Osteomyelitis: Difference between revisions

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== Background ==
==Background==
 
*Infection of the bone by [[bacteria]] or [[fungus]]
*Infection of the bone by bacteria or fungus  
*Etiology  
*Etiology  
**Contiguous spread (80%)  
**Contiguous spread (80%)  
**Hematogenous spread (20%)  
**Hematogenous spread (20%)  
***More common in peds (long bones)  
***More common in pediatric (long bones)  
***Less common in adults (spine)
***Less common in adults (spine)


== Risk Factors ==
===Risk Factors===
 
*[[DM|Diabetic]] patients with one or more of the following:  
*Diabetic pts with one or more of the following:  
**Skin ulceration >2cm  
**Skin ulceration >2cm  
**Positive probe-to-bone test  
**Positive probe-to-bone test  
**ESR >70 (83-92% Sn)  
**ESR >70 (83-92% Sn)  
**Abnormal x-ray
**Abnormal x-ray


== Diagnosis  ==
==Clinical Features==
 
*Pain at the site  
*Pain at the site  
**May also have warmth, swelling, erythema  
**May also have warmth, swelling, erythema  
==Differential Diagnosis==
{{Template:SSTI DDX}}
==Evaluation==
*X-ray  
*X-ray  
**May be normal early in the course  
**May be normal early in the course  
**Later will show bone demineralization, periosteal elevation, lytic lesions  
**Later will show bone demineralization, periosteal elevation, lytic lesions  
**Changes 10-21 days after infection
**Sn 43-75%, Sp 75-83%<ref>Pineda et al. Semin Plast Surg 2009;23:80–89.</ref>
*Blood culture  
*Blood culture  
*Bone scan
*CT
 
**Sn 67%, Sp 50%<ref>Pineda et al. Infect Dis Clin N Am. 2006, 20: 789–825</ref>
== Treatment  ==
*[[Mri|MRI]] is the standard for diagnosis (as early as 3-5 days after infection)<ref>Pineda C et al. Radiographic Imaging in Osteomyelitis: The Role of Plain Radiography, Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, and Scintigraphy. Semin Plast Surg. 2009 May; 23(2): 80–89.</ref>
 
*Bone scan is sensitive, but lacks specificity vs. MRI
{| width="500" border="1" cellpadding="1" cellspacing="1"
|-
| Risk Factor
| Likely Organism
| Initial Empiric Antibiotic Therapy
|-
| Elderly, hematogenous spread
| MRSA, MSSA, gram neg
| Vanco 1gm + (piperacillin-tazobactam 3.375 grams OR imipenem 500mg)
|-
| Sickle cell disease
| Salmonella, gram-negative bacteria
| Ciprofloxacin 400mg, consider vanco 1gm
|-
| DM or vascular insufficiency
| Polymicrobial: Staph, strep, coliforms, anaerobes
| Vanco 1gm + (piperacillin-tazobactam 3.375 grams OR imipenem 500mg)
|-
| IV drug user
| MRSA, MSSA, pseudomonas
| Vanco 1gm&nbsp;
|-
| Newborn
| MRSA, MSSA, GBS, gram-negative
| Vanco 15mg/kg load, then reduce dose, AND ceftazidime 30mg/kg IV q12 h
|-
| Children
| MRSA, MSSA
| Vanc 10mg/kg q6 h AND ceftazidime 50mg/kg q8hr
|-
| Postoperative (ortho)
| MRSA, MSSA
| Vanco 1gm
|-
| Human bite
| Strep or anaerobes
| Piperacillin-tazobactam 3.375gm OR imipenem 500mg
|-
| Animal bite
| Pasteurella, Eikenella
| Piperacillin-tazobactam 3.375gm OR imipenem 500mg
|}


==Management==
{{Osteomyelitis Antibiotics}}


==See Also==
==See Also==
*[[Vertebral Osteomyelitis]]
*[[Vertebral Osteomyelitis]]


== Source  ==
==References==
Tintinalli
<references/>


[[Category:Peds]] [[Category:Ortho]]
[[Category:Pediatrics]]
[[Category:Orthopedics]]
[[Category:ID]]

Latest revision as of 19:25, 6 October 2019

Background

  • Infection of the bone by bacteria or fungus
  • Etiology
    • Contiguous spread (80%)
    • Hematogenous spread (20%)
      • More common in pediatric (long bones)
      • Less common in adults (spine)

Risk Factors

  • Diabetic patients with one or more of the following:
    • Skin ulceration >2cm
    • Positive probe-to-bone test
    • ESR >70 (83-92% Sn)
    • Abnormal x-ray

Clinical Features

  • Pain at the site
    • May also have warmth, swelling, erythema

Differential Diagnosis

Skin and Soft Tissue Infection

Look-A-Likes

Evaluation

  • X-ray
    • May be normal early in the course
    • Later will show bone demineralization, periosteal elevation, lytic lesions
    • Changes 10-21 days after infection
    • Sn 43-75%, Sp 75-83%[1]
  • Blood culture
  • CT
    • Sn 67%, Sp 50%[2]
  • MRI is the standard for diagnosis (as early as 3-5 days after infection)[3]
  • Bone scan is sensitive, but lacks specificity vs. MRI

Management

Risk Factor Likely Organism Initial Empiric Antibiotic Therapy'
Elderly, hematogenous spread MRSA, MSSA, gram neg Vancomycin 1gm + (Piperacillin/Tazobactam 3.375 grams OR imipenem 500mg)
Sickle Cell Disease Salmonella, gram-negative bacteria Ceftriaxone 50mg/kg IV once daily OR Cefotaxime 50mg/kg IV three times daily, PLUS
  • Vancomycin 15mg/kg IV four times daily OR
  • Clindamycin 10mg/kg IV PO four times daily OR
  • Nafcillin 50 mg/kg IV four times daily to cover K. Kingae (common in daycare population)
DM or vascular insufficiency Polymicrobial: Staph, strep, coliforms, anaerobes Vancomycin 1gm + (Piperacillin/Tazobactam 3.375 grams OR imipenem 500mg)
IV drug user MRSA, MSSA, pseudomonas Vancomycin 1gm 
Newborn MRSA, MSSA, GBS, Gram Negative Vancomycin 15mg/kg load, then reduce dose, AND ceftazidime 30mg/kg IV q12 h
Children MRSA, MSSA Vancomycin 10mg/kg q6 h AND ceftazidime 50mg/kg q8hr
Postoperative (ortho) MRSA, MSSA Vancomycin 1gm
Human bite Strep, anaerobes, HACEK organism Piperacillin/Tazobactam 3.375gm OR imipenem 500mg
Animal bites Pasteurella, Eikenella, HACEK organism Piperacillin/Tazobactam 3.375gm OR imipenem 500mg
Foot puncture wound Pseudomonas Anti-pseudomonal, staph coverage

See Also

References

  1. ↑ Pineda et al. Semin Plast Surg 2009;23:80–89.
  2. ↑ Pineda et al. Infect Dis Clin N Am. 2006, 20: 789–825
  3. ↑ Pineda C et al. Radiographic Imaging in Osteomyelitis: The Role of Plain Radiography, Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, and Scintigraphy. Semin Plast Surg. 2009 May; 23(2): 80–89.
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