Osteomyelitis Management (IDSA 2015)

Algorithm Steps

1. ▶

   Start

   Suspected Osteomyelitis

   Bone pain, fever, elevated inflammatory markers

   1. ●

      Action

      Imaging

      MRI is gold standard

      • MRI: Sensitivity/specificity >90%
      • CT if MRI contraindicated
      • Plain films: May be negative early
      • Bone scan: If MRI not available
      1. ●

         Action

         Bone Biopsy/Culture

         Essential for targeted therapy

         • CT-guided or surgical biopsy
         • Culture + histopathology
         • Hold antibiotics 2 weeks before if possible
         • Blood cultures (positive in ~50% hematogenous)
         1. ◆

            Decision

            Type of Osteomyelitis

            1. ●

               Action

               Vertebral Osteomyelitis

               Hematogenous spread common

               • MRI entire spine
               • Blood cultures often positive
               • S. aureus most common
               • Immobilization/bracing
               1. ●

                  Action

                  Empiric Antibiotics

                  Start after cultures obtained

                  • MSSA: Nafcillin/Oxacillin 2g IV q4h or Cefazolin 2g IV q8h
                  • MRSA: Vancomycin 15-20mg/kg q12h or Daptomycin 6-8mg/kg
                  • GNR: Ceftriaxone or FQ
                  • Narrow to culture results
                  1. ◆

                     Decision

                     Surgical Debridement Needed?

                     Necrotic bone, hardware, abscess

                     1. ●

                        Action

                        Surgical Debridement

                        Remove necrotic/infected bone

                        • Curettage or excision
                        • Hardware removal if infected
                        • May need staged procedures
                        1. ●

                           Action

                           Duration of Therapy

                           6 weeks typically

                           • Vertebral: 6 weeks IV (may switch to PO)
                           • Long bone: 4-6 weeks
                           • DFO with residual bone: Longer/indefinite suppression
                           • After surgical debridement: 4-6 weeks
                           1. ✓

                              Outcome

                              Resolved

                              ESR/CRP normalizing, imaging improved

                           2. ⚠

                              Warning

                              Treatment Failure/Relapse

                              Re-biopsy, surgery, suppressive therapy

                     2. ●

                        Action

                        Medical Management Alone

                        If no surgical indication

            2. ●

               Action

               Contiguous (Non-vertebral)

               Adjacent soft tissue infection

               • Often post-surgical/trauma
               • Debridement usually required
               • Polymicrobial common
               • DFO: Probe-to-bone test
            3. ●

               Action

               Hematogenous (Long Bone)

               Children > adults

               • Search for primary source
               • S. aureus predominant
               • May respond to antibiotics alone