Osteomyelitis

остеомиелит фото Osteomyelitis is an inflammatory process of a purulent-necrotic nature that affects the bone tissue surrounding the periosteum and bone marrow. The causative agents of osteomyelitis, in the overwhelming majority of cases, are staphylococci and streptococci.

Osteomyelitis, which arose for the first time, is called acute. If the patient has a prolonged course of the disease with exacerbations and remissions, then it is a chronic inflammatory process of osteomyelitis. Often, with osteomyelitis, the entire bone tissue, including the bone marrow, is involved in the inflammation process. In the chronic process of osteomyelitis, bone sclerosis and deformity develop.

Cause of osteomyelitis

Osteomyelitis causes such bacterial pathogens as: Staphylococcus aureus, Staphylococcus epidermis (70% of cases), Streptococcus, Enterobacteria and Pseudomonas aeruginosa. In rare cases, the cause of osteomyelitis may be mycobacterium tuberculosis.

Osteomyelitis occurs as a result of the direct entry of pathogenic microorganisms into the bone and surrounding tissues due to an open fracture or due to significant inflammatory lesions in the area above the bone. Also, osteomyelitis occurs after operations on bone tissue (osteosynthesis), when the conditions of the antiseptic operative wound are poorly observed.

Chronic inflammatory processes in the body can also be attributed to the causes of osteomyelitis. These include: chronic sinusitis and tonsillitis, caries, a long non-healing umbilical wound in newborns, furunculosis, and the like. In such cases, microorganisms enter the bone tissue by the hematogenous route. Chronic inflammatory processes in the body are on the second place in frequency, after traumatization of bones.

In osteomyelitis, in most cases, the tubular bones of the upper and lower extremities, the bones of the skull and jaw, the vertebral column and the ribs are affected.

When there is a lesion of bone tissue by microorganisms, leukocytes are attached to the lesioned lesion, which produce certain lytic enzymes that have the property of decomposing bone tissue. On the blood vessels there is a spread of purulent exudate from the affected focus, which leads to sequestration of bone tissue. As a result, a focus of chronic infection is formed. Together with this, a new bone tissue begins to form in the area of ​​necrosis, the so-called cover. During the histological examination, the exact stage of osteomyelitis is established: acute or chronic.

Osteomyelitis symptoms

Osteomyelitis is caused by various pathogens and for various reasons, therefore, proceeds in different ways.

There are osteomyelitis acute, chronic, gunshot, post-traumatic, hematogenous, odontogenic, osteomyelitis of the jaw, osteomyelitis of the joints and spine, etc.

The signs of osteomyelitis depend on the area and area of ​​the lesion.

Acute osteomyelitis is characterized by an acute onset of the disease with rapid multiplication of pathogenic flora in the affected area, pronounced pain syndrome, signs of intoxication, large purulent discharge from the affected area and significant swelling of the tissues.

Chronic osteomyelitis occurs, often, subacute and is accompanied by periods of exacerbation and periods of remission.

Odontogenic osteomyelitis is accompanied by intense pain in the area of ​​the affected tooth with irradiation in the ear or eye, fever, chills, sleep disturbances, and lack of appetite.

Gunshot osteomyelitis is characterized in the early days of rapid suppuration of the wound. This is due to the fact that the wound with a gunshot wound is widely populated with pathogenic microflora, which develops due to numerous pockets and large areas of tissue necrosis. The localization of the focus, the state of the body's immune system and stressful situations also have a characteristic role here. But the main reason for the occurrence of gunshot osteomyelitis is insufficient sanitary and surgical treatment of the wound.

After suppuration of the wound, the process of inflammation passes to the bone, which is accompanied by a hectic fever, hypochromic anemia , weakness, leukocytosis and intoxication of the body. Local reactions in the affected area practically remain unchanged: the absence of infiltrations in the wound area, the swelling of the limb does not increase, a profuse exodus of pus. But, at the same time, the wound itself changes its appearance, which is characterized by a gray coating on it and the appearance of necrotic granulations. After this, the process of inflammation passes to the wound area of ​​the bone, extending under the periosteum and along the bone marrow channel. If you do not provide adequate treatment for acute gunshot osteomyelitis, the process of inflammation passes into a prolonged, that is, chronic.

At fractures of bones as a result of a gunshot wound, early or late inflammatory complications are more likely. The early purulent-necrotic complications that occur immediately after the lesion are caused by the rapid damage by the microorganisms of the bone marrow and manifestations of sepsis. Late complications can be caused by exacerbation of the inflammatory process. It should be noted that the destructive process is not formed in the bone marrow canal, but in the area of ​​bone fragments or a foreign body.

