Diagnosis and Management

of Osteomyelitis
JOHN HATZENBUEHLER, MD, and THOMAS J. PULLING, MD, Maine Medical Center, Portland, Maine

The incidence of chronic osteomyelitis is increasing because of the prevalence of predisposing conditions such as dia-
betes mellitus and peripheral vascular disease. The increased availability of sensitive imaging tests, such as magnetic
resonance imaging and bone scintigraphy, has improved diagnostic accuracy and the ability to characterize the infec- tion.
Plain radiography is a useful initial investigation to identify alternative diagnoses and potential complications. Direct
sampling of the wound for culture and antimicrobial sensitivity is essential to target treatment. The increased
incidence of methicillin-resistant Staphylococcus aureus osteomyelitis complicates antibiotic selection. Surgical
debridement is usually necessary in chronic cases. The recurrence rate remains high despite surgical intervention
and long-term antibiotic therapy. Acute hematogenous osteomyelitis in children typically can be treated with a four-
week course of antibiotics. In adults, the duration of antibiotic treatment for chronic osteomyelitis is typically
several weeks longer. In both situations, however, empiric antibiotic coverage for S. aureus is indicated. (Am Fam
Physician. 2011;84(9):1027-1033. Copyright © 2011 American Academy of Family Physicians.)
Insiden osteomielitis kronis meningkat karena prevalensi kondisi predisposisi
seperti diabetes mellitus dan penyakit vaskular perifer. Meningkatnya
ketersediaan tes pencitraan sensitif, seperti pencitraan resonansi magnetik dan
skintigrafi tulang, telah meningkatkan akurasi diagnostik dan kemampuan untuk
mengkarakterisasi infeksi. Radiografi polos adalah pemeriksaan awal yang
berguna untuk mengidentifikasi diagnosis alternatif dan potensi komplikasi.
Pengambilan sampel luka secara langsung untuk kultur dan sensitivitas
antimikroba sangat penting untuk pengobatan target. Peningkatan insiden
Staphylococcus aureus osteomyelitis yang resisten terhadap methicillin
mempersulit pemilihan antibiotik. Debridemen bedah biasanya diperlukan pada
kasus kronis. Tingkat kekambuhan tetap tinggi meskipun telah dilakukan
intervensi bedah dan terapi antibiotik jangka panjang. Osteomielitis hematogen
akut pada anak-anak biasanya dapat diobati dengan antibiotik selama empat
minggu. Pada orang dewasa, durasi pengobatan antibiotik untuk osteomielitis
kronis biasanya beberapa minggu lebih lama. Namun, dalam kedua situasi
tersebut, cakupan antibiotik empiris untuk S. aureus diindikasikan. (Am Fam
Physician. 2011; 84 (9): 1027-1033. Hak Cipta © 2011 American Academy of Family
Physicians.)
Osteomyelitis is generally cat- egorized as acute or chronic based on histopathologic find- ings, rather than duration of
the infection. Acute osteomyelitis is associated with inflammatory bone changes caused by pathogenic bacteria, and
symptoms typically present within two weeks after infection. Necrotic bone is present in chronic osteo- myelitis, and
symptoms may not occur until six weeks after the onset of infection. 1 Fur- ther classification of osteomyelitis is based
on the presumed mechanism of infection (e.g., hematogenous or direct inoculation of bacteria into bone from
contiguous soft tissue infection or a chronic overlying open wound). 2 The more complex Cierny-Mader classification
system was developed to help guide surgical management, but is generally not used in primary care.3
Osteomielitis umumnya digolongkan sebagai akut atau kronis berdasarkan
temuan-temuan sejarah, bukan lamanya infeksi itu terjadi. Osteomyelitis akut
dikaitkan dengan perubahan pada tulang yang disebabkan oleh bakteri patogen,
dan gejalanya biasanya muncul dalam waktu dua minggu setelah infeksi. Tulang
nekrotik muncul dalam osteomielitis kronis, dan gejalanya baru muncul enam
minggu setelah munculnya infeksi. 1 klasifikasi lebih lanjut tentang osteomielitis
didasarkan atas apa yang diduga sebagai mekanisme infeksi (misalnya,
hematoatau imunisasi langsung bakteri ke dalam tulang karena infeksi jaringan
lunak kontigous atau luka terbuka kronis yang overturn). 2 sistem klasifikasi sipil
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 yang lebih kompleks dikembangkan untuk membantu membimbing pengelolaan
