Cultures, Antibiotics and Osteomyelitis
I received this question from a reader: In suspected osteomyelitis do you stop antibiotics prior to obtaining a bone culture? For how long?
This comment came in under my entry on the VULCAN trial but I actually covered the question in a post almost exactly a year ago. I am reprinting my response here for more recent readers who may not have reviewed all of the earlier posts I will also summarize my current thinking at the bottom:
The question of whether or not the patient needed to be off of all antibiotic therapy prior to the culture was always less clearly delineated. It was almost an empirical belief that if a patient was on antibiotics at the time of the culture then the results would be unreliable. After all, if a culture is reported as showing “no growth” was this because the specimen was poor, the patient never had osteomyelitis in the first place, or the antibiotics had prevented the organism from growing?
A recent study by Louis Bernard and colleagues out of University Hospital of Geneva Switzerland, and published in the September 6, 2009 issue of the International Journal of Infectious Diseases challenges much of what we currently hold as sacrosanct. In this non-randomized, prospective trial 141 patient with 154 episodes of osteomyelitis each underwent 4 microbiological samplings. Sample “A” consisted of 2 consecutive sinus tract cultures with bone contact (“A1” & “A2”) after only local cleansing of the sinus tract with 0.9% saline. Sample “B” consisted of a surgical bone biopsy through the sinus. Sample “C” was a surgical biopsy obtained through an uninfected sited, referred to as the “gold standard”. Their results showed that when both sinus tract cultures “A1 & A2” revealed the same organism the concordance between “A” and gold standard “C” was 96%. They calculated the sensitivity as 91%, specificity as 86% and accuracy as 90%. On top of that, they found that the result was not affected depending on whether the patient was on antibiotics prior to the cultures or not.
In their Discussion the authors go out of their way to state that “in no way should these consecutive deep sinus tract specimens replace bone culture in situations where a biopsy can be readily obtained because bone culture remains the gold standard for the microbiological diagnosis of osteomyelitis”. There are sometimes, however, when a surgical culture is just not practical and that patient has already been started on antibiotic therapy, as the authors call it “clinical reality”.
Since this original post, my thought process has not changed much. I still believe that, if they have not yet been started, it is best to HOLD antibiotics if at all possible, until after the patient is taken to the OR for deep bone (or, for that matter, soft tissue) cultures. The “real world” gets involved, however, when you admit a patient through the Emergency Dept for the stated diagnosis of “infection” and do not plan on taking the pt to the OR until the next day. Unfortunately, in a case like this, you cannot realistically hold antibiotics or the hospital runs the risk of losing the admission. If the patient is going to the OR later the same day then I believe in holding the drug unless the pt is sick i.e. metabolically unstable, systemically unwell or septic.
What if the patient has already been started on antibiotics? Conventional wisdom still calls for the pt to be off antibiotics for at least 48 hours. I don’t believe there is any evidence to support that thinking. The Bernard study cited above does give us some hope that it doesn’t matter if the patient is still on antibiotics or not but I would still recommend, again if at all possible, taking the patient off the drugs for as long as it is feasible. Heck, I would go for a week if you can. There is no magic to 48 hours. The problem is that if the culture is negative, you don’t know whether it is negative because it is not osteo or if it is negative just because of the antibiotics. Also, the International Working Group on the Diabetic Foot (www.iwgdf.org) has shown in their diabetic foot osteomyelitis guidelines that the only independent factor leading to a positive response to antibiotic therapy for osteo is bone culture directed antibiotic therapy. We could really use those deep reliable cultures!