Post-traumatic osteomyelitis is similar to osteomyelitis in almost all settings. The purulent-inflammatory process also extends to the entire area of ​​the bone. Sometimes this process has the name of posttraumatic parotitis. The defeat of soft tissues during open fractures of the bones is the most common complication, which leads to the entry of pyogenic microflora into the area of ​​the damaged bone. The development of the inflammatory process in posttraumatic osteomyelitis is due to contamination of the wound at the time of injury and is accompanied by febrile temperature (39-40 ° C), pronounced leukocytosis, increased ESR, intoxication and anemia. Local manifestations are characterized by swelling of the tissues around the affected area, abundant removal of purulent contents from the wound, flushing of the skin and acute pain in the lesion.

Osteomyelitis of the joints manifests itself in the form of severe pain in the area of ​​the affected joint. The patient's movements are severely constrained. Often, the patient can not sit, not stand, for a given kind of localization of osteomyelitis. In the chronic course of osteomyelitis of the joint, the patient at risk of serious consequences, in the form of destruction of the joints (hip, knee, etc.). The only way out for such a course is endoprosthetics.

Sclerosing osteomyelitis Garre develops subacute and manifests itself, mainly at night. Characterized by night pain in the affected osteomyelitis limb, a violation of limb function and an increase in body temperature to low-grade figures (37.5 ° C). Also sclerosing osteomyelitis Garre is accompanied by puffiness of soft tissues with expansion of the subcutaneous venous network. Therefore, it is extremely important to conduct a differential diagnosis with sarcoma .

Albury osteomyelitis is characterized by lean local manifestations on the skin in the form of insignificant hyperemia and a slight infiltration of the soft tissues of the limb.

Also, a scant clinical picture may accompany the Brody abscess, in which the course of the disease is lethargic or of a torpid nature.

Osteomyelitis of the jaw

Osteomyelitis of the jaw is a purulent process of inflammation in the jaw region. It is characterized by the penetration of pathogenic pathogens into the bone tissue of the jaw, as well as destructive changes in it. Osteomyelitis of the jaw is considered one of the frequent diseases in dentistry surgery by the number of odontogenic inflammatory processes along with periodontitis of the jaw and periostitis of the jaw. It is localized mainly on the lower jaw and affects mainly the male sex. Among osteomyelitis of different localization, it accounts for more than a third of cases.

The osteomyelitis of the jaw is divided into: odontogenic (dental diseases), hematogenous (chronic foci of infection) and traumatic (jaw damage).

The causes of odontogenic osteomyelitis of the jaw can be: caries, pulpitis, periodontitis , pericoronitis, alveolitis , dental granuloma. The infection in the bone occurs through the infected root or dental pulp.

For the development of hematogenous osteomyelitis of the jaw, the main source of infection can be: furunculosis in the jaw region, purulent otitis, acute tonsillitis, umbilical septicemia and omphalitis of newborns, diphtheria and the like.

In case of hematogenous spread of the infectious process, the jawbone is initially affected, and later the dental tissues are involved.

Traumatic osteomyelitis of the jaw occurs as a result of fracture or gunshot wounds to the jaw. Also, the cause may be damage to the nasal mucosa. In such cases, infection in the bone tissue penetrates from the external environment.

The pathogenic flora that causes the osteomyelitis of the jaw is revealed in the form of microbial associations or monocultures, among which, mainly, is Staphylococcus aureus, group B streptococcus and other pathogenic anaerobic microorganisms.

Speaking about the symptoms of osteomyelitis of the jaw, it is necessary to take into account its stage. For acute course with osteomyelitis of the jaw is characterized by a sudden manifestation with the manifestation of common symptoms. It is noted in most cases: chills, a sharp increase in body temperature to 39-40 ° C, signs of body intoxication, sleep disturbance and lack of appetite.

With the development of the inflammatory process with odontogenic osteomyelitis of the jaw, the patient complains of an intense toothache with irradiation into the temporal lobes or into the orbit. Over time, the pain changes the character of localization and becomes diffuse. The causative tooth, as well as the neighboring teeth intact with it, are mobile, the gingival mucosa is edematous. From the pockets of the gums in the area of ​​the infected tooth, often a separation of the purulent discharge is observed. The patient has a sharp putrefactive smell from his mouth. As the infection spreads to soft tissues, there is a restriction of the mobility of the mouth, there is a difficulty in breathing and pain when swallowing. When osteomyelitis of the lower jaw appears numbness of the lower lip, as well as a feeling of tingling in it.

