Pediatric Osteomyelitis Treatment & Management

Updated: Feb 11, 2022
  • Author: Sabah Kalyoussef, DO; Chief Editor: Russell W Steele, MD  more...
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Medical Care

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. It is helpful to look at the local antibiogram to determine what are the MRSA rates as well as clindamycin susceptibilities for both MRSA and MSSA. If patients are moderately to severely ill in areas of clindamycin resistance greater than 10-20%, vancomycin, daptomycin, ceftaroline, or linezolid may be used. [9]

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. [16]

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. [17, 18]

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 aid with management. [19] The severity of disease in infections with organisms carrying the Panton-Valentine leukocidin (PVL) gene is also increasing. [3]

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.

The use of a third-generation cephalosporins alone to treat osteomyelitis is not recommended as it is not optimal regimen 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.



Consultation with a pediatric orthopedic surgeon and a pediatric infectious diseases specialist is 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. Aerobic and anaerobic culture samples may be performed to aid with diagnostic workup as well as pathology.


Diet and Activity


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. [6]