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chronic osteomyelitis
also see osteomyelitis
Clinical manifestations:
- frequently presents as subacute or chronic pain over affected bone
- fever & other systemic symptoms uncommon
- may underlie pressure ulcers & other chronic wounds not responding to therapy
Complications:
- bone penetration of antibiotics is low
- bone/plasma concentration ratio maximizes at ~0.3
- long-term antibiotic treatment often requires implantation of a central venous catheter that exposes the patient to intravenous catheter-related infections & thrombotic complications
Management:
- combined medical & surgical approach
- aggressive surgical debridement followed by a prolonged course of targeted antibiotic(s)
- adequate surgical debridement with removal of all dead & ischemic tissue & sinus tracts is key
- only curative strategy is wide surgical excision including healthy bone & soft tissues
- local excision & debridement is associated with high failure rates
- complete removal of infected bone & biofilm facilitates vascular supply & antibiotic access
- additional components of surgery that contribute to treatment success include
- management of dead space (bone defect after debridement &/or wide surgical excision)
- muscle flaps, bone grafts, calcium hydroxyapatite implants)
- stabilization of bone
- wound site coverage with skin grafts
- intravenous antibiotics have been the standard after adequate surgical management
- antibiotics that achieve the highest bone to serum concentration ratios
- fluoroquinolones, sulfamides, cyclines, macrolides, rifamycins, & oxazolidinones are also those with the highest oral bioavailability, thus good candidates for prolonged outpatient treatment of chronic osteomyelitis
- no significant difference between oral vs parenteral antibiotics if bacteria are sensitive to the antibiotic used
- combination therapy in selected cases may reduce possibility of selecting resistant organisms &/or add activity on biofilm
- delaying start of antibiotic treatment until bone culture, identification of the causative organism & antimicrobial sensititities is standard of care in treating chronic osteomyelitis
General
osteomyelitis
chronic infection (chronic infectious disease)
References
- Fantoni M, Taccari F, Giovannenze F.
Systemic antibiotic treatment of chronic osteomyelitis in adults.
Eur Rev Med Pharmacol Sci. 2019 Apr;23(2 Suppl):258-270.
PMID: 30977893 Free article.
- Medical Knowledge Self Assessment Program (MKSAP) 19.
American College of Physicians, Philadelphia 2021