http://www.webmd.com/pain-management/osteomyeltis-treatment-diagnosis-symptoms is an infection of the bone, a rare but serious condition.

Bones can become infected in a number of ways: Infection in one part of the body may spread into the bone, or an open fracture that exposes bone to may get infected.

What Causes Osteomyelitis?

In most cases, a bacteria called Staphylococcus aureus, a type of staph bacteria, causes osteomyelitis. Certain chronic conditions like diabetes may increase your risk for osteomyelitis.

Who Gets Osteomyelitis?

Only two out of every 10,000 people get osteomyelitis. The condition affects children and adults, although in different ways. Certain conditions and behaviors that weaken the immune system increase a person's risk for osteomyelitis, including:

Diabetes (most cases of osteomyelitis stem from diabetes) Sickle cell disease HIV or AIDS Rheumatoid arthritis Intravenous drug use Alcoholism Long-term use of steroids

Bone surgery, including hip and knee replacements, also increase the chance for infection to invade a bone.

Osteomyelitis in Children and Adults

In children, osteomyelitis is usually acute. Acute osteomyelitis comes on quickly, is easier to treat, and overall turns out better than chronic osteomyelitis. In children, osteomyelitis usually shows up in arm or leg bones. In adults, osteomyelitis can be either acute or chronic. People with diabetes, HIV, or peripheral vascular disease are more prone to chronic osteomyelitis, which persists or recurs, despite treatment. Whether chronic or acute, osteomyelitis often affects an adult's pelvis or vertebrae of the spine. It can also occur in the feet, especially in a person with diabetes.

Symptoms of Osteomyelitis
Acute osteomyelitis develops rapidly over a period of seven to 10 days. The symptoms for acute and chronic osteomyelitis are very similar and include:

Fever, irritability, fatigue Nausea Tenderness and swelling around the affected bone Lost range of motion

Osteomyelitis in the vertebrae makes itself known through severe back pain, especially at night.

Osteomyelitis Treatment
Figuring out if a person has osteomyelitis is the first step in treatment. It's also surprisingly difficult. Doctors rely on X-rays, blood tests, and bone scans to get a picture of what's going on. They also need to determine the type of organism, typically bacteria, causing the infection so they can prescribe the right medication. Treatment focuses on stopping infection in its tracks and preserving as much function as possible. Most people with osteomyelitis are treated with antibiotics, surgery, or both. Antibiotics help bring the infection under control and often make it possible to avoid surgery. People with osteomyelitis usually get antibiotics for several weeks through an IV, and then switch to a pill form. More serious or chronic osteomyelitis requires surgery to remove the infected tissue and bone. Osteomyelitis surgery prevents the infection from spreading further or getting so bad that amputation is the only remaining option.

Preventing Osteomyelitis
The best way to prevent osteomyelitis is to keep things clean. If you or your child has a cut, especially a deep cut, wash it completely. Flush out any open wound under running water for five minutes, then bandage it in sterile bandages. If you have chronic osteomyelitis, make sure your doctor knows about your medical history so you can work together to keep the condition under control. If you have diabetes, pay close attention to your feet and contact your doctor at the first sign of infection. The sooner you treat osteomyelitis, the better. In cases of acute osteomyelitis, early treatment prevents the condition from becoming a chronic problem that requires ongoing treatment. Besides the pain and inconvenience of repeated infections, getting osteomyelitis under control early provides the best chance for recovery.

http://www.mayoclinic.com/health/osteomyelitis/DS00759
Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Osteomyelitis can also begin in the bone itself if an injury exposes the bone to germs. In children, osteomyelitis most commonly affects the long bones of the legs and upper arm, while adults are more likely to develop osteomyelitis in the bones that make up the spine (vertebrae). People who have diabetes may develop osteomyelitis in their feet if they have foot ulcers. Once considered an incurable condition, osteomyelitis can be successfully treated today. Most people require surgery to remove parts of the bone that have died followed by strong antibiotics, often delivered intravenously, typically for at least six weeks.

