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Osteomyelitis: A Descriptive Study

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DOI: 10.4055/cios.2014.6.1.20 · Source: PubMed

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 Original Article Clinics in Orthopedic Surgery 2014;6:20-25 • http://dx.doi.org/10.4055/cios.2014.6.1.20

Osteomyelitis: A Descriptive Study

Laura Prieto-Pérez, MD, Ramón Pérez-Tanoira, PhD*, Elizabet Petkova-Saiz, MD,
Concepción Pérez-Jorge, PhD*, Cristina Lopez-Rodriguez, MD,

Beatriz Alvarez-Alvarez, MD, Jorge Polo-Sabau, MD, Jaime Esteban, MD*
Departments of Internal Medicine and *Clinical Microbiology, IIS-Fundación Jiménez Díaz, Madrid, Spain

Background: To analyze the incidence and clinical-microbiological characteristics of osteomyelitis (OM) in a tertiary Spanish hos-
pital.
Methods: All cases diagnosed with OM between January 2007 and December 2010 were retrospectively reviewed. The variables
examined include epidemiological characteristics, risk factors, affected bone, radiographic changes, histology, microbiological cul-
ture results, antibiotic treatment, and the need for surgery.
Results: Sixty-three cases of OM were diagnosed. Twenty-six patients (41.3%) had acute OM whereas 37 patients (58.7%) were
classified as chronic OM. OM may result from haematogenous or contiguous microbial seeding. In this group, 49 patients (77.8%)
presented with OM secondary to a contiguous source of infection and 14 patients had hematogenous OM (22.2%). Staphylococcus
aureus was the most commonly found microorganism.
Conclusions: OM mainly affected patients with risk factors related to the presence of vascular diseases. Antibiotic treatment
must be guided by susceptibility patterns of individual microorganisms, although it must be performed together with surgery in
most of the cases.
Keywords: Osteomyelitis, Bone infection, Antimicrobial therapy, Staphylococcus aureus, Debridement

Osteomyelitis (OM) is an inflammatory process accom- superficial, localized, or diffuse OM) and physiological
panied by bone destruction and caused by an infecting classes (healthy host, systemic and/or local compromise,
microorganism.1,2) It is an infectious disease that is dif- and treatment worse than the disease).1,3) This classifica-
ficult to diagnose, and treatment is complex because of its tion applies best to long and large bones and it is not very
heterogeneity, pathophysiology, clinical presentation, and useful for the digits, small bones, or the skull.2,6,7)
management.3-5) The Waldvogel scheme was used in this study, and
There are several ways to classify OM. The two our cases were classified according to the duration of the
major classification schemes are those described by Lew disease (acute or chronic), the mechanism of infection
and Waldvogel2) and Cierny et al.6) The Cierny-Mader OM (hematogenous or contiguous seeding), and the presence
classification combines both anatomic factors (medullar, of vascular insufficiency. Chronic OM is defined as long-
standing infection that evolves over months or even years,
characterized by the persistence of microorganisms, low-
Received April 4, 2013; Accepted June 24, 2013 grade inflammation, and the presence of dead bone (se-
This work was presented at the 10th Congress of the European Federation questrum) and fistulous tracts.8,9) Clinical signs persisting
of Internal Medicine and 32nd National Congress of the Spanish Society for longer than 10 days are associated with the develop-
of Internal Medicine. ment of necrotic bone and chronic OM.2,7) Chronic OM
Correspondence to: Ramón Pérez-Tanoira, PhD may also present as a recurrent or intermittent disease,
Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, Av. with periods of quiescence of variable duration.8)
Reyes Catolicos 2, Madrid, Spain The increasing age of the general population has
Tel: +34-915504900, Fax: +34-915494764 led to a rise in the prevalence of diabetes and peripheral
E-mail: ramontanoira@hotmail.com
Copyright © 2014 by The Korean Orthopaedic Association
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Clinics in Orthopedic Surgery • pISSN 2005-291X eISSN 2005-4408
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Prieto-Pérez et al. Osteomyelitis: A Descriptive Study
Clinics in Orthopedic Surgery • Vol. 6, No. 1, 2014 • www.ecios.org

