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Overview |
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Definition |
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Osteomyelitis is an infection of the bone, caused usually by bacteria but
occasionally by fungi. Several forms of osteomyelitis exist. Hematogenous
osteomyelitis, which occurs most often in children, generally develops in bones
with a good blood supply and rich marrow. Vertebral osteomyelitis begins as a
gradually developing back pain. Post-traumatic osteomyelitis commonly occurs in
patients with infected prostheses.
Once established in the bone, the infections can spread outward to the
adjacent soft tissue, where it causes abscesses. Antibiotics are first line
treatment. Unsuccessful treatment can result in chronic osteomyelitis. While
often symptom-free for long periods, this condition causes bone pain, recurring
infections, and constant or intermittent drainage of pus through the skin. The
drainage creates sinus tracts between the bone and the skin. It affects children
more than adults. |
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Etiology |
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The infection is most commonly caused by Staphylococcus aureus but
consider other microorganisms such as Mycobacterium tuberculosis. It
starts in soft tissue adjacent to bone or enters the body from external sources.
It reaches the bone via several routes (including the bloodstream, open wounds,
surgery on bones) and causes the bone marrow to swell. As it presses against the
bone's rigid outer wall, the marrow compresses blood vessels, reducing the
supply of blood to the bone or cutting it off entirely. Without treatment, parts
of the bone may die. Prosthetic devices may be source of
irritation. |
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Risk Factors |
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- Open bone fracture
- Bone surgery
- Attachment of metal to a bone
- Kidney dialysis
- Intravenous use of illegal drugs
- Implanted prosthesis
- Foot ulcers
- Diabetes
- Trauma
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Signs and Symptoms |
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Symptoms can be acute or chronic, depending on etiology.
- Intense pain and a sensation of heat at the site of the affected
bone
- Tenderness and swelling
- Persistent back pain, unrelieved by rest, heat, or
analgesics
- Abscesses in tissue surrounding the painful bone
- Fever, in some cases
- Fatigue, irritability, malaise
- Inflammation, generally localized with or without
drainage
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Differential
Diagnosis |
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- Infectious arthritis
- Charcot's joint (neuropathic joint disease)
- Bone tumors
- Cellulitis
- Other systemic infection
- Gout
- Other sources of localized
inflammation
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Diagnosis |
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Physical Examination |
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Patient typically looks sick, particularly children. They report tenderness
when palpated above the affected area of the bone. Fever is not necessarily an
indicator of osteomyelitis; patients may show minimal fever or no fever. Check
patient's TB status. Consider old chest X rays and family
history. |
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Laboratory Tests |
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Samples of blood, pus, joint fluid and, if necessary, the bone itself serve
to diagnose the infection and to identify the bacteria or fungi
responsible.
- An elevated white blood cell count typifies osteomyelitis in
children, but rarely in adults.
- ESR is typically high in both children and adults, particularly in
cases of vertebral osteomyelitis.
- Blood cultures indicate the pathogen that caused infection, most
commonly S. aureus. Fungal and tubercular infections are almost
impossible to diagnose without
cultures.
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Pathology/Pathophysiology |
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Pyogenic bacteria |
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Imaging |
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Radionuclide bone scans that use technetium phosphate give positive
indications of the condition, but they are less useful when osteomyelitis stems
from infected prostheses, because the technetium phosphate accumulates in
fracture sites, new bone, overlying areas of cellulitis, and aseptic loosened
areas of the prostheses. In these cases, conventional X rays reveal changes.
Computed tomography can help define the amount of bone destruction and indicate
the presence of complications of the infection, such as abscesses. Magnetic
resonance imaging serves to distinguish infection in soft tissue alone from that
in the bone. |
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Other Diagnostic
Procedures |
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- Palpate areas of apparent infection for signs of warmth and
tenderness.
- Carry out blood tests for white blood cell count and ESR.
- Perform blood culture to identify cause of infection.
- Biopsy the bone, where necessary, by needle aspiration or open
surgery.
- Needle biopsy of the infected bone itself, or open surgical biopsy,
is generally required to diagnose vertebral osteomyelitis. Aspiration applies to
the intervertebral disk space that appears
infected.
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Treatment Options |
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Treatment Strategy |
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A three-week course of antibiotics forms the first line of treatment of
osteomyelitis. Choice of antibiotic depends on identification of the infectious
agent. Bed rest should frequently accompany the treatment. Surgery is necessary
when detection and treatment of the infection occur too late to halt its
spread.
Extended bed rest and immobilization of the affected bones are recommended in
conjunction with antibiotics or antimicrobials. |
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Drug Therapies |
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Courses of antibiotics lasting several weeks should clear up infections
identified early. If diagnostic techniques identify the nature of the infection
precisely, antibiotic specific to that infection should be prescribed.
Antimicrobials are recommended for chronic osteomyelitis and forms of the
condition caused by fractures or infections in sites adjacent to the bone.
Oxacillin and nafcillin, effective against S. aureus, the most common
source of infection, should be given intravenously to children when tests do not
reveal a precise cause of infection. Start intravenously; change to oral
administration within days. For children, intravenous administration should
start as soon as the patient is diagnosed and hospitalized.
In cases of osteomyelitis that result from foot ulcers or diabetes, medical
treatment should include such antimicrobial agents as cefoxitin, cefotetan, or a
combination of aminoglycoside and clindamycin. |
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Surgical Procedures |
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Surgery may be necessary when osteomyelitis is identified late. Surgery is an
option more often in cases of chronic osteomyelitis, osteomyelitis caused by
fractures and infections in soft tissue contiguous to the bone, and that
originating in foot ulcers. Surgery can drain abscesses adjacent to the infected
bone and remove all dead tissue and bone. Antimicrobial or antibiotic therapy
should follow all cases of surgery.
Infected prostheses should be surgically removed, following several weeks of
antibiotic treatment, to permit a new prostheses to be implanted at the same
time. |
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Complementary and Alternative
Therapies |
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Osteomyelitis requires immediate medical attention. Alternative therapies can
be used concurrently to stimulate the immune system and optimize
recovery. |
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Nutrition |
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For overall immune support and to enhance healing, use the
following.
- Vitamin C (1,000 mg tid to qid)
- Zinc (30 to 50 mg/day for 1 month, then reduce to 25
mg/day)
- Vitamin E (400 to 800 IU/day)
- Vitamin A (10,000 to 15,000 IU/day) (avoid in pregnancy or women
considering becoming pregnant)
- Acidophilus (1 to 3 capsules/day, or 1 to 5 million
organisms/day)—to prevent antibiotic-induced diarrhea
and yeast infections
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Herbs |
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Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried
extracts (capsules, powders, teas), glycerites, or tinctures (alcohol extracts).
Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot
water. Steep covered 10 to 60 minutes and drink 2 to 4 cups/day. Tinctures may
be used singly or in combination.
Use one or more herbs from each category. Make a tincture using equal parts.
Take 15 to 20 drops tid to qid.
- Immune support: coneflower (Echinacea purpurea), lomatium
(Lomatium dissectum), astragalus (Astragalus
membranaceus)
- Anti-microbials: goldenseal (Hydrastis canadensis), barberry
(Berberis vulgaris), garlic (Allium sativum)
- Analgesics: valerian (Valeriana officinalis), St. John's wort
(Hypericum perforatum)
- For improved circulation: Ginkgo biloba 120 mg
bid
Alteratives are traditionally known as blood cleansers. Use the following
herbs in combination as an infusion. Drink 2 to 3 cups a day.
- Red clover (Trifolium pratense), burdock root (Arctium
lappa), yellowdock (Rumex crispus), yarrow (Achillea
millefolium), cleavers (Galium aparine), and licorice root
(Glycyrrhiza glabra). Licorice is contraindicated in
hypertension.
Topical applications aid abscess healing: Make a paste from the powders of
goldenseal root (Hydrastis canadensis) and slippery elm (Ulmus
fulva). Apply as needed. |
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Arnica for use after trauma or injury, especially with bruising
or a bruised, "beat up" feeling
- Ledum for puncture wounds that lead to abscesses, especially if
they feel better with cold applications
- Silica for enlarged, suppurating glands or abscesses,
especially in depleted individuals
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Acupuncture |
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May help stimulate immune response, reducing inflammation, pain, edema, and
fever. |
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Patient Monitoring |
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Careful monitoring is essential during antibiotic and antimicrobial
treatments. Look for rapid responses—24 to 48
hours—to the administration of antibiotics and
antimicrobials. |
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Other
Considerations |
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Prevention |
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Avoid strenuous activity or weight-bearing exercise until
healed. |
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Complications/Sequelae |
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Patients who do not receive treatment soon after the onset of infection and
those with immune deficiency may develop chronic osteomyelitis. Infections that
spread from foot ulcers to bones in the foot often involve several types of
bacteria and are difficult to cure by antibiotics alone. Abscess may occur. Cure
may require removal of the infected bone. Massage is contraindicated in
osteomyelitis due to concerns of spreading infection. |
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Prognosis |
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Most patients respond well with no long-term problems. Chronic osteomyelitis
can be quiescent for months to years. |
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References |
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Berkow R, ed. Merck Manual of Diagnosis and Therapy. 16th ed. Rahway,
NJ: Merck Research Laboratories; 1992.
Dambro MR, ed. Griffith's 5 Minute Clinical Consult. New York, NY:
Lippincott, Williams & Wilkins; 1998.
Larson DE, ed. Mayo Clinic Family Health Book. 2nd ed. New York, NY:
William Morrow and Company; 1996. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. |