Emedicine
Osteomyelitis is inflammation of the bone caused by an infecting organism. Although bone is normally resistant to bacterial colonization, events such as trauma, surgery, presence of foreign bodies, or prostheses may disrupt bony integrity and lead to the onset of bone infection. Osteomyelitis can also result from hematogenous spread after bacteremia. When prosthetic joints are associated with infection, microorganisms typically grow in biofilm, which protects bacteria from antimicrobial treatment and the host immune response. Early and specific treatment is important in osteomyelitis, and identification of the causative microorganisms is essential for antibiotic therapy.[1] The major cause of bone infections is Staphylococcus aureus. Infections with an open fracture or associated with joint prostheses and trauma often require a combination of antimicrobial agents and surgery. When biofilm microorganisms are involved, as in joint prostheses, a combination of rifampicin with other antibiotics might be necessary for treatment. Approximately 20% of adult cases of osteomyelitis are hematogenous, which is more common in males for unknown reasons.[2] The incidence of spinal osteomyelitis, as depicted in the image below, was estimated to be 1 in 450,000 in 2001. However, the overall incidence of vertebral osteomyelitis is believed to have increased in recent years because of intravenous drug use, increasing age of the population, and higher rates of nosocomial infection due to intravascular devices and other instrumentation. Posttraumatic osteomyelitis accounts for as many as 47% of cases of osteomyelitis. Other major causes of osteomyelitis include vascular insufficiency (mostly occurring in persons with diabetes; 34%) and hematogenous seeding (19%). Motor vehicle accidents, sports injuries, and the use of orthopedic hardware to manage trauma also contribute to the apparent increase in prevalence of posttraumatic osteomyelitis.

Osteomyelitis may complicate puncture wounds of the foot, occurring in 1.8%-6.4% of patients following injury.[5, 6, 7, 8, 9] Osteomyelitis is often diagnosed clinically with nonspecific symptoms such as fever, chills, fatigue, lethargy, or irritability. The classic signs of inflammation, including local pain, swelling, or redness, may also occur and normally disappear within 5-7 days.[1] Chronic posttraumatic osteomyelitis requires a detailed history for diagnosis, including information regarding the initial injury and previous antibiotic and surgical treatment. Weight bearing and function of the involved extremity are typically disturbed. Local pain, swelling, erythema, and edema may also be reported.[10] On physical examination, scars or local disturbance of wound healing may be noted along with the cardinal signs of inflammation.[10] Range of motion, deformity, and local signs of impaired vascularity are also sought in the involved extremity. If periosteal tissues are involved, point tenderness may be present.[12] In children, the clinical presentation of osteomyelitis can be challenging for physicians because it can present with only nonspecific signs and symptoms, and the clinical findings are extremely variable. Children may present with decreased movement and pain in the affected limb and adjacent joint, as well as edema and erythema over the involved area. In addition, children may also present with fever, malaise, and irritability. Newborns with osteomyelitis may demonstrate decreased movement of a limb without any other signs or symptoms. Surgery is indicated when the patient has not responded to specific antimicrobial treatment, if there is evidence of a persistent soft tissue abscess or subperiosteal collection, or if concomitant joint infection is suspected. Debridement of necrotic tissues, removal of foreign materials, and sometimes skin closure of chronic unhealed wounds are necessary in some cases. Although vertebral osteomyelitis does not usually require surgery, indications include failure to respond to antimicrobial therapy, neural compression, spinal instability, and/or drainage of epidural or paravertebral abscesses. The bony skeleton is divided into 2 parts: the axial skeleton and the appendicular skeleton. The axial skeleton is the central core unit, consisting of the skull, vertebrae, ribs, and sternum. The appendicular skeleton comprises the bones of the extremities. The human skeleton consists of 213 bones, of which 126 are part of the appendicular skeleton, 74 are part of the axial skeleton, and 6 are part of the auditory ossicles. Hematogenous osteomyelitis most commonly involves the vertebrae, but infection may also occur in the metaphysis of the long bones, pelvis, and clavicle. Vertebral osteomyelitis involves 2 adjacent vertebrae with the corresponding intervertebral disk. See the image below.

