Treatment is tailored to the patient and follows evidence based medicine
Dr. Karr - "Every patient that has a bone infection shares that commonality, but instead of providing the same treatment to everyone each patient needs to be treated uniquely based on the presentation of their bone infection and overall medical condition."
The treatment of osteomyelitis is different between all patients and thus the treatment is tailored to each patient. Rather than a single physician managing your bone infection a team of health care specialist in the area osteomyelitis and wound care will treat you at The Osteomyelitis Center of Central Florida. The level of evidence based medicine is noted where appropriate.
Antibiotics: The optimal route of administration of antibiotic therapy has not been established. Parenteral, oral, or initial parenteral therapy followed by oral therapy may be used on individual patient circumstances (A-III) . A minimum 8-week course is recommended (A-II). Some experts suggest an additional 1–3 months (and possibly longer for chronic infection or if debridement is not performed) of oral rifampin-based combination therapy with TMP-SMX, doxycycline-minocycline, clindamycin, or a fluoroquinolone, chosen on the basis of susceptibilities (C-III).
Our patients that receive the PAD-T procedure generally recieve four weeks of antibiotics.
INITIAL EVALUATION
Local and systemic compromise often result in treatment failure and recurrent infections. (2)
1. Laboratory
CBC: WBC count is highly variable and correlates poorly with treatment
A1C: Results from 2 randomized controlled trials, the Diabetes Control and Complication Trial and the United King- dom Prospective Diabetes Study, have shown that rigorous regulation of blood glucose to achieve hemoglobin A1C levels of approximately 7% reduces the risk of microvascu- lar complications in diabetic patients.
Erythrocyte sedimentation rate (ESR): combination with clinical suspicion in diabetic foot infections, the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the presence or absence of bone infection. As the ESR value increased, the positive predictive value increased, showing that the probability of a patient having OM based on ESR alone is greater the higher the ESR value. ESR rises rapidly but declines too slowly to guide treatment.
C-reactive protein (CRP): C-reactive protein is most sensitive to monitor therapeutic response and declines rapidly as the clinical picture improves. Failure of the C-reactive protein to decline after 48 to 72 hours of treatment should indicate that treatment may need to be altered.
SYSTEMIC CONSIDERATIONS
Dialysis: People on kidney dialysis are at higher risk for developing osteomyelitis due to the higher risk of bloodstream infections in these groups.
Diabetes: It has been estimated that approximately 15% to 25% of patients with diabetes will develop a diabetic foot ulcer at some point.1 Among these individuals, 14% to 24% will experience soft tissue infection, undergo an amputation for osteomyelitis, or both. Health care costs associated with diabetic foot ulcers are enormous, with treatment of these wounds accounting for 20% to 25% of all hospitalizations among persons who have diabetes.
DIAGNOSTICS
1. Radiographs: Useful in acute and chronic osteomyelitis as the clinical signs of osteomyelitis such as dense intramedullary sequestrum, endosteal scalloping, or involucrum are present and additional studies are not always needed. When radiographs fail to demonstrate definitive signs of a bone infection additional imaging may be necessary.
2. Nuclear scans: In osteomyelitis, regional or whole-body bone scintigraphy may be used in conjunction with 111In- leukocyte scintigraphy to detect sites of abnormal bone remodeling. Bone marrow scintigraphy using 99mTc-sulfur colloid can be a useful adjunct to assess marrow distribution at suspected osteomyelitis sites, particularly when the site is adjacent to orthopedic hardware and the neuropathic joint. Gallium scinti- graphy is usually preferred in patients with (a) neu-tropenia or (b) nonsuppurative or lymphocyte- mediated infections. 99mTc-HMPAO (exametazime)- labeled leukocyte scintigraphy is a frequently used option for acute infections, particularly in pediatric patients. (17)
2. Computed tomography: Useful for the evaluation of chronically infected united fractures for pre-operative planning in regards to the surgical approach.
3. MRI Magnetic resonance imaging (MRI) with gadolinium is the imaging modality of choice, particularly for detection of early osteomyelitis and associated soft-tissue disease (A-II). Erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level may be helpful to guide response to therapy (B-III) (1). MRI is useful for determining location and extent of involvement of the bone infection.
4. Blood tests include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and a test for C-reactive protein (CRP). Samples of blood may be cultured in an attempt identify the causative organism and determine antibiotic (or antifungal) sensitivities.
