Sandbox osteomyelitis: Difference between revisions

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==Acute Osteomyelitis in Adults – Empiric Therapy==
==Acute Osteomyelitis in Adults – Empiric Therapy==
 
Although osteomyelitis in adults usually has a subacute or chronic course, acute hematogenous seeding may occur in elderly patients, intravenous drug users, or patients with indwelling catheters.  The most commonly isolated microorganisms are ''Staphylococcus aureus'' and ''Streptococcus pneumonia''.  Empiric antibiotics with anti-staphylococcal and anti-streptococcal coverage should be administered based on local resistance data.
 
 
 
 
 
 
 


==Acute Osteomyelitis in Children – Empiric Therapy==
==Acute Osteomyelitis in Children – Empiric Therapy==
Line 18: Line 8:
ORSA, Oxacillin-resistant ''Staphylococcus aureus'';
ORSA, Oxacillin-resistant ''Staphylococcus aureus'';
CRSA, Clindamycin-resistant ''Staphylococcus aureus''.
CRSA, Clindamycin-resistant ''Staphylococcus aureus''.
</span>
</span><ref>{{Cite journal| doi = 10.1056/NEJMra1213956| issn = 1533-4406| volume = 370| issue = 4| pages = 352–360| last1 = Peltola| first1 = Heikki| last2 = Pääkkönen| first2 = Markus| title = Acute osteomyelitis in children| journal = The New England Journal of Medicine| date = 2014-01-23| pmid = 24450893}}</ref>


===High prevalence of OSSA in community===
===High prevalence of OSSA in community===
{{rx|Preferred regimen}}
{{rx|Preferred regimen}}
* First-generation cephalosporin ([[Cefadroxil]], [[Cefazolin]], [[Cephalexin]]) 1.5–2 g IV q4h for 4–6 wk
* First-generation cephalosporin ([[Cefadroxil]], [[Cefazolin]], [[Cephalexin]]) ≥150 mg/kg/day administered in 4 equal doses
</li>
</li>
{{rx|Alternative regimen}}
{{rx|Alternative regimen}}
* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{or2}}
* Antistaphylococcal penicillin ([[Cloxacillin]], [[Flucloxacillin]], [[Dicloxacillin]], [[Nafcillin]], [[Oxacillin]]) ≤ 200 mg/kg/day administered in 4 equal doses
* [[Oxacillin]] 1.5–2 g IV q4h for 4–6 wk {{and2}} [[Rifampin]] 600 mg PO qd
</li>
</li>
===High prevalence of ORSA in community===


===High prevalence of ORSA with low prevalence of CRSA in community===
===High prevalence of ORSA with low prevalence of CRSA in community===
 
{{rx|Preferred regimen}}
* [[Clindamycin]] ≥ 40 mg/kg/day administered in 4 equal doses
</li>


===High prevalence of ORSA with high prevalence of CRSA in community===
===High prevalence of ORSA with high prevalence of CRSA in community===
 
{{rx|Preferred regimen}}
* [[Vancomycin]] ≤ 40 mg/kg/day administered in 4 equal doses, adjust dosage to trough of 15–20 mcg/mL
</li>
{{rx|Alternative regimen}}
* [[Linezolid]] 30 mg/kg/day administered in 3 equal doses
</li>


==Chronic Osteomyelitis in Adults – Pathogen-Based Therapy==
==Chronic Osteomyelitis in Adults – Pathogen-Based Therapy==


 
===OSSA===
 
 
 
 
 
 
===Oxacillin-sensitive ''Staphylococcus aureus''===
{{rx|Preferred regimen}}
{{rx|Preferred regimen}}
* [[Oxacillin]] 1.5–2 g IV q4h for 4–6 wk {{or}} [[Cefazolin]] 1–2 g IV q8h for 4–6 wk
* [[Oxacillin]] 1.5–2 g IV q4h for 4–6 wk {{or}} [[Cefazolin]] 1–2 g IV q8h for 4–6 wk
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</li>
</li>


===Oxacillin-resistant ''Staphylococcus aureus''===
===ORSA===
{{rx|Preferred regimen}}
{{rx|Preferred regimen}}
* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{or}} [[Daptomycin]] 6 mg/kg IV q24h
* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{or}} [[Daptomycin]] 6 mg/kg IV q24h
Line 73: Line 59:
</li>
</li>


