute peripheral osteomyelitis: low MRSA prevalence
|
adults
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

The approach to treatment of osteomyelitis is complex, and often requires a multidisciplinary approach, with input from radiologists, vascular and orthopedic surgeons, infectious disease specialists, and wound care and rehabilitation specialists.[96]

The affected limb should be elevated and immobilized if necessary. Assessment should be undertaken for deep vein thrombosis, particularly with Staphylococcus aureus osteomyelitis since there is a high risk of venous thromboembolism during the first month following an episode of S aureus bacteremia.[98]​ See Deep vein thrombosis.

Any comorbidities should be addressed. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.[37]​ See Diabetic foot complications.

Pain relief should be provided to all patients as required. First-line analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. For more severe pain, an opioid (e.g., morphine, oxycodone) may be required for a short duration. If longer-term pain relief is required, a pain management specialist should be consulted.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

morphine sulfate: 10-30 mg orally (immediate-release) every 4 hours when required; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required; adjust dose according to response

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required, adjust dose according to response

Consider – surgery

Back
INITIAL
|
suspected acute peripheral osteomyelitis: low MRSA prevalence
|
adults
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Response to antibiotic therapy is typically rapid. However, if the affected limb deteriorates or imaging suggests progressive bone destruction, the choice of antibiotics should be discussed with microbiology. Surgery should be considered to prevent progression to chronic osteomyelitis. Once dead bone or a biofilm has become established, antibiotics alone cannot cure the infection and thorough surgical debridement is required.

1st line – empiric antibiotic therapy

Back
INITIAL
|
suspected acute peripheral osteomyelitis: low MRSA prevalence
|
children
1st line – 

empiric antibiotic therapy

Peripheral osteomyelitis usually occurs in the major long bones (e.g., femur, tibia, humerus), but can occur in other bones too.[12] An acute presentation has a history of <2 weeks.[12]

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Local sepsis protocols should be followed. See Sepsis in children.

Blood cultures should be considered in all children, in line with European Society For Paediatric Infectious Diseases (ESPID) recommendations.[12]

Most children are admitted to the hospital for intravenous therapy.[12] Some centers may use outpatient parenteral antimicrobial therapy with the insertion of a peripheral-inserted central line.[12]

In children with presumed acute hematogenous osteomyelitis who appear ill or have rapidly progressive infection, the Infectious Diseases Society of America (IDSA) recommends that empiric antimicrobial therapy should be started immediately rather than withholding antibiotics until invasive diagnostic procedures are performed.[4] In children with presumed acute hematogenous osteomyelitis who are not clinically ill and for whom an aspirate or biopsy by invasive diagnostic procedure is being planned prior to initiating antibiotics, the IDSA recommends that antibiotics should be withheld for no more than 48-72 hours.[4]

Initial antibiotic choice is based on the most likely causative organism, which in turn depends on the patient's age, immunization history, comorbidities, the prevalence of organisms in the community, and antimicrobial sensitivities.

Empiric therapy options for children with suspected acute peripheral osteomyelitis in areas of low MRSA prevalence (<10%) include nafcillin, oxacillin, or cefazolin.[4] Vancomycin is a common initial choice for children who are critically ill at presentation, regardless of regional MRSA prevalence.[4]

In the presence of a clinical presentation, physical examination, exposure history, or other risk factors that either are inconsistent with Staphylococcus aureus infection or suggest need for coverage for other organisms, additional empiric antimicrobial coverage for pathogens other than S aureus may be warranted. For example, additional coverage may be indicated in younger children (<4 years) for Kingella kingae or children with underlying hemoglobinopathies who have increased risk for Salmonella spp. infection.​[4][9]​​[12]

Pseudomonas is a rare cause of osteomyelitis in young children, unless there is trauma or puncture of the foot. If Pseudomonas is suspected, an empiric antibiotic regimen that covers Pseudomonas should be chosen. A local infectious disease specialist should be consulted about suitable options. The IDSA notes that non-fluoroquinolone antibiotics are preferred for children, owing to concerns for cartilage/tendon injury noted in animal toxicity studies of fluoroquinolones.[4]

Switching from intravenous to oral antibiotics after 2-4 days should be considered when the child has been afebrile for 24-48 hours, shows clinical improvement with reduced pain, inflammation, and improved mobility, and has a C-reactive protein (CRP) level that has decreased by at least 30% of the highest value.[12] In children who respond well to initial treatment, early transition from intravenous to oral therapy (after 3 days to 1 week) may be as effective as longer courses of intravenous antibiotics.[100][101]​ In children with acute hematogenous osteomyelitis presumed or proven to be caused by S aureus who have had an uncomplicated course and respond to initial therapy, the IDSA suggests a 3- to 4-week duration of antibiotics (parenteral plus oral) rather than a longer course.[4] Longer duration may be necessary for other pathogens, including more virulent strains of S aureus, and for complicated cases.[4]

Examples of antibiotic regimens are provided here; however, local protocols should be followed.

