9 J Gandhara Med Dent Sci April - June 2025 ORIGINAL ARTICLE : : THE COMPARISON OF MICROBIOLOGIC PATTERN IN CHRONIC OSTEOMYELITIS OVER 5 YEARS PERIOD, HAYATABAD MEDICAL COMPLEX, PESHAWAR Israr Ahmad 7 Muhammad Aamir 1 , Noor Rahman 2 , Muhammad Taimur 4 , Ih tisham Khattak 5 , Waleed Salman 6 , Safeer Ullah 3 , How to cite this article A amir M , R ahman N, Ullah S, Taimur M, Kh attak I , S alman W , et al. The Comparison of Microbiologic Pattern in Chronic Osteomyelitis Over 5 Years Period, Hayatabad Medical Complex, Peshawar. J Gandhara Med Dent Sci.2025;12(2):9-13. http://doi.org/ Date of Submiss ion: 06 - 06 - 2024 Date Revised: 09 - 0 9 - 2024 Date Acceptance: 09 - 09 - 2024 1 Trainee Medical Officer , De partment of Orthopedics, Hayatabad Medical Complex, Peshawar 4 Trainee Medical Officer , De partment of Orthopedics, Hayatabad Medical Complex, Peshawar 5 Trainee Medical Officer , De partment of Orthopedics, Hayatabad Medical Complex, Peshawar 6 Trainee Medical Officer , De partment of Orthopedics, Hayatabad Medical Complex, Peshawar 7 Pro fess or , De partment of Orthopedics , Hayatabad Medical Complex, Peshawar Corre spondence 2 No or R a hman , Associate P rofessor , D epartment of O rthopedics, Hayatabad Medical Complex, Peshawar +92 - 333 - 9702717 noor_elum@yahoo.com 3 R Trainee Medical Officer, Department of Orthopedics, Hayatabad Medical Complex, Peshawar ABSTRACT OBJECTIVES This study aimed to quantify the changes in microbiological patterns associated with chronic osteomyelitis over five years. It specifically focused on infections caused by multi - drug res istant (MDR) bacteria and the susceptibility of antimicrobial treatments in the Department of Orthopedic and Spine at HMC, Peshawar. METHODOLOGY This cross - sectional study was conducted in the Department of Orthopedic & Spine Surgery Hayatabad Medical Com plex Peshawar, Pakistan, from 1 st August 2023 to 31 st July 2024. The sample size was 133. A non - probability consecutive sampling technique was used for sampling. All patients fulfilling the inclusion criteria were included in our study. Patient’s age (< 45 years or > 45 years) & gender (men/women) were our demographic variables, while the presence of chronic osteomyelitis was our research variable. Data was analyzed using IBM - SPSS - V.25. RESULTS Out of 134 patients in the study, 70(52.2%) were males & 64(47. 8%) were females. Among patients in Group A, i.e., from 11th Nov 2018 to 1st Nov 2019, the most prevalent microbe causing osteomyelitis was Pseudomonas aeruginosa, 29%, followed by MRSA found in 26.3%. Among patients in Group B, i.e., 1 st Nov 2023 to 1 st N ov 2024, the most prevalent microbe causing osteomyelitis was Methicillin Sensitive Staph aureus (MSSA) 40.2% followed by Pseudomonas aeruginosa 13.8%. MRSA was isolated from 2 cases. Among instances of various osteomyelitis, E - Coli & Pseudomonas aeruginos a were the most resistant microbes to multiple antibiotics. CONCLUSION The evolving antibiotic resistance to various microbes has made it mandatory to perform cultures of infected bone & to use antibiotics that are sensitive to specific organisms. Further, in our setup, there has been a decline in several MRSA cases in 5 - year period causing osteomyelitis. Pseudomonas aeruginosa & E - Coli are associated with multi - drug - resistant Chronic Osteomyelitis. KEYWORDS: Osteomyelitis, Bone, Antibiotics, Infections INTRODUCTION Osteomyelitis is an inflammatory state of bones caused predominantly by an infection. 1 Osteomyelitis can be caused by trauma, surgical contamination, vascular insufficiency, or acute hematogenous osteomyelitis, which is more co mmon in pediatric age groups. 