Case 090: Acute Osteomyelitis

PATIENT PRESENTATION

Chief Complaint

“I hit my toe last night and have pain, redness, swelling and some drainage”

History of Present Illness

This is a 50-year-old female with past medical history of type 2 diabetes, HIV, and hypertension who presents to the emergency department with complaints for right fourth toe pain and redness. Patient states that approximately one week ago she was walking around outside and stepped on a thorn and received oral antibiotics that started with the letter “C” but since then the right toe has worsened.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What signs, symptoms, laboratory, and imaging support a diagnosis of acute osteomyelitis?

   Hint: See Clinical Presentation and Diagnosis in PPP

2. How would you classify this patient’s osteomyelitis?

   Hint: See Introduction in PPP

3. What microorganisms would be the most likely cause of infection in this patient?

   Hint: See Epidemiology and Etiology in PPP

4. What empirical antimicrobial agent(s), dosage regimen, and monitoring parameters would you recommend for this patient?

   Hint: See Treatment and Table 77-1 in PPP

5. What duration of antimicrobial therapy do you anticipate for this patient?

   Hint: See Treatment in PPP

FOLLOW-UP

The patient has now received IV antibiotics for 2 weeks. As the patient is getting ready for discharge, the ID physician is considering changing to oral antibiotics to complete therapy. What oral agents would you recommend?

Hint: See Treatment in PPP

CASE SUMMARY

Global Perspective

Acute osteomyelitis affects patients throughout the world. In developing countries, the diagnosis of acute osteomyelitis may be more challenging with limited access to advanced imaging studies (e.g., MRI). Antimicrobial therapy may differ globally on the basis of local or regional susceptibility patterns, access to hospitals, infusion centers, or outpatient parenteral antimicrobial therapy (OPAT) services, drug availability and cost. The use of oral antimicrobials for the treatment of acute osteomyelitis can play a significant role in reliable, clinically stable patients who have adequate source control and are able to tolerate oral medications.

Key References