General approach to management of osteomyelitis

For adults and children with sepsis or septic shock, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after taking blood samples for culture. If relevant, collect other samples (eg bone or pus samples) as soon as possible, but do not delay antibiotic administration to do so. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.

For adults without sepsis or septic shock, start empirical treatment while awaiting the results of culture and susceptibility testing if the patient has acute osteomyelitis or vertebral osteomyelitis associated with neurological compromise. In other adults, antibiotic therapy may be withheld until a microbiological diagnosis is made. If antibiotics are withheld, patients should be closely monitored and antibiotics should be started if the patient’s clinical condition deteriorates.

For adults, empirical regimens are included for:

• long-bone osteomyelitis
• mandibular osteomyelitis
• osteomyelitis complicating sacral pressure ulcers
• osteomyelitis contiguous with leg or foot ulcers, which is treated as per Infections of diabetes-related foot ulcers
• sternal osteomyelitis complicating median sternotomy (deep sternal wound infection)
• vertebral osteomyelitis
• osteomyelitis of the hand.

For children with osteomyelitis without sepsis or septic shock, empirical treatment should be started while awaiting the results of culture and susceptibility testing. However, in children with concurrent septic arthritis, it may be appropriate to withhold antibiotics until a diagnostic aspirate has been taken. Empirical therapy is the same for both long-bone and vertebral osteomyelitis in children – see Osteomyelitis in children. Other empirical regimens included for bone and joint infections of the hand and mandibular osteomyelitis.

Modify therapy according to the results of culture and susceptibility testing. For suggested regimens, see:

• Methicillin-susceptible Staphylococcus aureus (MSSA) native bone or joint infection
• Methicillin-resistant Staphylococcus aureus (MRSA) native bone or joint infection
• Kingella kingae native bone or joint infection
• Native bone or joint infection caused by other pathogens.

For adults and children with S. aureus bacteraemia associated with osteomyelitis, consider both the recommendations for osteomyelitis and the recommendations in Staphylococcus aureus bacteraemia, including sepsis and septic shock.

Prolonged antibiotic therapy is required to cure osteomyelitis in both adults and children. The duration of therapy depends on the patient’s age, duration of infection (acute or chronic), pathogen, site of infection and clinical response. Intravenous antibiotic therapy is usually required initially, particularly for acute osteomyelitis, but oral antibiotic therapy is usually preferred to complete the treatment course.

To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is also essential.