2 Traumatic osteomyelitis accounts for approx. 80% pathogenesis of osteomyelitis. 3 Osteomyelitis can be divided into acute and chronic types. Acute osteomyelitis can be defined as a recent bone infection with a systemic inflamm atory response, while chronic osteomyelitis is characterized by symptoms of 6 weeks to 3 months. 4,5 The presence of fever, chronic pain, erythema, swelling & tenderness around affected bone, impaired wound healing & persistent sinus tracts are the clinica l features associated with chronic osteomyelitis. 6 Cierny and Mader developed a classification system for chronic osteomyelitis, which combines both the stages of the anatomic disease, i.e., Medullary, Superficial, localized & diffuse, and physiologic stat e of host, i.e., Normal host, compromised host (systemic, locally or both) & a host in which treatment is worse than the disease (unfit for surgery). 7,8 In former times, experts usually recommended parenteral antibiotics for the treatment of osteomyelitis as penetration of antibiotics to bone is low. Traditionally, IV therapy was recommended for 4 - 6 weeks, followed by an oral route for weeks to months, while currently, Surgical debridement along with a Local antibiotic delivery system, followed by IV therap y for an initial 2 weeks, is recommended to achieve maximum serum 10.37762/jgmds.12-2.675
10 J Gandhara Med Dent Sci April - June 2025 concentration of antibiotic. The duration of antibiotic treatment shows that regimens less than 4 weeks are highly prone to failure & therapies longer than 6 weeks also don’t improve the out come. So, antibiotic regimens are used for 6 weeks. 9,10 Cierny - Mader devised a 2 - stage treatment of osteomyelitis. In the first stage, adequate debridement, wash & antibiotic - loaded cemented beads having Vancomycin & Gentamicin are mostly placed along wit h the obliteration of dead space. 11 In the second stage, after 4 - 6 weeks, beads are removed & replaced with a cancellous bone graft. 12 The antibiotics can also be locally transferred by antibiotic - coated nails, spacers & antibiotic - coated ILN. 13 Staph aure us is The most common organism causing osteomyelitis, accounting for approx. 75% of the cases & among these, 50% are caused by MRSA. Other organisms causing osteomyelitis include Streptococcal species, E - Coli, Pseudomonas & Enterococcal species. 14,15 Dudar eva et al., from Oxford, UK, conducted a study on two cohorts of patients having chronic osteomyelitis. 16 Their research found that from 2001 - 2004, Staph aureus was involved in 21.7% of cases of osteomyelitis, among which MRSA caused 9.6% of cases. Enterob acteriaceae was involved in 16.3% of cases, while pseudomonas was approximately 5.4%. Ten years later, from 2013 to 2017, it was found that Staph aureus is involved in 33.2% of cases, with 4.3% MRSA positive. Enterobacteriaceae was involved in 23.3%, while pseudomonas in 7.3% of cases. Pozo et al. from Spain, in a study, found that the tibia was the most commonly involved bone in non - union & the most frequently isolated bacteria were Staphylococcus aureus, i.e., 58.5% of positive cultures. 17 Singh et al. fr om Bihar, India in their study found that out of 132 patients having osteomyelitis, 43.9% isolates were Staphylococcus aureus positive (32.7% were MRSA positive & 67.2% were MSSA positive), Coagulase negative Staphylococcus aureus (CONS) was 9.8%, Enteroco ccus in 8.3%, E - coli in 18.9%, Klebsiella in 11.3%, Pseudomonas aeruginosa in 3.7% & Proteus mirabilis in 5.3%. 