Treatment of osteomyelitis.

The etiology, pathophysiology, and treatment of osteomyelitis are reviewed. Osteomyelitis may result from hematogenous bacterial emboli from a distant source lodging in the bone, the contiguous spread of an adjoining soft-tissue infection, or direct bacterial inoculation secondary to trauma or surgery. Hematogenous osteomyelitis most commonly occurs in children, and it usually is caused by a single organism, Staphylococcus aureus. Adults are most commonly affected by contiguous-spread osteomyelitis, and many infections occur in adults with vascular insufficiency. Staphylococcus aureus is the most common organism, but unlike hematogenous osteomyelitis, multiple organisms (including gram-negative bacteria) generally are involved. Successful treatment is predicated upon accurate classification of the disease, identification of the offending organism(s), surgical debridement if necessary, and prompt initiation of antibiotic therapy. Adults with acute osteomyelitis usually are given a penicillinase-resistant penicillin, ampicillin, or cephalosporin in doses of 8-12 g/day for four to six weeks. Carefully monitored oral drug therapy following initial injectable antibiotic therapy has been shown to be effective in children. Chronic osteomyelitis requires both surgery to remove infected tissue and high-dose injectable antibiotic therapy for four to six weeks; it is recommended that follow-up oral antibiotic therapy be continued for one to two months, or possibly as long as two years. Home antibiotic administration programs, oral antibiotic therapy, and investigational injectable antibiotics with once-daily dosing may allow patients with osteomyelitis who previously were hospitalized for prolonged periods to be treated at home in the future.