Osteomyelitis: Diagnosis and Treatment

 

Am Fam Physician. 2021 Oct ;104(4):395-402.

  Patient information: See related handout on osteomyelitis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Osteomyelitis is an inflammatory condition of bone secondary to an infectious process. Osteomyelitis is usually clinically diagnosed with support from imaging and laboratory findings. Bone biopsy and microbial cultures offer definitive diagnosis. Plain film radiography should be performed as initial imaging, but sensitivity is low in the early stages of disease. Magnetic resonance imaging with and without contrast media has a higher sensitivity for identifying areas of bone necrosis in later stages. Staging based on major and minor risk factors can help stratify patients for surgical treatment. Antibiotics are the primary treatment option and should be tailored based on culture results and individual patient factors. Surgical bony debridement is often needed, and further surgical intervention may be warranted in high-risk patients or those with extensive disease. Diabetes mellitus and cardiovascular disease increase the overall risk of acute and chronic osteomyelitis.

Osteomyelitis is an inflammatory condition of bone secondary to infection; it may be acute or chronic. Symptoms of acute osteomyelitis include pain, fever, and edema of the affected site, and patients typically present without bone necrosis in days to weeks following initial infection. Chronic osteomyelitis develops after months to years of persistent infection and may be characterized by the presence of necrotic bone and fistulous tracts from skin to bone.1,2 Osteomyelitis is further classified by mechanism of infection as hematogenous or nonhematogenous. With hematogenous osteomyelitis, bacteria are seeded into bone secondary to a bloodstream infection and the condition is most common in children, older adults, and immunocompromised populations.13 Nonhematogenous osteomyelitis occurs from direct inoculation in the setting of surgery or trauma or with spread from contiguous soft tissue and joint infections.1,2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The preferred diagnostic criterion for osteomyelitis is a positive bacterial culture from bone biopsy, but clinical, laboratory, and radiographic findings can also inform a clinical diagnosis.9,12

C

Consensus guideline and clinical review

Magnetic resonance imaging is the imaging modality of choice for suspected osteomyelitis, although plain film radiography is often done initially.13

C

Consensus guideline

In adult patients hospitalized with chronic osteomyelitis, parenteral followed by oral antibiotic therapy appears to be as effective as long-term parenteral therapy.37,38

B

Systematic review of eight small trials and a randomized controlled trial


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The preferred diagnostic criterion for osteomyelitis is a positive bacterial culture from bone biopsy, but clinical, laboratory, and radiographic findings can also inform a clinical diagnosis.9,12

C

Consensus guideline and clinical review

Magnetic resonance imaging is the imaging modality of choice for suspected osteomyelitis, although plain film radiography is often done initially.13

C

Consensus guideline

In adult patients hospitalized with chronic osteomyelitis, parenteral followed by oral antibiotic therapy appears to be as effective as long-term parenteral therapy.37,38

B

Systematic review of eight small trials and a randomized controlled trial


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN INFECTIOUS DISEASE

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not routinely use magnetic resonance imaging to diagnose bone infection (osteomyelitis) in the foot.

American Podiatric Medical Association


Source: For more information on the Choosing Wisely Campaign, see https://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN INFECTIOUS DISEASE

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not routinely use magnetic resonance imaging to diagnose bone infection (osteomyelitis) in the foot.

American Podiatric Medical Association


Source: For more information on the Choosing

The Authors

show all author info

DAVID C. BURY, DO, MPH, FAAFP, is program director of the Family Medicine Residency Program at Martin Army Community Hospital, Fort Benning, Ga., and is assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md. At the time this article was written, Dr. Bury was a fellow in the Leadership and Faculty Development Fellowship Program at Madigan Army Medical Center, Joint Base Lewis-McChord, Wash....

TYLER S. ROGERS, MD, FAAFP, is a fellow in the Leadership and Faculty Development Fellowship Program at Madigan Army Medical Center, an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, and a clinical assistant professor in the Department of Family Medicine at the University of Washington School of Medicine, Seattle.

MICHAEL M. DICKMAN, DO, MBA, FAAFP, is Chief of the Department of Soldier and Community Health at Madigan Army Medical Center, an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, and a clinical assistant professor in the Department of Family Medicine at the University of Washington School of Medicine. At the time this article was written, Dr. Dickman was a fellow in the Leadership and Faculty Development Fellowship Program at Madigan Army Medical Center.

Address correspondence to David C. Bury, DO, MPH, FAAFP, 6600 Van Aalst Blvd., Fort Benning, GA 31905 (email: david.c.bury@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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