18 Unawareness about the microbiology pattern over five years, antibiotic resistance & most common micro - organisms causing osteomyelitis in the O rthopedic unit, HMC, Peshawar, was our research problem. Our research will provide important information about the most common organisms involved in osteomyelitis & as a result, can help in the initiation of empirical therapy. It will also guide surgeons r egarding antibiotic resistance & the microbes’ sensitivity to various antibiotics. METHODOLOGY This cross - sectional study was conducted in the Department of Orthopedic & Spine Surgery Hayatabad Medical Complex Peshawar, Pakistan, from 1 st August 2023 to 31 st July 2024. Approval for the study was taken from the Hospital Ethical Committee & informed consent was taken from patients or attendants. The sample size was calculated using the Rao soft sample size calculator. The confidence interval is 95%, the an ticipated proportion is 9.6% & margin of error is 5%. The sample size was 133. A non - probability consecutive sampling technique was used for sampling. All adult patients aged>20 years with a diagnosis of chronic osteomyelitis were included in the study. Pa tients having a history of tuberculosis, autoimmune diseases such as Rheumatoid arthritis or SLE & cancer patients, which can affect bone health & healing, were excluded from the study. Chronic osteomyelitis was diagnosed using clinical and radiographic fi ndings. The diagnosis of chronic osteomyelitis was based on clinical assessment and the presence of sequestra or sinus tracts on X - rays or CT scans & a positive culture of sequestrum or sinus tracts. After receiving approval from the Hospital’s ethical com mittee, a study was conducted. All patients fulfilling the inclusion criteria were included in our study. Patient’s age (< 45 years or > 45 years) & gender (men/women) were our demographic variables, while the presence of chronic osteomyelitis was our rese arch variable. Patients were divided into two groups: Group A had confirmed diagnosis of chronic osteomyelitis from 11th Nov 2018 to 1st Nov 2019 & Group B had confirmed diagnosis of chronic osteomyelitis from 1 st Nov 2023 to 1 st Nov 2024. Deep bone sample s were taken from the infection site under strict aseptic measures to detect chronic osteomyelitis. Up to 10 samples were taken from each patient from abnormal tissues, including dead bone, granulation tissue & pus from the medullary cavity. All collection procedures were performed under the supervision of an Associate professor & a Professor in Orthopedics, having at least 15 years of post - fellowship experience & a trained staff nurse. All samples, i.e., deep infected tissues or pus, were sent for Culture and Sensitivity from the same laboratory. Gram staining & culture were used to detect the bacteria causing chronic osteomyelitis. The Kirby - Bauer disk diffusion technique was used to detect antibiotic susceptibility. Data was analyzed using IBM - SPSS - V.25. Mean± S.D was evaluated for numerical variables, i.e., age, gender & duration of illness. Categorical variables like gender, age groups & duration of illness were assessed by counts & percentages. Data is presented in the form of tables and diagrams. RESU LTS Out of 134 patients in the study, 70(52.2%) were males & 64(47.8%) were females. 82(61.1%) patients were The Comparison of Microbiologic Pattern in Chronic Osteomyelitis