bedah, tetapi umumnya tidak digunakan dalam perawatan pratama.3
Etiology
The most common pathogens in osteomyeli- tis depend on the patient’s age. Staphylococ- cus aureus is the most
common cause of acute and chronic hematogenous osteomyelitis in adults and children. Group A streptococ- cus,
Streptococcus pneumoniae, and Kingella kingae are the next most common pathogens in children. Group B streptococcal
infection occurs primarily in newborns.4 In adults,
S. aureus is the most common pathogen in bone and prosthetic joint infections. Increas- ingly, methicillin-
resistant S. aureus (MRSA) is isolated from patients with osteomyelitis. In some studies, MRSA accounted
for more than one-third of staphylococcal isolates. 5 In more chronic cases that may be caused by
contiguous infection, Staphylococcus epi- dermidis, Pseudomonas aeruginosa, Serratia marcescens, and
Escherichia coli may be iso- lated. Fungal and mycobacterial infections have been reported in patients with
osteo- myelitis, but these are uncommon and are generally found in patients with impaired immune function.6
Etiologi
patogen paling umum di osteomyelitis bergantung pada umur pasien.
Staphylococcus aureus adalah penyebab yang paling umum dari osteomielitis
hematogen akut dan kronis pada orang dewasa dan anak-anak. Grup A
streptococcus, streptococcus pneumoniae, dan Kingella kingae adalah patogen
paling umum berikutnya pada anak-anak. Infeksi streptokus grup B terutama terjadi
pada bayi yang baru lahir. 4 pada orang dewasa, S. aureus adalah patogen paling
umum dalam tulang dan infeksi sendi prostetik. Para pasien yang menderita
osteomielitis semakin kebal terhadap metil. Aureus (MRSA). Dalam beberapa
penelitian, MRSA mencakup lebih dari sepertiga staphylococcal isolat. 5 dalam
kasus-kasus yang lebih kronis, Staphylococcus epidermidis, Pseudomonas
aeruginosa, Serratia marcescens, dan Escherichia coli mungkin terisolasi. Infeksi
jamur dan bakteri telah dilaporkan pada pasien dengan osteo- myelitis, tetapi ini
tidak umum dan umumnya ditemukan pada pasien dengan kerusakan fungsi
kekebalan tubuh.6
Clinical Features
Acute hematogenous osteomyelitis results from bacteremic seeding of bone. Children are most often affected because
the meta- physeal (growing) regions of the long bones are highly vascular and susceptible to even minor trauma. More
than one-half of cases of acute hematogenous osteomyelitis in chil- dren occur in patients younger than five years.7
Children typically present within two weeks of disease onset with systemic symp- toms, including fever and irritability,
as well as local erythema, swelling, and tenderness over the involved bone. 8 Chronic osteomy- elitis in children is
uncommon.9
Chronic osteomyelitis is generally sec- ondary to open fractures, bacteremia, orcontiguous soft issue infection. The
incidence of significant infection within three months after an open fracture has been reported to be as high as 27
percent.10 The incidence appears to be independent of the length of time from the injury to surgery.10 Only 1 to 2
percent of prosthetic joints become infected.11
Hematogenous osteomyelitis is much less common in adults than in children. It typi- cally involves the vertebrae,
but can occur in the long bones, pelvis, or clavicle. Patients with vertebral osteomyelitis often have underlying medical
conditions (e.g., diabetes mellitus, cancer, chronic renal disease) or a history of intravenous drug use. 12 Back pain is the
primary presenting symptom.
Chronic osteomyelitis from contiguous soft tissue infection is becoming more common because of the increasing
prevalence of dia- betic foot infections and peripheral vascular disease. Up to one-half of patients with dia- betes develop
peripheral neuropathy, which may reduce their awareness of wounds and increase the risk of unrecognized infections.13
Peripheral vascular disease, which is also common in patients with diabetes, reduces the body’s healing response and
contributes to chronically open wounds and subsequent soft tissue infection. These conditions may act synergistically to
significantly increase the risk of osteomyelitis in these patients.14Clinical symptoms of osteomyelitis can be nonspecific
and difficult to recognize. They include chronic pain, persistent sinus tract or wound drainage, poor wound healing,
malaise, and sometimes fever.