Primary options

nafcillin: 100-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day

OR

oxacillin: 100-200 mg/kg/day intravenously given in divided doses every 4-6 hours, maximum 12 g/day

OR

cefazolin: 25-100 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 6 g/day

Secondary options

vancomycin: children 1-2 months of age: 45-60 mg/kg/day intravenously given in divided doses every 6-8 hours; children 3 months to 11 years of age: 60-80 mg/kg/day intravenously given in divided doses every 6 hours, maximum 3000 mg/day; children ≥12 years of age: 60-70 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 3000 mg/day

More

Plus – supportive care

Back
INITIAL
|
suspected acute peripheral osteomyelitis: low MRSA prevalence
|
children
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

The approach to treatment of osteomyelitis is complex, and often requires a multidisciplinary approach, with input from radiologists, vascular and orthopedic surgeons, infectious disease specialists, and wound care and rehabilitation specialists.[96]

The affected limb should be elevated and immobilized if necessary. Assessment should be undertaken for deep vein thrombosis, particularly with Staphylococcus aureus osteomyelitis since there is a high risk of venous thromboembolism during the first month following an episode of S aureus bacteremia.[98]​ See Deep vein thrombosis.

Any comorbidities should be addressed. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.[37]​ Diabetic foot infections are uncommon in children. Specialist advice should be sought. See Diabetic foot complications.

Pain relief should be provided to all patients as required. First-line analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Rectal administration of acetaminophen can provide pain relief longer than intravenous administration in children.[97]​ For more severe pain, an opioid (e.g., morphine, oxycodone) may be required for a short duration. If longer-term pain relief is required, a pain management specialist should be consulted.

Primary options

acetaminophen: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day

OR

ibuprofen: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day

Secondary options

morphine sulfate: consult specialist for guidance on dose

OR

oxycodone: consult specialist for guidance on dose

Consider – surgery

Back
INITIAL
|
suspected acute peripheral osteomyelitis: low MRSA prevalence
|
children
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Pediatric orthopedic advice should be sought. In children with acute hematogenous osteomyelitis who present with sepsis or have a rapidly progressive infection, the Infectious Diseases Society of America (IDSA) recommends that debridement of the infected bone and any associated abscesses should be performed as soon as possible after diagnosis, rather than treating with medical therapy alone.[4] The European Society for Paediatric Infectious Diseases (ESPID) recommends that surgery should be considered in the following situations: persistent or recurring fever after 3-4 days; periosteal abscess with persistent fever and raised CRP; sequestration; MRSA or Panton-Valentine leukocidin (PVL)-positive S aureus; chronic osteomyelitis; prosthetic material.[12] Once dead bone or a biofilm has become established, antibiotics alone cannot cure the infection and thorough surgical debridement is required.

suspected acute peripheral osteomyelitis: high MRSA prevalence

1st line – empiric antibiotic therapy

Back
INITIAL
|
suspected acute peripheral osteomyelitis: high MRSA prevalence
|
adults
1st line – 

empiric antibiotic therapy

Peripheral osteomyelitis usually occurs in the major long bones (e.g., femur, tibia, humerus), but can occur in other bones too.[12] An acute presentation has a history of <2 weeks.[12]​ For a patient with diabetes and suspected osteomyelitis in a foot, see the patient group "suspected acute osteomyelitis in diabetic foot," below.

Any patient who is systemically unwell should be admitted to the hospital for intravenous antibiotic therapy.

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Local sepsis protocols should be followed. See Sepsis in adults.

Blood cultures should be considered in patients with fever suspected of having peripheral bone infection.[1] If blood cultures are indicated, samples should be taken before commencing antibiotics.[1]

Initial antibiotic choice is based on the most likely causative organism, which in turn depends on the patient's age, immunization history, comorbidities, the prevalence of organisms in the community, and antimicrobial sensitivities.

In adults with suspected acute peripheral osteomyelitis in areas of high MRSA prevalence (>10%), vancomycin is the drug of choice. Daptomycin is a reasonable alternative if the patient cannot tolerate vancomycin or if vancomycin is contraindicated.