5. Other possible tests include open bone biopsy for a bone culture.
TREATEMNT
Antibiotics:
The optimal route of administration of antibiotic therapy has not been established.
Parenteral, oral, or initial parenteral therapy followed by oral therapy may be used on individual patient circumstances (A-III) (1). The optimal duration of therapy for MRSA osteomyelitis is unknown. Some recommend a minimum 8-week course (A-II) (1). Others recommend six weeks. (16) Some experts suggest an additional 1–3 months (and possibly longer for chronic infection or if debridement is not performed) of oral rifampin-based combination therapy with TMP-SMX, doxycycline-minocycline, clindamycin, or a fluoroquinolone, chosen on the basis of susceptibilities (C-III) (1).
Individuals may be able to receive intravenous (IV) therapy at work if a clean space that permits privacy, equipment to handle infusion, and refrigeration of medication can be made available. A home health nurse may be brought to the workplace to assist in this treatment plan.
Recent studies demonstrate that oral antibiotics can achieve levels in bone that exceed MICs of targeted organisms. Oral antibiotic therapy with highly bioavailable agents is an acceptable alternative to parenteral therapy (3). The widely held preference for parenteral therapy for chronic osteomyelitis is based more on custom than evidence. There are actually fewer published studies of parenteral than oral therapy for osteomyelitis, and success rates are consistently similar for both routes. (3) Adding rifampin to a variety of antibiotic regimens has been shown to improve the cure rates in: animal models, retrospective studies in humans, and randomized clinical trials of chronic osteomyelitis and orthopedic implant infections. (3) In particular, fluoroquinolones, linezolid, and trimethoprim have been found to achieve bone concentrations at 50% of serum (6,7) Other orally available agents to which many community associated strains of methicillin-resistant Staphylococcus aureus (MRSA) are susceptible are doxycycline and clindamycin. (8,9,10,11) Preferred oral agents, based on both pharmacokinetic and clinical data, include fluoroquinolones or TMP-SMX, which achieve high cure rates when administered for 8–16 weeks, particularly in the context of concomitant surgical debridement (3).
Antibiotics available for parenteral administration include IV vancomycin (B-II) and daptomycin 6 mg/kg/dose IV Once daily (B-II) (1). Similar to b-lactam antibiotics, vancomycin penetrates bone poorly. (3,4) Daptomycin also penetrates bone relatively poorly, but levels are probably high enough to exceed the target MICs for bacteria in bone. (5)
Some antibiotic options with parenteral and oral routes of administration include the following: TMP-SMX 4 mg/kg/dose (TMP component) twice daily in combination with rifampin 600 mg once daily (B-II), linezolid 600 mg twice daily (B-II), and clindamycin 600 mg every 8 h (B-III) (1). Some experts recommend the addition of rifampin 600 mg daily or 300–450 mg PO twice daily to the antibiotic chosen above (B-III) (1). Because serum concentrations of rifampin increase dramatically at doses, 450mg/d, prescribing 600 mg once daily should suffice. (12,13) For patients with concurrent bacteremia, rifampin should be added after clearance of bacteremia.
Our patients that receive the PAD-T procedure generally receive four weeks of antibiotics. Clinicians must individualize the duration of antibiotic therapy based on the patient’s clinical and radiographic response, with continued monitoring after cessation of therapy. (3) Surgical resection of necrotic and infected bone, in conjunction with antibiotic therapy, appears to increase the cure rate of chronic osteomyelitis. However, not all cases of chronic osteomyelitis require surgical debridement for cure. (3)
Pediatric considerations
For children with acute hematogenous MRSA osteomyelitis and septic arthritis, IV vancomycin is recommended (A-II) (1). If the patient is stable without ongoing bacteremia or intravascular
infection, clindamycin 10–13 mg/kg/dose IV every 6–8 h (to administer 40 mg/kg/day) can be used as empirical therapy if the clindamycin resistance rate is low (eg, ,10%) with transition to oral therapy if the strain is susceptible (A-II) (1). The exact duration of therapy should be individualized, but typically a minimum3–4-week course is recommended for septic arthritis and a 4–6-week course is recommended for osteomyelitis.
