Microbiology More than 95% of cases of hematogenous osteomyelitis

are caused by a single organism. Staphylococcus aureus accounts for

50% of isolates. Other common pathogens include group B streptococci
and Escherichia coli during the newborn period and group A
streptococci in early childhood. Vertebral osteomyelitis is due to E.
coli and other enteric bacilli in _25% of cases. S. aureus, Pseudomonas
aeruginosa, and Serratia infections are associated with intravenous
drug use in some parts of the United States and may involve
the sacroiliac, sternoclavicular, or pubic joints as well as the spine.
Salmonella spp. and S. aureus are the major causes of long-bone osteomyelitis
complicating sickle cell anemia and other hemoglobinopathies.
Tuberculosis and brucellosis affect the spine more often than
other bones. Other common sites of tuberculous osteomyelitis include
the small bones of the hands and feet, the metaphyses of long bones,
the ribs, and the sternum.
Unusual causes of hematogenous osteomyelitis include disseminated
histoplasmosis, coccidioidomycosis, and blastomycosis in endemic
areas. Immunocompromised persons on rare occasions develop
osteomyelitis due to atypical mycobacteria, Bartonella henselae, or
Pneumocystis or to species of Candida, Cryptococcus, or Aspergillus.
Hematogenous osteomyelitis with Mycobacterium bovis has been reported
following intravesicular instillation of bacille Calmette-Gue´rin
(BCG) for cancer of the bladder. The etiology of chronic relapsing
multifocal osteomyelitis, an inflammatory condition of children that is
characterized by recurrent episodes of painful lytic lesions in multiple
bones, has not been identified.
OSTEOMYELITIS SECONDARY TO A CONTIGUOUS FOCUS OF INFECTION _
Clinical
Features This broad category of osteomyelitis accounts for _80% of
all cases and occurs most commonly in adults. It includes infections
introduced by penetrating injuries, such as bites, puncture wounds, and
open fractures; by surgical procedures; and by direct extension of infection
from adjacent soft tissues. Generalized vascular insufficiency
and the presence of a foreign body are important predisposing factors
and make infection more difficult to cure.
Frequently, the diagnosis of this type of osteomyelitis is not made
until the infection has already become chronic. The pain, fever, and
inflammatory signs due to acute infection may be attributed to the
original injury or to overlying soft tissue infection. An indolent infection
may become apparent only weeks or months later, when a sinus
tract develops, a surgical wound breaks down, or a fracture fails to
heal. It may be impossible to distinguish radiographic abnormalities
due to osteomyelitis from those due to the precipitating condition.
A special type of contiguous-focus osteomyelitis occurs in the setting
of peripheral vascular disease and nearly always involves the
small bones of the feet of adult diabetic patients. This type of infection
is a major cause of morbidity and hospitalization for patients with
diabetes and results in many thousands of amputations per year. Diabetic
neuropathy exposes the foot to frequent trauma and pressure
sores, and the patient may be unaware of infection as it spreads into
bone. Poor tissue perfusion impairs normal inflammatory responses
and wound healing and creates a milieu that is conducive to anaerobic
infections. It is often during the evaluation of a nonhealing ulcer, a
swollen toe, or acute cellulitis that a radiograph provides the first evidence
of osteomyelitis. If bone is palpable during examination of the
base of an ulcer with a blunt surgical probe, osteomyelitis is likely.
Microbiology S. aureus is a pathogen in more than half of cases of
contiguous-focus osteomyelitis. However, in contrast to hematogenous
osteomyelitis, these infections are often polymicrobial and are more
likely to involve gram-negative and anaerobic bacteria. Hence a mixture
of staphylococci, streptococci, enteric organisms, and anaerobic
bacteria may be isolated from a diabetic foot infection or pelvic osteomyelitis
underlying a decubitus ulcer. Aerobic and anaerobic bacteria
cause osteomyelitis following surgery or soft tissue infection of
the oropharynx, paranasal sinuses, gastrointestinal tract, or female genital
tract. A human bite may result in mixed infection of the hand, with
anaerobes included among the etiologic agents. S. aureus is the principal
cause of postoperative infections; coagulase-negative staphylococci
are common pathogens after implantation of orthopedic appliances;
and these organisms as well as gram-negative enteric bacilli,
atypical mycobacteria, and Mycoplasma may cause sternal osteomyelitis
after cardiac surgery. Infection with P. aeruginosa is frequently
associated with puncture wounds of the foot (especially by a nail
through a sneaker) or with thermal burns, and Pasteurella multocida
infection commonly follows cat bites.

Osteomyelitis of the small bones of the feet in persons with vascular

disease usually requires surgical treatment. The effectiveness of
the surgery is limited by the blood supply to the site and the body’s
ability to heal the wound. Revascularization of the extremity is indicated
if the vascular disease involves large arteries. In cases of decreased
perfusion due to small-vessel disease, foot-sparing surgery
may fail, and the best option is often suppressive therapy or amputation.
The duration of antibiotic therapy depends on the surgical procedure
performed. When the infected bone is removed entirely but
residual infection of soft tissues remains, antibiotic therapy should be
given for 2 weeks; if amputation eliminates infected bone and soft
tissue, standard surgical prophylaxis is given; otherwise, postoperative
antibiotics must be given for 4 to 6 weeks.