During acute osteomyelitis of the jaw, pronounced inflammatory infiltration is observed in the affected area, puffiness and reddening of the soft tissues, local enlargement of the groups of lymph nodes (submaxillary, cervical, parotid), thus the facial contours acquire an asymmetric shape.

Also, there is a formation of subperiosteal abscesses, adenophlegmon and peribiosteal phlegmon. Osteomyelitis of the upper jaw with diffuse flow is complicated by phlegm of the orbit, thrombophlebitis of the facial veins, and sinusitis.

In the subacute process of the osteomyelitis of the jaw, the general condition is markedly improved, inflammatory infiltration is reduced, but the mobility of the teeth may increase.

The chronic process with osteomyelitis of the jaw appears as a complication of poorly treated acute osteomyelitis and has a protracted course.

The destructive process proceeds with the phenomena of intoxication and an increase in regional lymph nodes, because of which fistulas with purulent discharge and expressed granulations can form, and large sequestrants can also appear.

Often, in chronic course, osteomyelitis of the jaw leads to a fracture of the jaw. Deformation of the jaw and trismus can also be observed.

Diagnosis of the osteomyelitis of the jaw is not complicated and is based on data of anamnesis, examination of a dental surgeon, traumatologist and laboratory data. It is important to carry out a differential diagnosis with periodontitis, pericoronitis, alveolitis, and the like.

The first task in the treatment of osteomyelitis of the jaw is the elimination of the purulent focus, which is the cause of inflammation. With the development of odontogenic osteomyelitis of the jaw, extraction of the tooth is shown, with the development of the hematogenous - the sanation of the chronic foci of infection, with traumatic - the primary surgical treatment of infected and gunshot wounds.

General treatment consists of detoxification, immunomodulating, symptomatic, desensitizing therapy. Treatment also includes the appointment of massive antibiotic therapy with semisynthetic penicillins, cephalosporins, macrolides.

With chronic osteomyelitis of the jaw after the X-ray examination of the jaw, the question of sequestrectomy - removal of sequestered bone patches is solved. After carrying out this manipulation, the bone cavity is subjected to washing with antiseptic means and filling with osteoplastic materials with antibiotics. When there is a threat of a jaw fracture, splinting is performed.

Acute osteomyelitis

Symptomatics and course of acute osteomyelitis depend on a large number of factors: the state of the body's immune system, the method of infection, the age of the patient, the presence of chronic foci of infection.

Acute osteomyelitis is divided into exogenous and endogenous acute osteomyelitis. In the development of endogenous osteomyelitis (hematogenous osteomyelitis), infectious microorganisms enter the bone tissue with the flow of blood from the primary focus located in the region of the pharyngeal lymphoid ring, the mucous membranes of the nasopharynx and the oral cavity. This form of osteomyelitis also develops in children due to the peculiarities of the blood supply to the child's bone system.

Factors that contribute to the development of acute course of hematogenous osteomyelitis are: viruses, acute and chronic purulent inflammatory diseases, unbalanced diet, hypothermia, hypovitaminosis, diabetes mellitus , liver and kidney diseases. Also, a significant role is played by injuries with damage to the periosteum and bone tissue.

Other forms of acute osteomyelitis (gunshot, postoperative, post-traumatic and contact) are considered exogenous. With such forms of acute osteomyelitis, infectious agents enter the bone tissue from the external environment or from surrounding soft tissues. The main feature of exogenous acute osteomyelitis is the penetration of the infectious process into all elements of bone tissue without a primary inflammatory focus in the bone marrow canal.

Acute hematogenous osteomyelitis is characteristic mainly for childhood, while in a third of cases the symptoms of the disease appear in infants. With this form of osteomyelitis, long tubular bones are involved in the infection process, much less often - flat and short.

There are three forms of acute hematogenous osteomyelitis: adynamic (toxic), septic-piemic and local. For acute osteomyelitis in the septic-piemic form is characterized by an acute onset with febrile temperature, pronounced intoxication of the body, persistent vomiting, headaches, chills. There may be a violation of consciousness, hemolytic jaundice and delirium. The patient's condition is very difficult. During the first two days after the onset of the disease, severe pains appear with a clear localization in the affected bone, while the affected limb is in a forced position, active movements are not possible. In the affected area, severe swelling and hyperemia of the skin is determined. There is also an increase in the venous pattern.

