02/16/2018

Osteomyelitis

Dr. ABDEL-RAHMAN YOUSSEF, MBBCh, MD, PhD

Assistant Professor in Microbiology & Immunology
Faculty of Dentistry
Umm Al-Qura University

The bone consists of the the haversian system that contains the matrix rings
(lamellae) & the osteon canal. Inside these lamellae, the osteocytes are located in the
lucanae. the periosteum surrounds the bone and held to the compact
bone by Sharpey's fibers. blood vessels run through these canals and deliver blood
through the bone.

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Osteomyelitis
• Osteomyelitis is an inflammatory condition of the bone,
which begins as an infection of the medullary cavity,
rapidly involves the haversian systems, and extends to
involve the periosteum of the affected area

• Osteomyelitis can develop as the result of:

1. Contiguous spread from adjacent soft tissues and
joints
2. Hematogenous seeding
3. Direct inoculation of microorganisms into the bone by
trauma or surgery

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Osteomyelitis
• It can result when bacteria or fungi invade a bone
• In children, bone infections most commonly occur in the
long bones of the arms and legs
• In adults, they usually appear in the hips, spine, and feet
• Bone infections can leave a bone permanently damaged

Classification of osteomyelitis
Classification is based on the duration of illness and the
mechanism of infection

Classification based on the duration of illness:

1. Acute osteomyelitis: infection develops within 2 weeks. The
pain can be intense, more common in children and the
condition can be life threatening.
2. Subacute osteomyelitis: Infection develops within 1-2 months
3. Chronic osteomyelitis: infection starts at least after 2 months

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Classification according to mechanism of infection :

1. Hematogenous osteomyelitis, the infection may start as a
mild upper respiratory or urinary tract infection, and
travel through the bloodstream. This type is more
common in children

2. Exogenous osteomyelitis, post-traumatic or in poor blood

circulation develop from a minor scrape or cut

Risk factors
1. Local factors:
• Trauma: A deep puncture wound or a fracture that
breaks the skin (open wound) occurs in 80 % of cases
• Orthopaedic surgery of bones or joints especially with
metal implants

2. Systemic factors
• Decreased vascularity conditions (diabetes, peripheral
arterial disease) where bones may not be getting a
steady supply of immune cells.
• A weak immune system e.g. chemotherapy or
radiation, uncontrolled diabetes, malnutrition, dialysis,
having a urinary catheter, injecting addictive drugs.

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• Pathogenesis
• When an infection develops inside a bone, the immune
system will attempt to stop it with infection-fighting
leucocytes.
• If the infection is not treated and the immune system is
unable to deal with the bacteria, a collection of dead white
blood cells will build up inside the bone, forming abscess.
• In cases of chronic osteomyelitis, abscesses can block the
blood supply to the bone, which will eventually cause the
bone necrosis.

Suppurative Osteomyelitis of Jaw

• Source of infection is usually an adjacent focus of infection
associated with teeth or with local trauma.

• It is a polymicrobial infection, predominating anaerobes

such as Bacteriods, Porphyromonas or Provetella.

• Staphylococci may be a cause when an open fracture is

involved.

• Mandible is more prone than maxilla as vascular supply is

readily compromised.

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Microbial causes of Osteomyelitis

• The commonest causative organism is Staphylococcus

aureus.

• In infants: Staphylococcus aureus, Streptococcus

agalactiae and Escherichia coli are the most frequent
causes.

• In children below the age of 4 years : Staphylococcus

aureus, Streptococcus pyogenes and Haemophilus
influenzae are common.

• In adults Staphylococcus aureus is the most common

bacteria associated with hematogenous osteomyelitis

• Pseudomonas osteomyelitis is seen in drug addicts and

has predilection for spine

• In immunocompromised patients, unusual organisms are

commonly isolated.

• When Osteomyelitis results from direct inoculation or

contiguous spread, multiple organisms are usually
isolated.

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Tuberculosis Osteomyelitis
• The incidence of tuberculosis osteomyelitis varies based
on the geographic region and patient risk factors for the
disease.
• It can involve any bone due to its hematogenous
dissemination with predilection for the spine (Pott’s
disease).

Signs and symptoms of Osteomyelitis

• Pain, swelling, redness, and tenderness in

the affected area

• Irritability, lethargy or fatigue

• Fever, chills, and sweating

• Drainage from an open wound near the infection site or

through the skin

• The symptoms of chronic osteomyelitis are not always

obvious, or they could resemble the symptoms of an
injury

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Laboratory Findings
• Sample: Bone biopsy or needle aspiration is best for
organism identification

• Blood cultures are positive in about 50% to 75% in

hematogenous osteomyelitis
• Laboratory changes suggestive of infection:
➢ Elevations of white blood cell count (leucocytosis)
➢ High C-reactive protein (CRP) level
➢ High Erythrocyte Sedimentation Rate (ESR) level

• The CRP/ESR can be an excellent screening tool to

measure response to treatment

Evaluation for TB associated osteomyelitis includes

• Acid-fast bone cultures

• Ziehl-neelsen stains,
• Histopathology (granulomatous inflammation)
• Chest radiograph (looking for active or evidence of
previous TB)

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MANAGEMENT AND TREATMENT

I. Acute haematogenous type:
• Surgery and antibiotic treatment are complementary
• Surgical removal of necrotic tissues or abscesses
• If such removal is effective, antibiotics should prevent their
reformation and primary wound closure should be safe
• Antibiotics should be continued after surgery
• 6 week course of intravenous antibiotics is given
• Follow up is continued for at least 1 year

II. Subacute haematogenous type:

• Curettage followed by treatment with appropriate
antibiotics for all lesions that seem to be aggressive

• IV antibiotics for 48 hrs followed by a 6 week course of

oral antibiotics

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III. Chronic osteomyelitis:

• Surgical treatment mainstay
• Antibiotic duration is controversial
6 week is the traditional duration
1 week IV, 6 weeks of oral therapy

VI. In tuberculosis osteomyelitis:

• Treatment involves an extended course of multiple anti
mycobacterial agents and should be based
on sensitivity testing

Antibiotic
• The selection of antibiotic should be based on in-vitro
susceptibilities of the microorganisms causing the
infection and ability to penetrate the bone.

• Antibiotic using depot devices and techniques: Use of

antibiotic depots local delivery of antibiotics that is heat
stable and in powder form allows for high local
concentrations of antibiotic with little systemic
absorption.

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