Alternatives to vancomycin and clindamycin include the following: daptomycin 6 mg/kg/day IV once daily (C-III) or linezolid 600 mg PO/IV twice daily for children >12 years of age and 10 mg/kg/dose every 8 h for children ,12 years of age C-III) (1).
Wound care: Negative pressure wound therapy can be a useful adjunct therapy in the salvage of limb threatening diabetic foot infections. (15)
Hyperbaric oxygen therapy: Chronic Refractory Osteomyelitis - The use of adjunctive hyperbaric oxygen therapy for chronic refractory osteomyelitis as adjunctive therapy has been supported to be clinically effective and cost effective, and it is an appropriate use.
Therapy: The type of rehabilitation for osteomyelitis depends on the location of the infected bone. In general, rehabilitation is aimed at restoring normal range of motion, flexibility, strength, and endurance. The goal of rehabilitation for progressive osteomyelitis is to maintain function and enhance mobility.
As strength continues to progress, endurance becomes a focus in the individual's rehabilitation program for osteomyelitis. Aerobic exercises that increase cardiovascular fitness are recommended. The American Heart Association recommends 30 to 60 minutes of aerobic activity 3 or 4 times a week.
Occupational therapy helps individuals arrange their homes and organize their lives in ways that support their physical and mental well-being. Activities are also provided to relieve the mental boredom of inactivity. Devices and techniques that help the individual communicate are invaluable in maintaining peace of mind. The rehabilitation program varies among individuals with progressive osteomyelitis as the intensity and progression of the exercise depends on the stage of the disease and individual's overall health.
Nutrition: Dietary changes alone, though an important consideration when treating your osteomyelitis, may be seriously insufficient in resolving your bone infection. Further scientific research evidence may be needed to determine the true efficacy of foods historically used in treating osteomyelitis.
Diet and nutrition can be an important aspect of a well-rounded osteomyelitis treatment plan. Foods that contain significant amounts of vitamins A, C and E, selenium and zinc may be helpful in treating this health problem. Probiotics -- acidophilus and bifidobacteria -- may also be beneficial in treating osteomyelitis. Avoiding alcohol and increasing your consumption of fresh fruits and vegetables, whole grains and fish are important general dietary strategies in treating this condition.
Spinach may be a beneficial food in treating your osteomyelitis, due to its high vitamin A content. Spinach contains significant amounts of vitamins A, C, E and K, manganese, folate, magnesium, iron, calcium and potassium.
Circulation: Transcutaneous oxygen tension levels can be a decent indicator for healing outcomes and can assist in determination of the appropriate level of amputation in treatment failure.
Surgery: Surgical debridement and drainage of associated soft tissue abscesses is the mainstay of therapy and should be performed whenever feasible (A-II) (1). For septic arthritis drainage or debridement of the joint space should always be performed (A-II) (1).
Prosthetic infection: Remove the implant followed by staged surgical bone debridement, temporary bone void filler with antibiotics, oral/IV antibiotics until there is no further bone destruction on radiographs and negative bone cultures followed by bone grafting.
Caveated osteomyelitis: staged surgical bone debridement, temporary bone void filler with antibiotics, oral/IV antibiotics until there is no further bone destruction on radiographs and negative bone cultures followed by bone grafting. (2)
External fixation may be required for stabilization.
Non caveated osteomyelitis: PAD-T.
Fixation: Rigid external fixation, especially in long bones, is paramount for stabilization and healing when indicated. (14)
References:
1. Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). Clinical Infectious Diseases Advance Access published January 4, 2011
2. Testworth K, Cierny G. Osteomyelitis Debridement Techniques. Clin Ortho and Rel Research. No 360 pp 87-96. 1999.
3. Brad Spellberg, B, Lipsky BA.CLINICAL PRACTICE d CID 2012:54 (1 February) 397-403
4. Graziani AL, Lawson LA, Gibson GA, Steinberg MA, MacGregor RR.
Vancomycin concentrations in infected and noninfected human bone. Antimicrob Agents Chemother 1988; 32:1320–2.
5. Traunmuller F, Schintler MV, Metzler J, et al. Soft tissue and bone
penetration abilities of daptomycin in diabetic patients with bacterial
foot infections. J Antimicrob Chemother 2010; 65:1252–7.
6. Wacha H, Wagner D, Schafer V, Knothe H. Concentration of ciprofloxacin in bone tissue after single parenteral administration to patients older than 70 years. Infection 1990; 18:173–6.