With the local form of acute hematogenous osteomyelitis, the process proceeds more gently. The symptoms of the local inflammatory process are observed. The general condition practically does not suffer.

In the toxic form of acute osteomyelitis of the hematogenous nature, a lightning-fast course of the inflammation process develops, with a predominance of symptoms of a disorder in the general state of the organism. In the first 24 hours, body temperature rises rapidly to 40-41 ° C, a sharp drop in blood pressure, meningeal symptoms, loss of consciousness and convulsions. Acute heart failure develops fast enough . Along with this, local symptoms are mild or absent, which greatly complicates the correct diagnosis and the appointment of timely medication.

For the diagnosis can be used: ultrasound, MRI, CT and X-ray examination of the affected area, a laboratory blood test.

Treatment of hematogenous acute osteomyelitis consists in the appointment of: antibiotic therapy, detoxification therapy, immunocorrection, antioxidant therapy, desensitization, limb immobilization, exchange correction, biostimulation, vitamin therapy, laser irradiation.

In addition to conservative treatment is also used operative. In infants, the phlegmon is opened. In adolescents and older children, an autopsy of the purulent-inflammatory focus is performed with the addition of osteoperforation. In the resulting holes, special tubes are installed to insert antibiotics and antiseptics inside the affected bone.

Traumatic acute osteomyelitis appears as a complication of open bone injuries, orthopedic surgeries and gunshot wounds. Develops within two weeks after the injury. The leading role in its occurrence is played by non-observance of the rules of antiseptics and asepsis in the course of surgical intervention. The general condition of the organism has a definite value. The development of acute osteomyelitis with open trauma and gunshot wounds is promoted by such factors as the intensity of microbial contamination, the area of ​​tissue destruction, the virulence of the infection, the violation of the local circulation and the immune response of the organism to traumatic effects.

Post-traumatic osteomyelitis is characterized by both general and local symptoms. Heavy intoxication develops, severe weakness, a state of weakness, chills, headache and nausea. Body temperature reaches above 39 ° C. Local symptoms begin to manifest themselves one week after the appearance of the general. In the affected area, severe pain, hyperemia and swelling of the tissues are observed. A profuse amount of purulent contents is released from the wound cavity.

Treatment of posttraumatic acute osteomyelitis is surgical. Such interventions are performed against a background of conservative treatment, as in hematogenous acute osteomyelitis. Remove the necrotic bone fragments and purulent copious granulations, carry out sequestrectomy. Do rinsing and drainage. For limb immobilization, skeletal traction, Ilizarov's apparatus with extra-osteosynthesis can be used.

Contact acute osteomyelitis begins with the transition of the inflammatory process to the bone from the surrounding tissues. It develops with long purulent-inflammatory processes (furunculosis, panaritium , etc.). It manifests itself as a pronounced local soreness, extensive swelling and the appearance of fistulas. Therapy is a complex approach. Surgical intervention is applied against a background of massive antibiotic therapy and other medications. During surgical intervention, the lesions of the affected lesions and excision of necrotic tissues are performed with drainage of the open cavities. If there is a lesion of all the tissues of the finger (with a panaritium) or another limb, then the question of amputation can be considered.

Chronic osteomyelitis

Clinical manifestations in chronic osteomyelitis are caused by the amount of bone destruction and the period of the disease (remission or exacerbation). During the transition from acute osteomyelitis to chronic osteomyelitis, the patient notes some improvement. The intensity of the pain syndrome in the limbs decreases, acquiring a noisy character. The body temperature is normalized, signs of intoxication disappear. In the affected area, fistulas are formed, which can be of a multiple character with a small purulent discharge. In half the cases, a number of fistulas are grouped into a network of infected tubules that open on the skin. Sometimes such fistulas are at a great distance from the hearth, affected by osteomyelitis. In the future, ankylosis, curvature or lengthening of the bone is formed. There have also been cases of limb shortening. The remission of chronic osteomyelitis can last from several weeks to several months.

The exacerbation of chronic osteomyelitis is very similar to the onset of acute, but in a more erased form. The exacerbation of chronic osteomyelitis is facilitated by the closure of the fistula, which forms a build-up of pus in the cavity and increases the pressure inside the bone. The patient's condition worsens, the pain intensifies in the affected area. They are swollen tissues, hyperemia of the skin and febrile body temperature. The picture of the blood also changes: leukocytosis develops, the granularity of erythrocytes is formed, the rate of erythrocyte sedimentation increases significantly. After the opening of the purulent focus, the patient's condition rapidly improves.

