Diagnosis and Management of Osteomyelitis -- American Family Physician

Clinical Description Acute hematogenous osteomyelitis occurs predominantly in children, with the metaphysis of long bones the most common location. Patients usually present within several days to one week after the onset of symptoms. In addition to local signs of inflammation and infection, patients have signs of systemic illness, including fever, irritability and lethargy. Typical clinical findings include tenderness over the O steomyelitis is an inflammation of bone caused by a pyogenic organism. Historically, osteomyelitis has been categorized as acute, subacute or chronic, with the presentation of each type based on the time of disease onset (i.e., occurrence of infection or injury). Acute osteomyelitis develops within two weeks after disease onset, subacute osteomyelitis within one to several months and chronic osteomyelitis after a few months. Because osteomyelitis is a complex disease state, various classification systems have emerged beyond the general categories of acute, subacute and chronic. The Waldvogel classification system divides osteomyelitis into the categories of hematogenous, contiguous and chronic (Table 1). The more recent CiernyMader staging system is based on the status of the disease process, not etiology, chronicity or other factors (Table 2). The terms “acute” and “chronic”are not used in the Cierny-Mader system. The stages in this system are dynamic and may be altered by changes in the medical condition of the patient (host), successful antibiotic therapy and other treatments. Although the classification systems for osteomyelitis help describe the infection and determine the need for surgery, the categories do not apply to special circumstances (i.e., Acute osteomyelitis is the clinical term for a new infection in bone. This infection occurs predominantly in children and is often seeded hematogenously. In adults, osteomyelitis is usually a subacute or chronic infection that develops secondary to an open injury to bone and surrounding soft tissue. The specific organism isolated in bacterial osteomyelitis is often associated with the age of the patient or a common clinical scenario (i.e., trauma or recent surgery). Staphylococcus aureus is implicated in most patients with acute hematogenous osteomyelitis. Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, Serratia marcescens and Escherichia coli are commonly isolated in patients with chronic osteomyelitis. For optimal results, antibiotic therapy must be started early, with antimicrobial agents administered parenterally for at least four to six weeks. Treatment generally involves evaluation, staging, determination of microbial etiology and susceptibilities, antimicrobial therapy and, if necessary, debridement, dead-space management and stabilization of bone. (Am Fam Physician 2001;63:2413-20.) Diagnosis and Management of Osteomyelitis