7. Von Baum H, Bottcher S, Abel R, Gerner HJ, Sonntag HG. Tissue and serum concentrations of levofloxacin in orthopaedic patients. Int J Antimicrob Agents 2001; 18:335–40.
8. Centers for Disease Control and Prevention (CDC). Outbreaks of community-associated methicillin-resistant Staphylococcus aureus skin infections–Los Angeles County, California, 2002–2003. MMWR Morb
Mortal Wkly Rep 2003; 52:88.
9. Eady EA, Cove JH. Staphylococcal resistance revisited: communityacquired methicillin resistant Staphylococcus aureus—an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 2003; 16:103–24.
10. Frank AL, Marcinak JF, Mangat PD, et al. Clindamycin treatment of methicillin-resistant Staphylococcus aureus infections in children. Pediatr Infect Dis J 2002; 21:530–4.
11. Bancroft E, Kilgore G, Jones A, et al. Four outbreaks of communityassociated methicillin-resistant Staphylococcus aureus in Los Angeles County. In: The 41st Annual Meeting of the Infectious Disease Society of America. San Diego, CA, 2003.
12. Peloquin CA, Jaresko GS, Yong CL, Keung AC, Bulpitt AE, Jelliffe RW. Population pharmacokinetic modeling of isoniazid, rifampin, and pyrazinamide. Antimicrob Agents Chemother 1997; 41:2670–9. CLINICAL PRACTICE d CID 2012:54 (1 February) d 405
13. Acocella G. Pharmacokinetics and metabolism of rifampin in humans. Rev Infect Dis 1983; 5(Suppl 3):S428–32.
14. Cierny G. Infected Tibia1 Nonunions (1981-1995) The Evolution of Change. CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 360, pp 97-105
15. Kim BS, Choi WJ, Baek MK et. al. Limb Salvage in Severe Diabetic Foot Infection. Foot and Ankle intern. Vol 32 No 1, pp 31-37. 2011
16. Rod-Fleury T, Dunkel N, Assal M e.t al. Duration of post-surgical antibiotic therapy for adult chronic osteomyelitis: a single-centre experience. International Orthopaedics (2011) 35:1725–1731
17. Palestro CJ, Brown ML, Forstrom LA, et. al. Society of Nuclear Medicine Procedure Guideline for 111In-Leukocyte Scintigraphy for Suspected
Infection/Inflammation. Version 3.0, approved June 2, 2004.
Antibiotics: The optimal route of administration of antibiotic therapy has not been established. Parenteral, oral, or initial parenteral therapy followed by oral therapy may be used on individual patient circumstances (A-III) . A minimum 8-week course is recommended (A-II). Some experts suggest an additional 1–3 months (and possibly longer for chronic infection or if debridement is not performed) of oral rifampin-based combination therapy with TMP-SMX, doxycycline-minocycline, clindamycin, or a fluoroquinolone, chosen on the basis of susceptibilities (C-III).
Our patients that receive the PAD-T procedure generally recieve four weeks of antibiotics.
INITIAL EVALUATION
Local and systemic compromise often result in treatment failure and recurrent infections. (2)
1. Laboratory
CBC: WBC count is highly variable and correlates poorly with treatment
A1C: Results from 2 randomized controlled trials, the Diabetes Control and Complication Trial and the United King- dom Prospective Diabetes Study, have shown that rigorous regulation of blood glucose to achieve hemoglobin A1C levels of approximately 7% reduces the risk of microvascu- lar complications in diabetic patients.
Erythrocyte sedimentation rate (ESR): combination with clinical suspicion in diabetic foot infections, the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the presence or absence of bone infection. As the ESR value increased, the positive predictive value increased, showing that the probability of a patient having OM based on ESR alone is greater the higher the ESR value. ESR rises rapidly but declines too slowly to guide treatment.
C-reactive protein (CRP): C-reactive protein is most sensitive to monitor therapeutic response and declines rapidly as the clinical picture improves. Failure of the C-reactive protein to decline after 48 to 72 hours of treatment should indicate that treatment may need to be altered.
SYSTEMIC CONSIDERATIONS
Dialysis: People on kidney dialysis are at higher risk for developing osteomyelitis due to the higher risk of bloodstream infections in these groups.