Osteomyelitis of T10 secondary to streptococcal disease. Photography by David Effron MD, FACEP. The lumbar spine is most commonly affected, followed by the thoracic and cervical regions. See the image below.

Osteomyelitis, chronic. T1- and T2-weighted sagittal MRIs show bone marrow edema in L1 and obliteration of the disk space between L1 and L2. Posttraumatic osteomyelitis begins outside the bony cortex and works its way in toward the medullary canal, typically found in the tibia. Contiguous-focus osteomyelitis often occurs in the bones of the feet in patients with diabetes mellitus and vascular compromise. See the image below.

Osteomyelitis, chronic. Image in a 56-year-old man with diabetes shows chronic osteomyelitis of the calcaneum. Note air in the soft tissues. For more information about the relevant anatomy, see Skeletal System Anatomy in Adults and Osteology (Bone Anatomy).

The learner will be better able to: 1) Explain the principles reflected in the history and discovery of osteomyelitis 2) Generate a differential diagnosis given a patient case 3) Describe the distinct features of a radiological image of a patient with osteomyelitis 4) Explain factors that influence the incidence of osteomyelitis in a given population 5) Identify classic features of osteomyelitis given a patient case http://osteomyelitis.stanford.edu/pages/main.html INTRODUCTION Osteomyelitis is defined as an inflammation or an infection in the bone marrow and surrounding bone. The disease is classified as either acute or chronic, depending on the length of time the infection or symptoms persist. Symptoms include pain, warmth and/or swelling in the bone. Chronic osteomyelitis may last for years , with slow death of bone tissue from a reduced blood supply. Signs and symptoms may be absent, however, causing difficulty in diagnosing the chronic infection. Pathogens infect bone in posttraumatic osteomyelitis after a recent fracture. Bacteria, fungus and other microorganisms are typically the causative agents. The more susceptible a bone is to fracturing, the greater the chances of becoming infected and developing disease. Trauma from recent injuries and diabetes are major risk factors for osteomyelitis.The bone can be directly infected from the wound or indirectly via the blood from another site of infection, called hematogenous osteomyelitis. The vertebrae and pelvis are often affected in adults in this bloodborne variety, while children are usually affected in long bones. EPIDEMIOLOGY The incidence of osteomyelitis after open fractures is reported to be 2% to 16%, depending significantly on the grade of trauma and the type of treatment administered. Prompt and thorough treatment help reduce the risk of infection, decreasing the probability of developing osteomyelitis. This is particularly important for patients with the following risk factors: diabetes, altered immune states and recent trauma. The tibia is the most frequent site of posttraumatic osteomyelitis , since it is the most vulnerable bone with the least vigorous blood supply in the body. The classification of osteomyelitis can be broken down into the following categories: exogenous ostemyelitis (47%), secondary to vascular insufficiency (34%) and hematogenous osteomyeltis (19%). The implantation of an orthopedic device (pins, plate, screws, artificial joint) can also seed infection as a nidus for pathogens, and therefore create post-operative osteomyelitis.

The growing skeleton is also at risk. Any bone can be affected but it is usually the weightbearing bones before the physis has closed. At the physis on the metaphyseal side, end arteries form a capillar loop which may rupture following minor trauma. This region of blood stasis may

