Suspected osteomyelitis (adult)
Bone pain or tenderness with fever, raised ESR or CRP, bacteraemia, or a foot ulcer that probes to bone.
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Infectious DiseaseManagement
Osteomyelitis in Adults (IDSA 2015 vertebral, IWGDF/IDSA 2023 diabetic foot)
Osteomyelitis in Adults (IDSA 2015 vertebral, IWGDF/IDSA 2023 diabetic foot): Suspected osteomyelitis (adult) → Adults with native bone infection only →...
Pathway Overview
23 steps
Algorithm Steps
23 total
01Start 02Warning Adults with native bone infection only
Not for children, prosthetic joint infection, or infection around fracture fixation or a spinal implant.
- Children: use a paediatric pathway (PIDS/IDSA 2021 acute haematogenous osteomyelitis)
- Prosthetic joint, fracture fixation or spinal implant: orthopaedic and ID team care
03Action Initial assessment: neurological exam, 2 blood culture sets, ESR and CRP
Take blood cultures before the first antibiotic dose.
- Full motor and sensory neurological examination
- 2 sets of blood cultures (aerobic and anaerobic)
- Baseline ESR and CRP
- Look for a source: recent S. aureus bacteraemia, endocarditis, IV lines, injecting drug use
04Warning Red flags: sepsis, shock, or new or worsening neurological deficit
Take blood cultures, then start empiric IV antibiotics now. Do not hold antibiotics for a biopsy.
- New weakness, numbness, sphincter change or epidural abscess: urgent spine surgery review now
- Still try to get tissue for culture, without delaying antibiotics
- Severe diabetic foot infection, gangrene or deep abscess: urgent surgical review
05Action Red flags only: empiric IV antibiotics now (adult doses)
Cover staphylococci including MRSA, streptococci and gram-negative bacilli. Adjust doses for kidney function. Check first for severe beta-lactam allergy and melioidosis risk (tropical north).
- Vancomycin IV plus ceftriaxone 2 g IV daily
- Vancomycin: dose by weight and kidney function, with AUC-guided monitoring
- Pseudomonas risk: cefepime 2 g IV 8-hourly in place of ceftriaxone
- Severe beta-lactam allergy: daptomycin plus a quinolone, with ID advice
- Severe diabetic foot infection with necrosis or ischaemia: piperacillin-tazobactam IV; add vancomycin if MRSA risk
- Tropical northern Australia: consider melioidosis; use the local empiric guideline
06Action Imaging: MRI is the test of choice
Plain X-rays can be normal early in the infection.
- Spine: MRI (sensitivity 97%, specificity 93%)
- MRI not possible: CT, PET, or gallium/Tc-99m bone scan
- Diabetic foot: probe-to-bone test, plain X-ray and ESR or CRP first; MRI if still in doubt
07Action Stable, normal neurology: get the organism before antibiotics
Hold antibiotics until bone or blood cultures identify the organism. If already on antibiotics, 1 to 2 weeks off before biopsy is reasonable when safe.
- Spine, blood cultures grow S. aureus, S. lugdunensis or Brucella: biopsy not needed
- Otherwise: image-guided or surgical bone biopsy for culture and histology
- Diabetic foot: bone sample, not a swab. Treat spreading soft-tissue infection now
- Risk of TB, fungi or Brucella: request these cultures
- Vertebral biopsy grows only a skin organism (coagulase-negative staphylococci other than S. lugdunensis, Cutibacterium) with negative blood cultures: repeat the biopsy
- Vertebral biopsy nondiagnostic: test for anaerobes, fungi, Brucella and TB, then repeat image-guided, endoscopic or open biopsy
- Red flags at any time: start empiric antibiotics now
08Decision Site of osteomyelitis?
- Vertebral (spine)
09Action Vertebral osteomyelitis (discitis): ID and spine surgeon review
Check the MRI for an epidural or paraspinal abscess.