Diagnosis of osteomyelitis with chronic course consists in radiographic examination and in CT, and does not cause any difficulties in its conduct.

In the presence of cavities in the affected area with osteomyelitis, surgery is indicated. Also, surgical intervention is used for frequent relapses of the disease with intoxication, intense pain syndrome, impaired sensitivity and limb functioning. In chronic osteomyelitis, sequestrectomy is performed, in which all granulations, sequestrants are removed, fistulas and osteomyelitic cavities are excised. Such manipulation is carried out with subsequent drainage. After draining and sanitizing the cavities, plastic bone is performed.

Hematogenous osteomyelitis

Hematogenous osteomyelitis is an inflammatory-destructive disease of bone tissue that develops with hematogenous entry of pathogens of infection. Basically, it is caused by golden staphylococcus, hemophilic and pseudomonas aeruginosa, group B streptococci.

Pathogenic microflora with hematogenous osteomyelitis falls into the bone tissue with the flow of blood in the septic embolus complex from different foci of infection ( pyelonephritis , tonsillitis , mastitis, furunculosis, etc.).

Symptoms of hematogenous osteomyelitis in middle-aged people are poorly expressed in comparison with children. In adults, the vertebral column is affected predominantly. Body temperature rarely reaches high figures and remains within 37.5-38 ° C. Patients may complain about a slight malaise. Also, with hematogenous osteomyelitis, there is localized damage to bone tissue. In this case, sequestration is very rare. In 10% of cases there is a transition of the inflammatory process to the joint, with the formation of joint osteomyelitis.

Diagnosis of the disease is based on anamnesis, laboratory data, CT, ultrasound and X-ray. In certain cases, radioisotope scanning of bone tissue may be required.

Differential diagnosis is performed with bone tuberculosis, malignant and benign bone processes, osteomycosis and syphilis of the bone.

In acute hematogenous osteomyelitis, both conservative and operational therapies are used. The use of broad-spectrum antibiotics is shown. There is also an opening with subsequent drainage of abscesses and bone osteoperforation. In certain cases, sequestrectomy is performed.

From conservative treatment are appointed: antibiotics as intramuscular, and intravenously. This is especially true of the acute course of the disease. In such cases, the advantage is given to those antibiotics that have tropism to the bone tissue (Lincomycin, Kefzol, Fusidin). Assign sulfonamide preparations (sodium thiosulfate). Also, immunotherapy with antistaphylococcal G-globulin, transfusion of freshly citrated blood, antistafilokovaya plasma is carried out. The use of proteolytic enzymes by injection is shown, which gives a good therapeutic effect. After active treatment of hematogenous osteomyelitis, the fixing effect is provided by: physiotherapy, electroionophoresis, UHF and laser therapy on the inflammation focus.

Odontogenic osteomyelitis

Odontogenic osteomyelitis is an infectious process of inflammatory-allergic nature, characterized by the presence of an infectious process in the jaw or in the tooth.

With the flow of odontogenic osteomyelitis is acute and chronic. In the prevalence of distinguish: limited, focal and diffuse.

The causes of inflammation are also considered the presence of chronic foci of infection.

In the acute course of odontogenic osteomyelitis, the patient has severe localized pain in the jaw, on the side of the affected tooth. Pain can be given along the trigeminal nerve (in the eye, ear and temple). With the defeat of the lower jaw, the patient notes numbness of the lips, obstructed movement of the lower jaw and soreness in swallowing. The general condition of patients with odontogenic osteomyelitis is worsened. The first headache, weakness, an increase in body temperature to 39-40 ° C. Somewhat later, the local symptoms of odontogenic osteomyelitis also join in.

During the examination of the patient, the swelling of the soft tissues is determined. Infiltration with severe pain syndrome during palpation. Mucous transitional folds are hyperemic and edematous, during several teeth the alveolar process is thickened.

When X-ray examination, there are characteristic changes for some forms of periodontitis. Typical for osteomyelitis signs can be seen on the roentgenogram in a few weeks. In the picture they look like fuzziness in the area of ​​bone tissue with foci of necrosis.