11 J Gandhara Med Dent Sci January - March 2025 >45 years and 52(38.8%) were <45years old. The average duration of osteomyelitis was 6 weeks. Among patients having chronic osteomyelitis, 14.8% o f patients had diabetes mellitus & 5.2% of patients were hypertensive. Among patients in Group A, i.e., from 11 th Nov 2018 to 1 st Nov 2019, the most prevalent microbe causing osteomyelitis was Pseudomonas aeruginosa, 29% (21/72). MRSA was found in 26.3% (1 9/72), E - Coli was obtained from 22.2% (16/72) isolates, MSSA was found in 15.2% (11/72), Klebsiella pneumonia 4.1% (3/72), Actinobacteria & Aeromonas hydrophilia were found in one patient. Among patients in Group B, i.e., from 1 st Nov 2023 to 1 st Nov 2024, the most prevalent microbe causing osteomyelitis was Methicillin Sensitive Staph aureus (MSSA) 40.2% (29/72). Pseudomonas aeruginosa was found in 13.8% (10/72), E - coli 12.5% (9/72), Klebsiella pneumonia 11.1% (8/72), Streptococcus pyogenes 6.9% (5/72), Co agulase negative Staph aureus 5.5% (4/72), Enterobacter species 4.1% (3/72), one case of Citrobacter specie and bacillus cereus was found. MRSA was isolated from 2 cases. Among instances of various osteomyelitis, E - Coli & Pseudomonas aeruginosa were the mi crobes most resistant to multiple antibiotics. The chi - square test of independence was used to find the association between the most prevalent microbes in both groups, i.e., Group A & Group B, in causing chronic osteomyelitis & the results were statistical ly significant, i.e., p - value<0.05 showing increased prevalence of Methicillin sensitive staph aureus in causing chronic osteomyelitis in group A as compared to group B. Table 1: Chi - square test of independence to find association between most prevalent microbes in Groups A & B MS SA Pseudomonas Aeruginosa Total Chi- square value P- Value Group A Observed 29 10 32 11.42 41 0.00 0725 Expected 20 15.5 35.5 Group B Observed 11 21 39 Expected 20 15.5 35.5 Total 80 62 142 Table 2: Comparison of m icrobiological pattern in chronic osteomyelitis patients over 5 years Micro - Organism Methicillin Sensitive Staph aureus (MSSA) Methicillin Resistant Staph aureus (MRSA) Pseudomonas Aeruginosa Escherichia - Coli Klebsiella Pneumonia Streptococcus pyogenes Group A Group B 29(40.2%) 11(15.2%) 2(2.7%) 19(26.3%) 10(13. 8%) 21(29%) 9(12.5%) 16(22.2%) 8(11.1%) 3(4.1%) 5(6.9%) None Table 3: Antibiotics and their sensitivity/resistance pattern in various microbes in Group B Antibiotics MS SA (n=29) Pseudomo nas A eruginosa (n=10) E - Coli (n=9) MRSA (n=2) Vancomycin Sen sitive Resi stant Sen sitive Resi stant Sen sitive Resi stant Sen sitive Resi stant Piperacillin - Tazobactam 18 11 -- 10 -- 9 02 09 Ceftazidime avibactam -- -- 1 9 4 5 -- 9 Oxacillin -- -- 1 9 1 8 -- 9 Linezolid 8 21 -- 10 -- 9 -- 9 Doxycycline 27 2 -- 10 -- 9 -- 9 Fusidic acid 25 4 -- 10 6 3 -- 9 Clindamycin 25 4 -- 10 -- 9 -- 9 Fosfomycin 24 5 -- 10 -- 9 -- 9 Cloramphe - Nicol -- -- -- 10 4 5 -- 9 Amikacin -- -- -- 10 3 6 -- 9 Gentamicin -- -- 3 7 6 3 -- 9 Cefepime -- -- 2 8 3 6 -- 9 Meropenem -- -- 4 6 -- 9 -- 9 -- -- 4 6 6 3 -- 9 Table 4: Antibiotics and their sensitivity/resistance pattern in various microbes in Group B Antibiotics Bacillus cereus (n=04) Klebsiella P neumonia (n=8) Coagulase negative Staph aureus (n=4) Sensiti ve Resist ant Sensiti ve Resist ant Sensiti ve Resist ant Vancomycin 04 -- -- 10 02 2 Piperacillin - Tazobactam -- 4 -- 08 -- -- Oxacillin -- 04 -- 08 02 02 Linezolid 01 03 -- 08 04 -- Doxycycline -- 4 01 7 03 01 Fusidic acid -- 4 -- 8 -- -- Clindamycin 01 03 -- 8 03 01 Cefepime -- 04 -- 8 -- -- Meropenem 01 03 2 06 -- -- Fosfomycin -- 04 07 01 -- -- Ceftazidime avibactam -- -- 04 04 -- -- DISCUSSION Chronic osteomyelitis is a prolonged, lasting infection of bone & bone marrow. Chronic osteomyelitis is well known for being resistant & requires aggressive surgical debridement in addition to antibiotic therapy. 1 The dead bone and implant are the favorite sites for bacteria to adhere to & res ult in biofilm formation. 19 Chronic osteomyelitis may require antibiotic therapy for months to years & as a result, microbe identification is necessary for long - term treatment. 20 Injudicious antibiotic use has led to antibiotic resistance; hence, The Comparison of Microbiologic Pattern in Chronic Osteomyelitis