attract circulating bacteria ("everybody has bacteria circulating, periodically" -HH Jones) . Once escaped through the vascular system, bacteria can set up shop in surrounding tissues. ETIOLOGY The presence of bacteria alone in an open fracture is not sufficient to cause osteomyelitis. In most cases, the body's immune system is capable of preventing the colonization of pathogens. The micro-environment determines whether infection occurs. The timing and extent of treatment are critical in determining whether infection develops. The likelihood of developing ostemyelitis increases with impaired immune function, extensive tissue damage, or reduced blood supply to the affected area. Patients with diabetes, poor circulation or low white blood cell count are at greater risk. Bacterial or fungal infection cause most osteomyelitis. Infection induces a large polymorphonuclear response from bone marrow, particularly staphylococcus aureus, streptococcus and haemophilus influenza. Staphylococcus infection predominates today and before the era of antiobiotics. CLINICAL DIAGNOSIS AND MANIFESTATIONS The diagnosis of osteomyelitis is made from clinical, laboratory and imaging studies. When the skeletal system is involved, pain, fever and leukocytosis (an increase in white blood cell count due to infection or inflammation) occur. The affected area is painful. Initial x-rays are typically normal. As early as 4 days, an area of lucency may be seen on x-ray. Usually, the changes are not recognized until 10 days or two weeks have passed. Subperiosteal new bone formation in the affected area is present, representing periosteal elevation from encroaching pus. If not successfully treated, pus enlarges the bone appearing as increased lucency, which surrounds sclerotic, dead bone . This inner dead bone is called the sequestrum (sequestered from blood supply), and the outer periosteal reaction laminates to form the involucrum. (See diagram at right.) Draining sinuses develop when the pressure of pus exceeds the containment of the soft tissue. This further deprives the bone of its blood supply. This in turn harbors more bacteria, and the process cannot be reversed until extensive debridement of the area occurs-until the environment changes to one that promotes healing. DIFFERENTIAL DIAGNOSIS Ewing sarcoma Osteosarcoma Reactive bone marrow edema Traumatic or stress fractures

Inflammatory arthritis Gout SUMMARY Osteomyelitis is an infection involving the bone. The bones usually affected are the weightbearing bones, particularly before the physis has closed. Exogenous osteomyelitis occurs from open trauma, sometimes relatively minor in nature. Hematogenous osteomyelitis occurs from bacteria circulating in the bloodstream. Acute and chronic subtypes are classified according to the timing and duration of the infection.

Osteomyelitis In Adults

https://www.clinicalkey.com/topics/orthopedicsurgery/osteomyelitis-in-adults.html Key points

Osteomyelitis is an infection of the bone Many species of organisms have been implicated in the etiology of osteomyelitis, with Staphylococcus aureus being the most commonly isolated organism Patients with osteomyelitis typically present with localized pain and swelling accompanied by nonspecific symptoms, including chills, fever, and malaise Several diagnostic modalities are used to determine the presence of osteomyelitis, including laboratory tests, radiographic imaging, radionuclide studies, and cross-sectional imaging. The gold standard for diagnosing osteomyelitis is bone biopsy and culture Treatment of osteomyelitis involves both antimicrobial therapy, with administration of antibiotics for at least 4 to 6 weeks, and surgical intervention, which involves debridement, dead space management, and bone stabilization Complications of osteomyelitis include abscess formation, sepsis, bone deformity, limited range of movement, and motor and sensory deficits Approximately 20% to 30% of patients with osteomyelitis experience recurrence within 2 years, even with appropriate medical and surgical treatment

Background
Description

Osteomyelitis is an inflammation or infection of the bone and may include the marrow, cortex, and periosteum; surrounding soft tissues are often involved as well

The condition may arise from trauma, bacteremia, surgery, or orthopedic implants that disrupt the integrity of the bone, as well as from overlying infections, such as those associated with diabetic foot ulcerations There are two major systems for classifying osteomyelitis. The Waldvogel classification system is based on the pathogenesis of the infection, whereas the Cierny-Mader staging and classification system categorizes the disease according to the extent of involvement and the patient's physiologic status, which is valuable in determining treatment and prognosis

Waldvogel classification system Osteomyelitis is classified according to the mechanism of infection (hematogenous or contiguous) and the presence of vascular insufficiency:

Hematogenous osteomyelitis o Occurs when bone tissue is seeded by pathogenic organisms during the course of bacteremia o Accounts for 20% of cases of osteomyelitis in adults o The vertebrae are the most common site of hematogenous infection in adults, but the long bones, pelvis, and clavicle may also be affected Vertebral osteomyelitis is divided into the following two categories: Pyogenic infections, which are most commonly caused by S. aureus (40%-45% of all cases) Nonpyogenic (granulomatous) infections, which are most commonly caused by Mycobacterium tuberculosis Vertebral osteomyelitis occurs most commonly in men between 60 and 70 years of age and involves the lumbar spine Osteomyelitis secondary to a contiguous focus of infection o Occurs after a traumatic bone injury or as a result of the spread of infection from a nearby source (eg, soft tissue infection) o Common associated factors include a history of surgical reduction and internal fixation of fractures, prosthetic devices, open fractures, and chronic soft tissue infections; decubitus ulcer; burn; or regional soft tissue infection o More common in older patients, who generally develop infections following cellulitis or arthroplasties; infection in younger patients usually occurs as a result of trauma or surgery o Most often affects the tibia and femur Osteomyelitis associated with vascular insufficiency o Caused by impaired blood supply to susceptible tissues o Usually occurs in older patients and in patients with diabetes mellitus or severe atherosclerosis In patients with diabetes, the small bones of the feet are most often involved; neuropathy may also be present The risk of developing osteomyelitis is greater in patients with large (>2 cm in diameter) and deep (>3 mm) diabetic ulcers and if the bone is exposed

Osteomyelitis may be classified as acute, subacute, or chronic, depending on the time to clinical presentation relative to the introduction of infection.

Acute osteomyelitis is characterized as a suppurative infection presenting with edema, small vessel thrombosis, and vascular congestion within 2 weeks of onset Subacute osteomyelitis may be more indolent, presenting 1 to several months after infection Chronic osteomyelitis is the result of longstanding infection, which may take months or years to develop or which has been suppressed by the host ('remission') or partially treated so that it remains relatively dormant for long periods before becoming clinically apparent. Chronic osteomyelitis is characterized by the presence of necrotic bone (sequestrum); new bone formation; drainage or sinus tracts; and the presence of leukocytes, lymphocytes, and histiocytes. It can be recognized in patients with a history of osteomyelitis who experience a recurrence of pain, erythema, and swelling, along with a draining sinus

Cierny-Mader staging and classification system Osteomyelitis is categorized according to the portion of bone affected; the physiologic status of the patient; and risk factors that affect immunity, metabolism, and vascularity. The first part of the system categorizes osteomyelitis according to anatomic type, as follows:

Stage 1: medullary osteomyelitis o Limited to the medullary cavity o Often caused by a solitary organism o Causes include hematogenous spread and infections from orthopedic devices (intramedullary rods) Stage 2: superficial osteomyelitis o Involves the cortex o Often caused by an adjacent soft tissue infection o Exposed, infected outer necrotic surface of bone is observed at the base of a soft tissue wound o Local ischemia is seen Stage 3: localized osteomyelitis o May involve both the medulla and cortex, but the bone generally remains stable, as the infection does not involve its entire diameter Stage 4: diffuse osteomyelitis o Extensive disease o May occur on both sides of a nonunion or a joint o Involves the entire thickness of the bone, with loss of stability

The second part of the system describes the patient's physiologic status, as deficiencies of leukocyte recruitment, phagocytosis, or vascular supplies may promote osteomyelitis and contribute to its chronicity. The physiologic class of the infected patient is often more important than the anatomic type because the state of the host is the strongest predictor of treatment failure.

