Last updated: September 13, 2023

Summarytoggle arrow icon

Osteomyelitis is an infection of the bone; it occurs following hematogenous (seeded from a remote source) or exogenous (expansion from nearby tissue) spread of pathogens, most commonly Staphylococcus aureus. Individuals are at increased risk of osteomyelitis following trauma, placement of surgical implants or hardware, or if they are immunosuppressed or have poor tissue perfusion. Osteomyelitis can be either acute or chronic and manifests with signs of local inflammation, including swelling, pain, redness, and warmth. Systemic signs, such as fever and chills, are more common in acute infection. Diagnosis is supported via laboratory tests, imaging, and/or biopsy. In most cases, antibiotic therapy should be delayed until culture results are obtained, so as to better tailor treatment. Empiric antibiotic therapy for osteomyelitis is reserved for patients with signs of sepsis or rapidly progressing infections. Surgery may be necessary to remove necrotic bone, abscesses, infected foreign bodies, or fistulae. Osteomyelitis in adults often assumes a chronic course and requires prolonged treatment, whereas children typically make a quick and full recovery.

The diagnosis and management of vertebral osteomyelitis are described in “Spinal infections.”

Definitiontoggle arrow icon

  • Osteitis: a general term for inflammation of the bone
  • Osteomyelitis: infection of the bone

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Routes of infection [3]

  • Hematogenous osteomyelitis: (endogenous osteomyelitis): caused by hematogenous dissemination of a pathogen
  • Exogenous osteomyelitis: caused by a spread of bacteria (typically multiple pathogens) from the surrounding environment [4]
    • Posttraumatic: infection following deep injury (penetrating injury, open fractures, severe soft tissue injury)
    • Contiguous: spread of infection from adjacent tissue

Risk factors for osteomyelitis [5]


Most common pathogens causing osteomyelitis [5]
Pathogens Commonly affected groups
Staphylococcus aureus (most common cause)
  • Children and adults
  • Individuals that recreationally use IV drugs [6]
  • Patients with vertebral lesions
  • Patients with prosthetics [7]
  • Diabetic patients with foot ulcers and pressure ulcers
Staphylococcus epidermidis
  • Patients with prosthetics
Pseudomonas aeruginosa
Enterobacteriaceae Salmonella
  • Patients with UTIs
Mycobacterium tuberculosis
Pasteurella multocida
  • Bites from dogs and cats
Fungi (e.g., Candida)

Clinical featurestoggle arrow icon

Acute osteomyelitis and subacute osteomyelitis [5]

  • Onset: within days or weeks; associated with acute bone inflammation
  • Duration: < 2 weeks (acute) or 2–6 weeks (subacute) [3][8]
  • Symptoms: pain at the site of infection; in patients with peripheral neuropathy the pain may be mild or absent
  • Possible localized findings: : point tenderness, swelling, redness, warmth
  • Possible systemic findings: : malaise, fever, chills

Features of underlying disease (e.g., peripheral neuropathy, signs of peripheral arterial disease) may be seen in both acute and chronic osteomyelitis.

Chronic osteomyelitis

  • Onset: develops slowly (over months or years) following acute infection
  • Associated with: avascular bone necrosis and sequestrum formation (necrotic bone fragment that has become detached from the original bone) [9]
  • Duration: typically > 6 weeks
  • Symptoms: recurrent pain lasting weeks to months, maybe cyclical [3]
  • Possible localized findings
    • Swelling, redness
    • Deformity
    • Impaired healing of overlying wounds
    • Local sinus tract formation, perhaps draining pus
    • Positive probe-to-bone test [10]
  • Systemic findings: typically absent; may include low-grade fever, malaise

A positive probe-to-bone test is strongly suggestive of osteomyelitis, especially in diabetic patients with risk factors for osteomyelitis. [10][11]

The symptoms of chronic osteomyelitis may be subtle and the diagnosis may only become apparent when late complications occur (e.g., pathological fracture, loosening of implants). [12]

Diagnosticstoggle arrow icon

The following recommendations are for nonvertebral osteomyelitis; diagnostics for vertebral osteomyelitis are detailed separately in “Spinal infections.”