12 J Gandhara Med Dent Sci January - March 2025 culture & continuous monitoring are necessary for treating chronic osteomyelitis. 21 Dudareva et al., in their study, found that Multidrug resistance pathogens associated with osteomyelitis were found in 17.1% of infections in the 2001 - 2004 cohort & were found in 1 5.2% of cases of infection from the 2013 - 2017 cohort. 16 Their study found that a combination of glycopeptide, i.e., Vancomycin & aminoglycoside, i.e., Gentamicin, has the lowest resistance, with 58.8% of infections susceptible to these antibiotics’ combina tions. In our study, it was found that among patients in Group A, i.e., 11th Nov 2018 to 1st Nov 2019, the most prevalent microbe causing osteomyelitis was Pseudomonas aeruginosa 29%, followed by MRSA was found in 26.3%, E - Coli 22.2%, MSSA 15.2%, Klebsiell a pneumonia 4.1%. Among patients in Group B i.e., 1 st Nov 2023 to 1 st Nov 2024, the most prevalent microbe causing osteomyelitis was Methicillin Sensitive Staph aureus (MSSA) 40.2% followed by Pseudomonas aeruginosa 13.8%, E - coli 12.5%, Klebsiella pneumoni a 11.1%, Streptococcus pyogenes 6.9%, Coagulase negative Staph aureus 5.5%, Enterobacter species 4.1% & MRSA was isolated from 2 cases. Among instances of osteomyelitis, E - Coli & Pseudomonas aeruginosa were the most resistant microbes to multiple antibioti cs. Similar to our study, Dudareva et al. from Oxford, UK, found that Staph aureus was involved in 21.7% of cases of osteomyelitis, among which MRSA caused 9.6% of cases. Similarly, Pozo et al. from Spain found that the most commonly isolated bacteria were Staphylococcus aureus, i.e., 58.5% of positive cultures. Singh et al. from Bihar, India, in a study, found that out of 132 patients having osteomyelitis, 43.9% isolates were Staphylococcus aureus positive (32.7% were MRSA positive & 67.2% were MSSA positi ve), E - coli in 18.9%. 16,17,18 Antibiotic resistance is one of the main concerns in treating osteomyelitis patients. Our study found that MRSA, E - Coli & Pseudomonas aeruginosa were most resistant to multiple antibiotic regimens. Similar to our research, Jer zy et al. found that approx. 83% of Staph aureus were resistant to Methicillin & 67% were resistant to Ceftazidime. Gram - negative bacteria were resistant to multiple drugs, i.e., E - Coli was sensitive to only Ceftazidime, while Pseudomonas aeruginosa was se nsitive to Ceftazidime & Ciprofloxacin. Similar to our study, Zhang et al. from China found that the resistance of Pseudomonas aeruginosa strains to Cefotaxime, cefuroxime, cefazolin & cefoxitin was nearly 100%. E - Coli resistance to Ciprofloxacin was 44.4% . 22,23 LIMITATIONS The study is limited by its cross - sectional design, preventing assessment of the progression of root resorption over time. Being a single - center study, the findings may not be generalizable to other populations. Radiographic limitation s, including the lack of three - dimensional imaging like CBCT, may result in diagnostic inaccuracies. Observer bias in radiographic interpretation could also affect reliability. Additionally, the study does not include histological confirmation, and potenti al confounding factors such as orthodontic treatment, trauma, or systemic conditions may not be