Osteomyelitis

* yo M/F with PMH of *, presenting with
* days constant/intermitent, progressively worsening/improving

  • CC: Bone pain / concern for osteomyelitis

  • PP: Pain, tenderness, swelling, erythema, warmth, drainage, fever/chills, difficulty bearing weight, chronic wound/ulcer, possible overlying cellulitis.

  • PN: No rapidly progressive necrosis, crepitus, severe compartment findings, or systemic instability unless severe infection/sepsis present.

  • pertinent SHx: tobacco, EtOH, drug use

  • Etiology: Contiguous spread from diabetic foot ulcer/SSTI, bacteremia, trauma, pressure ulcer, or direct inoculation causing bone infection.

  • risk factors: DM, PAD, chronic wounds/pressure ulcers, bacteremia, SSTI, trauma/injury, prosthetic joint/hardware, necrotizing infection, immunocompromised state, vascular insufficiency.

  • initial DATA:

    • Vitals; assess for >2 SIRS criteria/systemic inflammation

    • CBC, BMP/Cr, ESR/CRP

    • Blood cultures is systematic signs

    • MRSA nares

    • XR affected area

    • MRI w/ contrast (preferred imaging)

    • Prior wound/blood culture data if available

    • Physical exam: MSK/cellulitis findings, neurovascular exam

  • pending DATA: Blood/wound cultures, MRI results, operative/deep tissue cultures, inflammatory marker trends.

  • MEDS: Home diabetic medications, recent antibiotics, anticoagulants/antiplatelets, empiric IV antibiotics if unstable/septic.

  • COURSE: Undergoing infectious workup and imaging for osteomyelitis; consulting podiatry/ortho and ID for possible debridement and deep cultures prior to antibiotics if clinically stable.

Plan :

  • If clinically stable: hold antibiotics until deep tissue/bone cultures obtained if feasible

  • If unstable/septic shock:

    • cefepime 2 g IV q8h + metronidazole 500 mg IV q8h ± vancomycin IV (pharmacy dosed)

    • De-escalate per cultures

  • consult ID and podiatry/ortho for debridement, bone biopsy, and culture collection

  • MRI w/ contrast to evaluate extent of osteomyelitis/abscess

  • Trend CBC, BMP, ESR/CRP, renal function, fever curve daily

  • Follow blood and operative cultures

  • wound care consult for dressing changes/offloading

  • consider vascular surgery consult if PAD/poor perfusion concern

  • PT/OT when appropriate

  • optimize glycemic control

  • monitor for sepsis, worsening cellulitis, abscess, necrotizing infection, or neurovascular compromise

  • Long-term antibiotics guided by cultures and surgical findings (typically ~6 weeks if residual infected bone remains)

Note:
Diabetic Foot Infection that is Contiguous (soft tissue) or Hematogenous

  • Organisms: S. aureus and Staph epi (in prosthetic joints) are most common; GNRs, anaerobes and polymicrobial infections are also seen.

  • Contiguous-focus is injury or extension from a soft tissue infection._Diabetic foot infections: subtype of contiguous-focus osteo. or Hematogenous osteomyelitis (e.g., vertebral): common in IVDU, DM, is metastatic spread of existing infection due to bacteremia.

  • need bone biopsy/culture for definitive diagnosis, we dont really do, we do MRI

  • consider FDG-PET/CT if MRI not possible

  • Prolonged antibiotic therapy (at least 6 weeks)

  • Normal ESR or CRP does not rule out osteomyelitis

  • Vertebral body osteo and epidural abscess may require urgent NSG decompression.

  • Assess peripheral vasculature, consider arterial flow studies/vascular surgery consult