Osteomyelitis

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Osteomyelitis  is  an  infection  of  the  bone  or  bone  marrow  caused  by  pyogenic  bacteria  or  mycobacteria  or  fungi.  This  condition  is  most  common  in  children  under  12  years.  Staphylococci  aureus are the most frequent responsible organisms. In patients with sickle cell disease Salmonella  species  become  more  common  pathogens  than  in  healthy  hosts.  Can  be  classified  as  acute  or  chronic depending on duration of symptoms. 

Clinical presentation of acute osteomyelitis

  • Fever, malaise, severe pain at the site of infection, fatigue, irritability, restriction of movement (pseudo paralysis of limb in neonates) local edema, erythema, and tenderness
  • A history of recent trauma, surgery, or infection of another organ If the infection is close to a joint there may be a ‘sympathetic’ effusion or concomitant septic arthritis.

Note: Risk Factors: Poor social economic status, immunosuppression and or malnutrition 

Investigations

  • Total and differential White Blood Cell count 
  • Erythrocyte sedimentation Rate
  • C- Reactive protein
  • Urinalysis
  • Urine for Culture and Sensitivity
  • Blood for Culture and Sensitivity or
  • Aspirated pus for Culture and Sensitivity 
  • Bone Biopsy for Culture and Sensitivity
  • Polymerase  Chain  Reaction (PCR) for special case like Kingella kingae species  
  • Bone Scan using Technetium –99  in acute infection 
  • Ultrasound
  • Plain X-ray
  • CT scan in complex anatomical regions like shoulder, pelvic, spine 

Pharmacological Treatment 

B: cloxacillin (IV) 1–2g 6hourly then continue with ampicillin + cloxacillin (FDC) (PO) 500mg 8hourly to complete 3-6weeks course or until CRP and x-ray become negative

OR 

C: ampicillin + sulbactam (FDC) (IV) 3g 6hourly for two weeks 

THEN 

B: amoxillin + clavulanate (FDC)(PO) 625mg 12hourly for 4weeks

Patients with penicillin allergy consider:

S: clindamycin (IV) 60mg 6hourly for 2weeks then orally to complete 4-6weeks 

AND 

C: ciprofloxacin (IV) 400mg 12hourly for 2weeks then orally to complete 4-6weeks 

For sickle cell patient if salmonella spp is suspected consider:

C: ciprofloxacin (IV) 400mg 12hourly for 4weeks, you may change to oral after 2weeks 

Surgical management  

Surgical drainage and bone window recommended in all cases presenting with history lasting > 24  hours,  

Clinical presentation of chronic osteomyelitis

A patient with a history of osteomyelitis who is experiencing a recurrence of pain, erythema, and  swelling in association with or without pus draining sinus 

Investigations 

  • Total and differential White Blood Cell count
  • Stop antibiotic for two weeks before bone biopsy for culture and sensitivity
  • Polymerase Chain Reaction  (PCR ) for special case like Kingella kingae species
  • Erythrocyte sedimentation rate
  • C-reactive protein
  • Bone Scan using Technetium –99  in acute infection
  • Plain X-ray
  • CT scan in complex anatomical regions like shoulder, pelvic, spine

Pharmacological management 

B: amoxicillin + clavulanate (FDC) (PO) 625mg 12hourly for 6weeks 

Surgical management  

  • Extensive  surgical  debridement  of  all  devitalized  tissue  and  dead  bone,  dead  space  filled  with  antibiotic beads

Antibiotics cement mixture 

S: vancomycin at a dosage of 2–4g per 40g of cement