Diabetes: It has been estimated that approximately 15% to 25% of patients with diabetes will develop a diabetic foot ulcer at some point.1 Among these individuals, 14% to 24% will experience soft tissue infection, undergo an amputation for osteomyelitis, or both. Health care costs associated with diabetic foot ulcers are enormous, with treatment of these wounds accounting for 20% to 25% of all hospitalizations among persons who have diabetes.
DIAGNOSTICS
1. Radiographs: Useful in acute and chronic osteomyelitis as the clinical signs of osteomyelitis such as dense intramedullary sequestrum, endosteal scalloping, or involucrum are present and additional studies are not always needed. When radiographs fail to demonstrate definitive signs of a bone infection additional imaging may be necessary.
2. Nuclear scans: In osteomyelitis, regional or whole-body bone scintigraphy may be used in conjunction with 111In- leukocyte scintigraphy to detect sites of abnormal bone remodeling. Bone marrow scintigraphy using 99mTc-sulfur colloid can be a useful adjunct to assess marrow distribution at suspected osteomyelitis sites, particularly when the site is adjacent to orthopedic hardware and the neuropathic joint. Gallium scinti- graphy is usually preferred in patients with (a) neu-tropenia or (b) nonsuppurative or lymphocyte- mediated infections. 99mTc-HMPAO (exametazime)- labeled leukocyte scintigraphy is a frequently used option for acute infections, particularly in pediatric patients. (17)
2. Computed tomography: Useful for the evaluation of chronically infected united fractures for pre-operative planning in regards to the surgical approach.
3. MRI Magnetic resonance imaging (MRI) with gadolinium is the imaging modality of choice, particularly for detection of early osteomyelitis and associated soft-tissue disease (A-II). Erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) level may be helpful to guide response to therapy (B-III) (1). MRI is useful for determining location and extent of involvement of the bone infection.
4. Blood tests include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and a test for C-reactive protein (CRP). Samples of blood may be cultured in an attempt identify the causative organism and determine antibiotic (or antifungal) sensitivities.
5. Other possible tests include open bone biopsy for a bone culture.
TREATEMNT
Antibiotics:
The optimal route of administration of antibiotic therapy has not been established.
Parenteral, oral, or initial parenteral therapy followed by oral therapy may be used on individual patient circumstances (A-III) (1). The optimal duration of therapy for MRSA osteomyelitis is unknown. Some recommend a minimum 8-week course (A-II) (1). Others recommend six weeks. (16) Some experts suggest an additional 1–3 months (and possibly longer for chronic infection or if debridement is not performed) of oral rifampin-based combination therapy with TMP-SMX, doxycycline-minocycline, clindamycin, or a fluoroquinolone, chosen on the basis of susceptibilities (C-III) (1).
Individuals may be able to receive intravenous (IV) therapy at work if a clean space that permits privacy, equipment to handle infusion, and refrigeration of medication can be made available. A home health nurse may be brought to the workplace to assist in this treatment plan.
Recent studies demonstrate that oral antibiotics can achieve levels in bone that exceed MICs of targeted organisms. Oral antibiotic therapy with highly bioavailable agents is an acceptable alternative to parenteral therapy (3). The widely held preference for parenteral therapy for chronic osteomyelitis is based more on custom than evidence. There are actually fewer published studies of parenteral than oral therapy for osteomyelitis, and success rates are consistently similar for both routes. (3) Adding rifampin to a variety of antibiotic regimens has been shown to improve the cure rates in: animal models, retrospective studies in humans, and randomized clinical trials of chronic osteomyelitis and orthopedic implant infections. (3) In particular, fluoroquinolones, linezolid, and trimethoprim have been found to achieve bone concentrations at 50% of serum (6,7) Other orally available agents to which many community associated strains of methicillin-resistant Staphylococcus aureus (MRSA) are susceptible are doxycycline and clindamycin. (8,9,10,11) Preferred oral agents, based on both pharmacokinetic and clinical data, include fluoroquinolones or TMP-SMX, which achieve high cure rates when administered for 8–16 weeks, particularly in the context of concomitant surgical debridement (3).