Treatment of odontogenic osteomyelitis in the acute phase is carried out exclusively in a hospital. Surgical sanitation of the purulent focus, drainage and elimination of the causative tooth is performed. After surgical treatment, antibiotic therapy is carried out, including the use of broad-spectrum antibiotics. Together with antibiotic therapy, desensitizing, anti-inflammatory and symptomatic therapy is performed. A good effect is obtained by physiotherapy on the fifth day after the beginning of treatment of odontogenic osteomyelitis.

Osteomyelitis in children

In children, due to the physiological features of the functioning of the circulatory system, osteomyelitis of the epiphyseal form is more common. When it is affected cartilaginous tissue. In older children, in most cases, develops hematogenous osteomyelitis associated with inflammation of the tubular bones. Since the focus of inflammation of bone tissue makes it difficult to know about yourself, often there are certain difficulties with adequate diagnosis. Such features are fraught with complications as well as with a fatal outcome.

The causes of osteomyelitis in children are: serious infectious diseases ( syphilis , tuberculosis, brucellosis , etc.), infection of the open wound with pyogenic aerobic bacteria (streptococci and staphylococci), after performing orthopedic operations with non-observance of the rules of antiseptic, infection of bone tissue from nearby inflammatory foci soft tissues.

The signs of osteomyelitis in children largely depend on the age, immunity and the area of ​​the bone site in the child. In newborns and infants, the course of osteomyelitis affects mainly the general condition. There is concern, pallor of the skin, refusal to eat, high temperature (40-41 ° C), lethargy. In half the cases, the course of the disease is accompanied by vomiting and diarrhea . The child tries to spare the limb and, at the slightest touch to the affected limb, it is heard with a shrill cry, which also makes it difficult to correctly diagnose, given the patient's too little age.

Local signs of osteomyelitis in children are manifested in the form of skin hyperemia in the affected area. After a few days, hyperemia is observed throughout the limb. When untimely referral to the doctor, purulent foci can spread throughout the body.

In older children, the severity of symptoms is somewhat brighter, but there is no such rapid development of symptoms, compared with infants. Hyperemia of the limb in older children appears a week or more after the first manifestations of osteomyelitis.

Treatment of osteomyelitis in children is similar to that of osteomyelitis in adults, but given the child's age and the high percentage of complications, after surgery on the affected area, the child is carefully observed in intensive care. A massive antibacterial, anti-inflammatory, desensitizing therapy is performed. It should be borne in mind that antibiotics are prescribed by a long course both intravenously and intramuscularly. Usually, antibiotics of several groups (penicillins + cephalosporins, macrolides + cephalospirins, etc.) are prescribed. Rehabilitation after an osteomyelitis is prolonged and lasts for 4-6 months, including sanatorium treatment, vitamin therapy and immunotherapy.

Osteomyelitis treatment

In the treatment of osteomyelitis, compulsory admission to hospital is indicated. Along with surgical treatment of the affected area, it is necessary to prescribe massive antibiotic therapy (intravenous and intramuscular antibacterial drugs), powerful detoxification therapy (plasma and blood transfusion), immunostimulants, vitamin therapy, hemosorption, hyperbaric oxygenation.

In the treatment of acute hematogenous osteomyelitis in children under six years of age, the use of: Cefuroxime and Amoxicillin / Clavulanate (first-line drugs); Ampicillin / Sulbactam, Ceftriaxone and Oxacillin (alternative drugs).

Children older than six years and adults for the treatment of acute hematogenous osteomyelitis are: Oxacillin and Gentamicin, Amoxicillin / Clavulanate (first-line drugs); Cefuroxime, Cephalosoline and Netilmicin, Lincomycin and Gentamicin, Clindamycin and Gentamicin, Fluoroquinolone and Rifampicin (alternative drugs).

For post-traumatic and postoperative osteomyelitis, the following are prescribed: Ofloxacin, Ciprofloxacin and Lincomycin (first line of remedy); Cefepime, Vancomycin and Cephalosporins of the third-fourth generation, Imipenem, Linezolid and Ceftriaxone.

In osteomyelitis of the joints and spine are assigned: Oxacillin, Ceftriaxone and Aminoglycosides (first line of the remedy); Ciprofloxacin and Rifampicin (alternatives).

For patients who are on hemodialysis and for drug addicts apply: Oxacilin and Ciprofloxacin, Vancomycin and Ciprofloxacin.

For patients with sickle cell anemia: Ciprofloxacin or Third generation cephalosporins (Ceftriaxone, Cefotaxime, Cefoperazone).

Also, patients are strictly shown: immobilization of the limb with a lapet of gypsum, rest, physiotherapy (UHF, UFO, electrophoresis), proper diet.