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[102]​ Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[103][104]

Intravenous therapy should be switched to appropriate oral antibiotic therapy when clinically indicated. Once the organism is identified by culture or polymerase chain reaction (PCR), and sensitivity to antibiotics is determined, antibiotic therapy should be narrowed accordingly.

The optimal duration of antimicrobial therapy is not certain.​[57]​ Response to antibiotic treatment is typically rapid. However, if the affected limb deteriorates or imaging suggests progressive bone destruction, choice of antibiotics should be discussed with microbiology. Surgery should be considered to prevent progression to chronic osteomyelitis.

Examples of antibiotic regimens are provided here; however, local protocols should be followed.

Primary options

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

More

Secondary options

daptomycin: 6 mg/kg intravenously every 24 hours

Plus – supportive care

Back
INITIAL
|
suspected acute peripheral osteomyelitis: high MRSA prevalence
|
adults
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

The approach to treatment of osteomyelitis is complex, and often requires a multidisciplinary approach, with input from radiologists, vascular and orthopedic surgeons, infectious disease specialists, and wound care and rehabilitation specialists.[96]

The affected limb should be elevated and immobilized if necessary. Assessment should be undertaken for deep vein thrombosis, particularly with Staphylococcus aureus osteomyelitis since there is a high risk of venous thromboembolism during the first month following an episode of S aureus bacteremia.[98]​ See Deep vein thrombosis.

Any comorbidities should be addressed. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.[37]​ See Diabetic foot complications.

Pain relief should be provided to all patients as required. First-line analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. For more severe pain, an opioid (e.g., morphine, oxycodone) may be required for a short duration. If longer-term pain relief is required, a pain management specialist should be consulted.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

morphine sulfate: 10-30 mg orally (immediate-release) every 4 hours when required; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required; adjust dose according to response

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required, adjust dose according to response

Consider – surgery

Back
INITIAL
|
suspected acute peripheral osteomyelitis: high MRSA prevalence
|
adults
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Response to antibiotic therapy is typically rapid. However, if the affected limb deteriorates or imaging suggests progressive bone destruction, the choice of antibiotics should be discussed with microbiology. Surgery should be considered to prevent progression to chronic osteomyelitis. Once dead bone or a biofilm has become established, antibiotics alone cannot cure the infection and thorough surgical debridement is required.

1st line – empiric antibiotic therapy

Back
INITIAL
|
suspected acute peripheral osteomyelitis: high MRSA prevalence
|
children
1st line – 

empiric antibiotic therapy

Peripheral osteomyelitis usually occurs in the major long bones (e.g., femur, tibia, humerus), but can occur in other bones too.[12] An acute presentation has a history of <2 weeks.[12]

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Local sepsis protocols should be followed. See Sepsis in children.

Blood cultures should be considered in all children, in line with European Society For Paediatric Infectious Diseases (ESPID) recommendations.[12]

Most children are admitted to the hospital for intravenous therapy.[12] Hospital admission may be particularly important in regions with a high rate of MRSA or Panton-Valentine leukocidin (PVL)-positive Staphylococcus aureus, worse clinical severity, and in high-risk patients (e.g., infants, immunocompromised children).[12] Some centers may use outpatient parenteral antimicrobial therapy with the insertion of a peripheral-inserted central line.[12]

In children with presumed acute hematogenous osteomyelitis who appear ill or have rapidly progressive infection, the Infectious Diseases Society of America (IDSA) recommends that empiric antimicrobial therapy should be started immediately rather than withholding antibiotics until invasive diagnostic procedures are performed.[4] In children with presumed acute hematogenous osteomyelitis who are not clinically ill and for whom an aspirate or biopsy by invasive diagnostic procedure is being planned prior to initiating antibiotics, the IDSA recommends that antibiotics should be withheld for no more than 48-72 hours.[4]

Initial antibiotic choice is based on the most likely causative organism, which in turn depends on the patient's age, immunization history, comorbidities, the prevalence of organisms in the community, and antimicrobial sensitivities.

