Recommendations for the treatment of osteomyelitis

Recommendations for the treatment of osteomyelitis

I. Which classification should be used?
1. An ideal classification of osteomyelitis should considerthe different aspects that influence its pathophysiology, addressing all the possible etiologies and parameters of temporal evolution. It should also be closely correlated with the histological data and should include proposals for the treatment of each classification stage. In general, the Waldvogel classification is recommended for its greater clinical applicability,and the Cierny and Mader classification3 for its clearly defined surgical treatment proposals (Tables 1 and 2).

II. Which subsidiary tests are important for the diagnosis of osteomyelitis?
2. The diagnosis of osteomyelitis considers a range of clinical signs and symptoms, laboratory tests, imaging studies and histological analyses, as well as the identification of pathogens by means of bone tissue or blood cultures.
3. In terms of laboratory tests, serum leukocyte count and inflammatory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), can assist in the initial diagnosis of osteomyelitis. However, these are non-specific tests and are more useful in the control
of treatment.
4. The histology of biological samples should be carried out in all suspect cases, and bone biopsy, soft tissue, and bone sequestra can confirm the diagnosis of osteomyelitis.
5. A definitive diagnosis of osteomyelitis is obtained with microbiological identification of the pathogen in bone,through a bone biopsy. Samples obtained through swabs of the fistula or secretions for use in cultures will result in false positive results, as they identify microorganisms that colonize the skin. At least three different samples of bone tissue should be obtained, in order to increase the positivity of the test. Antimicrobial therapy should be started after collecting culture samples or at the same time as anesthetic induction. Patients should stop any antibiotics two weeks before collecting culture samples, if possible. In cases of osteomyelitis with osteosynthesis or in infected arthroplasties, sonication of the implants significantly increases the identification of pathogens.
6. The use of complementary imaging methods can be important in the early diagnosis of osteomyelitis. It can also assist in rapid start of treatment and followup, enabling ineffective treatments to be modified. In acute osteomyelitis, a plain radiography shows osteomyelitis only after two weeks. Magnetic resonance imaging (RMI) is considered the main type of imaging in the evaluation of bone infections, as it can detect osteomyelitis as early as three to five days of infection. Computed tomography (CT) is of little use in the diagnosis of acute infection, but is important for investigating bone sequestra and planning surgery. Three-phase bone scintigraphy, scintigraphy with Gallium-67 and the positron emission tomography (PET-CT) are examinations that help in the differentiation of doubtful cases.

III. What are the recommendations for the treatment of osteomyelitis?
7. The success of osteomyelitis treatment, particularly in cases related to implants, is closely linked to extensive surgical debridement and adequate antibiotic therapy.

8. Starting empirical antibiotics in anesthetic induction prevents the risks of bacteremia arising from surgical manipulation of infection without adequate antibiotic coverage. Yet, it does not interfere with the positivity of cultures taken during the procedure. Empirical antibiotic can also be started after collecting culture samples in non-septic patients.
9. Empirical coverage of Staphylococcus aureus is recommended, given the epidemiological importance of this agent. The local prevalence of methicillin resistance,even in community-acquired cases, is variable and should also be observed.
10. Acute infections can be treated initially with extensive surgical cleaning associated with antibiotic therapy lasting four to six weeks. Chronic infections should be treated with extensive surgical debridement, removal of any implants and antibiotic therapy lasting three to six months.

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