===''Enterococcus'' or ''Streptococcus'' (MIC ≥0.5 μg/mL) or ''Abiotrophia'' or ''Granulicatella''===
===''Enterococcus'' or ''Streptococcus'' (MIC ≥ 0.5 μg/mL) or ''Abiotrophia'' or ''Granulicatella''===
{{rx|Preferred regimen}}
{{rx|Preferred regimen}}
* [[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 wk ± [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk {{or2}}
* [[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 wk ± [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk {{or2}}
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===Group A beta-hemolytic ''Streptococcus'', ''Haemophilus influenzae'' type b, and ''Streptococcus pneumoniae''===
===Group A beta-hemolytic ''Streptococcus'', ''Haemophilus influenzae'' type b, and ''Streptococcus pneumoniae''===
{{rx|Preferred regimen}}
* [[Ampicillin]] 150–200 mg/kg/day administered in 4 equal doses {{or}} [[Amoxicillin]] 150–200 mg/kg/day administered in 4 equal doses
</li>
{{rx|Alternative regimen}}
* [[Chloramphenicol]] 75 mg/kg/day administered in 3 equal doses
</li>
==Vertebral Osteomyelitis==
<span style="font-size: 85%;">
'''Abbreviations''':
OSSA, oxacillin-sensitive ''Staphylococcus aureus'';
ORSA, Oxacillin-resistant ''Staphylococcus aureus'';
CRSA, Clindamycin-resistant ''Staphylococcus aureus''.
</span><ref>{{Cite journal| doi = 10.1056/NEJMcp0910753| issn = 1533-4406| volume = 362| issue = 11| pages = 1022–1029| last = Zimmerli| first = Werner| title = Clinical practice. Vertebral osteomyelitis| journal = The New England Journal of Medicine| date = 2010-03-18| pmid = 20237348}}</ref>
===OSSA or coagulase-negative staphylococci===
{{rx|Preferred regimen}}
* [[Oxacillin]] 2 g IV q6h {{or2}}
* [[Cefazolin]] 1–2 g IV q8h
</li>
{{rx|Alternative regimen}}
* [[Levofloxacin]] 750 mg PO qd {{and2}} [[Rifampin]] 300 mg PO bid
</li>
===ORSA===
{{rx|Preferred regimen}}
* [[Vancomycin]] 1 g IV q12h
</li>
{{rx|Alternative regimen}}
* [[Daptomycin]] ≥ 6 mg/kg IV q24h {{or2}}
* [[Levofloxacin]] 500–750 mg PO/IV daily {{and2}} [[Rifampin]] 600–900 mg PO qd
</li>
===''Streptococcus''===
{{rx|Preferred regimen}}
* [[Penicillin G]] 5 MU IV q6h
</li>
{{rx|Alternative regimen}}
* [[Ceftriaxone]] 2 g IV q24h
</li>
===''Enterobacteriaceae'', quinolone-susceptible===
{{rx|Preferred regimen}}
* [[Ciprofloxacin]] 750 mg PO q12h
</li>
{{rx|Alternative regimen}}
* [[Ceftriaxone]] 2 g IV q24h
</li>
===''Enterobacteriaceae'', quinolone-resistant===
{{rx|Preferred regimen}}
* [[Imipenem]] 500 mg IV q6h
</li>
===''Pseudomonas aeruginosa''===
{{rx|Preferred regimen}}
* [[Cefepime]] 2 g IV q8h {{or}} [[Ceftazidime]] 2 g IV q8h x 2–4 wk, followed by [[Ciprofloxacin]] 750 mg PO bid
</li>
{{rx|Alternative regimen}}
* [[Piperacillin–Tazobactam]] 750 mg PO q12h x 2–4 wk, followed by [[Ciprofloxacin]] 750 mg PO bid
</li>
===Anaerobes===
{{rx|Preferred regimen}}
* [[Clindamycin]] 300–600 mg IV q6–8h
</li>
{{rx|Alternative regimen}}
* [[Penicillin G]] 5 MU IV q6h {{or}} [[Ceftriaxone]] 2 g IV q24h (against gram-positive anaerobes) {{or2}]
* [[Metronidazole]] 500 mg PO tid (against gram-negative anaerobes)
</li>


