Chronic Osteomyelitis

Clinical Description

These are usually from inadequately treated acute episodes, which include acute osteomyelitis and acute-on-chronic osteomyelitis. Some may arise from the onset as a chronic infection due to mycobacteria or fungi. The patient is usually not ill-looking unless there is an acute exacerbation.

Causes

• Acute bacterial infections of bone and joints
• Mycobacterium tuberculosis and fungal infections
• Infected orthopedic implants
• Iatrogenic

Signs and Symptoms

• Infection may remain quiescent, with acute or sub−acute exacerbations which manifest as discharging sinuses.
• X−ray features: periosteal reaction, new bone formation(involucrum), dead bone (sequestrum), bone abscesses, rarefaction of bone.

Investigations

• As per acute osteomyelitis

Treatment

• Surgical treatment by sequestrectomy when an adequate involucrum has formed
• Antibiotic treatment for febrile flare-ups of infection as for acute osteomyelitis.

Pharmacological

Adults

• Flucloxacillin 500 mg 6 hourly IV for 2-4 weeks

Children

• Flucloxacillin
• 5-12 years; 250 mg 6 hourly for 2-4 weeks
• 1-5 years; 125 mg 6 hourly for 2-4 weeks
• < 1 year; 62.5 mg 6 hourly for 2-4 weeks

And

Adults

• Ciprofloxacin 400 mg IV 8-12 hourly for 14 days (to be infused over 60 minutes)

Children

• Ciprofloxacin 10 mg/kg 12 hourly for 14 days (to be infused over 60 minutes)

In patients with penicillin sensitivity

Adults

• Clindamycin 300 mg 6 hourly for 7 days IV

Children

• Clindamycin 3-6 mg/kg 6 hourly for 7 days

Or

Adults

• Ciprofloxacin 400 mg 8-12 IV hourly for 14 days (to be infused over 60 minutes)

Children

• Ciprofloxacin 10 mg/kg 12 hourly for 14 days (to be infused over 60 minutes)

Or

Adults

• Augmentin 1.2 g 12 hourly IV (Increased to 1.2 g 8 hourly for 7 days in severe infections)

Children

• Augmentin
• 12-18 years; 600 mg to 1.2 g 12 hourly (Increased to 1.2 g 8 hourly for 7 days in severe infections )
• 3 months-12 years; 30 mg/kg 12 hourly (Increased to 30 mg/kg 8 hourly for 7 days in severe infections)
• 7 days-3 months; 30 mg/kg 8 hourly for 7 days
• Preterm and < 7 days; 30 mg/kg 12 hourly for 7 days

And

Adults

• Ciprofloxacin 400 mg 8-12 IV hourly for 14 days (to be infused over 60 minutes)

Children

• Ciprofloxacin 10 mg/kg 12 hourly for 14 days (to be infused over 60 minutes)
• Antibiotic cover for surgery as appropriate after culture and sensitivity testing
• Antibiotic impregnated cement spacer indicated for local control of infection
• Give Ibuprofen 400mg 8 hourly after food

Alternatively:

• Give Aspirin 10mg/kg every 8hrs, preferably after food, up to an adult maximum of 600 mg per dose
• For children, give Paracetamol instead of Aspirin