Management of Osteomyelitis

Key Principles

The American College of Physicians and orthopedic specialists recommend that osteomyelitis be treated by a multidisciplinary team including orthopedic surgeons, infectious disease specialists, and interventional radiologists to reduce morbidity, mortality, and preserve quality of life 1
Orthopedic surgeons are essential for performing surgical debridement, bone resection, and reconstruction procedures that are often necessary for definitive treatment of osteomyelitis 2, 3
Infectious disease specialists guide appropriate antibiotic selection and duration based on culture results and patient factors 1
Interventional radiologists perform image-guided bone biopsies when needed for definitive diagnosis 4, 3
Podiatrists may perform bone biopsies and surgical procedures, particularly for diabetic foot osteomyelitis 3

Bone biopsy is the gold standard for diagnosis and should be performed by a properly trained physician (orthopedic surgeon, podiatrist, or interventional radiologist) 2, 4
Percutaneous biopsy should preferably be done under fluoroscopic or CT guidance 3
MRI is the most accurate imaging study for defining bone infection and should be ordered when diagnosis remains uncertain 5
Cultures of bone specimens provide more accurate microbiologic data than soft tissue specimens 6

Determine extent of infection through appropriate imaging 7
Obtain bone cultures to guide antibiotic therapy 3
Surgical intervention should be strongly considered in cases with substantial bone necrosis or exposed joint, functionally compromised foot, presence of resistant pathogens, or limb with uncorrectable ischemia 1
Base selection of antibiotics on bone culture results rather than soft tissue cultures 1
Initial parenteral therapy followed by oral antibiotics with good bioavailability 8
Duration of antibiotics depends on surgical approach, ranging from 2-14 days if infected bone is completely removed to 4-6 weeks for non-surgical management 1

Non-surgical management with antibiotics alone might be considered in specific situations, such as no acceptable surgical target, patient has limb ischemia caused by unreconstructable vascular disease, infection confined to forefoot with minimal soft tissue loss, or surgical management carries excessive risk 7
Published reports on nonsurgical treatment with prolonged antibiotics have reported clinical success in approximately 65%-80% of cases 6

Relying on soft tissue cultures rather than bone cultures to guide antibiotic therapy 1
Continuing the same antibiotic regimen that previously failed 1
Inadequate surgical debridement of necrotic bone 1
Not addressing vascular insufficiency which limits antibiotic delivery 1

Whether the original diagnosis was correct should be considered when therapy fails 6
If there is residual necrotic or infected bone that should be resected when therapy fails 6
If the selected antibiotic regimen covered the causative organisms and achieved adequate bone levels when therapy fails 6
Whether non-infectious complications are the real cause of the problem when therapy fails 6