Antibiotics available for parenteral administration include IV vancomycin (B-II) and daptomycin 6 mg/kg/dose IV Once daily (B-II) (1). Similar to b-lactam antibiotics, vancomycin penetrates bone poorly. (3,4) Daptomycin also penetrates bone relatively poorly, but levels are probably high enough to exceed the target MICs for bacteria in bone. (5)
Some antibiotic options with parenteral and oral routes of administration include the following: TMP-SMX 4 mg/kg/dose (TMP component) twice daily in combination with rifampin 600 mg once daily (B-II), linezolid 600 mg twice daily (B-II), and clindamycin 600 mg every 8 h (B-III) (1). Some experts recommend the addition of rifampin 600 mg daily or 300–450 mg PO twice daily to the antibiotic chosen above (B-III) (1). Because serum concentrations of rifampin increase dramatically at doses, 450mg/d, prescribing 600 mg once daily should suffice. (12,13) For patients with concurrent bacteremia, rifampin should be added after clearance of bacteremia.
Our patients that receive the PAD-T procedure generally receive four weeks of antibiotics. Clinicians must individualize the duration of antibiotic therapy based on the patient’s clinical and radiographic response, with continued monitoring after cessation of therapy. (3) Surgical resection of necrotic and infected bone, in conjunction with antibiotic therapy, appears to increase the cure rate of chronic osteomyelitis. However, not all cases of chronic osteomyelitis require surgical debridement for cure. (3)
Pediatric considerations
For children with acute hematogenous MRSA osteomyelitis and septic arthritis, IV vancomycin is recommended (A-II) (1). If the patient is stable without ongoing bacteremia or intravascular
infection, clindamycin 10–13 mg/kg/dose IV every 6–8 h (to administer 40 mg/kg/day) can be used as empirical therapy if the clindamycin resistance rate is low (eg, ,10%) with transition to oral therapy if the strain is susceptible (A-II) (1). The exact duration of therapy should be individualized, but typically a minimum3–4-week course is recommended for septic arthritis and a 4–6-week course is recommended for osteomyelitis.
Alternatives to vancomycin and clindamycin include the following: daptomycin 6 mg/kg/day IV once daily (C-III) or linezolid 600 mg PO/IV twice daily for children >12 years of age and 10 mg/kg/dose every 8 h for children ,12 years of age C-III) (1).
Wound care: Negative pressure wound therapy can be a useful adjunct therapy in the salvage of limb threatening diabetic foot infections. (15)
Hyperbaric oxygen therapy: Chronic Refractory Osteomyelitis - The use of adjunctive hyperbaric oxygen therapy for chronic refractory osteomyelitis as adjunctive therapy has been supported to be clinically effective and cost effective, and it is an appropriate use.
Therapy: The type of rehabilitation for osteomyelitis depends on the location of the infected bone. In general, rehabilitation is aimed at restoring normal range of motion, flexibility, strength, and endurance. The goal of rehabilitation for progressive osteomyelitis is to maintain function and enhance mobility.
As strength continues to progress, endurance becomes a focus in the individual's rehabilitation program for osteomyelitis. Aerobic exercises that increase cardiovascular fitness are recommended. The American Heart Association recommends 30 to 60 minutes of aerobic activity 3 or 4 times a week.
Occupational therapy helps individuals arrange their homes and organize their lives in ways that support their physical and mental well-being. Activities are also provided to relieve the mental boredom of inactivity. Devices and techniques that help the individual communicate are invaluable in maintaining peace of mind. The rehabilitation program varies among individuals with progressive osteomyelitis as the intensity and progression of the exercise depends on the stage of the disease and individual's overall health.
Nutrition: Dietary changes alone, though an important consideration when treating your osteomyelitis, may be seriously insufficient in resolving your bone infection. Further scientific research evidence may be needed to determine the true efficacy of foods historically used in treating osteomyelitis.
Diet and nutrition can be an important aspect of a well-rounded osteomyelitis treatment plan. Foods that contain significant amounts of vitamins A, C and E, selenium and zinc may be helpful in treating this health problem. Probiotics -- acidophilus and bifidobacteria -- may also be beneficial in treating osteomyelitis. Avoiding alcohol and increasing your consumption of fresh fruits and vegetables, whole grains and fish are important general dietary strategies in treating this condition.
Spinach may be a beneficial food in treating your osteomyelitis, due to its high vitamin A content. Spinach contains significant amounts of vitamins A, C, E and K, manganese, folate, magnesium, iron, calcium and potassium.
Circulation: Transcutaneous oxygen tension levels can be a decent indicator for healing outcomes and can assist in determination of the appropriate level of amputation in treatment failure.