Class A: normal host o Normal physiologic, metabolic, and immune functions o Associated with a much better prognosis Class B: host factors limit normal immune response and healing o Immunocompromised, either locally (Bl), systemically (Bs), or both (Bls)

Local factors include problems of perfusion (peripheral vascular disease, vasculitis, venous stasis, lymphedema) o Systemic factors include hypoxemia, illnesses associated with impaired immune function (chronic renal or hepatic insufficiency, malignancy, diabetes), or use of immunosuppressive medication (steroids) o The goal of treatment is to remove the factors that lead to the development of osteomyelitis Class C: health of host does not allow full treatment o Treatment poses a greater risk than the infection itself o Surgery may not be possible because of the patient's debilitated or immunocompromised status

Epidemiology

There are several recent trends in the epidemiology of osteomyelitis. Acute hematogenous osteomyelitis is decreasing in incidence, whereas the incidence of osteomyelitis due to direct inoculation or contiguous focus of infection is increasing. This is attributed to the increase in both trauma (due to motor vehicle accidents) and orthopedic surgical procedures Osteomyelitis secondary to open fractures occurs in 3% to 25% of cases, usually in young men in their twenties and thirties Foot ulcers occur in 2% of patients with diabetes every year, 15% of whom will develop osteomyelitis. Recurrent infection occurs in up to 36% of patients with diabetes Vertebral osteomyelitis is responsible for 2% to 4% of all cases of osteomyelitis, with an annual incidence of 5.3 cases per million persons. Men are more commonly affected than women, with a mean age at presentation of 61 years

Causes and risk factors

Causes:

The focus for hematogenous osteomyelitis may vary from a mild skin infection to bacterial endocarditis; it is also a complication among intravenous drug users Osteomyelitis secondary to a contiguous focus of infection may be caused by the direct inoculation of bacteria through trauma, from spread of adjacent soft tissue infection, or introduction of infection during preoperative or intraoperative procedures. Predisposing factors include surgical reduction and internal fixation of fractures, prosthetic devices, open fractures, and chronic soft tissue infections Osteomyelitis secondary to vascular insufficiency is often associated with diabetes mellitus. Infection often results from minor trauma to the feet, such as infected nail beds or skin ulceration. Inadequate tissue perfusion limits local tissue response to injury Multiple organisms are responsible for osteomyelitis in different populations. The causative organism is related to the age, clinical history, and immune status of the patient (see Table 1). S. aureus is the most common cause in all cases

Table 1. Organisms Commonly Implicated in Osteomyelitis in Different Patient Populations

Category of Osteomyelitis Hematogenous osteomyelitis

Population Patients of all ages Neonates Infants and children Intravenous drug users Patients with sickle cell disease HIV-infected patients Patients with nosocomial infections

Vertebral osteomyelitis (hematogenous and contiguous focus)

Contiguous-focus osteomyelitis

Osteomyelitis associated with vascular insufficiency

S. aure Entero Haemo S. aure Strepto Barton S. aure immun Adults (most commonly) S. aure Patients with urinary tract infections Aerob Intravenous drug users S. aure Patients undergoing spinal surgery Coagu Patients with infections of Candid intravascular devices Patients living in endemic regions M. tub blastom Patients exposed to contaminated soil Clostr Nocar specie Patients with orthopedic devices S. aure Patients with decubitus ulcers Entero specie Patients with a history of cat bites Pasteu Patients with a history of human bites Eikene (including clenched-fist injury) Patients with puncture injuries on the P. aeru foot Patients with periodontal infection Actino Patients with diabetes Polym aerobi

HIV = human immunodeficiency virus Risk factors:

Diabetes mellitus Immunocompromise Neuropathy Vascular insufficiency Intravenous drug use Open fractures Local trauma Orthopedic hardware (including prosthetic joints)

Hemodialysis Sickle cell disease Dental infections Urinary tract infections Catheter-related bloodstream infection

Associated disorders

Occurs more frequently in patients with diabetes mellitus, vascular insufficiency, or immunosuppression Recent history of surgical procedure or joint or bone trauma

Screening
Not applicable.

