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 ¹⁾.

Antibiotics for skull osteomyelitis alone are rarely curative. Treatment usually involves surgical debridement of the infected skull, biting off the infected bone with rongeurs 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 ²⁾.

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.