Gejala klinis
osteomielitis akut akibat penggumpalan tulang di pinggang. Anak-anak
paling sering terkena dampak ini karena daerah metaphyseal (tumbuh) pada
tulang yang panjang sangat vaskular dan rentan terhadap trauma bahkan kecil.
Lebih dari setengah kasus osteomielitis akut pada anak-anak terjadi pada pasien
yang usianya lebih dari lima tahun. 7 dalam waktu dua minggu, anak-anak
biasanya mengidap gejala sistemis, termasuk demam dan mudah marah, juga
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eritthema setempat, pembengkakan, dan kelembutan pada tulang yang
bersangkutan. 8 osteomielitis kronis jarang dialami anak-anak. 9
osteomielitis kronis umumnya tidak gampang patah tulang, bacteremia, atau
kontiguous soft issue. Kasus infeksi yang signifikan dalam tiga bulan setelah
terbuka retakan telah dilaporkan setinggi 27 persen. 10 peristiwa ini tampaknya
tidak berkaitan dengan panjangnya sejak cedera hingga pembedahan. 10 hanya
1 sampai 2 persen sendi prostetik yang terinfeksi. 11
osteomielitis, penyakit hematoid, jauh lebih jarang didapati pada orang
dewasa daripada pada anak-anak. Ini biasanya mencakup tulang belakang, tetapi
dapat terjadi pada tulang yang panjang, pinggul, atau tulang selangka. Para
pasien dengan osteomielitis vertebral sering kali memiliki problem kesehatan
yang mendasarinya (misalnya, diabetes melitus, kanker, penyakit keturunan
kronis) atau sejarah penggunaan obat lewat jarum suntik. 12 nyeri punggung
adalah gejala yang paling utama.
Osteomielitis kronis akibat infeksi jaringan lunak contiguous menjadi lebih
umum karena meningkatnya meluasnya infeksi kaki betik dan penyakit
pembuluh darah tepi. Hingga setengah pasien dengan dia- betes
mengembangkan uropati perifer, yang dapat mengurangi kesadaran mereka
akan luka dan meningkatkan risiko infeksi yang tidak dikenali. 13 penyakit
pembuluh darah tepi, yang juga umum terjadi pada pasien diabetes, mengurangi
respons penyembuhan tubuh dan turut menyebabkan luka yang terbuka secara
kronis serta infeksi jaringan lunak setelahnya. Kondisi ini mungkin bertindak
secara sinergis untuk secara signifikan meningkatkan risiko osteomielitis pada
pasien ini. 14 gejala osteomielitis yang klinis dapat tidak spesifik dan sulit
dikenali. Ini mencakup rasa sakit yang kronis, saluran sinus yang terus-menerus
atau drainase luka, penyembuhan luka yang buruk, malaise, dan kadang-kadang
demam.
SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidenc
Clinical recommendation e rating References

