Skull osteomyelitis treatment [Neurosurgery Wiki]

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====== Skull osteomyelitis treatment ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1fedKcOVZacBs6mS6hnyUmtjTmOHh9uxnjtNQMbXdNeDUgEkGb/?limit=15&utm_campaign=pubmed-2&fc=20230619050507}}
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Early identification of the causative [[pathogen]], appropriate broad-spectrum [[antibiotic]] therapy over a period of 8-20 weeks, and aggressive surgical [[debridement]] are essential for managing cranial [[osteomyelitis]]. On the other hand, inadequate treatment is responsible for refractory cases and poses a great diagnostic challenge. A new classification dividing cranial osteomyelitis into sinorhino-otogenic versus nonsinorhino-otogenic groups could prove valuable for clinical communication and treatment
((Mortazavi MM, Khan MA, Quadri SA, Suriya SS, Fahimdanesh KM, Fard SA,
Hassanzadeh T, Taqi MA, Grossman H, Tubbs RS. Cranial Osteomyelitis: A
Comprehensive Review of Modern Therapies. World Neurosurg. 2018 Mar;111:142-153. 
doi: 10.1016/j.wneu.2017.12.066. Epub 2017 Dec 15. Review. PubMed PMID: 29253689.
)).
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[[Antibiotic]]s for [[skull osteomyelitis]] alone are rarely curative. 


===== Surgery =====

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[[Treatment]] usually involves surgical [[debridement]] of the infected [[skull]], biting off the infected bone with [[rongeur]]s until a normal snapping sound replaces the more muted sound made by rongeuring infected bone. In the case of an infected craniotomy [[bone flap]], the flap usually must be removed and discarded, and the edges of the skull rongeured back to healthy bone. Bone suspected of infection should be sent for cultures.

Closure of the scalp is then performed either leaving a bone defect (for later [[cranioplasty]]) or cranioplasty can be performed using [[titanium]] [[mesh]].

Debridement surgery is followed by at least 6–12 weeks of antibiotics
((Bernard L, Dinh A, Ghout I, et al. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet. 2015; 385:875–882)).

Until [[MRSA]] is ruled out: [[vancomycin]] + [[cefepime]] or [[meropenem]]. Culture results guide the choice of antibiotic. Once [[MRSA]] is ruled out, vancomycin may be changed to penicillinase-resistant synthetic penicillin (e.g. [[nafcillin]]). Most treatment failures occurred in patients treated with < 4 weeks of antibiotics following surgery.

[[Cranioplasty]] may be performed ≈ 6 months post-op if there are no signs of residual [[infection]].


===== References =====