Surgery: Surgical debridement and drainage of associated soft tissue abscesses is the mainstay of therapy and should be performed whenever feasible (A-II) (1). For septic arthritis drainage or debridement of the joint space should always be performed (A-II) (1).
Prosthetic infection: Remove the implant followed by staged surgical bone debridement, temporary bone void filler with antibiotics, oral/IV antibiotics until there is no further bone destruction on radiographs and negative bone cultures followed by bone grafting.
Caveated osteomyelitis: staged surgical bone debridement, temporary bone void filler with antibiotics, oral/IV antibiotics until there is no further bone destruction on radiographs and negative bone cultures followed by bone grafting. (2)
External fixation may be required for stabilization.
Non caveated osteomyelitis: PAD-T.
Fixation: Rigid external fixation, especially in long bones, is paramount for stabilization and healing when indicated. (14)
References:
1. Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). Clinical Infectious Diseases Advance Access published January 4, 2011
2. Testworth K, Cierny G. Osteomyelitis Debridement Techniques. Clin Ortho and Rel Research. No 360 pp 87-96. 1999.
3. Brad Spellberg, B, Lipsky BA.CLINICAL PRACTICE d CID 2012:54 (1 February) 397-403
4. Graziani AL, Lawson LA, Gibson GA, Steinberg MA, MacGregor RR.
Vancomycin concentrations in infected and noninfected human bone. Antimicrob Agents Chemother 1988; 32:1320–2.
5. Traunmuller F, Schintler MV, Metzler J, et al. Soft tissue and bone
penetration abilities of daptomycin in diabetic patients with bacterial
foot infections. J Antimicrob Chemother 2010; 65:1252–7.
6. Wacha H, Wagner D, Schafer V, Knothe H. Concentration of ciprofloxacin in bone tissue after single parenteral administration to patients older than 70 years. Infection 1990; 18:173–6.
7. Von Baum H, Bottcher S, Abel R, Gerner HJ, Sonntag HG. Tissue and serum concentrations of levofloxacin in orthopaedic patients. Int J Antimicrob Agents 2001; 18:335–40.
8. Centers for Disease Control and Prevention (CDC). Outbreaks of community-associated methicillin-resistant Staphylococcus aureus skin infections–Los Angeles County, California, 2002–2003. MMWR Morb
Mortal Wkly Rep 2003; 52:88.
9. Eady EA, Cove JH. Staphylococcal resistance revisited: communityacquired methicillin resistant Staphylococcus aureus—an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 2003; 16:103–24.
10. Frank AL, Marcinak JF, Mangat PD, et al. Clindamycin treatment of methicillin-resistant Staphylococcus aureus infections in children. Pediatr Infect Dis J 2002; 21:530–4.
11. Bancroft E, Kilgore G, Jones A, et al. Four outbreaks of communityassociated methicillin-resistant Staphylococcus aureus in Los Angeles County. In: The 41st Annual Meeting of the Infectious Disease Society of America. San Diego, CA, 2003.
12. Peloquin CA, Jaresko GS, Yong CL, Keung AC, Bulpitt AE, Jelliffe RW. Population pharmacokinetic modeling of isoniazid, rifampin, and pyrazinamide. Antimicrob Agents Chemother 1997; 41:2670–9. CLINICAL PRACTICE d CID 2012:54 (1 February) d 405
13. Acocella G. Pharmacokinetics and metabolism of rifampin in humans. Rev Infect Dis 1983; 5(Suppl 3):S428–32.
14. Cierny G. Infected Tibia1 Nonunions (1981-1995) The Evolution of Change. CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 360, pp 97-105
15. Kim BS, Choi WJ, Baek MK et. al. Limb Salvage in Severe Diabetic Foot Infection. Foot and Ankle intern. Vol 32 No 1, pp 31-37. 2011
16. Rod-Fleury T, Dunkel N, Assal M e.t al. Duration of post-surgical antibiotic therapy for adult chronic osteomyelitis: a single-centre experience. International Orthopaedics (2011) 35:1725–1731
17. Palestro CJ, Brown ML, Forstrom LA, et. al. Society of Nuclear Medicine Procedure Guideline for 111In-Leukocyte Scintigraphy for Suspected
Infection/Inflammation. Version 3.0, approved June 2, 2004.
