Chronic Osteomyelitis and Chronic Septic Arthritis

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These are usually from inadequately treated acute episodes, which include acute osteomyelitis, acute septic arthritis, acute-on-chronic osteomyelitis, and acute-on-chronic septic arthritis. Some may arise from the onset as a chronic infection due to mycobacteria or fungi. 

The patient is usually not ill-looking unless there is an acute exacerbation.

Cause

  • Acute bacterial infections of bone and joints
  • Mycobacterium tuberculosis and fungal infections 
  • Infected orthopaedic implants
  • Iatrogenic

Symptoms

  • Chronic discharging sinuses
  • Pain 
  • Deformity 

Signs

  • Swelling
  • Tenderness 
  • Deformity
  • Scarring
  • Chronic discharging sinuses
  • Hyper-pigmentation of the involved part

Investigations

  • FBC, ESR
  • X-ray 
  • CT scan 

TreatmentTreatment Objectives

  • Eradicate infection
  • Restore function
  • Prevent and correct deformities

Non-pharmacological treatment

  • Wound dressing
  • Splinting
  • Surgery
  • Sequestrectomy
  • Implant removal

Pharmacological treatment 

See sections below

Referral Criteria

All patients should be referred as soon as possible to an orthopaedic specialist.

Treatment - acute flare up of infection

1st Line Treatment

Evidence Rating: [B]

  • Cloxacillin, IV

Adults

500 mg 6 hourly for 2-4 weeks

Children 

5-12 years; 250 mg 6 hourly for 2-4 weeks

1-5 years; 125 mg 6 hourly for 2-4 weeks

< 1 year; 62.5 mg 6 hourly for 2-4 weeks 

And

  • Ciprofloxacin, IV (to be infused over 60 minutes)

Adults

400 mg 8-12 hourly for 14 days

Children 

10 mg/kg 12 hourly for 14 days

For acute flare up of infection in patients with penicillin sensitivity

1st Line Treatment

Evidence Rating: [B]

  • Clindamycin, IV,

Adults

300 mg 6 hourly for 7 days

Children

3-6 mg/kg 6 hourly for 7 days

And

  • Ciprofloxacin, IV, (to be infused over 60 minutes)

Adults

400 mg 8-12 hourly for 14 days

Children 

10 mg/kg 12 hourly for 14 days

Treatment - acute flare up of infection in patients with sickle cell disease

1st Line Treatment

Evidence Rating: [B]

  • Cloxacillin, IV

Adults

500 mg 6 hourly for 2-4 weeks

Children 

5-12 years; 250 mg 6 hourly for 2-4 weeks

1-5 years; 125 mg 6 hourly for 2-4 weeks

< 1 year; 62.5 mg 6 hourly for 2-4 weeks 

And

  • Ciprofloxacin, IV (to be infused over 60 minutes)

Adults

400 mg 8-12 hourly for 14 days

Children 

10 mg/kg 12 hourly for 14 days

2nd Line Treatment

Evidence Rating: [B]

Clindamycin, IV

Adults

300 mg 6 hourly for 4 weeks or until clinical improvement

Children

3-6 mg/kg 6 hourly for 2-4 weeks

And

  • Ciprofloxacin, IV (to be infused over 60 minutes)

Adults

400 mg 8-12 hourly for 14 days

Children 

10 mg/kg 12 hourly for 14 days

Or

  • Amoxicillin + Clavulanic Acid, IV

Adults

1.2 g 12 hourly, increased to 1.2 g 8 hourly for 7 days in severe infections 

Children

12-18 years; 600 mg to 1.2 g 12 hourly, increased to 1.2 g 8 hourly for 7 days in severe infections

3 months-12 years; 30 mg/kg 12 hourly, increased to 30 mg/kg 8 hourly for 7 days in severe infections

7 days-3 months; 30 mg/kg 8 hourly for 7 days

Preterm and < 7 days; 30 mg/kg 12 hourly for 7 days

And

  • Ciprofloxacin, IV, (to be infused over 60 minutes)

Adults

400 mg 8-12 hourly for 14 days

Children 

10 mg/kg 12 hourly for 14 days

Treatment - Pain Relief

For pain relief

(See section on pain relief in ‘Acute Orthopaedic Infections’)