- Blood cultures grow a typical endocarditis organism (e.g. S. aureus, viridans streptococci, E. faecalis): echocardiography (TTE/TOE)
- Subacute illness with endemic exposure: Brucella serology and blood cultures
- TB risk: interferon-gamma release assay or tuberculin skin test
10Decision Vertebral: surgery indicated?
Progressive neurological deficit, deformity or instability, or bacteraemia or pain that persists on treatment.
- If Yes
11Action Vertebral, surgery indicated: debridement with or without stabilisation
Urgent if there is a neurological deficit. Send operative tissue for culture and histology. Then continue with directed therapy.
- Progressive neurological deficit, progressive deformity or spinal instability
- Persistent or recurrent bacteraemia without another source
- Worsening pain despite appropriate antibiotics
If No12Action Vertebral, no surgical indication: antibiotics alone
Continue with directed therapy. Worse bone imaging at 4 to 6 weeks is not a reason for surgery if symptoms, examination and ESR/CRP are improving.
- Diabetic foot
13Action Diabetic foot osteomyelitis: check blood supply and need for surgery
Urgent surgical review for severe infection, gangrene, necrotising infection, deep abscess or compartment syndrome.
- Check for peripheral artery disease (PAD): pulses, Doppler, ankle- or toe-brachial index
- PAD with foot infection: urgent surgical and vascular review
- Temperate climate: do not target Pseudomonas unless grown from the site in recent weeks
- Tropical or subtropical climate (e.g. northern Australia), moderate or severe infection: Pseudomonas is more common; consider empiric cover
- Manage with the multidisciplinary foot team
14Decision Diabetic foot: antibiotics alone suitable?
Forefoot only, no need for urgent drainage, no PAD and no exposed bone.
- If Yes
15Action Forefoot, no PAD, no exposed bone: antibiotics without surgery
Treat for 6 weeks with directed therapy. Reassess for surgery if it does not improve.
If No16Action Diabetic foot, not for antibiotics alone: resect infected bone plus antibiotics
Send the bone margin for culture and histology; the result sets the duration. Then continue with directed therapy.
- Other bone site
17Action Other adult bone infection (no implant): orthopaedic and ID review
Includes spread from a wound or ulcer, and blood-borne long-bone infection. Then continue with directed therapy.
- Bone biopsy or operative samples for culture and histology
- Debride dead bone (sequestrum) and drain abscesses
- Blood-borne infection: look for the source, including endocarditis
18Action All sites, organism known: directed therapy (adult doses)
Narrow to culture and susceptibility results. Adjust doses for kidney function. Check for S. aureus bacteraemia or endocarditis, beta-lactam allergy, pregnancy and regular paracetamol use.
- MSSA: flucloxacillin 2 g IV 6-hourly, or cefazolin 2 g IV 8-hourly
- MRSA: vancomycin IV, dose by weight and kidney function, AUC-guided
- Streptococci: benzylpenicillin, or ceftriaxone 2 g IV daily
- Enterococcus: benzylpenicillin or amoxicillin IV by susceptibility. Cephalosporins are not active
- Gram-negative bacilli: by susceptibility; ciprofloxacin 750 mg orally 12-hourly if susceptible
- Ciprofloxacin: risk of tendon rupture (older age, corticosteroids), aortic aneurysm and QT prolongation; use another agent if these apply and one is available
- Penicillin allergy, not severe: cefazolin is usually suitable. Anaphylaxis: ID or allergy advice before any cephalosporin. Severe delayed reaction (SJS/TEN, DRESS): avoid all beta-lactams; use vancomycin or daptomycin with ID advice
- Switch to a highly bioavailable oral agent when stable and improving; oral is as effective as IV (OVIVA trial)
- S. aureus bacteraemia or endocarditis: agree oral switch and duration with ID
- Flucloxacillin: check liver function on long courses; caution with regular paracetamol (metabolic acidosis)
- Pregnancy: avoid ciprofloxacin if possible (TGA category B3); seek ID advice
19Action Total antibiotic duration by site (adult)
IV or highly bioavailable oral. These are total durations for bacterial infection. Candida and TB need 6 months or more.
- Vertebral, bacterial: 6 weeks
- Vertebral, Brucella: 3 months
- Diabetic foot, no surgery or dead bone left: 6 weeks
- Diabetic foot, positive bone margin after resection: 3 weeks
- Diabetic foot, all infected bone removed: 2 to 5 days
- Vertebral with endocarditis, MRSA, severe bone destruction or undrained abscess: ID may extend beyond 6 weeks
- Candida: fluconazole for 6 to 12 months, with ID
- TB of bone or spine: rifampicin-based regimen for 6 to 9 months or longer, with the TB service
- Other sites: agree with ID; usually 4 to 8 weeks in total
20Action Follow-up: clinical review and ESR/CRP at about 4 weeks
- Do not repeat MRI routinely if improving
- Pain, residual deficit, raised markers or imaging alone do not prove failure
- Monitor blood count, kidney and liver function during long courses
- Diabetic foot: judge remission at least 6 months after antibiotics end
21Decision Improving clinically, with falling ESR/CRP?
- If Yes
22Outcome Improving: complete the planned course
Review after antibiotics end for relapse.
If No23Action Not improving: assess for treatment failure
Unchanged or rising ESR/CRP after 4 weeks raises suspicion.
- Vertebral: MRI to look at the epidural and paraspinal soft tissues
- New tissue samples for bacterial, fungal and TB culture and histology
- Spine or orthopaedic surgeon and ID review
- Diabetic foot: reassess blood supply, dead bone and need for surgery
Guideline Source
IDSA 2015 Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults with native bone only. Not for children, prosthetic joint infection or infection around fracture fixation or spinal implants.
- Red flags (sepsis, shock, neurological deficit): start empiric antibiotics at once. The antibiotic hold before biopsy applies only to stable patients with normal neurology.
- Diabetic foot content follows IWGDF/IDSA 2023. Other non-vertebral sites have no specific guideline; agree the plan and duration with ID and orthopaedics.
- Empiric and directed regimens follow IDSA 2015 Table 2 with Australian equivalents; follow local antibiograms and ID advice.
Contraindicated Populations
Children (use PIDS/IDSA 2021 paediatric guideline)Prosthetic joint infectionFracture-related infection or infection around orthopaedic or spinal implants
Applicable Regions
AUUSEU
AU: Nafcillin and oxacillin are not used in Australia: use flucloxacillin 2 g IV 6-hourly. In tropical northern Australia, consider melioidosis (Burkholderia pseudomallei) in sepsis with bone or joint infection and follow local empiric guidance.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Osteomyelitis in Adults (IDSA 2015 vertebral, IWGDF/IDSA 2023 diabetic foot)?
The Osteomyelitis in Adults (IDSA 2015 vertebral, IWGDF/IDSA 2023 diabetic foot) is a management clinical algorithm for Infectious Disease. It provides a structured decision tree to guide clinical decision-making, based on IDSA 2015 Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults.
What guideline is the Osteomyelitis in Adults (IDSA 2015 vertebral, IWGDF/IDSA 2023 diabetic foot) based on?
This algorithm is based on IDSA 2015 Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults (DOI: 10.1093/cid/civ482).
What are the limitations of the Osteomyelitis in Adults (IDSA 2015 vertebral, IWGDF/IDSA 2023 diabetic foot)?
Known limitations include: Adults with native bone only. Not for children, prosthetic joint infection or infection around fracture fixation or spinal implants.; Red flags (sepsis, shock, neurological deficit): start empiric antibiotics at once. The antibiotic hold before biopsy applies only to stable patients with normal neurology.; Diabetic foot content follows IWGDF/IDSA 2023. Other non-vertebral sites have no specific guideline; agree the plan and duration with ID and orthopaedics.; Empiric and directed regimens follow IDSA 2015 Table 2 with Australian equivalents; follow local antibiograms and ID advice.. Individual patient factors may require deviation from these recommendations.
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