The preferred diagnostic criterion for C 17, 21

osteomyelitis is a positive bacterial culture
from bone biopsy in the setting of bone
necrosis.
Magnetic resonance imaging is as sensitive as C 27-30
and more specific than bone scintigraphy in
the diagnosis of osteomyelitis.
Parenteral followed by oral antibiotic B 31, 36
therapy is as effective as long-term
parenteral therapy for the treatment of
chronic osteomyelitis in adults.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-

quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual
practice, expert opinion, or case series. For information about the SORT evidence
rating system, go to http://www.aafp.org/afpsort.xml.

Diagnosis
Acute osteomyelitis in children is primarily a clinical diagnosis based on the rapid onset and localization of
symptoms. Systemic symptoms such as fever, lethargy, and irritability may be present. The physical exami- nation
should focus on identifying common findings, such as erythema, soft tissue swelling or joint effusion, decreased
joint range of motion, and bony tenderness. The iden- tification of a bacterial infection may be dif- ficult because
blood cultures are positive in only about one-half of cases.15 Because of the difficulty of diagnosis, the potential
severity of infection in children, the high disease recurrence rate in adults, and the possible need for surgical
intervention, consultation with an infectious disease subspecialist and an orthopedic subspecialist or plastic sur-
geon is advised.16
The diagnosis of osteomyelitis in adults can be difficult. A high index of clinical suspicion is required, along with
recognition of clinical symptoms and supportive laboratory and imaging studies (Table 1).17 The initial evaluation
should include questions to determine the patient’s history of systemic symptoms (e.g., lethargy, malaise,
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 extremity or back pain, fever) and predisposing factors (e.g., dia- betes, peripheral vascular disease, history of
trauma or intravenous drug use). The physical examination should focus on locating a possible nidus of infection,
assessing peripheral vascular and sensory function, and exploring any ulcers for the presence of bone. If a
contiguous infection with ulcer is present, such as in diabetic foot infections, the use of a ster- ile steel probe to
detect bone may be helpful in confirming the presence of osteomyelitis. Although a 1995 study found that this test
had a positive predictive value of 89 percent,18 a more recent study in a population with a lower prevalence of
osteomyelitis found a positive predictive value of only 57 percent.19
Laboratory investigations can be helpful, but generally lack specificity for osteomyeli- tis. Leukocytosis and
increased erythrocyte sedimentation rate and C-reactive protein levels may be present. These inflammatory markers
are especially likely to be elevated in children with acute osteomyelitis. A persistently normal erythrocyte
sedimentation rate and C-reactive protein level virtually rule out osteomyelitis.20 The C-reactive protein level
correlates with clinical response to therapy and may be used to monitor treatment.8
Microbial cultures are essential in the diagnosis and treatment of osteomyelitis. The preferred diagnostic criteria
for osteo- myelitis are a positive culture from bone biopsy and histopathology consistent with necrosis.17,21 Few
studies have assessed treat- ment outcomes based primarily on bone biopsy results. Positive blood cultures may
obviate the need for a bone biopsy, especially when they are combined with substantial clinical or radiographic
evidence of osteo- myelitis. Superficial wound cultures do not contribute significantly to the diagnosis of
osteomyelitis; the organisms identified by such cultures correspond with bone biopsy culture results in only about
one-third of cases.22 Chronic infections are more likely to have polymicrobial involvement, includ- ing anaerobic,
mycobacterial, and fungal organisms. Specific cultures or microbio- logic testing may be required for suspected
pathogens.23
Diagnosis
Osteomyelitis akut pada anak-anak khususnya adalah Diagnosis klinis yang
didasarkan atas timbulnya gejala-gejala yang cepat dan lokalisasi. Gejala - gejala
sistemis seperti demam, kelesuan, dan mudah marah mungkin ada. Exami — nation
secara fisik harus memusatkan perhatian pada mengenali temuan-temuan umum,
seperti eritema, pembengkakan jaringan lunak atau fusi sendi, berkurangnya
jangkauan gerak sendi, dan kelembutan tulang. Identifikasi utama infeksi bakteri
mungkin dif- ficult karena kultur darah positif dalam setengah kasus saja. 15 karena
