The management of osteomyelitis in the adult
Introduction
Osteomyelitis is one a most challenging condition for both physicians and patients, with an incidence of 21.8 per 100,000 person/years in the United States.1 It an inflammatory state of the bone caused by a microorganism; it can involve either the trabecular or the cortical bone, the bone marrow and the periosteum.2 Osteomyelitis can be generally classified in four categories: acute, chronic, diabetic foot related, and implant related, but several and more articulated classifications have been developed. A classification for osteomyelitis (OM) has been proposed by Waldvogel in 1970, based on the source of infection.3 Three different conditions have been considered: OM caused by local spreading from a contiguous focus of infection; OM secondary to vascular insufficiency (more likely to develop in the diabetic foot); and haematogenous OM, derived from a condition of bacteraemia.3 This classification is useful for pathological definition of the disease. A more clinical classification was developed by Cierny and Mader in 1983 for chronic OM.4 This classification is widely used in daily clinical practice, and has shown a good prognostic value. The main histo-pathological lesion of OM is the sequestrum, which consists in formation of necrotic bone, which lays in the midst of the infected tissue.2 A sequestrum derives from the destruction of bone tissue and bone matrix from inflammatory factors, including leucocytes and cytokines that increase the osteoclasts activity. Because of the lack of vascularization, and hence the impossibility to be reached by immunity cells and drugs, the sequestrum is the cause of persistent infection, since the pathogens are embedded in it. Several bacteria and fungi are common infecting microorganism. Staphylococcus aureus and Staphylococcus epidermidis are the most common pathogens, because of their presence in the normal flora of the skin. Other relevant bacteria are Enterococcus spp, Streptococcus spp; among the fungi, Candida5, 6 and Aspergillus6 have been reported.
The diagnosis of OM is using a multidisciplinary approach involving laboratory medicine, imaging, and pathology. Therapy is based on a multi-area treatment involving antibiotic drugs administration and surgery. The present review collected and analysed the recent scientific evidence about the epidemiology and clinical management of OM, giving an overview on the most common pathogens causing OM, diagnostic techniques and therapeutic options for acute and chronic OM.
Section snippets
Methods
An online search was performed to retrieve studies concerning the research topic. Medline (http://www.ncbi.nlm.nih.gov/pubmed), Cochrane (http://www.thecochranelibrary.com/view/0/index.html) and Google scholar (http://scholar.google.it/) were searched to retrieve studies published between 1990 and present. The following search key words have been used: “(“osteomyelitis”[MeSH Terms] OR “osteomyelitis”[All Fields]) AND (“therapy”[Subheading] OR “therapy”[All Fields] OR “treatment”[All Fields] OR
Results
To present a clear overview on results of the studies included, each section is divided considering the type of OM, among acute, chronic, and diabetes foot OM (DFO) (see Table 1).
Discussion
Osteomyelitis is common, and remains a challenge for both the surgeon and the patient. In the literature, debate is present concerning its treatment, while fewer studies focus on diagnostic methods. The normal skin flora is more likely to be the direct cause of OM than other pathogens. S. aureus and S. epidermidis5, 23 are the most common pathogens, together with Streptococci and gram negative bacteria which are common in organic secretions or are brought into the site of infection by foreign
Conclusion
The present article provides a general and updated overlook on osteomyelitis in adults, especially regarding diagnosis and treatment. A management flow chart is proposed in Fig. 1, showing the basic steps which should be followed for an evidence-based clinical approach to this condition. The lack of comparison studies and randomized controlled trials makes it difficult to have proper information about the relative efficacy of the different therapies. Furthermore, the heterogeneity of the design
Funding
No financial support has been received for the writing of the present piece of work.
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