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Chronic osteomyelitis — Clinical Guidelines

Overview

Chronic osteomyelitis encompasses persistent bone infections, often bacterial but also includes nonbacterial forms like chronic nonbacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO). These conditions are characterized by recurrent bone inflammation and lesions without clear evidence of bacterial infection in nonbacterial forms 1 2.

Diagnosis

Key Criteria: Typical radiographic or MRI findings, bone pain, exclusion of malignancy, infection, vitamin C deficiency, and hypophosphatasia 1 2.

Clinical Features: Site and pattern of bone lesions, age at onset, coexisting conditions, fever 1 2.

Laboratory/Pathology: Bone biopsy findings (if performed), anemia, elevated C-reactive protein, and erythrocyte sedimentation rate 1 2.

Threshold Score: Total score ≥55 points required for classification 1 2.

Diagnostic Challenges: Suspicion of overlapping conditions like lymphoma in CRMO cases necessitates thorough bone biopsy 3.

Management

First-Line Treatments: Nonsteroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief in CRMO 4.

Adjunctive Treatments: Intravenous or oral bisphosphonates in refractory cases 4.

Infectious Osteomyelitis: Antibiotics tailored to culture and sensitivity results when bacterial etiology is confirmed 4.

Supportive Care: Pain management, physical therapy, and monitoring for complications 4.

Special Populations

Pediatrics: Specific criteria validated for pediatric chronic nonbacterial osteomyelitis (CNO) by EULAR/ACR 1 2.

Comorbidities: Careful differentiation from malignancies, especially in cases with atypical presentations 3.

Key Recommendations

Use EULAR/ACR classification criteria requiring typical imaging findings, bone pain, and exclusion of other conditions for diagnosing pediatric CNO (Evidence: Strong 1 2).

Perform bone biopsy when clinical suspicion of overlapping conditions like lymphoma exists to avoid diagnostic pitfalls (Evidence: Moderate 3).

Initiate NSAIDs for symptom management in CRMO, escalating to bisphosphonates if there is no response (Evidence: Expert opinion 4).

References

1 Zhao Y, Oliver MS, Schnabel A, Wu EY, Wang Z, Marino A et al.. EULAR/American College of Rheumatology Classification Criteria for Pediatric Chronic Nonbacterial Osteomyelitis. Arthritis & rheumatology (Hoboken, N.J.) 2026. link 2 Zhao Y, Oliver MS, Schnabel A, Wu EY, Wang Z, Marino A et al.. EULAR/ACR classification criteria for paediatric chronic nonbacterial osteomyelitis (CNO). Annals of the rheumatic diseases 2025. link 3 Sulko J. Diagnostic difficulties: chronic recurrent multifocal osteomyelitis and lymphoma. One or two diseases?. Journal of pediatric orthopedics. Part B 2013. link 4 Vanhoenacker FM, Baekelandt J, Vanwambeke K, Willemen D, De Schepper AM. Chronic recurrent multifocal osteomyelitis. Journal belge de radiologie 1998. link

Chronic osteomyelitis