sulit didiagnosis, tingkat kekambuhan penyakit tinggi pada anak, tingkat kekambuhan
penyakit pada orang dewasa, dan perlunya campur tangan dalam pembedahan,
berkonsultasi dengan spesialis penyakit menular dan spesialis spesialis ortopedi atau
spesialis plastik disarankan. 16
Diagnosis osteomielitis pada orang dewasa bisa jadi sulit. Diperlukan indeks
kecurigaan klinis yang tinggi, disertai dengan pengakuan terhadap gejala-gejala klinis
dan dukungan penelitian laboratorium dan pencitraan (tabel 1). 17 pemeriksaan awal
hendaknya mencakup pertanyaan untuk menentukan sejarah pasien atas gejala
sistemis (misalnya, kelesuan, malaise, kelelahan atau sakit punggung, demam) dan
faktor penentu (misalnya, diabetes, penyakit pembuluh darah tepi, riwayat trauma atau
penggunaan obat lewat jarum suntik). Pemeriksaan fisik harus fokus untuk mencari
kemungkinan nidus dari infeksi, menilai fungsi pembuluh darah tepi dan sensorik, dan
menjelajahi bisul apapun untuk kehadiran tulang. Jika infeksi yang kongtikus dengan
borok ada, seperti infeksi kaki diabetes, penggunaan alat penyelidik logam ster untuk
mendeteksi tulang mungkin berguna untuk memastikan adanya osteomielitis.
Meskipun sebuah studi tahun 1995 menemukan bahwa tes ini memiliki nilai prediktif
positif 89 persen,18 studi yang lebih baru dalam populasi dengan tingkat yang lebih
rendah dari osteomielitis menemukan nilai prediksi positif hanya 57 persen.19
Investigasi laboratorium dapat membantu, tetapi umumnya kurang spesifik
untuk osteomyeli- tis. Leukocytosis dan peningkatan laju sedimentasi eritrosit dan
tingkat protein c-reaktif mungkin ada. Peradangan ini kemungkinan besar akan
meningkat pada anak-anak yang menderita osteomielitis akut. Tingkat sedimentasi
eritrosit yang normal dan tingkat protein c-reaktif secara terus-menerus hampir
mencegah osteomielitis. 20 kadar protein c — reaktif berkorelasi dengan respons
klinis terhadap terapi dan dapat digunakan untuk memonitor pengobatan.8
Kultur mikroba sangat penting dalam diagnosis dan pengobatan osteomielitis.
Kriteria diagnosis utama untuk osteomyelitis adalah kultur positif dari biopsi tulang
dan histopatologi konsisten dengan nekrosis. 17,21 beberapa studi telah menilai hasil
perawatan - ment terutama berdasarkan hasil biopsi tulang. Budaya darah positif
mungkin meniadakan biopsi tulang, khususnya jika dikombinasikan dengan bukti
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klinis atau radiografi yang substansial tentang osteo- myelitis. Kultur luka ringan tidak
banyak berperan dalam diagnosis osteomielitis; Organisme yang diidentifikasi oleh
budaya seperti itu bersesuaian dengan budaya biopsi tulang hanya menghasilkan
sekitar sepertiga kasus. 22 infeksi kronis lebih besar kemungkinannya terkena
keterlibatan polimicrobia, termasuk anaerobik, mikobakteria, dan organisme fungi.
Budaya atau pengujian mikrobio - logika tertentu mungkin diperlukan untuk patogen
diduga.23
Table 1. Diagnostic Criteria for Table 2. Diagnostic Imaging Studies for Osteomyelitis
Chronic Osteomyelitis
Sensitivity Specificit
Imaging modality (%) y (%) Comments
Imaging studies (e.g., plain radiography,
magnetic resonance imaging, bone
Computed 67 50 Generally should not be used in
scintigraphy) demonstrating contiguous soft
tomography osteomyelitis evaluation
tissue infection or bony destruction
Leukocyte 61 to 84 60 to 68 Combining with
Clinical signs
scintigraphy technetium-99 bone
Exposed scintigraphy can increase
bone specificity
Persistent sinus tract Magnetic resonance 78 to 90 60 to 90 Useful to distinguish
Tissue necrosis overlying bone imaging between soft tissue
and bone infection,
Chronic wound overlying surgical hardware
and to determine
Chronic wound overlying fracture extent of infection;
Laboratory evaluation less useful in locations
Positive blood cultures of surgical hardware
Elevated C-reactive protein level because of image
distortion
Elevated erythrocyte sedimentation rate
Plain radiography 14 to 54 68 to 70 Preferred imaging modality;
NOTE: Items listed in order of decreasing diagnostic (anteroposterior, useful to rule out other
ability for osteomyelitis. If osteomyelitis is suspected, lateral, and oblique pathology
a bone biopsy with bacterial culture should be consid- views)
ered for definitive diagnosis.
Positron emission 96 91 Expensive; limited availability
Information from reference 17. tomography
Technetium-99 bone 82 25 Low specificity, especially if
scintigraphy patient has had recent
trauma or surgery; useful
to differentiate
osteomyelitis from
cellulitis, and in patients
in whom magnetic resonance
imaging is contraindicated
Information from references 24 through 30.