For children with suspected acute peripheral osteomyelitis in areas of high MRSA prevalence (>10%), vancomycin or clindamycin may be considered.[4] Vancomycin is a common initial choice for children who are critically ill at presentation, regardless of regional MRSA prevalence.[4]

In the presence of a clinical presentation, physical examination, exposure history, or other risk factors that either are inconsistent with S aureus infection or suggest need for coverage for other organisms, additional empiric antimicrobial coverage for pathogens other than S aureus may be warranted. For example, additional coverage may be indicated in younger children (<4 years) for Kingella kingae or children with underlying hemoglobinopathies who have increased risk for Salmonella spp. infection.​[4][9]​​[12]

Pseudomonas is a rare cause of osteomyelitis in young children, unless there is trauma or puncture of the foot. If Pseudomonas is suspected, an empiric antibiotic regimen that covers Pseudomonas should be chosen. A local infectious disease specialist should be consulted about suitable options. The IDSA notes that non-fluoroquinolone antibiotics are preferred for children, owing to concerns for cartilage/tendon injury noted in animal toxicity studies of fluoroquinolones.[4]

Switching from intravenous to oral antibiotics after 2-4 days should be considered when the child has been afebrile for 24-48 hours, shows clinical improvement with reduced pain, inflammation, and improved mobility, and has a C-reactive protein (CRP) level that has decreased by at least 30% of the highest value.[12] In children who respond well to initial treatment, early transition from intravenous to oral therapy (after 3 days to 1 week) may be as effective as longer courses of intravenous antibiotics.[100][101]​ In children with acute hematogenous osteomyelitis presumed or proven to be caused by S aureus who have had an uncomplicated course and respond to initial therapy, the IDSA suggests a 3- to 4-week duration of antibiotics (parenteral plus oral) rather than a longer course.[4] Longer duration may be necessary for other pathogens, including more virulent strains of S aureus, and for complicated cases.[4]

Examples of antibiotic regimens are provided here; however, local protocols should be followed.

Primary options

vancomycin: children 1-2 months of age: 45-60 mg/kg/day intravenously given in divided doses every 6-8 hours; children 3 months to 11 years of age: 60-80 mg/kg/day intravenously given in divided doses every 6 hours, maximum 3000 mg/day; children ≥12 years of age: 60-70 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 3000 mg/day

More

OR

clindamycin: 25-40 mg/kg/day intravenously given in divided doses every 6-8 hours, maximum 4.8 g/day

Plus – supportive care

Back
INITIAL
|
suspected acute peripheral osteomyelitis: high MRSA prevalence
|
children
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

The approach to treatment of osteomyelitis is complex, and often requires a multidisciplinary approach, with input from radiologists, vascular and orthopedic surgeons, infectious disease specialists, and wound care and rehabilitation specialists.[96]

The affected limb should be elevated and immobilized if necessary. Assessment should be undertaken for deep vein thrombosis, particularly with Staphylococcus aureus osteomyelitis since there is a high risk of venous thromboembolism during the first month following an episode of S aureus bacteremia.[98]​ See Deep vein thrombosis.

Any comorbidities should be addressed. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.[37]​ Diabetic foot infections are uncommon in children. Specialist advice should be sought. See Diabetic foot complications.

Pain relief should be provided to all patients as required. First-line analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Rectal administration of acetaminophen can provide pain relief longer than intravenous administration in children.[97]​ For more severe pain, an opioid (e.g., morphine, oxycodone) may be required for a short duration. If longer-term pain relief is required, a pain management specialist should be consulted.

Primary options

acetaminophen: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day

OR

ibuprofen: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day

Secondary options

morphine sulfate: consult specialist for guidance on dose

OR

oxycodone: consult specialist for guidance on dose

Consider – surgery

Back
INITIAL
|
suspected acute peripheral osteomyelitis: high MRSA prevalence
|
children
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Pediatric orthopedic advice should be sought. In children with acute hematogenous osteomyelitis who present with sepsis or have a rapidly progressive infection, the Infectious Diseases Society of America (IDSA) recommends that debridement of the infected bone and any associated abscesses should be performed as soon as possible after diagnosis, rather than treating with medical therapy alone.[4] The European Society for Paediatric Infectious Diseases (ESPID) recommends that surgery should be considered in the following situations: persistent or recurring fever after 3-4 days; periosteal abscess with persistent fever and raised CRP; sequestration; MRSA or Panton-Valentine leukocidin (PVL)-positive S aureus; chronic osteomyelitis; prosthetic material.[12] Once dead bone or a biofilm has become established, antibiotics alone cannot cure the infection and thorough surgical debridement is required.

suspected acute native vertebral osteomyelitis

1st line – empiric antibiotic therapy

Back
INITIAL
|
suspected acute native vertebral osteomyelitis
|
adults
1st line – 

empiric antibiotic therapy

In adults with suspected native vertebral osteomyelitis who have a normal and stable neurologic examination and stable hemodynamics, empirical antimicrobial therapy should not be given until a microbiologic diagnosis is established.[13]

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Local sepsis protocols should be followed. See Sepsis in adults.

