Osteomyelitis

exp date isn't null, but text field is

Infection of bone by pus-forming bacteria, mainly affecting older children and adults.

Causes

  • Most commonly S. aureus, following infection elsewhere in the body.
  • Less common organisms include:
    • Streptococci
    • E. coli
    • Proteus
    • Pseudomonas aeruginosa
    • Haemophilus influenzae in children.
  • Streptococcus and Salmonella are common causes in sickle cell disease

Risk factors:

  • Sickle cell disease
  • Tuberculosis
  • Trauma/Open fractures
  • Vascular insufficiency
  • Use of illicit drugs
  • Sepsis

Signs and symptoms:

Acute osteomyelitis

  • Onset is usually over several days
  • Fever, usually high but may be absent, especially in neonates
  • Severe pain at the site of infection
  • Tenderness and differential warmth at the site of infection
  • Swelling at the surrounding tissues and joint

Chronic osteomyelitis

  • May present with pain
  • Localized erythema
  • Swelling, sometimes in association with a draining sinus tract

Differential diagnosis

  • Infection of joints
  • Injury (trauma) to a limb; fracture (children)
  • Bone cancer (osteosarcoma)
  • Pyomyositis (bacterial infection of muscle)
  • Cellulitis
  • Sickle-cell disease (sickling crisis)

Complications

  • Pathological fractures
  • Chronic osteomyelitis

Investigations

  • Total and differential WBC
  • Erythrocyte sedimentation rate (ESR); C-reactive proteins (CRP)
  • Urinalysis, urine culture, and sensitivity
  • Blood culture and sensitivity
  • Pus culture and sensitivity
  • Plain radiograph of affected limb

Treatment Objectives

  • Relieve pain
  • Reduce swelling
  • Reduce fever
  • Eradicate infection
  • Prevent complications

Non-pharmacological treatment

  • Immobilize the affected limb, splint
  • Tepid sponging
  • Surgery to drain subperiosteal and soft tissue abscesses

Pharmacological treatment

Pain and fever relief:

Adult:

Paracetamol oral

500mg, three to four times a day

Ibuprofen oral

400mg, three times a day

Child:

Paracetamol, oral suspension

125mg/5ml, three to four times a day

Ibuprofen oral suspension

200mg/5ml, three times a day 

Note: Ibuprofen should not be given to children less than three months

 

Acute osteomyelitis (empirical treatment while awaiting microbial sensitivity report)

Adult:

Cloxacillin IV

500 mg every 6 hours for 2 weeks. Continue orally for at least 4 weeks (but up to 3 months)

OR

Clindamycin oral

600mg every 8 hours

Child:

Cloxacillin oral

50 mg/kg every 6 hours

OR

Clindamycin oral

3-6mg/kg every 6 hours

 

Osteomyelitis in patients with sickle cell

Adult:

Ampicillin IV

2 g, every 6 hours for 5-12 weeks

PLUS

Cloxacillin IV

1–2 g every 6 hours for 6-12 weeks

PLUS

Chloramphenicol IV

500 mg every 6 hours if salmonella is suspected for 2 – 3 weeks

Child:

Cloxacillin, IV

6 – 12 years: 250mg every 6 hours

1 – 5 years: 125mg every 6 hours

< 1 year: 62.5mg every 6 hours

Cloxacillin Powder for oral liquid: 125 mg (as sodium salt)/5 mL

 

Chronic osteomyelitis

Surgery is the treatment of choice. Antibiotics are not generally recommended

Referral

Refer patients with the following problems to an orthopaedic surgeon:

  • Patients not responding to treatment (persistent fever and pain after 2 days)
  • Fluctuant abscess that requires drainage
  • Complications e.g. pathological fracture, chronic osteomyelitis