vascular disease, both predisposing and complicating OM, Table 1. Symptoms, Mechanisms of Infections, Risk Factors, and
which if not managed adequately, may result in amputa- Results of Radiographic and Histologic Investigations in
tion, sepsis, or death.10,11) The timing of its diagnosis and the 63 Patients
treatment is crucial in the diabetic patient in order to
avoid later amputation.12) Variable Acute (26) Chronic (37)
The different kinds of OM often require diverse Symptom
treatments, such as surgical debridement or resection and/ Duration (wk) <2 >2
or prolonged antibiotic therapy.13) The cornerstone of ef- Skin change 3 9
fective management of OM is early diagnosis and aggres-
Pain 18 22
sive treatment with thorough debridement and culture-di-
rected antibiotic therapy.1,5,9,14) In order to obtain accurate Fever 4 3
pathogen identification, the treating surgeon should take Rhabdomyolysis - 2
appropriate tissue samples. The gold standard for OM Sepsis 1 1
diagnosis consists of a biopsy specimen and its culture in Mechanism of infection
order to identify the infecting organism.4,8)
Hematogenous 8 6
In chronic OM, the antibiotic choice should be
Bacteriemia 2 2
based on sensitivity data: a short course of intravenous an-
tibiotics, followed by a prolonged course of oral antibiotics Skin lesion 4 3
is the usual therapy.14) Trauma 2 -
Staphylococcus aureus represents the most common Odontogena - 1
isolated microorganism in most types of OM, affecting Contiguous 18 31
50% to 70% of cases.15,16) Other microorganisms common-
Bacteriemia 9 19
ly found in cases of OM include aerobic Gram-positive
cocci like coagulase-negative staphylococci , and also aero- Skin lesions 7 11
bic Gram-negative bacilli and anaerobes, these latter ones Trauma 2 -
are often isolated as part of mixed infections.17) Odontogena - 1
Risk factor
METHODS Vascular insufficiency 4 7

Patients appearing in hospital records as having diagnosis Diabetes mellitus 7 7

of OM between January 1, 2007 and December 31, 2010 Atherosclerosis 2 7
were reviewed. Patients with implant-related OM were History of chronic liver disease 1 6
excluded from the study. The clinical records and radio- Chronic renal failure 1 3
graphs of every patient were retrospectively studied using
History of tuberculosis - 2
a predefined protocol, which included age, sex, site of in-
Human immunodeficiency virus 1 2
fection, and response to treatment. These variables were all
compared. A summary of the findings is shown in Table 1. Cancer 3 3
Diagnosis of OM was based on the assessment of Protheses 1 9
the Infectious Disease Department of the hospital, taking Radiographic change
into account both clinical assessment and physical exami- Unknown 4 4
nation, along with wound or blood cultures, histology, and
Ultrasonography 1 -
radiographic examinations.
During the studied period, cultures from different Bone scintigraphy 1 -
samples were performed according to commonly accepted Nuclear magnetic resonance 6 14
techniques. Isolated microorganisms were identified by X-ray 11 16
common biochemical tests (coagulase and oxidase) and Computed tomography 3 3
commercial identification kits (API System, bioMérieux,
Histological study
Marcy L’Etoile, France). Susceptibility testing was per-
formed using a disc-plate assay according to the EUCAST Positive 5 (19*) 4
protocols.18) The study was approved by the Ethics Re- *Test not done on remaining patients.
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Prieto-Pérez et al. Osteomyelitis: A Descriptive Study
Clinics in Orthopedic Surgery • Vol. 6, No. 1, 2014 • www.ecios.org

search Committee of the hospital. Site of Infection

Both phalanxes and long bones of the lower extremities
Data Analysis were the most commonly involved sites (55.6% each).
For the statistical study, frequency analysis was used to Chronic OM occurred more frequently than acute OM in
obtain a distribution of age and treatment for acute or the metatarsus, calcaneus, and hip (Fig. 2). No significant
chronic OM. Fisher exact test was used to examine the differences were found in other bones regarding acute
significance of the association (contingency) between pa- and chronic conditions of the disease. Other bones in-
tient outcomes (favorable or unfavorable) and treatment cluded the talus, scaphoid, clavicle, occipital, ribs, frontal,
(antimicrobial, surgical, and combined therapy). EPI-Info ischium, and radius. Fifty-five patients (87.3%) had recent
ver. 3.5.1. (Centers for Disease Control and Prevention, history of trauma or skin lesions that were considered the
Atlanta, GA, USA) was used in order to perform the sta- source of the infection.
tistical studies.
Microbiological Results
Twenty-eight patients (44.4%) had 1 positive sample
RESULTS whereas 14 patients (22.2%) had 2 or more positive sam-
A total of 63 patients were included in the study. Forty-six ples. A summary of microbiological data is shown in Table
of them were males (73.01%). Acute OM was common in 2. Among the 20 patients with past history of trauma, 13
the 1st–2nd decades of life whereas chronic OM frequency patients (65.0%) had a positive culture, and among the 35
increased with age, as is shown in Fig. 1. Age distribution patients with previous history of a skin lesion, 23 patients
for both acute and chronic OM is also shown in Fig. 1.