IMAGING
Imaging is useful to characterize the infec- tion and to rule out other potential causes of symptoms. Plain
radiography, technetium-99 bone scintigraphy, and magnetic reso- nance imaging (MRI) are the most useful
modalities (Table 224-30). Plain radiographyusually does not show abnormalities caused by osteomyelitis until about
two weeks after the initial infection, when nearly 50 percent of the bone mineral content has been lost.24 Typical
findings include non- specific periosteal reaction and osteolysis (Figure 1). Plain radiography is a useful first step that
may reveal other diagnoses, such as metastases or osteoporotic fractures. It generally complements information pro-
vided by other modalities and should not be omitted, even if more advanced imaging is planned.25
The role of computed tomography in the diagnosis of osteomyelitis is limited. Although computed tomography is
superior to MRI in detecting necrotic fragments of bone, its overall value is generally less than that of other
imaging modalities. Computed tomography should be used only to deter- mine the extent of bony destruction (espe-
cially in the spine), to guide biopsies, or in patients with contraindications to MRI.26
MRI provides better information for early detection of osteomyelitis than do other imaging modalities (Figure 2). MRI
can detect osteomyelitis within three to five days of disease onset.24 Most studies of the diag- nostic accuracy of MRI in
detecting osteo- myelitis included patients with diabetic foot ulcers.27 The sensitivity and specificity of MRI in the
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 diagnosis of osteomyelitis may be as high as 90 percent.28,29 Because MRI can also detect necrotic bone, sinus tracts, or
abscesses, it is superior to bone scintigra- phy in diagnosing and characterizing osteo- myelitis.28 Its use can be limited,
however, if surgical hardware is present.
Nuclear imaging can be helpful in diag- nosing osteomyelitis (Figure 3). Three-phase technetium-99 bone
scintigraphy and leuko- cyte scintigraphy are usually positive within a few days of the onset of symptoms.24 The
sensitivity of bone scintigraphy is compa- rable to MRI, but the specificity is poor. Leukocyte scintigraphy also
has poor speci- ficity, but when combined with three-phase bone scintigraphy, sensitivity and specificity are
improved.29 Bone and leukocyte scintig- raphy can provide valuable information if MRI is contraindicated or
unavailable. 30
Other imaging modalities seem promising for the diagnosis of osteomyelitis, but they are not routinely used. Positron
emission tomography has the highest sensitivity and specificity—more than 90 percent—but it is expensive and not as
widely available as other modalities. 29 The role of musculoskeletal ultrasonography in the diagnosis of osteomy- elitis is
evolving. Some studies suggest that in some patients, such as those with sickle cell disease, detection of subperiosteal
fluid col- lections can be useful or even diagnostic; however, reliable estimates of sensitivity and specificity are lacking.26
Pencitraan
Pencitraan berguna untuk mencirikan penyakit menular dan untuk
menyingkirkan penyebab gejala potensial lainnya. Radiografi biasa, scintigrafi
technetium-99, dan magnetic reso- nance pencitraan (MRI) adalah modalitas
yang paling berguna (tabel 224-30). Radiografi biasa biasanya tidak
memperlihatkan ketidaknormalan yang disebabkan oleh osteomielitis hingga
kira-kira dua minggu setelah infeksi awal itu, sewaktu hampir 50 persen
kandungan mineral pada tulang telah hilang. 24 temuan khas mencakup reaksi
dan osteopsis berkala (gambar 1). Radiografi sederhana adalah langkah pertama
yang berguna yang dapat menyingkapkan diagnosis lain, seperti metastasis atau
patah tulang osteoporosis. Ini secara umum melengkapi informasi yang
didukung oleh modalitas lainnya dan hendaknya tidak dihilangkan, bahkan jika
pencitraan yang lebih maju direncanakan.25
Peranan komputerisasi tomografi dalam diagnosis osteomyelitis terbatas.
Meskipun computed tomography lebih unggul dari MRI untuk mendeteksi
fragmen-fragmen tulang yang nekrotik, nilai keseluruhannya secara keseluruhan
lebih rendah daripada nilai modalitas pencitraan lainnya. Computed tomography
hendaknya digunakan hanya untuk mencegah — menambang sejauh kerusakan
tulang (espe- khususnya di tulang belakang), untuk memandu biopsi, atau pada
pasien dengan kontraksi hingga mrien.26
MRI menyediakan informasi yang lebih baik untuk deteksi awal osteomiitis
daripada modalitas pencitraan lainnya (gambar 2). MRI dapat mendeteksi
osteomyelitis dalam waktu tiga sampai lima hari sejak awal penyakit. 24
kebanyakan penelitian atas akurasi diagnosis dan nostik MRI untuk mendeteksi
osteo- myelitis mencakup para pasien dengan infeksi kaki diabetes. 27
sensitivitas dan spesifisitas MRI dalam diagnosis osteomyelitis mungkin
setinggi 90 persen. 28,29 karena MRI dapat juga mendeteksi sistem saraf tulang,
saluran sinus, atau abses, MRI lebih unggul daripada sumsum tulang untuk
mendiagnosis dan mencirikan osteomyelitis. 28 namun, penggunaannya bisa
jadi terbatas jika ada alat bedah.
Pencitraan nuklir dapat berguna dalam diag- nosing osteomyelitis (gambar 3).
Teknologi tiga fase — 99 scintigrafi tulang dan leuko- cyte scintigrafi biasanya
positif dalam beberapa hari setelah gejalanya muncul. 24 sensitivitas bintigrafi
tulang bisa diatasi dengan MRI, tetapi spesifikasinya buruk. Scintigrafi
Leukocyte juga memiliki speci yang rendah - ficity, tetapi jika dikombinasikan
dengan tiga-fase tulang scintigrafi, sensitivitas dan spesifik ditingkatkan. 29
tulang dan leukocyte scintig- raphy dapat memberikan informasi berharga jika
MRI mengalami kontraindikasi atau tidak tersedia. 30
Modalitas pencitraan lainnya tampaknya menjanjikan untuk diagnosis
osteomielitis, tetapi tidak digunakan secara rutin. Positron emission tomography
memiliki sensitivitas dan spesifikasi tertinggi — lebih dari 90 persen — tetapi itu
mahal dan tidak tersedia sebanyak modalitas lainnya. 29 peranan
muskuloskeletal ultrasonografi dalam diagnosis osteomy — elitis berkembang.
Beberapa penelitian memperlihatkan bahwa pada beberapa pasien, seperti yang
mengidap penyakit sel sabit, pendeteksian cairan kol - lections dapat berguna
atau bahkan diagnosis; Meskipun demikian, estimasi yang dapat dipercaya
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mengenai kepekaan dan kehati-hatian adalah renda.26
Figure 1. Plain radiograph showing osteomy- elitis of the
distal fourth metatarsal and distal third and fourth phalanges
(arrows). Cortical disruption and osteolysis are present.