Approach [5][10]

In stable patients, defer antibiotics until blood cultures and/or bone biopsy have been taken. Do not delay antibiotic administration in patients with signs of sepsis.

Laboratory studies [10]


Routine imaging [10][13][14]

X-ray is the recommended initial imaging modality because it is inexpensive and can rule out differential diagnoses; however, it may miss acute osteomyelitis as findings are typically visible only 10–14 days after symptom onset. [10][13]

Imaging in special circumstances [15]

Bone biopsy [10][14]

Bone biopsy with cultures is the confirmatory test for osteomyelitis and should be performed unless there are characteristic imaging features of osteomyelitis and positive blood cultures.

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

The following recommendations are for the treatment of nonvertebral osteomyelitis. For treatment of vertebral osteomyelitis, see “Treatment of spinal infections.”


Acute hematogenous osteomyelitis can typically be treated with antibiotic therapy alone. Management of acute osteomyelitis due to contiguous spread and chronic osteomyelitis usually requires surgical debridement of infected tissue. [18][21]

Antibiotic therapy [5][18][21]

When indicated, obtain a bone biopsy preferably before administering antibiotic therapy to maximize diagnostic yield. [17]

Empiric antibiotic therapy for osteomyelitis

Avoid giving vancomycin with piperacillin-tazobactam; while the combination provides cover against both S. aureus and Pseudomonas, it has a high risk of nephrotoxicity. [22]

Pathogen-directed antibiotics

Pathogen-directed antibiotic therapy for osteomyelitis [5][10][18][21]
Pathogen First-line Alternative
Staphylococcus spp. Methicillin-susceptible S. aureus (MSSA)
Methicillin-resistant S. aureus (MRSA) [24]
Enterococcus spp. Penicillin-susceptible
Enterobacteriaceae Quinolone-sensitive
Pseudomonas aeruginosa
Beta-hemolytic streptococci
  • Consider adding rifampin in patients with retained surgical hardware/foreign bodies. [18]

Supportive therapy [21]

Surgery [21][25]

  • Manage patient factors that may have impacted healing prior to surgery (e.g., anemia, poor nutrition).
  • The decision for surgery should be made in consultation with infectious disease specialists.
  • The choice of procedure depends on site of infection, presence of hardware, and patient factors (e.g., comorbidities).
  • Continue antibiotic therapy after surgery, even if bone has been successfully debrided.
Potential surgical interventions in osteomyelitis [10][21]
Surgical intervention
Chronic osteomyelitis
Acute osteomyelitis refractory to antibiotic treatment
Infected prosthetic joint or foreign body
Posttraumatic osteomyelitis
  • Debridement of grossly infected wounds
  • Removal of surgical hardware may be required.
Overlying abscess
Poor wound healing or limb ischemia

Subtypes and variantstoggle arrow icon

Brodie abscess

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Special patient groupstoggle arrow icon

Osteomyelitis in children [10][19][27]

Overview [10]

Clinical features [28]


Treatment [10][19]

Stable patients

Signs of sepsis or rapidly progressive infection

Complications [27]

  • Similar to those seen in adults (see “Complications”)
  • The following are more common in children

Maintain a high index of suspicion for osteomyelitis in children; delayed diagnosis and treatment can have detrimental effects on bone development, affecting growth and causing severe long-term impairment.