Fig. 1. Age of 63 patients with osteomyelitis. Fig. 2. Sites of osteomyelitis in 63 patients.

Table 2. Frequency of Microbiological Isolates from Acute and Chronic Osteomyelitis

Acute (26) Chronic (37)

Variable
Bacteriemia Skin lesion Trauma Odontogena Bacteriemia Skin lesion Trauma Odontogena Sinusitis
Staphylococcus aureus 1 4 4 - 1 2 3 - -
Other gram-positive cocci 1 3 - - - 2 2 1 1
Cram-negative bacilli - 4 - - 1 1 2 - -
Candida spp. - - - - - - 1 - -
Polymicrobial - - 1 - - 7 - - -
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Prieto-Pérez et al. Osteomyelitis: A Descriptive Study
Clinics in Orthopedic Surgery • Vol. 6, No. 1, 2014 • www.ecios.org

(65.7%) had a positive culture. an unfavorable outcome (95% CI, 0.2 to 36.0). For surgical
therapy, rates were 13.3% (95% CI, 1.7 to 40.5) and 7.7%
Treatment and Outcome (95% CI, 0.2 to 36.0). For combined treatment, they were
Fourteen patients (22.2%) received antimicrobial therapy 80.01% (95% CI, 51.9 to 95.7) and 84.6% (95% CI, 54.6
alone, 5 patients (7.9%) received surgical therapy alone, to 98.1), respectively. There were no statistical differences
whereas 44 patients (69.84%) were given a combination of in outcome between antimicrobial, surgical, or combined
antimicrobial and surgical therapy. therapy (p = 0.50, Fisher exact test).