In adults with suspected native vertebral osteomyelitis and neurologic compromise, the Infectious Diseases Society of America (IDSA) recommends immediate surgical intervention and initiation of empiric antimicrobial therapy instead of withholding antimicrobial therapy prior to an image-guided diagnostic aspiration biopsy.[13] In suspected native vertebral osteomyelitis without neurologic compromise, the IDSA recommends that whenever possible, initiation of antibiotic therapy should be delayed for a limited period of time until bone cultures can be obtained.[13] Pending further studies, the IDSA recommends that holding antibiotics when feasible for 1-2 weeks is reasonable in these circumstances.[13] 

Initial antibiotic choice is based on the most likely causative organism, which in turn depends on the patient's age, immunization history, comorbidities, the prevalence of organisms in the community, and antimicrobial sensitivities. Local protocols should be consulted. The following regimens are based on recommendations from the IDSA. The antibiotic regimen should cover staphylococci (including MRSA), streptococci, and gram-negative bacilli. An example of a suitable regimen is vancomycin plus a third- or fourth-generation cephalosporin (e.g., ceftriaxone, cefepime) or a carbapenem (e.g., meropenem) depending on risk of a resistant organism. For patients with an allergy or intolerance to first-line options, daptomycin plus a fluoroquinolone (e.g., ciprofloxacin) should be given.[13]

If Pseudomonas is suspected, an empiric antibiotic regimen that covers Pseudomonas should be chosen. A local infectious disease specialist should be consulted about suitable options.

Fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[102]​ Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[103][104]

Empiric antifungal and antimycobacterial therapy should not be prescribed in most situations.[13]

Examples of antibiotic regimens are provided here; however, local protocols should be followed.

Primary options

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

More

-- AND --

ceftriaxone: 1-2 g intravenously every 24 hours

or

cefepime: 1-2 g intravenously every 8-12 hours

or

meropenem: 1 g intravenously every 8 hours

Secondary options

daptomycin: 6 mg/kg intravenously every 24 hours

and

ciprofloxacin: 400 mg intravenously every 8-12 hours

Plus – supportive care

Back
INITIAL
|
suspected acute native vertebral osteomyelitis
|
adults
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

The approach to treatment of osteomyelitis is complex, and often requires a multidisciplinary approach, with input from radiologists, vascular and orthopedic surgeons, infectious disease specialists, and wound care and rehabilitation specialists.[96]

Assessment should be undertaken for deep vein thrombosis, particularly with Staphylococcus aureus osteomyelitis since there is a high risk of venous thromboembolism during the first month following an episode of S aureus bacteremia.[98]​ See Deep vein thrombosis.

Any comorbidities should be addressed. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.[37]​ See Diabetic foot complications.

Pain relief should be provided to all patients as required. First-line analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. For more severe pain, an opioid (e.g., morphine, oxycodone) may be required for a short duration. If longer-term pain relief is required, a pain management specialist should be consulted.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

morphine sulfate: 10-30 mg orally (immediate-release) every 4 hours when required; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required; adjust dose according to response

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required, adjust dose according to response

Consider – surgery

Back
INITIAL
|
suspected acute native vertebral osteomyelitis
|
adults
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

In adults with suspected native vertebral osteomyelitis and neurologic compromise with or without impending sepsis or hemodynamic instability, the Infectious Diseases Society of America (IDSA) recommends immediate surgical intervention and initiation of empiric antimicrobial therapy instead of withholding antimicrobial therapy prior to an image-guided diagnostic aspiration biopsy.[13]

Surgical intervention is required for progressive neurologic deficits, progressive deformity, and spinal instability with or without pain or recurrent bloodstream infection (without alternative source) despite adequate antimicrobial therapy.[13]

1st line – empiric antibiotic therapy

Back
INITIAL
|
suspected acute native vertebral osteomyelitis
|
children
1st line – 

empiric antibiotic therapy

For children with suspected spondylodiscitis or vertebral osteomyelitis, advice on empiric antibiotic regimens should be sought from microbiology and from an infectious disease specialist.

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Local sepsis protocols should be followed. See Sepsis in children.

