Merck Manual

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Steven Schmitt

, MD, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University

Last full review/revision Oct 2020| Content last modified Oct 2020

Osteomyelitis is a bone infection usually caused by bacteria, mycobacteria, or fungi.

  • Bacteria, mycobacteria, or fungi can infect bones by spreading through the bloodstream or, more often, by spreading from nearby infected tissue or a contaminated open wound.

  • People have pain in one part of the bone, fever, and weight loss.

  • Blood tests and imaging tests are done, and doctors remove a sample of bone for tests.

  • Antibiotics are given for weeks, and surgery may be needed to remove the infected bone.

Osteomyelitis occurs most commonly in young children and in older people, but all age groups are at risk. Osteomyelitis is also more likely to occur in people with serious medical conditions.

When a bone becomes infected, the soft, inner part (bone marrow) often swells. As the swollen tissue presses against the rigid outer wall of the bone, the blood vessels in the bone marrow may become compressed, which reduces or cuts off the blood supply to the bone.

Without an adequate blood supply, parts of the bone may die Osteonecrosis Osteonecrosis is the death of a segment of bone caused by an impaired blood supply. Osteonecrosis can be caused by an injury or can occur spontaneously. Typical symptoms include pain, limited... read more . These areas of dead bone are difficult to cure of infection because it is difficult for the body’s natural infection-fighting cells and antibiotics to reach them.

The infection can also spread outward from the bone to form collections of pus (abscesses) in nearby soft tissues, such as the muscle. Abscesses occasionally drain spontaneously through the skin.

Causes of Osteomyelitis

Bones, which usually are well-protected from infection, can become infected through three routes:

  • The bloodstream (which may carry an infection from another part of the body to the bones)

  • Direct invasion (via open fractures, surgery, or objects that pierce the bone)

  • Infections in nearby structures, such as natural or artificial joints or soft tissues

Spread through the blood

When organisms that cause osteomyelitis spread through the bloodstream, infection usually occurs in

  • The ends of leg and arm bones in children

  • The spine (vertebrae) in adults, particularly older people

Infections of the vertebrae are referred to as vertebral osteomyelitis. People who are older, are debilitated (such as people living in nursing homes), have sickle cell disease, undergo kidney dialysis, or inject drugs using nonsterile needles are particularly susceptible to vertebral osteomyelitis.

Staphylococcus aureus Staphylococcus aureus Infections Staphylococcus aureus is the most dangerous of all of the many common staphylococcal bacteria. These gram-positive, sphere-shaped (coccal) bacteria (see figure How Bacteria Shape Up) often cause... read more Staphylococcus aureus Infections is the bacteria that most commonly causes osteomyelitis that spreads via the bloodstream. Mycobacterium tuberculosis Tuberculosis (TB) Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis. It usually affects the lungs. Tuberculosis is spread mainly when people breathe air... read more Tuberculosis (TB) (the bacteria that causes tuberculosis) and fungi can spread the same way and cause osteomyelitis, particularly in people who have a weakened immune system (such as those with HIV infection Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection is a viral infection that progressively destroys certain white blood cells and can cause acquired immunodeficiency syndrome (AIDS). HIV is transmitted... read more Human Immunodeficiency Virus (HIV) Infection , with certain cancers Overview of Cancer A cancer is an abnormal growth of cells (usually derived from a single abnormal cell). The cells have lost normal control mechanisms and thus are able to multiply continuously, invade nearby... read more , or who are undergoing treatment with drugs that suppress the immune system Secondary immunodeficiency disorders Immunodeficiency disorders involve malfunction of the immune system, resulting in infections that develop and recur more frequently, are more severe, and last longer than usual. Immunodeficiency... read more ) or who live in areas where certain fungal infections are common.

Direct invasion

Bacteria or fungal seeds (called spores) may infect the bone directly through open fractures, during bone surgery, or from contaminated objects that pierce the bone.

Osteomyelitis may occur where a piece of metal has been surgically attached to a bone, as is done to repair a hip or other fracture (see Figure: Repairing a Fractured Hip Repairing a Fractured Hip Hip fractures may occur in the round upper end (head) of the thighbone, in the narrow part of the thighbone just below the head (neck), or in the bumps in the broader area just below the neck... read more ). Also, bacteria or fungal spores may infect the bone to which an artificial joint (prosthesis) is attached (see Artificial Joint Infectious Arthritis Artificial Joint Infectious Arthritis Artificial joints can become infected by bacteria. Bacteria may infect the artificial joint during or after surgery, causing infection. Symptoms may include pain, swelling, and limited range... read more ). The organisms may be carried into the area of bone surrounding the artificial joint during the operation to replace the joint, or the infection may occur later.

Spread from nearby structures

Osteomyelitis may also result from an infection in nearby soft tissue. The infection spreads to the bone after several days or weeks. This type of spread is particularly likely to occur in older people.

Such an infection may start in an area damaged by an injury or surgery, radiation therapy, or cancer or in a skin ulcer (particularly a foot ulcer) caused by poor circulation or diabetes. A sinus, gum, or tooth infection may spread to the skull.

