Osteomyelitis medical therapy: Difference between revisions

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==Overview==
==Acute Osteomyelitis in Adults – Empiric Therapy==
Osteomyelitis often requires prolonged [[antibiotic]] therapy, with a course lasting a matter of weeks or months. A [[PICC line]] or [[central venous catheter]] is often placed for this purpose. Initial first line antibiotic choice is determined by the patient's history and regional differences in common infective organisms. Prior to the widespread availability and use of antibiotics, [[maggot|blow fly larvae]] were sometimes [[maggot therapy|deliberately introduced]] to the wounds to feed on the infected material, effectively scouring them clean.<ref>{{cite journal |last=Baer M.D. |first=William S. |year=1931 |title=The Treatment of Chronic Osteomyelitis with the Maggot (Larva of the Blow Fly) |journal=Journal of Bone and Joint Surgery |volume=13 |pages=438–475 |url=http://www.ejbjs.org/cgi/content/abstract/13/3/438 |accessdate= 2007-11-12}}</ref><ref>{{cite journal
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.
| quotes = yes
 
| last=McKeever
==Acute Osteomyelitis in Children – Empiric Therapy==
| first=Duncan Clark
<span style="font-size: 85%;">
| year=2008|month=June
'''Abbreviations''':
| title=The classic: maggots in treatment of osteomyelitis: a simple inexpensive method. 1933
OSSA, oxacillin-sensitive ''Staphylococcus aureus'';
| journal=Clin. Orthop. Relat. Res.
ORSA, Oxacillin-resistant ''Staphylococcus aureus'';
| volume=466
CRSA, Clindamycin-resistant ''Staphylococcus aureus''.
| issue=6
</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>
| pages=1329–35
 
| pmid = 18404291
===High prevalence of OSSA in community===
| doi = 10.1007/s11999-008-0240-5
{{rx|Preferred regimen}}
}}</ref> [[Hyperbaric oxygen therapy]] has been shown to be a useful [[wikt:adjunct|adjunct]] to the treatment of [[wikt:refractory|refractory]] osteomyelitis.<ref>{{cite journal |author=Mader JT, Adams KR, Sutton TE |title=Infectious diseases: pathophysiology and mechanisms of hyperbaric oxygen |journal=J. Hyperbaric Med |volume=2 |issue=3 |pages=133–140 |year=1987 |url=http://archive.rubicon-foundation.org/4339 |accessdate=2008-05-16}}</ref><ref>{{cite journal |author=Kawashima M, Tamura H, Nagayoshi I, Takao K, Yoshida K, Yamaguchi T |title=Hyperbaric oxygen therapy in orthopedic conditions |journal=Undersea Hyperb Med |volume=31 |issue=1 |pages=155–62 |year=2004 |pmid=15233171 |url=http://archive.rubicon-foundation.org/4000 |accessdate=2008-05-16}}</ref> A treatment lasting 42 days is practiced in a number of facilities.<ref>Putland M.D, Michael S., Hyperbaric Medicine, Capital Regional Medical Center, Tallahassee, Florida, personal inquiry June 2008.</ref>
* First-generation cephalosporin ([[Cefadroxil]], [[Cefazolin]], [[Cephalexin]]) ≥150 mg/kg/day administered in 4 equal doses
</li>
{{rx|Alternative regimen}}
* Antistaphylococcal penicillin ([[Cloxacillin]], [[Flucloxacillin]], [[Dicloxacillin]], [[Nafcillin]], [[Oxacillin]]) ≤ 200 mg/kg/day administered in 4 equal doses
</li>
 
===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===
{{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==
 
===OSSA===
{{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
</li>
{{rx|Alternative regimen}}
* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{or2}}
* [[Oxacillin]] 1.5–2 g IV q4h for 4–6 wk {{and2}} [[Rifampin]] 600 mg PO qd
</li>
 
===ORSA===
{{rx|Preferred regimen}}
* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{or}} [[Daptomycin]] 6 mg/kg IV q24h
</li>
{{rx|Alternative regimen}}
* [[Linezolid]] 600 mg PO/IV q12h for 6 wk ± [[Rifampin]] 600–900 mg PO qd {{or2}}
* [[Levofloxacin]] 500–750 mg PO/IV daily ± [[Rifampin]] 600–900 mg PO qd
</li>
 
===Penicillin-sensitive ''Streptococcus''===
{{rx|Preferred regimen}}
* [[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 wk {{or}} [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 wk {{or}} [[Cefazolin]] 1–2 g IV q8h for 4–6 wk
</li>
{{rx|Alternative regimen}}
* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk
</li>
 
===''Enterococcus'' or ''Streptococcus'' (MIC ≥ 0.5 μg/mL) or ''Abiotrophia'' or ''Granulicatella''===
{{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}}
* [[Ampicillin]] 12 g/day IV continuously or q4h for 4–6 wk ± [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk
</li>
{{rx|Alternative regimen}}
* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk ± [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk
</li>
 
===''Enterobacteriaceae''===
{{rx|Preferred regimen}}
* [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 wk {{or}} [[Ertapenem]] 1 g IV q24h
</li>
{{rx|Alternative regimen}}
* [[Levofloxacin]] 500–750 mg PO q24h {{or}} [[Ciprofloxacin]] 500–750 mg PO q12h for 4–6 wk
</li>
 
===''Pseudomonas aeruginosa''===
{{rx|Preferred regimen}}
* [[Cefepime]] 2 g IV q12h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Imipenem]] 500 mg IV q6h for 4–6 wk
</li>
{{rx|Alternative regimen}}
* [[Ciprofloxacin]] 750 mg PO q12h {{or}} [[Ceftazidime]] 2 g IV q8h for 4–6 wk
</li>
 
==Chronic Osteomyelitis in Children – Pathogen-Based Therapy ==
 
===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>
 


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Needs content]]
[[Category:Orthopedics]]
[[Category:Orthopedics]]
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
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[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Disease]]
[[Category:Disease]]
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Revision as of 20:56, 28 April 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


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

    • 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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