Primary prevention
Summary approach

Patients with diabetes should have a complete examination of the lower extremities annually and inspection of the feet for wounds at interim routine follow-up visits. Measures to prevent diabetic foot ulcers should be emphasized. A high index of suspicion should be maintained for the contiguous spread of local diabetic foot infections to the bone, with continuous evaluation for signs and symptoms of the development of osteomyelitis Patients with open fractures who are able to receive antibiotics within 6 hours of injury and prompt surgical treatment have a reduced risk of developing osteomyelitis The use of prophylactic antibiotics prior to bone surgery has been shown to prevent wound infections Scrupulous care should be taken to avoid health careassociated osteomyelitis, with careful attention to intravascular and urinary catheters, surgical incisions, and other wounds

Population at risk

Patients with diabetes mellitus Patients undergoing orthopedic surgery, including placement of prostheses and other clean surgery and management of open fractures

Preventive measures
In patients with diabetes mellitus:

Measures to prevent diabetic foot include excellent foot hygiene, glycemic control, and use of protective footwear

Patients should be instructed to examine their feet daily and to seek prompt medical care for new wounds or other injuries to the feet A complete evaluation of the lower extremities should be done annually, and the feet should be inspected for wounds at periodic follow-up visits in the interim Patients with Charcot joints or other abnormalities that result in friction with shoes may require specially adapted shoes In patients undergoing foot surgery or amputation, the use of protective footwear postoperatively is helpful in preventing subsequent ulceration and infection

In patients with open fractures:

Administration of antibiotics within 6 hours of injury and prompt surgical treatment are associated with a reduced risk of developing osteomyelitis A continued 24-hour regimen of penicillin or first-generation or second-generation cephalosporins is also beneficial

In patients undergoing bone surgery:

Administration of prophylactic antibiotics has proven to be successful in the prevention of infection following surgery, particularly in patients with noncompound hip fractures and those receiving total hip and knee prostheses o In patients undergoing clean bone surgery, intravenous antibiotics are administered 30 minutes before skin incision and up to 24 hours following the procedure. A firstgeneration or second-generation cephalosporin is appropriate in many cases; vancomycin may be used in patients who are allergic to cephalosporin and in settings with a high prevalence of methicillin-resistant staphylococci o In patients undergoing surgery for closed fractures, the use of penicillin, first-generation cephalosporins (eg, cefazolin), or second-generation cephalosporins (eg, cefamandole, cefuroxime) has led to a reduction in postsurgical infection Standard preoperative procedures, such as the use of antimicrobial shower, shaving, and topical disinfectants, should be followed. Observation of such procedures, together with the use of surgical rooms with laminar airflow and prophylactic antibiotic therapy, has led to a reduction in the postsurgical rate of infection to 0.5% to 2%, depending on the type of joint replacement

Evidence

An observational study of 2,847 patients receiving antibiotic prophylaxis for elective surgical procedures showed that surgical wound infections occurred in 0.6% of those who received antibiotics preoperatively, 1.4% of those who received antibiotics perioperatively (relative risk [RR], 2.4 compared to the preoperative group), 3.3% of those who received antibiotics postoperatively (RR, 5.8), and 3.8% of those who received early antibiotic treatment (RR, 6.7). Administration of antibiotics during the preoperative period was associated with the lowest risk of surgical wound infection.[1]Level of evidence: 1

References

Read more about Osteomyelitis in adults from this First Consult monograph:

Diagnosis | Differential diagnosis | Treatment | Resources | Summary of evidence

More Key Resources

Overview
Osteomyelitis (includes Tables and Images) Mandell: Principles & Practice of Infectious Diseases, 7th ed.

Signs & Symptoms

Clinical Manifestations of Osteomyelitis in Children (includes Table) Kliegman: Nelson Textbook of Pediatrics, 19th ed.

