Abstract Osteitis

In 61 patients the effectiveness of imipenem in the treatment of chronic post-traumatic osteitis

was examined. The diagnosis of post-traumatic osteitis was based on clinical and radiological
signs of infection, as well as a positive bone culture from a surgical specimen. The average
duration of treatment was 10 days with a dosage 3 X 500 mg imipenem daily. The most
commonly identified pathogen was Staphylococcus aureus. In 75% of the cases an infection with
Gram-positive pathogens was found. The majority of Gram-negative infections was caused by
Pseudomonas aeruginosa. The rate of elimination was greater than 90% for both Gram-positive
and Gram-negative bacteria. A definite cure was achieved in 80% of the reported cases, only four
patients (7%) showed a recurrence of the infection. Allergic reactions or other adverse effects
were not observed except for diarrhoea in four patients. The high rate of therapeutic effectiveness
as well as the excellent toleration justify the use of imipenem in the treatment of chronic posttraumatic osteitis.

--------------------------------------------------Osteomyelitis
Introduction
Osteomyelitis is a heterogenous group of infections that can be classified by their
chronicity, their microbiology and their origin. It includes hematogenously born
infections, those arising from a contiguous focus, post-traumatic and post-operative
infections and those complicated by the presence of foreign material. While most
infections are caused by S. aureus, the microbiology can be complex and is influenced by
the origin of the infection, its chronicity and the presence of hardware.
The variable nature of osteomyelitis precludes the development of simple, uniform
treatment guidelines, however, there are a few basic treatment principles that should be
applied to all infections. All infections should be treated by debridement of infected and
necrotic bone; all dead-space should be eliminated by the placement of bone grafts or
muscle flaps; all infections require soft-tissue coverage to promote revascularization; and
all require prolonged antibiotics courses directed against the organisms cultivated from
the bone.
Specific Recommendations
It is highly desireable to base antibiotic choices on bone or tissue cultures rather than
wound or sinus swabs. Teams should be encouraged to obtain cultures from bone and
deep tissue samples at the time of debridement to guide antibiotic treatment.
Antibiotic treatment of osteitis should be for 4 weeks. Osteitis is defined as an
infection extending to the surface of the bone but without bone necrosis or the presence
of bone in an infected operative field.
Treatment of true osteomyelitis in the absence of hardware requires debridement and
antibiotics for 6 to 8 weeks.
The presence of infected hardware complicates the management of osteomyelitis since
debridement without hardware removal is associated with significantly lower cure rates.
However, fracture instability and non-union are a consequence of inadequate fixation and

the application of external fixation can be challenging or not at all possible. Whenever
possible infected hardware should be removed and a staged approach (hardware removal,
interval antibiotic treatment followed by fixation with new hardware and bone grafting)
adopted.
Antibiotic treatment of hardware-associated osteomyelitis with retention of the original
hardware should generally be for 12 weeks. This is most successful in cases where the
infection comes to attention early after the initial operation and is due to a highly
treatable organism (e.g. penicillin susceptible streptococci).
Antibiotic treatment of hardware-associated osteomyelitis after single-stage (hardware
swap during one operation) or two and three stage operation can be for 8 to 12 weeks.
Rifampin should be part of the antibiotic regimen for rifampin-susceptible, hardwareassociated Staphylococcus infections. The addition of rifampin for non-hardware
associated Staphylococcus infections can be considered. The use of rifampin for other
Gram-positive and selected Gram-negative infections can be considered.
The route of antibiotic administration can be parenteral or oral, provided the oral
bioavailability of individual agents is high. There is no proven benefit of parenteral
therapy over oral therapy and no required duration of parenteral therapy before
transitioning to oral therapy.
Treatment of drug-resistant Gram-negative infections or those with possible inducible
drug resistance should include 2 active agents for the first 7 to 14 days.
Diabetic foot infections require a combined medical and surgical approach to achieve
high cure rates. Antibiotic therapy without surgical debridement of necrotic bone often
results in failure with the need for more extensive debridement or amputation later.
Antibiotic choice should be based on bone cultures and generally includes coverage for S.
aureus (often MRSA) and streptococci, Gram-negative organisms if the infection is longstanding or previously treated and anaerobes for chronic infections with extensive
necrosis (the fetid foot).
Treatment of extensive, chronic osteomyelitis (e.g. pelvic osteomyelitis) with medical
therapy alone is almost never successful. Antibiotic treatment for infection flares
(fever, bacteremia, increased drainage) should be of limited duration (4 to 6 weeks) to
help minimize the development drug-resistant bacteria. Individuals who are not surgical
candidates or suffer from repeated, severe exacerbations may be considered for chronic
suppressive therapy with oral agents after an initial intensive 4 to 6 week course.
Establishing a definitive treatment plan coordinated with plastic, orthopedic or general
surgery and the out-patient rehabilitation service (CORP clinic, phone number: ) is key to
curing these difficult infections.
Indications for surgical intervention in the treatment of vertebral tuberculosis are
neurological deficits, spine instability, cervical spine disease and failure of medical
therapy. While surgical debridement is generally not needed for microbiological cure, it
does lead to faster symptom resolution and less kyphosis in those who present with
extensive disease.
References
Drancourt, M., et al., Oral rifampin plus ofloxacin for treatment of Staphylococcusinfected orthopedic implants. Antimicrob Agents Chemother, 1993. 37(6): p. 1214-8.

Lew, D. and F. Waldvogel, Osteomyelitis. N Engl J Med, 1997. 336(14): p. 999-1007.

Patzakis, M.J., et al., Treatment of chronic osteomyelitis with muscle flaps. Orthop Clin
North Am, 1993. 24(3): p. 505-9.
Zimmerli, W., et al., Role of rifampin for treatment of orthopedic implant-related
staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI)
Study Group [see comments]. JAMA, 1998. 279(19): p. 1537-41
StengleD, Bauwens K, Sehouli J, Ekkernkamp A, Porzsolt F. Systematic review and
meta-analysis of antibiotic therapy for bone and joint infections. Lancet Infec Dis,
2001;1:175-88.

Summary
Chronic osteomyelitis is a relatively common infection and is often a lifelong disease. Traditionally,
osteomyelitis has been treated with 46 weeks of parenteral antibiotics after definitive debridement surgery.
Antibiotic-impregnated cement beads have also been used as adjuvant therapy for chronic osteomyelitis.
However, this time frame of antibiotic treatment has no documented superiority over other time intervals, and
there is no evidence that prolonged parenteral antibiotics will penetrate the necrotic bone. There is no solid
evidence in the medical literature to support the continuous use of long duration antibiotic treatment for
chronic osteomyelitis. A small number of comparative trials on the treatment of chronic osteomyelitis have
been published. Also, the type of surgical procedures practiced in the past in treating chronic osteomyelitis
and the lack of effective muscle flap application might have contributed to the prolonged antibiotic treatment.
And although the surgical approach to the treatment of chronic osteomyelitis has advanced markedly, still the
same duration of antibiotic treatment is adopted. In this review we question the continuous and traditional
use of long-term antibiotic treatment for chronic osteomyelitis in spite of the advances in surgical treatment
using flaps. The medical literature, including studies in animals and humans, was searched for evidence to
support the use of short courses of antibiotics. We hope this review will provoke the initiation of animal
studies and clinical trials assessing the use of short courses of antibiotics for chronic osteomyelitis