fully accounted for. CONCLUSIONS The treatment of chronic osteomyelitis, in addition to aggressive surgical debridement, requires prolonged antibiotic therapy . Due to evolving antibiotic resistance to various microbes, it is mandatory to perform a culture of infected bone & to use antibiotics that are sensitive to specific organisms. Further, in our setup, there has been a decline in several MRSA cases in 5 5 - y ear period causing osteomyelitis. Pseudomonas aeruginosa & E - Coli are associated with multi - drug - resistant Chronic Osteomyelitis. CONFLICT OF INTEREST: None FUNDING SOURCES: None REFERENCES 1. Masters EA, Ricciardi BF, Bentley KL, Moriarty TF, Schwarz EM, Muthukrishnan G. Skeletal infections: microbial pathogenesis, immunity and clinical management. Nat Rev Microbiol. 2022;20(7):385 - 400. doi:10.1038/s41579 - 022 - 00684 - 1. 2. Skedros JG, Smith TR, Cronin JT. Osteomyelitis with abscess associated with acute closed upper humerus fracture in an adult: A case report. Clin Case Rep. 2023;11(7):e7640. doi:10.1002/ccr3.7640. 3. Wang X, Zhang M, Zhu T, Wei Q, Liu G, Ding J. Flourishing antibacterial strategies for osteomyelitis therapy. Adv Sci. 2023;10(11):220615 4. doi:10.1002/advs.202206154. 4. Kronig I, Vaudaux P, Suva D, Lew D, Uçkay I. Schlossberg's Clinical Infectious Disease. Oxford University Press; 2022. 5. Yu B, Pacureanu A, Olivier C, Cloetens P, Peyrin F. Assessment of the human bone lacuna - canalicula r network at the nanoscale and impact of spatial resolution. Sci Rep. 2020;10(1):4567. doi:10.1038/s41598 - 020 - 61573 - 4. 6. Schwarz EM, McLaren AC, Sculco TP, Brause B, Bostrom M, Kates SL, et al. Adjuvant antibiotic - loaded bone cement: concerns with curren t use and research to make it work. J Orthop Res. 2021;39(2):227 - 239. doi:10.1002/jor.24836. 7. or N, Dujovny E, Rinat B, Rozen N, Rubin G. Treatment of chronic osteomyelitis with antibiotic - impregnated polymethyl methacrylate (PMMA) – the Cierny approach: is the second stage necessary? BMC Musculoskelet Disord. 2022;23(1):38. doi:10.1186/s12891 - 021 - 04913 - 3. 8. Olasinde AA, Adetan O, Bankole JK, Jones GE, Ogunlusi JD, Oluwadiya KS. Outcome of two - stage treatment of Cierny/Mader type III and IV chronic osteo myelitis of the long bones. SN Compr Clin Med. 2024;6(1):1 - 6. doi:10.1007/s42399 - 023 - 01324 - 5. The Comparison of Microbiologic Pattern in Chronic Osteomyelitis
13 J Gandhara Med Dent Sci January - March 2025 LICENSE: JGMDS publishes its articles under a Creative Commons Attribution Non-Commercial Share-Alike license ( CC-BY-NC-SA 4.0 ). COPYRIGHTS: Authors retain the rights without any restrictions to freely download, print, share and disseminate the article for any lawful purpose.It includes scholarlynetworks such as Research Gate, Google Scholar, LinkedIn, Academia.edu, Twitter, and other academic or professional networking sites. LICENSE: JGMDS publishes its articles under a Creative Commons Attribution Non-Commercial Share-Alike license ( CC-BY-NC-SA 4.0 ). COPYRIGHTS: Authors retain the rights without any restrictions to freely download, print, share and disseminate the article for any lawful purpose.It includes scholarlynetworks such as Research Gate, Google Scholar, LinkedIn, Academia.edu, Twitter, and other academic or professional networking sites. 9. Matthews PC, Conlon CP, Berendt AR, Kayley J, Jefferies L, Atkins BL, et al. Outpatient parenteral antimicrobial therapy (OPAT): is it safe for selected patie nts to self - administer at home? A retrospective analysis of a large cohort over 13 years. J Antimicrob Chemother. 2007;60(2):356 - 362. doi:10.1093/jac/dkm203. 