Clinical Characteristics of Acute Hematogenous Osteomyelitis (includes Image) Long: Principles & Practice of Pediatric Infectious Diseases, 3rd ed., Revised Reprint

Etiology Diagnosis
Current concepts in imaging diabetic pedal osteomyelitis (includes Images) Donovan A - Radiol Clin North Am - 01-NOV-2008; 46(6): 1105-24, vii

Infectious and inflammatory disorders (includes Images) Pruthi S - Radiol Clin North Am - 01-NOV-2009; 47(6): 911-26 Applications of PET and PET/CT in the evaluation of infection and inflammation in the skeletal system (includes Images) Cheng G - PET Clin - July, 2010; 5(3); 375-385

Treatment & Management

Osteomyelitis: General Principles (includes Images and Tables) Mandell: Principles & Practice of Infectious Diseases, 7th ed.

Hyperbaric oxygen: Applications in infectious disease (includes Image) Kaide CG - Emerg Med Clin North Am - 01-MAY-2008; 26(2): 571-95, xi

Patient Education
Managing Your Osteomyelitis

Practice Guidelines

Practice Guidelines for Outpatient Parenteral Antimicrobial Therapy (2004) Source: Infectious Diseases Society of America

Drugs
Clindamycin Nafcillin Vancomycin

Symptoms of osteomyelitis may include:

a high temperature (fever) of 38C (100.4F) or above bone pain, which can often be intense swelling, redness and a warm sensation in the affected area

Osteomyelitis most commonly affects the long bones in the legs, but other bones, such as those in the back or arms can also be affected. Read more about the symptoms of osteomyelitis. The condition is often referred to as acute osteomyelitis when the infection develops following an injury, infection or underlying condition. It's referred to as chronic osteomyelitis when the condition regularly returns.

When to see your GP

Osteomyelitis can affect people of any age, so you should visit your GP if you or your child experiences persistent bone pain with a fever. Very young children do not always develop a fever when they have osteomyelitis and they may not be able to communicate that they have bone pain. You should see your GP if your child becomes irritable, has a reduced appetite and is reluctant to use a certain part of their body (most often an arm or leg).

Why does osteomyelitis happen?

Osteomyelitis develops when the bone becomes infected. In most cases, bacteria is responsible for the infection, although it can also be caused by fungi. Blood tests and a biopsy may be used to determine whether you have an infection and what caused it. Read more about diagnosing osteomyelitis.

There are two ways the infection can occur:

following an injury (known as contiguous osteomyelitis) - such as a fractured bone, animal bite or during surgery via the bloodstream (known as haematogenous osteomyelitis)

Contiguous osteomyelitis is more common in adults, whereas haematogenous osteomyelitis is more common in children. Certain things can increase your chances of developing osteomyelitis. For example, if you have a condition that affects the blood supply to certain parts of your body, such as diabetes, or a condition that weakens the immune system, such as rheumatoid arthritis. Osteomyelitis can become chronic osteomyelitis if not treated quickly, as the bones can become permanently damaged, resulting in persistent pain and loss of function. Read more about the causes of osteomyelitis.

How is osteomyelitis treated?

Osteomyelitis is usually treated with antibiotics, used for at least four to six weeks. At first, you may have to receive this while staying in hospital, but you should be able to take them at home when you start to get better. In severe or chronic cases of osteomyelitis, surgery may be used in combination with antibiotics. Surgery is most often used to removed damaged bone and drain pus from wounds. Read more about treating osteomyelitis.

Complications
Osteomyelitis usually responds well to antibiotics. However, for people with underlying conditions that increase the risk of osteomyelitis, such as diabetes, there is a chance the infection could come back. As a last resort, amputation is sometimes used if the blood supply to the bone is severely reduced. However, these days it is highly unlikely this will be necessary, as the condition can usually be treated before it reaches this stage. Read more about the complications of osteomyelitis.

Preventing osteomyelitis
It is not always possible to avoiding getting osteomyelitis, but there are steps you can take to reduce your chances.

Cleaning wounds thoroughly with water and dressing them in a clean bandage will reduce your chances of getting an infection from an injury. Improving your general health will help reduce the risk of developing osteomyelitis or another condition that causes high blood pressure or a weakened immune system. Read more about preventing osteomyelitis.