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Pediatric Osteomyelitis Treatment & Management

  • Author: Sabah Kalyoussef, DO; Chief Editor: Russell W Steele, MD  more...
Updated: May 02, 2016

Medical Care

See the list below:

  • Optimal antibiotic selection, adequate dosing, and a sufficiently prolonged antibiotic course with monitoring for clinical response and for the toxicity of therapy are essential. The decision must be tailored to the age of the patient, local resistance patterns, pathogen suspected, and compliance with the agent prescribed.
  • Promptly initiate antibiotic treatment, preferably after obtaining blood and bone aspirates for culture. Initially, select one or more antimicrobial agents that provide adequate coverage for common pathogens, until therapy can be narrowed.
  • The usual choice is an antistaphylococcal antibiotic; nafcillin, vancomycin, clindamycin, and cefazolin are the preferred agents. Clindamycin may be used if resistance is less than or equal to 10% in the community setting after D-testing is performed.
  • Linezolid has good Gram-positive coverage, including MRSA and has excellent oral bioavailability and additional studies supporting its varied use. However, it is an expensive option and not well studied in the treatment of osteomyelitis.[14]
  • Intravenous therapy is still recommended for initial treatment. Various studies have started oral therapy after a few days of intravenous therapy. The entire duration of treatment remains between 3-6 weeks until normalization of the C-reactive protein level.[15, 16]
  • Consider vancomycin as an alternative to clindamycin for empiric therapy in patients who live in communities that have a higher incidence of penicillin-resistant S pneumoniae or CA-MRSA. Reports of CA-MRSA osteomyelitis are increasing worldwide, with IDSA guidelines now available to aide with management.[17] The severity of disease in infections with organisms carrying the Panton-Valentine leukocidin (PVL) gene is also increasing.[6]
  • Although Haemophilus influenzae type b (Hib) disease has virtually disappeared from the Hib-immune population, third-generation cephalosporins (eg, cefotaxime, ceftriaxone) are used in addition to nafcillin or clindamycin for empiric antibiotic therapy. This additional treatment is commonly used in children younger than 3 years.
  • Do not use third-generation cephalosporins alone to treat osteomyelitis because they are not optimal for treating serious S aureus infections.
  • Cefuroxime, a second-generation cephalosporin, can be used as a single agent against both methicillin-sensitive S aureus and Hib, if they are the suspected pathogens.
  • The increasing incidence of penicillin-resistant S pneumoniae warrants the use of a clindamycin and cefotaxime/ceftriaxone combination in infants and children.
  • When treating neonatal osteomyelitis, consider nafcillin and tobramycin or vancomycin and gentamicin combinations to provide coverage of bacteria from the Enterobacteriaceae family, in addition to group B streptococci and S. aureus.
  • In children and adolescents with penetrating trauma of the foot, perform surgical debridement before considering antipseudomonal treatment. Infection can occur days to weeks before initial presentation, as history is vital to the diagnosis.
  • For further details, see Follow-up.

Surgical Care

See the list below:

  • As mentioned above, patients may require a bone biopsy to ensure a correct diagnosis and appropriate antimicrobial therapy.
  • Consultation with orthopedic surgeons is helpful in determining whether surgery is necessary for diagnosis and treatment.


See the list below:

  • Consultation with an orthopedic surgeon and infectious diseases specialist are helpful in the management of osteomyelitis.
  • Intervention radiologists with a focus on bone pathology would be very helpful to obtain a bone biopsy in a difficult location under fluoroscopic guidance.


No specific diet is recommended.



Weight bearing and aggressive physical activity should be restricted until the infection and treatment course are completed, as noted recently in S aureus infections.[3]

Contributor Information and Disclosures

Sabah Kalyoussef, DO Attending Physician, Pediatric Infectious Diseases and Hospital Medicine, The Children's Hospital at St Peter's University Hospital

Sabah Kalyoussef, DO is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Gary J Noel, MD Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician, New York-Presbyterian Hospital

Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

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