Symptoms of Osteomyelitis

In acute osteomyelitis, infections of the leg and arm bones cause fever and, sometimes days later, pain in the infected bone. The area over the bone may be sore, red, warm, and swollen, and movement may be painful. The person may lose weight and feel tired.

When osteomyelitis results from infections in nearby soft tissues or direct invasion by an organism, the area over the bone swells and becomes painful. Abscesses may form in the surrounding tissue. These infections may not cause fever.

Infection around an infected artificial joint or limb typically causes persistent pain in that area.

Vertebral osteomyelitis usually develops gradually, causing persistent back pain and tenderness when touched. Pain worsens with movement and is not relieved by resting, applying heat, or taking pain relievers (analgesics). People often do not have fever, which is usually the most obvious sign of an infection.

Chronic osteomyelitis may develop if osteomyelitis is not treated successfully. It is a persistent infection that is very difficult to get rid of. Sometimes, chronic osteomyelitis is undetectable for a long time, causing no symptoms for months or years. More commonly, chronic osteomyelitis causes bone pain, recurring infections in the soft tissue over the bone, and constant or intermittent drainage of pus through the skin. Such drainage occurs when a passage (sinus tract) forms from the infected bone to the skin surface and pus drains through the sinus tract.

Diagnosis of Osteomyelitis

  • Blood tests

  • Imaging tests, such as x-rays, computed tomography (CT), magnetic resonance imaging (MRI), a bone scan, or a white blood cell scan

Symptoms and findings found by doctors during a physical examination may suggest osteomyelitis. For example, doctors may suspect osteomyelitis in a person who has persistent pain in part of a bone, who may or may not have a fever, and who feels tired much of the time.

If doctors suspect osteomyelitis, they do a blood test for inflammation by measuring one of the following:

  • Erythrocyte sedimentation rate (ESR—a test that measures the rate at which red blood cells settle to the bottom of a test tube containing blood)

  • Level of C-reactive protein (a protein that circulates in the blood and dramatically increases in level when there is inflammation)

Inflammation is usually present if the ESR and C-reactive protein level are increased. Also, blood tests often indicate elevated levels of white blood cells. The results of these blood tests are not enough to make the diagnosis of osteomyelitis. However, results that show little or no inflammation may suggest a person does not have osteomyelitis.

Alternatively, a bone scan Bone scanning A doctor can often diagnose a musculoskeletal disorder based on the history and the results of a physical examination. Laboratory tests, imaging tests, or other diagnostic procedures are sometimes... read more Bone scanning (images of bone made after injecting a substance called radioactive technetium) may be done. The infected area almost always appears abnormal on bone scans, except in infants because scans do not reliably indicate abnormalities in growing bones. However, a bone scan cannot always distinguish infections from other bone disorders. White blood cell scans (images made after radioactive indium–labeled white blood cells are injected into a vein) can help distinguish between infection and other disorders in areas that are abnormal on bone scans.

To diagnose a bone infection and identify the organisms causing it, doctors may take samples of blood, pus, joint fluid, or the bone itself to test. Usually, for vertebral osteomyelitis, samples of bone tissue are removed with a needle or during surgery.

Prognosis of Osteomyelitis

The prognosis for people with osteomyelitis is usually good with early and proper treatment. However, sometimes chronic osteomyelitis develops, and a bone abscess may return weeks to months or even years later.

Treatment of Osteomyelitis

  • Antibiotics or antifungal drugs

  • Sometimes surgery

  • For abscesses, usually drainage

Antibiotics and antifungal drugs

For children and adults who have recently developed bone infections through the bloodstream, antibiotics are the most effective treatment. If the bacteria causing the infection cannot be identified, then antibiotics that are effective against Staphylococcus aureus and many types of bacteria (broad-spectrum antibiotics) are used. Depending on the severity of the infection, antibiotics may be given by vein (intravenously) for about 4 to 8 weeks. Then, antibiotics may be continued by mouth for a longer period of time depending on how the person responds to them. Some people have chronic osteomyelitis and need months of antibiotic treatment.

If a fungal infection is identified or suspected, antifungal drugs are required for several months. If the infection is detected at an early stage, surgery is usually not necessary.

Surgery and drainage

For adults who have bacterial osteomyelitis of the vertebrae, the usual treatment is antibiotics for 4 to 8 weeks. Sometimes bed rest is needed, and the person may need to wear a brace. Surgery may be needed to drain abscesses or to stabilize affected vertebrae (to prevent the vertebrae from collapsing and thereby damaging nearby nerves, the spinal cord, or blood vessels).

When osteomyelitis results from a nearby soft-tissue infection, treatment is more complex. Usually, all the dead tissue and bone are removed surgically, and the resulting empty space is packed with healthy skin or other tissue. Then the infection is treated with antibiotics. Broad-spectrum antibiotics may be required for more than 3 weeks after surgery.

When an abscess is present, it usually needs to be drained surgically. Surgery may also be needed for people with persistent fever and weight loss.

More Information about Osteomyelitis

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

  • Arthritis Foundation: Comprehensive information on various types of arthritis, including osteomyelitis, and information regarding living with arthritis

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