Plus – supportive care

Back
INITIAL
|
suspected acute native vertebral osteomyelitis
|
children
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

The approach to treatment of osteomyelitis is complex, and often requires a multidisciplinary approach, with input from radiologists, vascular and orthopedic surgeons, infectious disease specialists, and wound care and rehabilitation specialists.[96]

Assessment should be undertaken for deep vein thrombosis, particularly with Staphylococcus aureus osteomyelitis since there is a high risk of venous thromboembolism during the first month following an episode of S aureus bacteremia.[98]​ See Deep vein thrombosis.

Any comorbidities should be addressed. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.[37]​ Diabetic foot infections are uncommon in children. Specialist advice should be sought. See Diabetic foot complications.

Pain relief should be provided to all patients as required. First-line analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Rectal administration of acetaminophen can provide pain relief longer than intravenous administration in children.[97]​ For more severe pain, an opioid (e.g., morphine, oxycodone) may be required for a short duration. If longer-term pain relief is required, a pain management specialist should be consulted.

Primary options

acetaminophen: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day

OR

ibuprofen: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day

Secondary options

morphine sulfate: consult specialist for guidance on dose

OR

oxycodone: consult specialist for guidance on dose

Consider – surgery

Back
INITIAL
|
suspected acute native vertebral osteomyelitis
|
children
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Indications for surgical management of pediatric spinal disease include lack of response to antibiotics, progressive kyphosis, or neurologic compromise.[105]​ In practice, if spondylodiscitis or vertebral osteomyelitis is suspected in a child, advice should be sought from pediatrics and/or pediatric orthopedics, depending on local resources.

suspected acute osteomyelitis in diabetic foot

1st line – empiric antibiotic therapy

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INITIAL
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suspected acute osteomyelitis in diabetic foot
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adults
1st line – 

empiric antibiotic therapy

Antibiotic therapy without surgical resection of the bone should be considered in patients with diabetes and uncomplicated forefoot osteomyelitis, for whom there is no other indication for surgical treatment.[37] Samples should be taken for microbiologic testing before, or as close as possible to, the start of antibiotic therapy.[36]

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Local sepsis protocols should be followed. See Sepsis in adults.

Empiric antibiotic therapy in patients with suspected diabetic foot infection should be commenced as soon as possible. Antibiotic agents should be chosen from among those that have demonstrated efficacy for osteomyelitis in clinical studies.[36][37]

The duration of antibiotic treatment for diabetic foot osteomyelitis should be for no longer than 6 weeks. If the infection does not clinically improve within the first 2-4 weeks, the need for collecting a bone specimen for culture, undertaking surgical resection, or selecting an alternative antibiotic regimen should be reconsidered.[37] 

For more information, see Diabetic foot complications.

Plus – supportive care

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INITIAL
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suspected acute osteomyelitis in diabetic foot
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adults
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Advice should be sought from the multidisciplinary foot care service.[36][42] This is a limb-threatening or life-threatening diabetic foot problem.[36] Diabetic foot care teams can include (or should have ready access to) specialists in various fields; patients with a diabetic foot infection may especially benefit from consultation with an infectious disease or clinical microbiology specialist and a surgeon with experience and interest in managing diabetic foot infections.[42]

Patients with probable diabetic foot osteomyelitis with concomitant soft tissue infection should be urgently evaluated for the need for surgery as well as intensive postoperative medical and surgical follow-up.[37]

The affected limb should be elevated and immobilized if necessary. Assessment should be undertaken for deep vein thrombosis, particularly with Staphylococcus aureus osteomyelitis since there is a high risk of venous thromboembolism during the first month following an episode of S aureus bacteremia.[98]​ See Deep vein thrombosis.

Any comorbidities should be addressed. It is particularly important to maintain strict blood glucose control in any patient with diabetes and a major infection such as osteomyelitis.[37]

Pain relief should be provided to all patients as required. First-line analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. For more severe pain, an opioid (e.g., morphine, oxycodone) may be required for a short duration. If longer-term pain relief is required, a pain management specialist should be consulted.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

morphine sulfate: 10-30 mg orally (immediate-release) every 4 hours when required; 2.5 to 10 mg subcutaneously/intravenously/intramuscularly every 2-6 hours when required; adjust dose according to response

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required, adjust dose according to response

Consider – surgery

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INITIAL
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suspected acute osteomyelitis in diabetic foot
|
adults
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Patients who have probable diabetic foot osteomyelitis with concomitant soft tissue infection should be urgently evaluated for surgical intervention as well as intensive postoperative medical and surgical follow-up.[37]

During surgery to resect bone for diabetic foot osteomyelitis, obtaining a specimen of bone for culture (and, if possible, histopathology) at the stump of the resected bone should be considered to identify if there is residual bone infection.

1st line – referral to specialist

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INITIAL
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suspected acute osteomyelitis in diabetic foot
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children
1st line – 

referral to specialist

Diabetic foot infections are uncommon in children. Specialist advice should be sought from the multidisciplinary foot care service.[36][42] Patients with a diabetic foot infection may particularly benefit from consultation with an infectious disease or clinical microbiology specialist and a surgeon with experience and interest in managing diabetic foot infections.[42] See Diabetic foot complications.

ACUTE

confirmed acute peripheral osteomyelitis: adults and children

1st line – pathogen-targeted antibiotic therapy

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ACUTE
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confirmed acute peripheral osteomyelitis: adults and children
1st line – 

pathogen-targeted antibiotic therapy

When microbiologic results are available, the antibiotic should be reviewed and changed accordingly, using a narrow-spectrum antibiotic, if appropriate.​[4][13]

Response to antibiotic treatment is typically rapid. However, if the limb deteriorates or imaging suggests progressive bone destruction, choice of antibiotics should be discussed with microbiology. Surgery should be considered to prevent progression to chronic osteomyelitis. Once dead bone or a biofilm has become established, antibiotics alone cannot cure the infection and thorough surgical debridement is required.

The optimal duration of antimicrobial therapy for osteomyelitis is not certain.​[57]​ However, the IDSA makes recommendations for some types of osteomyelitis. For instance, in children with acute hematogenous osteomyelitis presumed or proven to be caused by Staphylococcus aureus who have had an uncomplicated course and responded to initial therapy, the IDSA suggests a 3- to 4-week duration of antibiotics (parenteral plus oral) rather than a longer course.[4] Longer durations of antibiotics may be necessary for other pathogens, including more virulent strains of S aureus, and for complicated cases.[4]

confirmed acute native vertebral osteomyelitis: adults and children

1st line – pathogen-targeted antibiotic therapy

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ACUTE
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confirmed acute native vertebral osteomyelitis: adults and children
1st line – 

pathogen-targeted antibiotic therapy

When microbiologic results are available, the antibiotic should be reviewed and changed accordingly, using a narrow-spectrum antibiotic, if appropriate.

Most patients with confirmed bacterial native vertebral osteomyelitis should receive 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy.[13]

In suspected native vertebral osteomyelitis, when the etiologic 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.[57]​ Therefore, targeted antibiotic therapy may need to be started when polymerase chain reaction (PCR) results are available and infection has been confirmed, regardless of whether culture and sensitivity results are available. Local antibiotic protocols should be consulted with advice from microbiology in endemic areas. Evaluation by a spine surgeon and an infectious disease specialist should be sought in nonendemic areas.[13] A total duration of 3 months of antimicrobial therapy is recommended for most patients with native vertebral osteomyelitis caused by Brucella species.[13] For more information, see Brucellosis.

confirmed acute osteomyelitis in diabetic foot: adults and children

1st line – pathogen-targeted antibiotic therapy

Back
ACUTE
|
confirmed acute osteomyelitis in diabetic foot: adults and children
1st line – 

pathogen-targeted antibiotic therapy

When microbiologic results are available, the antibiotic should be reviewed and changed accordingly, using a narrow-spectrum antibiotic, if appropriate.

Advice should be sought from the multidisciplinary foot care service.[36][42] This is a limb-threatening or life-threatening diabetic foot problem.[36] Patients with a diabetic foot infection may particularly benefit from consultation with an infectious disease or clinical microbiology specialist and a surgeon with experience and interest in managing diabetic foot infections.[42] Diabetic foot infections are uncommon in children. Specialist advice should be sought. See Diabetic foot complications.

ONGOING

chronic osteomyelitis

1st line – clinical assessment, disease staging, optimization of comorbidities

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ONGOING
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chronic osteomyelitis
1st line – 

clinical assessment, disease staging, optimization of comorbidities

When there is dead bone, or a biofilm has become established, antibiotics alone cannot cure the infection and surgery is required for full cure.

The following need to be undertaken:

Assessment of the degree of disease allowing accurate clinical staging (using the Cierny-Mader classification).[2]

Full discussion with the patient about the treatment options and the potential associated risks.

Diagnostic tests to assess general health and the condition of the limb (blood tests, scanning, angiography, image-guided biopsy).

