Osteomyelitis
Not yet clinically reviewed
This protocol was migrated from the earlier Pharmapedia and Ward Guide apps for educational use. Follow your hospital's own policies and consult seniors when in doubt.
- Fever associated with pain and tenderness of involved bone
- Diagnosis usually requires culture of bone biopsy
- Elevated ESR and CRP
- Radiographs early in the course are typically negative
Management guidelines of vertebral osteomyelitis
- Urgent management (IDSA 2015, UMHS 2013)
a) If neurologic compromise, impending sepsis, hemodynamically unstable
i) Urgent surgical consultation and intervention
ii) Begin empiric antibiotics
iii) UMHS 2013; Neurological checks every 4 hours while hospitalized
2. Antibiotics (DSA 2015)
a) If normal, stable neurologic exam and hemodynamics, hold empiric antibiotics untill organism identified (may be up to 1-2 weeks).
b) If unstable, i.e., septic, in septic shock, sever or progressive neurologic deficits start empiric antibiotics while obtaining cultures / serologies ( DSA 2015 , UMHS 2013 )
c) Specific antibiotic recommendations.
3. Duration of therapy ( DSA 2015 )
a) Treat most bacterial VO with total of 6 weeks parenteral or highly bioavailable oral antibiotics
b) Treat Brucella VO for 3 months
c) See organism - specific guidelines for treatment of fungal or mycobacteril
Management after Stabilization ( 2015 )
- Monitor ESR and / or CRP after 4 weeks of antibiotics
- Assess regularly for change in clinical status
- Determining treatment failure
a) Not necessarily treatment failure if there is persistent pain, residual neurologic defects, elevated ESR / CRP , or findings on imaging
b) Suspect treatment failure if: Unchanged or increasing ESR / CRP after 4 weeks of treatment (patients with 50 % reduction in ESR after 4 weeks rarely develop treatment failure) Persistent or progressive pain, systemic symptoms of infection
4. if treatment failure suspected
a) Repeat MRI, attention to paraspinal and epidural soft tissue
b) If clinical or MRI evidence of treatment failure, repeat aspiration or surgical biopsy to test for cultures, histology, and changes pathology
c) If persistent or recurrent bloodstream infection without other source, or worsening pain, consult surgery for debridement with or without stabilization
d) Do not perform surgical debridement for bony imaging findings alone in a patient who is improving clinically ( symptoms, physical exam , and inflammatory markers )