10. Lassoued Ferjani H, Makhlouf Y, Maatallah K, Triki W, Ben Nessib D, Kaffel D, et al. Managemen t of chronic recurrent multifocal osteomyelitis: review and update on the treatment protocol. Expert Opin Biol Ther. 2022;22(6):781 - 787. doi:10.1080/14712598.2022.2070599. 11. Bharti A, Saroj UK, Kumar V, Kumar S, Omar BJ. A simple method for fashioning an antibiotic - impregnated cemented rod for intramedullary placement in infected non - union of long bones. J Clin Orthop Trauma. 2016;7(Suppl 2):171 - 176. doi:10.1016/j.jcot.2016.06.008. 12. Ziran BH, Rao N, Hall RA. A dedicated team approach enhances the outco mes of osteomyelitis treatment. Clin Orthop Relat Res. 2003;(414):31 - 36. doi:10.1097/01.blo.0000079260.43407.0a. 13. Thonse R, Conway JD. Antibiotic cement - coated nails for the treatment of infected nonunion and segmental bone defects. J Bone Joint Surg Am . 2008;90(Suppl 4):163 - 174. doi:10.2106/JBJS.H.00631. 14. Zelmer AR, Nelson R, Richter K, Atkins GJ. Can intracellular Staphylococcus aureus in osteomyelitis be treated using current antibiotics? A systematic review and narrative synthesis. Bone Res. 2022; 10(1):53. doi:10.1038/s41413 - 022 - 00213 - 5. 15. Chen Y, Liu Z, Lin Z, Lu M, Fu Y, Liu G, et al. The effect of Staphylococcus aureus on innate and adaptive immunity and potential immunotherapy for S. aureus - induced osteomyelitis. Front Immunol. 2023;14:121989 5. doi:10.3389/fimmu.2023.1219895. 16. Dudareva M, Hotchen AJ, Ferguson J, Hodgson S, Scarborough M, Atkins BL, et al. The microbiology of chronic osteomyelitis: changes over ten years. J Infect. 2019;79(3):189 - 198. doi:10.1016/j.jinf.2019.06.005. 17. Garc ia del Pozo E, Collazos J, Carton JA, Camporro D, Asensi V. Factors predictive of relapse in adult bacterial osteomyelitis of long bones. BMC Infect Dis. 2018;18(1):635. doi:10.1186/s12879 - 018 - 3579 - 2. 18. Singh A, Biswas PP, Sen A. Clinical and microbiolog ical profile of chronic osteomyelitis cases concerning virulence markers in Staphylococcus aureus. J Evol Med Dent Sci. 2020;9(9):625 - 634. doi:10. 19. Kaur J, Gulati VL, Aggarwal A, Gupta V. Bacteriological profile of osteomyelitis with special reference t o Staphylococcus aureus. Indian J Pract Dr. 2008;4(6):1 - 9. 20. Jha Y, Chaudhary K. Diagnosis and treatment modalities for osteomyelitis. Cureus. 2022 Oct 26;14(10):e30737. doi: 10.7759/cureus.30737. 21. Tsang ST, Epstein GZ, Ferreira N. Critical bone defec t affecting the outcome of management in anatomical type IV chronic osteomyelitis. STLR. 2024;19(1):26. 22. Jerzy K, Francis H. Chronic osteomyelitis - based flora, antibiotic sensitivity and treatment challenges. Open Orthop J. 2018;12:153 - 163. doi: 10.2174 /1874325001812010153. 23. Zhang X, Lu Q, Liu T, Li Z, Cai W. Bacterial resistance trends among the intraoperative bone culture of chronic osteomyelitis in an affiliated hospital of South China for twelve years. BMC Infect Dis. 2019;19(1):823. doi: 10.1186/ s12879 - 019 - 4435 - 3. CONTRIBUTORS 1. Muhammad Aamir - Concept & Design; Data Acquisition; D ata A nalysis/ I nterpretation; Drafting Manuscript; C ritical Revision 2. Noor Rahman - C ritical R evision ; S upervision; Final Approval 3. Safeer U llah - Data Acquisition; D ata A nalysis/ I nterpretation; D rafting M anuscript 4 . Muhammad Taimur - D ata A cquisition; D ata A nalysis/ I nterpretation 5. Ihtisham K hattak - D ata A cquisition; D ata A nalysis/ I nterpretation 6 . Waleed Salman - Data Acquisition; Data Analysis/Interpretation 7. Israr Ahmad - Critical Revision; S upervision; Final Approval The Comparison of Microbiologic Pattern in Chronic Osteomyelitis