==Specific Considerations==
==Specific Considerations==
Vertebral osteomyelitis


Osteomyelitis in patients with diabetes mellitus
Osteomyelitis in patients with diabetes mellitus
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Culture-Negative Osteomyelitis
Culture-Negative Osteomyelitis
==References==
{{reflist|2}}

Latest revision as of 20:56, 28 April 2015

Acute Osteomyelitis in Adults – Empiric Therapy

Although osteomyelitis in adults usually has a subacute or chronic course, acute hematogenous seeding may occur in elderly patients, intravenous drug users, or patients with indwelling catheters. The most commonly isolated microorganisms are Staphylococcus aureus and Streptococcus pneumonia. Empiric antibiotics with anti-staphylococcal and anti-streptococcal coverage should be administered based on local resistance data.

Acute Osteomyelitis in Children – Empiric Therapy

Abbreviations: OSSA, oxacillin-sensitive Staphylococcus aureus; ORSA, Oxacillin-resistant Staphylococcus aureus; CRSA, Clindamycin-resistant Staphylococcus aureus. [1]

High prevalence of OSSA in community

    • High prevalence of ORSA with low prevalence of CRSA in community

    • Clindamycin ≥ 40 mg/kg/day administered in 4 equal doses

    • High prevalence of ORSA with high prevalence of CRSA in community

    • Vancomycin ≤ 40 mg/kg/day administered in 4 equal doses, adjust dosage to trough of 15–20 mcg/mL
    • Linezolid 30 mg/kg/day administered in 3 equal doses

    • Chronic Osteomyelitis in Adults – Pathogen-Based Therapy

    OSSA

    • ORSA

    • Penicillin-sensitive Streptococcus

    • Enterococcus or Streptococcus (MIC ≥ 0.5 μg/mL) or Abiotrophia or Granulicatella

    • Penicillin G 20 MU/day IV continuously or q4h for 4–6 wk ± Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk
      OR
    • Ampicillin 12 g/day IV continuously or q4h for 4–6 wk ± Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk

    • Enterobacteriaceae

    • Pseudomonas aeruginosa

    • Chronic Osteomyelitis in Children – Pathogen-Based Therapy

    Group A beta-hemolytic Streptococcus, Haemophilus influenzae type b, and Streptococcus pneumoniae

    • Ampicillin 150–200 mg/kg/day administered in 4 equal doses OR Amoxicillin 150–200 mg/kg/day administered in 4 equal doses

    • Vertebral Osteomyelitis

    Abbreviations: OSSA, oxacillin-sensitive Staphylococcus aureus; ORSA, Oxacillin-resistant Staphylococcus aureus; CRSA, Clindamycin-resistant Staphylococcus aureus. [2]

    OSSA or coagulase-negative staphylococci

    • ORSA

    • Streptococcus

    • Enterobacteriaceae, quinolone-susceptible

    • Enterobacteriaceae, quinolone-resistant

    • Pseudomonas aeruginosa

    • Anaerobes

    • Specific Considerations

    Osteomyelitis in patients with diabetes mellitus

    Osteomyelitis in patients with vascular insufficiency

    SAPHO syndrome

    Chronic recurrent multifocal osteomyelitis

    Osteitis Pubis

    Osteomyelitis of the Clavicle

    Osteomyelitis in Hemodialysis Patients

    Osteomyelitis in Patients with Sickle Cell Disease

    Gaucher’s Disease

    Osteomyelitis in Injection Drug Users

    Skeletal Mycobacterial Infection

    Fungal Osteomyelitis

    Brodie’s Abscess

    Culture-Negative Osteomyelitis


    References

    1. ↑ Peltola, Heikki; Pääkkönen, Markus (2014-01-23). "Acute osteomyelitis in children". The New England Journal of Medicine. 370 (4): 352–360. doi:10.1056/NEJMra1213956. ISSN 1533-4406. PMID 24450893.
    2. ↑ Zimmerli, Werner (2010-03-18). "Clinical practice. Vertebral osteomyelitis". The New England Journal of Medicine. 362 (11): 1022–1029. doi:10.1056/NEJMcp0910753. ISSN 1533-4406. PMID 20237348.
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