Prognosistoggle arrow icon

Referencestoggle arrow icon

  1. Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton LJ 3rd, Huddleston PM 3rd. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am. 2015; 97 (10): p.837-45.doi: 10.2106/JBJS.N.01350 . | Open in Read by QxMD
  2. Nickerson EK, Sinha R. Vertebral osteomyelitis in adults: an update. Br Med Bull. 2016; 117 (1): p.121-138.doi: 10.1093/bmb/ldw003 . | Open in Read by QxMD
  3. Panteli M, Giannoudis PV. Chronic osteomyelitis: what the surgeon needs to know. EFORT Open Rev. 2016; 1 (5): p.128-135.doi: 10.1302/2058-5241.1.000017 . | Open in Read by QxMD
  4. Hotchen AJ, McNally MA, Sendi P. The Classification of Long Bone Osteomyelitis: A Systemic Review of the Literature. J Bone Jt Infect. 2017; 2 (4): p.167-174.doi: 10.7150/jbji.21050 . | Open in Read by QxMD
  5. Bury DC, Rogers TS, Dickman MM. Osteomyelitis: Diagnosis and Treatment. Am Fam Physician. 2021; 104 (4): p.395-402.
  6. Allison DC, Holtom PD, Patzakis MJ, Zalavras CG. Microbiology of bone and joint infections in injecting drug abusers. Clin Orthop Relat Res. 2010; 468 (8): p.2107-12.doi: 10.1007/s11999-010-1271-2 . | Open in Read by QxMD
  7. Olson ME, Horswill AR. Staphylococcus aureus osteomyelitis: bad to the bone. Cell Host Microbe. 2013; 13 (6): p.629-31.doi: 10.1016/j.chom.2013.05.015 . | Open in Read by QxMD
  8. Helm C, Huschart E, Kaul R, Bhumbra S, Blackwood RA, Mukundan D. Management of Acute Osteomyelitis: A Ten-Year Experience. Infect Dis Rep. 2016; 8 (3): p.6350.doi: 10.4081/idr.2016.6350 . | Open in Read by QxMD
  9. Lew DP, Waldvogel FA. Osteomyelitis. The Lancet. 2004; 364 (9431): p.369-379.doi: 10.1016/s0140-6736(04)16727-5 . | Open in Read by QxMD
  10. Schmitt SK. Osteomyelitis. Infect Dis Clin North Am. 2017; 31 (2): p.325-338.doi: 10.1016/j.idc.2017.01.010 . | Open in Read by QxMD
  11. Lam K, van Asten SAV, Nguyen T, La Fontaine J, Lavery LA. Diagnostic Accuracy of Probe to Bone to Detect Osteomyelitis in the Diabetic Foot: A Systematic Review. Clinical Infectious Diseases. 2016; 63 (7): p.944-948.doi: 10.1093/cid/ciw445 . | Open in Read by QxMD
  12. Walter G, Kemmerer M, Kappler C, Hoffmann R. Treatment algorithms for chronic osteomyelitis. Dtsch Arztebl Int. 2012; 109 (14): p.257-64.doi: 10.3238/arztebl.2012.0257 . | Open in Read by QxMD
  13. Niels van der, Diederik P.J. Smeeing, Roderick M. Houwert, Falco Hietbrink, Geertje A.M. Govaert, Detlef van der. Brodie's Abscess: A Systematic Review of Reported Cases. J Bone Jt Infect. 2019; 4 (1): p.33-39.doi: 10.7150/jbji.31843 . | Open in Read by QxMD
  14. Expert Panel on Musculoskeletal Imaging:., Beaman FD, von Herrmann PF, et al. ACR Appropriateness Criteria® Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot). J Am Coll Radiol. 2017; 14 (5S): p.S326-S337.doi: 10.1016/j.jacr.2017.02.008 . | Open in Read by QxMD
  15. Walker EA, Beaman FD, Wessell DE, et al. ACR Appropriateness Criteria® Suspected Osteomyelitis of the Foot in Patients With Diabetes Mellitus. J Am Coll Radiol. 2019; 16 (11): p.S440-S450.doi: 10.1016/j.jacr.2019.05.027 . | Open in Read by QxMD