Figure 2. Magnetic resonance image demon- strating

abnormal T1-weighted signal within the calcaneus (long
arrow), consistent with osteomyelitis. Inferior cortical
disruption and contiguous soft tissue fluid and edema are also
present (short arrow).

Figure 3. Bone scintigraphy images demonstrating localized

increased radioactive tracer uptake within the left calcaneus,
consistent with osteomyelitis.

Treatment
Treatment of osteomyelitis depends on appropriate antibiotic therapy and often requires surgical removal of
infected and necrotic tissue. Choice of antibiotic therapy should be determined by culture and sus- ceptibility
results, if possible (Table 3).31,32 In the absence of such information, broad- spectrum, empiric antibiotics should be
administered. False-negative blood or biopsy cultures are common in patients who have begun antibiotic therapy. If
clinically pos- sible, delaying antibiotics is recommended until microbial culture and sensitivity results are
available. Indications for surgery include antibiotic failure, infected surgical hardware, and chronic osteomyelitis
with necrotic bone and soft tissue. 33
Acute hematogenous osteomyelitis in children typically requires a much shorter course of antibiotic
therapy than does chronic osteomyelitis in adults. Although randomized controlled trials are lacking,
therapy with four days of parenteral antibi- otics followed by oral antibiotics for a total of four weeks seems
to prevent recurrence in children who have no serious underly- ing pathology.34 In immunocompromised
children, the transition to oral antibiotics should be delayed, and treatment should continue for at least six
weeks based on clinical response.7 Recurrence rates are typically higher in this population. Surgical
treatment in immunocompetent children is rare.
Despite the use of surgical debridement and long-term antibiotic therapy, the recur- rence rate of chronic
osteomyelitis in adults is about 30 percent at 12 months.35 Recurrence rates in cases involving P. aeruginosa are
even higher, nearing 50 percent. The optimal duration of antibiotic treatment and route of delivery are unclear.36 For
chronic osteomy- elitis, parenteral antibiotic therapy for two to six weeks is generally recommended, with a
transition to oral antibiotics for a total treat- ment period of four to eight weeks. 31 Long- term parenteral therapy is
likely as effective as transitioning to oral medications, but has similar recurrence rates with increased adverse
effects.31,36 In some cases, surgery is necessary to preserve viable tissue and pre- vent recurrent systemic infection.
Antibiotic regimens for the empiric treat- ment of acute osteomyelitis, particularly in children, should include an
agent directed against S. aureus. Beta-lactam antibiotics are first-line options unless MRSA is suspected. If methicillin
resistance among community isolates of Staphylococcus is greater than 10 percent, MRSA should be considered in
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9
 initial antibiotic coverage.34 Intravenous van- comycin is the first-line choice. In patients with diabetic foot infections or
penicillin allergies, fluoroquinolones are an alter- nate option for staphylococcal infections; these agents seem to be as
effective as beta- lactams.32 Fluoroquinolones also cover quinolone-sensitive enterobacteria and other gram-negative rods.

Perawatan
Perawatan osteomyelitis bergantung pada terapi antibiotik yang tepat dan sering kali
perlu pembedahan pengangkatan jaringan yang terinfeksi dan nekrotik. Pilihan terapi
antibiotik hendaknya ditentukan oleh budaya dan sus — hasil pengecapan, jika mungkin
(tabel 3). 31,32 karena tidak adanya informasi seperti itu, spektrum luas, antibiotik empiris
harus diberikan. Fal-negatif darah atau budaya biopsi umum pada pasien yang telah
memulai terapi antibiotik. Jika bisa diterapkan secara klinis, menunda antibiotik
direkomendasikan sampai kultur mikroba dan sensitivitas tersedia. Indikasi pembedahan
mencakup kegagalan antibiotik, perangkat bedah yang terinfeksi, dan osteomielitis kronis
dengan tulang nekrotik dan jaringan lunak. 33
Osteomielitis akut penderita hematogen pada anak-anak biasanya membutuhkan
terapi antibiotik yang jauh lebih singkat daripada osteomyelitis kronis pada orang dewasa.
Meskipun uji coba terkontrol acak tidak ada, terapi dengan empat hari antibi parenteral -
otik yang diikuti oleh antibiotik oral selama total empat minggu tampaknya mencegah
kambuhnya anak-anak yang tidak memiliki kelainan serius di bawah. 34 dalam anak-anak
yang diimunisasi, transisi menuju antibiotik oral harus ditunda, dan perawatan hendaknya
dilanjutkan selama setidaknya enam minggu berdasarkan respon klinis. 7 tingkat
pengulangan biasanya lebih tinggi di populasi ini. Perawatan bedah pada anak-anak yang
diberi kekebalan jarang terjadi.
Meskipun penggunaan dekmen bedah dan terapi antibiotik jangka panjang, angka
osteomielitis kronis pada orang dewasa sekitar 30 persen pada usia 12 bulan. 35 tingkat
pengulangan kasus yang melibatkan P. aeruginosa bahkan lebih tinggi, hampir 50 persen.
Lamanya pengobatan antibiotik yang optimal dan rute persalinan tidak jelas. 36 untuk
osteomy — elitis, terapi antibiotik parenteral selama dua sampai enam minggu secara
umum direkomendasikan, dengan transisi menuju antibiotik mulut untuk total periode
pengobatan empat sampai delapan minggu. 31 terapi parenteral jangka panjang
kemungkinan besar sama efektifnya dengan beralih ke pengobatan lisan, tetapi tingkat
kekambuhan yang sama dengan meningkatnya dampak negatifnya. 31,36 dalam beberapa
kasus, pembedahan diperlukan untuk mempertahankan jaringan yang layak dan infeksi
sistemis pra - ventilasi.
Resimen antibiotik untuk pengobatan empiris - ment dari osteomielitis akut, terutama
pada anak-anak, harus mencakup agen yang diarahkan melawan S. aureus. Beta-lactam
antibiotik adalah pilihan baris pertama kecuali MRSA dicurigai. Jika resistensi methicillin di
antara isolasi masyarakat dari Staphylococcus lebih besar dari 10 persen, MRSA harus
dipertimbangkan dalam cakupan antibiotik awal. 34 intravena van- comycin adalah pilihan
pertama. Pada pasien penderita diabetes infeksi kaki atau alergi penisilin, fluoroquinolones
merupakan alternatif alternatif untuk infeksi staphylococcal; Agen-agen ini tampaknya sama
efektifnya dengan beta- lactams. 32 fluoroquinquinolones juga mencakup enterobakteri
yang sensitif quinolone