Acute osteomyelitis
Twenty-four patients (92.31%) were initially managed with
DISCUSSION
antibiotics, and 14 of these cases (53.84%) were treated Traditionally, chronic OM has been considered a condi-
with surgery as well. Every other case was treated with sur- tion that follows a hematogenous spread of microorgan-
gery alone. Among patients who received medical treat- isms.19) In this series, as in recent reports, this category has
ment, antibiotics were given over a minimum of 4 weeks been considerably substituted by posttrauma and device-
in 13 cases (54.17%). A combination of antibiotics was related chronic OM, as well as contiguous disease from
administered in 14 cases (58.33%), whereas monotherapy diabetic foot infections and skin lesions.20)
was used in 9 cases (37.5%). Ciprofloxacin was given in During childhood, hematogenous OM is more
combination with other antibiotics in 7 cases (50%) and commonly found than contiguous seeding, and it is char-
amoxicillin/clavulanic acid, cloxacillin, or ciprofloxacin acterized by an acute febrile illness in addition to pain and
was used as a single-agent antimicrobial in 6 cases (25.0%). immobility of the affected limb.3,21,22) In this study, every
Complications developed in 4 cases, including amputa- patient under 18 years had hematogenous OM (6 pa-
tion of the toe phalanx in two of them. The distribution tients).
according to treatment with antimicrobial therapy alone, In contrast, bacteremia in adults rarely results in
using frequency analysis, was 27.8% for a favorable out- OM, and secondary spread from a contiguous focus of
come (95% confidence interval [CI], 9.7 to 53.59) and infection, such as from a surgical wound, is more com-
25% for an unfavorable outcome (95% CI, 0.6 to 80.6). For mon. 9,21) In hematogenous OM in childhood, shorter
surgical therapy, rates were 11.1% (95% CI, 1.4 to 34.7) courses of parenteral antibiotics followed by oral therapy
and 0% (95% CI, 0.0 to 60.2); finally, for combined therapy for several weeks obtain a good success rate; provided that
61.1% (95% CI, 35.7 to 82.7) and 75% (95% CI, 19.4 to the organism is known and adherence with treatment is
99.4), respectively. No statistical differences in outcomes good, the clinical signs subside rapidly.1,2)
were found between antimicrobial, surgery, or combined There were no statistical differences in outcome
therapy (p = 0.53, Fisher exact test). regarding the metatarsus, found between antimicrobial,
surgical, or combined therapy, probably because of the use
Chronic osteomyelitis of antibiotics with high activity against the causative mi-
These patients were initially managed with antibiotics in croorganisms. However, the relatively low number of cases
34 cases (91.9%); 30 cases (81.1%) also required surgery, included must be considered as a possible cause of these
while the remaining 2 patients were treated with surgery results. The high proportion of patients with an unfavor-
alone. Antimicrobial therapy was administered for a mini- able outcome following combined therapy (82.4%) might
mum of 4 weeks in 21 cases (61.8%). A combination of be explained by this therapy since it was the treatment
antibiotics was used in 19 cases (55.9%), with ciprofloxa- chosen in the majority of the studied cases (69.9%).
cin the antibiotic most frequently used in these combina- Treatment of acute OM usually requires adequate
tions (10 cases, 52.6%). Monotherapy was used in 14 cases debridement, drainage of pus, and prolonged courses of
(41.2%) and amoxicillin/clavulanic acid, cloxacillin, or antimicrobial therapy. In the presence of acute infection
ciprofloxacin were used in 9 cases (26.5%). Complications there are no evidence-based guidelines to dictate whether
were reported in 13 cases (35.1%), and amputation was hardware should be removed or retained.
performed in 7 cases (18.9%). Three of these cases were Single-agent antimicrobial therapy is generally ad-
foot phalanxes. The frequency distribution according to equate for the treatment of OM except for infections of
treatment, using frequency analysis, was 6.7% for anti- prosthetic joints (for which an antimicrobial combination
microbial therapy alone in patients who had a favorable including rifampicin is commonly used) and chronic OM.
outcome (95% CI, 0.2 to 31.9) and 7.7% in patients with As a general principle, these antibiotics should be given
 24
Prieto-Pérez et al. Osteomyelitis: A Descriptive Study
Clinics in Orthopedic Surgery • Vol. 6, No. 1, 2014 • www.ecios.org

for 4–6 weeks and, if possible, endovenously. Where qui- may call for earlier amputation or for excision of infected
nolones are used, an early switch to oral administration is bone.10,17) In our series, 5 patients were amputees of foot
appropriate.2) Treatment requires isolation of the causative phalanxes; surgery is more likely to be appropriate and
pathogen or pathogens as well as significant debridement cost-effective when infection involves a bone that is not
for removal of all infective and necrotic material, both essential to the foot’s architecture.24) Limited limb-saving
originating in the bone origin and in soft tissue.15,23) surgery and prolonged antibiotic therapy directed toward
One of the reasons why results for chronic OM were the definitive causative bacteria constitute a more appro-
worse in this study could be the increased rate of positive priate approach for all other cases. This may decrease limb
polymicrobial cultures compared to acute OM, and the loss through amputations.10,23)
elevated use of monotherapy.
Fifty-five patients (87.30%) had previous history of
trauma or skin infection, a significant risk factor for bone
CONFLICT OF INTEREST
and joint infections caused by S. aureus . The seriousness No potential conflict of interest relevant to this article was
of this risk factor is presumably because of the high fre- reported.
quency with which this bacteria causes skin and soft-tissue
infections.21,22)
ACKNOWLEDGEMENTS
Amputation is an accepted form of treatment for
some cases of OM. In our series, 4 out of the 9 patients The authors wish to thank for the assistance of the pro-
who required amputation (44.4%) had vascular disease gram CONSOLIDER-INGENIO 2010 FUNCOAT-
or diabetes mellitus. These factors become a substantial CSD2008-00023 to carry out this study. We also wish to
risk of failure for a single course of antimicrobial therapy thank Mr. Oliver Shaw for editing the manuscript in Eng-
in cases of OM which are complicated by vascular disease lish.
or diabetes; indeed, signs of recurrence in these patients

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