  16. Pineda C, Espinosa R, Pena A. Radiographic Imaging in Osteomyelitis: The Role of Plain Radiography, Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, and Scintigraphy. Sem Plast Surg. 2009; 23 (02): p.080-089.doi: 10.1055/s-0029-1214160 . | Open in Read by QxMD
  17. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  18. Hirschfeld CB, Kapadia SN, Bryan J, et al. Impact of diagnostic bone biopsies on the management of non-vertebral osteomyelitis: A retrospective cohort study. Medicine (Baltimore). 2019; 98 (34): p.e16954.doi: 10.1097/MD.0000000000016954 . | Open in Read by QxMD
  19. Fraimow HS. Systemic Antimicrobial Therapy in Osteomyelitis. Seminars in Plastic Surgery. 2009; 23 (02): p.090-099.doi: 10.1055/s-0029-1214161 . | Open in Read by QxMD
  20. Woods et al. Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics. J Pediatric Infect Dis Soc. 2021; 10 (8): p.801-844.doi: 10.1093/jpids/piab027 . | Open in Read by QxMD
  21. Marais LC, Ferreira N, Aldous C, Sartorius B, Le Roux T. A modified staging system for chronic osteomyelitis. J Orthop. 2015; 12 (4): p.184-92.doi: 10.1016/j.jor.2015.05.017 . | Open in Read by QxMD
  22. Rao N, Ziran BH, Lipsky BA. Treating Osteomyelitis: Antibiotics and Surgery. Plastic & Reconstructive Surgery. 2011; 127: p.177S-187S.doi: 10.1097/prs.0b013e3182001f0f . | Open in Read by QxMD
  23. Kolinsky DC, Liang SY. Musculoskeletal Infections in the Emergency Department. Emerg Med Clin North Am. 2018; 36 (4): p.751-766.doi: 10.1016/j.emc.2018.06.006 . | Open in Read by QxMD
  24. Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Vancomycin Therapeutic Guidelines: A Summary of Consensus Recommendations from the Infectious Diseases Society of America, the American Society of Health‐System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis. 2009; 49 (3): p.325-327.doi: 10.1086/600877 . | Open in Read by QxMD
  25. Liu C, Bayer A, Cosgrove SE et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis. 2011; 52 (3): p.e18-55.doi: 10.1093/cid/ciq146 . | Open in Read by QxMD
  26. Lipsky et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012; 54 (12): p.e132-e173.doi: 10.1093/cid/cis346 . | Open in Read by QxMD
  27. Le Saux N, Howard A, Barrowman NJ, Gaboury I, Sampson M, Moher D. Shorter courses of parenteral antibiotic therapy do not appear to influence response rates for children with acute hematogenous osteomyelitis: a systematic review. BMC Infect Dis. 2002; 2: p.16.doi: 10.1186/1471-2334-2-16 . | Open in Read by QxMD
  28. Berendt AR, Peters EJG, Bakker K, et al. Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment. Diabetes Metab Res Rev. 2008; 24 (S1): p.S145-S161.doi: 10.1002/dmrr.836 . | Open in Read by QxMD
  29. Gornitzky AL, Kim AE, O’Donnell JM, Swarup I. Diagnosis and Management of Osteomyelitis in Children. JBJS Rev. 2020; 8 (6): p.e19.00202-e19.00202.doi: 10.2106/jbjs.rvw.19.00202 . | Open in Read by QxMD
  30. Thakolkaran N, Shetty AK. Acute Hematogenous Osteomyelitis in Children. Ochsner J. ; 19 (2): p.116-122.doi: 10.31486/toj.18.0138 . | Open in Read by QxMD
  31. Yagupsky P. Outbreaks of Kingella kingae infections in daycare facilities. Emerg Infect Dis. 2014; 20 (5): p.746-53.doi: 10.3201/eid2005.131633 . | Open in Read by QxMD

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