Table 3. Initial Antibiotic Therapy for Treatment of Osteomyelitis in Adults

Organism Preferred regimens Alternative regimens

Anaerobes Clindamycin, 600 mg IV every 6 hours Cefotetan (Cefotan), 2 g IV every 12 hours

Ticarcillin/clavulanate (Timentin), 3.1 g IV every Metronidazole, 500 mg IV every 6 hours
4 hours

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2011
 Enterobacteriaceae Ticarcillin/clavulanate, 3.1 g IV every 4 hours Ceftriaxone, 2 g IV every 24 hours
(e.g., Escherichia coli), Piperacillin/tazobactam (Zosyn), 3.375 g IV every
quinolone-resistant 6 hours

Enterobacteriaceae, Fluoroquinolone (e.g., ciprofloxacin [Cipro], Ceftriaxone, 2 g IV every 24 hours

quinolone-sensitive 400 mg IV every 8 to 12 hours)

Pseudomonas aeruginosa Cefepime, 2 g IV every 8 to 12 hours, plus Imipenem/cilastatin (Primaxin), 1 g IV every

ciprofloxacin, 400 mg IV every 8 to 12 hours 8 hours, plus aminoglycoside
Piperacillin/tazobactam, 3.375 g IV every 6 hours,
plus ciprofloxacin, 400 mg IV every 12 hours

Staphylococcus aureus, Vancomycin, 1 g IV every 12 hours Trimethoprim/sulfamethoxazole (Bactrim,

methicillin-resistant
For patients allergic to vancomycin: Linezolid (Zyvox), Septra), 1 double-strength tablet every
600 mg IV every 12 hours 12 hours
Minocycline (Minocin), 200 mg orally
initially, then 100 mg daily
Fluoroquinolone (e.g., levofloxacin
[Levaquin], 750 mg) IV daily plus rifampin,
600 mg IV every 12 hours

S. aureus, methicillin- Nafcillin or oxacillin, 1 to 2 g IV every 4 hours Ceftriaxone, 2 g IV every 24 hours

sensitive Cefazolin, 1 to 1.5 g IV every 6 hours Vancomycin, 1 g IV every 12 hours

Streptococcus species Penicillin G, 2 to 4 million units IV every 4 hours Ceftriaxone, 2 g IV every 24 hours
Clindamycin, 600 mg IV every 6 hours

IV = intravenously.
Information from references 31 and 32.

Data Sources: A PubMed search was completed in Clinical Queries using the key terms osteomyelitis, imaging, diagnosis, and treatment. The
search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Agency for Healthcare
Research and Quality evidence reports, the Cochrane database, the Database of Abstracts of Reviews of Effects, the National Guideline
Clearinghouse, and Dynamed. Search date: June 2, 2010.
The Authors
JOHN HATZENBUEHLER, MD, is a faculty member at the Maine Medical Center Family Medicine Residency Pro- gram, Portland, and associate
director of sports medicine at the Maine Medical Center Primary Care Sports Medicine Fellowship Program, Portland.
THOMAS J. PULLING, MD, is a family physician and sports medicine fellow at the Maine Medical Center.
Address correspondence to John Hatzenbuehler, MD, 272 Congress St., Portland, ME 04102 (e-mail: hatzej@ mmc.org). Reprints are not available from the authors.
Author disclosure: No relevant financial affiliations to disclose.

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