Synopsis
Understand persistent bone infection as a combined microbiological, dead-space, stability and soft-tissue problem, protect diagnostic yield, identify malignant change, and plan durable multidisciplinary eradication or suppression.
- Chronic osteomyelitis is an anatomical disease of sequestrum, biofilm, dead space, instability and inadequate soft-tissue cover; antibiotics alone rarely correct all five.
- A draining sinus communicating with bone strongly supports infection, but a superficial sinus swab usually reflects colonisers and should not select definitive therapy.
- If septic, take blood cultures and start parenteral treatment immediately. If stable, avoid empirical antibiotics and preserve deep-sample yield for a planned bone-infection pathway.
Key red flags
Fever, hypotension, spreading erythema, escalating deep pain or abrupt cessation of drainage with swelling suggests acute-on-chronic abscess or sepsis and needs urgent source-control assessment.
Investigation priorities
Assess chronic bone architecture, union and implant status.
Management branches
Sepsis, spreading infection, abscess, neurovascular compromise or threatened fracture complicates chronic disease.
- Stabilise physiology, obtain blood cultures and start immediate parenteral therapy when septic.
- Protect an unstable bone segment and obtain urgent radiographs and source-focused cross-sectional imaging.
Chronic pain, sinus or infected non-union is present without systemic instability.
Key medicines
Post-sampling empirical antimicrobial therapyAfter five deep cultures and histology are obtained, give the full adult regimen in the trust's chronic bone-infection protocol, then review with preliminary results at 48 hours and replace it with an organism-, surgery- and organ-function-specific prescription.
Rifampicin-containing therapy when specifically selectedUse only as one component of an infection-specialist regimen for a proven susceptible staphylococcal infection with retained implant or biofilm relevance, after adequate debridement and wound control; never prescribe rifampicin alone.