Osteomyelitis: Epidemiology and Diagnosis

Epidemiology:
3 Ways of Infecting the Bone
- Hematogenous most common in children. Cultures?
- Direct inoculation
- Contiguous spread from adjacent tissue

Hematogenous spread
- Location: Adults vs. Children
- Most often in children
- But what if it happens in adults younger than 40?
- Some risk factors
- Central lines
- Sickle cell disease Bug associated with?
- Urethral catheterization
- Urinary tract infection
- Point: Look for sources of bacteremia

Children
- 3 risk factors in newborns for osteomyelitis.

- Location of osteomyelitis in the long bone

Adults
More often affects the vertebrae then sternoclavicular and pelvic bones.
- 32 year old male with osteomyelitis in pelvic bones?
- Which vertebrae is most common?


Most common bugs by age:
Newborns: S. aureus. Enterobacter, Groups A and B Strep
Children (4 months to 4 years): S. aureus. Group A strep, H. influenzae,
Enterobacter
Children (4 years to adult): S. aureus (80%) Group A Strep, H. influenze,
Enterobacter
Adults: S. aureus, Enterobacter, Streptococcus

* Note: H. influenzae caused osteomyelitis in children

* Note: About osteomyelitis in patients with different diseases
- Sickle cell anemia:
- Chronic Granulomatous Disease:
- HIV + patients:
- Puncture wounds of feet:
Osteomyelitis: Epidemiology and Diagnosis
When to suspect osteomyelitis?
Acute vs. Chronic
- Be careful in adults who may have acute osteomyelitis because:

- Pathognomonic finding of chronic osteomyelitis?

Diagnosis:
- Some basic things to look for
> 2 cm
2
ulcer in a diabetic
Can visualize the bone
ESR > 70. But not always useful. Mostly just not useful.

- Note on your
index of suspicion
and letting it guide
diagnosis.
Consider these
scenarios

- 70 y/o patient with
PMHx of CVA,
HLD, and HTN who
was found to have
Stage 3 sacral
ulcers.



Bone biopsy and culture: SN 95% and SP 99% Gold Standard. Why is it
important? 3 reasons
1.
2.
3.
* Sometimes not done. Why?

Sending for cultures what do you want to look for? 4 cultures

Osteomyelitis: Epidemiology and Diagnosis
Other diagnostic modalities:
- Probe to bone test: SN only 66% and specificity 85%, positive predictive
value 89%.
- ESR > 70 mm/hr: Positive likelihood ratio of 11 (95% CI, 1.6- 79.0).
- In different study had sensitivity of 28%.
- MRI: 90% sensitivity and 79% specificity

Suggested approach:
1. History & Physicial, Risk factors diabetes, neuropathy, IVDU,
vasculopathy, bacteremia
2. Can you see the bone or touch the bone with a probe?
3. Moderate index of suspicion: Get Blood cultures (x4), ESR, CRP, WBC
4. Question: What about bone biopsy?
- Was the blood culture positive for likely bugs?
- Do you really think that its osteomyelitis? Then just treat
- Plain radiograph is concerning bone biopsy if no culture findings

5. Plain radiograph is negative but you still think its osteomyelitis (diabetic,
ESR, PTBT)
- Go for something better than plain films
- Diabetics
- Vertebral osteomyelitis
- No MRI available
- Patient has metal in the body

6. Trouble
- Blood cultures negative
- Needle aspirate negative
- Clinical suspicion still high
- What do you do next?

Osteomyelitis: Epidemiology and Diagnosis
7. Can empiric therapy ever be appropriate?


* One additional idea after the surgical consult has been placed: