Medical management: urgent IV antibiotics are started after blood cultures are taken — typically flucloxacillin or clindamycin to cover Staphylococcus aureus (the most common organism). Surgical management: if there is a subperiosteal abscess on MRI/ultrasound, or if the child is not improving after 48 hours of IV antibiotics, surgical drainage is performed. An incision is made over the affected bone, the periosteum is opened, and pus is drained. The bone surface is washed, and samples are taken for culture. A drain may be left. The operation takes 30–60 minutes.
Surgery is needed when an abscess has formed (seen on MRI or ultrasound), when the child is not responding to IV antibiotics within 48 hours, or when there is a concern about adjacent joint infection (as the metaphysis is intracapsular in the hip, shoulder, elbow, and ankle).
IV antibiotics alone are appropriate when there is no abscess, the child is responding clinically (temperature settling, inflammatory markers falling), and there is no concern about adjacent joint involvement.
Blood cultures (before antibiotics if possible). Blood tests: CRP, ESR, WCC. MRI to confirm the diagnosis and assess for abscess, subperiosteal collection, and adjacent joint involvement. Ultrasound as a rapid alternative for subperiosteal collections.
Drainage of the abscess, identification of the organism, and rapid clinical improvement. Most children with appropriately treated acute osteomyelitis recover fully without long-term sequelae.
Prolonged antibioticsExpected
IV antibiotics for at least three to five days, then oral for a total of three to six weeks guided by CRP.
RecurrenceUncommon
If antibiotics are stopped too early or if the organism is resistant.
Chronic osteomyelitisUncommon
If acute infection is not adequately treated, it may become chronic — much harder to eradicate.
Growth plate damageUncommon
The infection may damage the adjacent physis, causing growth disturbance or angular deformity.
Pathological fractureUncommon
Through weakened infected bone.
SepticaemiaUncommon
Systemic spread of infection.
Adjacent joint infectionUncommon
The metaphysis is intracapsular at the hip, shoulder, elbow, and ankle — infection can spread into the joint.
Venous thrombosisRare
Panton-Valentine Leukocidin (PVL) Staph aureus causes DVT in children.
General anaesthesia for surgical drainage. Emergency case — fasting status managed pragmatically.
IV antibiotics for three to five days minimum, transitioned to oral when CRP is falling and the child is clinically improving. Oral antibiotics for a total of three to six weeks guided by CRP. Most children recover rapidly — returning to school within one to two weeks and full activity within four to six weeks. Long-term monitoring for growth disturbance if the physis was involved.
Twice-weekly blood tests (CRP) to guide antibiotic duration. Clinical review at two weeks, six weeks, and three months. X-ray at six weeks (may show periosteal new bone — a sign of previous infection, not ongoing disease). Long-term review if growth plate involvement.
How do children get osteomyelitis?
Most commonly from haematogenous spread — bacteria in the bloodstream (often from a minor skin wound or sore throat) seed the metaphysis of a long bone, where blood flow is slow and turbulent. The distal femur and proximal tibia are the most common sites.
Will my child need long-term antibiotics?
Typically three to six weeks total (a few days IV then oral). The duration is guided by CRP — antibiotics continue until CRP normalises. Shorter courses (three weeks) are increasingly supported by evidence for uncomplicated cases.
What is PVL?
Panton-Valentine Leukocidin is a toxin produced by some strains of Staphylococcus aureus. PVL-producing strains cause more aggressive infections with higher rates of abscess formation, deep vein thrombosis, and multifocal disease. Surgical drainage is almost always needed for PVL infections.