Optimization of any comorbidities (e.g., anemia of chronic disease; coagulopathies; diabetes mellitus, control of which is often difficult in the context of uncontrolled infection and may require hospitalization for optimization before surgery; vascular insufficiency, which may need to be addressed before healing to ensure optimal healing; sickle cell disease - exchange transfusion may be needed before embarking on surgery to minimize the risks of bone infarct, sickle crisis, and wound healing problems caused by an anesthetic). Poor nutritional status, smoking, and substance dependence also need to be addressed.

Plus – surgery

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ONGOING
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chronic osteomyelitis
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surgical candidate
Plus – 

surgery

Treatment recommended for ALL patients in selected patient group

Patients who are surgical candidates and who wish to attempt cure need full surgical debridement. Details of the debridement surgery undertaken depend on the type of infection according to the Cierny-Mader classification and the clinical circumstances.[2] Samples should always be taken for microbiology and histology assessment, preferably before antibiotic therapy is started.[4] Surgical excision of all affected necrotic tissue is necessary to eradicate infection.

At the end of debridement, the whole operative field is likely to be contaminated with bacteria disseminated during surgery.[108] Bone is an unyielding tissue, so any defect will remain and will fill with hematoma, providing an ideal environment for the propagation of bacteria and allowing early biofilm development. Various antibiotic-containing materials have been used to fill bony defects. A local antibiotic carrier can achieve high local antibiotic concentrations without systemic toxicity, because they can elute high concentrations of antibiotic locally, often in the order of 10-100 times the minimum inhibitory concentration of the organisms that are present.[111][112]

Following debridement the bone may be unstable and need temporary support with a monolateral frame to prevent fracture and aid postoperative rehabilitation.[47] Staged reconstruction is sometimes needed.

Plus – systemic antibiotics

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ONGOING
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chronic osteomyelitis
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surgical candidate
Plus – 

systemic antibiotics

Treatment recommended for ALL patients in selected patient group

Intravenous antibiotics are started once intraoperative sampling has been completed. An empiric regimen appropriate to the flora encountered in the hospital's region is appropriate. A protocol using a glycopeptide and a carbapenem showed coverage of 96% of all organisms subsequently cultured.[107] This same study revealed that one third of organisms cultured were resistant to a penicillin-based empiric antibiotic regime. The carbapenem is usually stopped after 48 hours' culture if no gram-negative organisms have been cultured at that point. Once full intraoperative culture results are known, a definitive regimen can be selected.

The optimal duration of antimicrobial therapy is not certain. If the osteomyelitic bone has been fully resected, a course of antibiotic therapy lasting 2-6 weeks may be adequate as long as operative wounds are healing without any signs of infection. This can be an appropriate course of oral antibiotics, based on microbial cultures and sensitivities.

One multicenter, randomized controlled trial of 1054 patients demonstrated that oral antibiotic therapy is noninferior to intravenous antibiotic therapy following surgical treatment of bone or joint infection.​​[57]

Plus – rehabilitation

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ONGOING
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chronic osteomyelitis
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surgical candidate
Plus – 

rehabilitation

Treatment recommended for ALL patients in selected patient group

Functional rehabilitation should be arranged.

Plus – individualized treatment

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ONGOING
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chronic osteomyelitis
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not a surgical candidate or surgery not wanted
Plus – 

individualized treatment

Treatment recommended for ALL patients in selected patient group

Full cure may involve complex surgery with potential complications, staged reconstruction, antimicrobial drug reactions, and prolonged time in treatment and rehabilitation. Therefore, an approach that controls current symptoms, but with the possibility of later recurrence, may be a more attractive option for some patients.

In group C patients under the Cierny-Mader classification (patients who are so severely compromised that treatment has an unacceptable risk-benefit ratio, or those with few symptoms from their infection) it is reasonable to withhold treatment or just to treat symptomatic flare-ups with short antibiotic courses. Selection of an appropriate antibiotic regime can be informed by radiologically guided biopsy.

Biopsy-guided or empiric antibiotic therapy may be considered in some cases where the patient is unfit for surgery, or unwilling to have surgery. This is unlikely to cure chronic infection but it may alleviate symptoms. If a trial of therapy is successful, long-term suppression may be considered. Long-term suppressive antibiotic usage needs to be balanced against the significant risk of poor adherence, adverse effects, and drug interactions. More studies are needed to determine the best antibiotic regimen and duration of therapy.

Limited surgery may be an option for patients who are not candidates for curative limb salvage surgery (e.g., those with implants in situ that would provide a challenging reconstructive problem if they were removed). While not effecting a cure, it may reduce the infective load.

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