Osteomyelitis medical therapy: Difference between revisions

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Revision as of 20:27, 11 August 2015

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

Overview

Treatment of osteomyelitis typically involves complete surgical debridement followed by antimicrobial therapy against suspected pathogens based on predisposing host factors and local resistance patterns. The optimal duration of therapy for chronic osteomyelitis remains uncertain. The standard recommendation for treating chronic osteomyelitis is ≥ 4–6 weeks of parenteral antibiotics. However, oral antibiotics may achieve adequate concentrations in the bone with similar cure rates as compared to parental administration, and can be considered in selected cases.

Antimicrobial Regimen

Osteomyelitis, candidal

Osteomyelitis, candidal ^[1]

Preferred regimen (1): Fluconazole 400 mg/day (6 mg/kg/day) PO for 6–12 months
Preferred regimen (2): Amphotericin B 3–5 mg/kg/day PO for several weeks THEN Fluconazole for 6–12 months
Alternative regimen (1): Anidulafungin 200 mg loading dose THEN 100 mg/day PO
Alternative regimen (2): Caspofungin 70mg loading dose THEN 50 mg/day PO
Alternative regimen (3): Micafungin 100 mg/day PO
Alternative regimen (4): Amphotericin B deoxycholate 0.5–1 mg/kg/day PO for several weeks THEN Fluconazole for 6–12 months
Note: Duration of therapy usually is prolonged (6–12 months); Surgical debridement is frequently necessary

Osteomyelitis, chronic

1. Chronic Osteomyelitis in Adults – Pathogen-Based Therapy ^[2]

1.1 OSSA

Preferred regimen (1): Oxacillin 1.5–2 g IV q4h for 4–6 weeks
Preferred regimen (2): Cefazolin 1–2 g IV q8h for 4–6 weeks
Alternative regimen (1): Vancomycin 15 mg/kg IV q12h for 4–6 weeks
Alternative regimen (2): Oxacillin 1.5–2 g IV q4h for 4–6 weeks AND Rifampin 600 mg PO qd

1.2 ORSA

Preferred regimen (1): Vancomycin 15 mg/kg IV q12h for 4–6 weeks
Preferred regimen (2): Daptomycin 6 mg/kg IV q24h
Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 6 weeks ± Rifampin 600–900 mg PO qd
Alternative regimen (2): Levofloxacin 500–750 mg/day PO/IV ± Rifampin 600–900 mg PO qd

1.3 Penicillin-sensitive Streptococcus

Preferred regimen (1): Penicillin G 20 MU/day IV continuously or q4h for 4–6 weeks
Preferred regimen (2): Ceftriaxone 1–2 g IV/IM q24h for 4–6 weeks
Preferred regimen (3): Cefazolin 1–2 g IV q8h for 4–6 weeks
Alternative regimen: Vancomycin 15 mg/kg IV q12h for 4–6 weeks

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

Preferred regimen (1): Penicillin G 20 MU/day IV continuously or q4h for 4–6 weeks ± Gentamicin 1 mg/kg IV/IM q8h for 1–2 weeks
Preferred regimen (2): Ampicillin 12 g/day IV continuously or q4h for 4–6 weeks ± Gentamicin 1 mg/kg IV/IM q8h for 1–2 weeks
Alternative regimen: Vancomycin 15 mg/kg IV q12h for 4–6 weeks ± Gentamicin 1 mg/kg IV/IM q8h for 1–2 weeks

1.5 Enterobacteriaceae

Preferred regimen (1): Ceftriaxone 1–2 g IV/IM q24h for 4–6 weeks
Preferred regimen (2): Ertapenem 1 g IV q24h
Alternative regimen (1): Levofloxacin 500–750 mg PO qd
Alternative regimen (2): Ciprofloxacin 500–750 mg PO bid for 4–6 weeks

1.6 Pseudomonas aeruginosa

Preferred regimen (1): Cefepime 2 g IV q12h
Preferred regimen (2): Meropenem 1 g IV q8h
Preferred regimen (3): Imipenem 500 mg IV q6h for 4–6 weeks
Alternative regimen (1): Ciprofloxacin 750 mg PO q12h
Alternative regimen (2): Ceftazidime 2 g IV q8h for 4–6 weeks

2. Chronic Osteomyelitis in Children – Pathogen-Based Therapy

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

Preferred regimen (1): Ampicillin 150–200 mg/kg/day q6h
Preferred regimen (2): Amoxicillin 150–200 mg/kg/day q6h
Alternative regimen: Chloramphenicol 75 mg/kg/day q8h

Osteomyelitis, contiguous with vascular insufficiency

Osteomyelitis, contiguous with vascular insufficiency ^[3]

Debride overlying ulcer and send bone specimen for histology and culture.
No empiric antimicrobial therapy unless acutely ill.
Antibiotic therapy should be based on culture results and treat for 6 weeks.
Revascularize if possible.

Osteomyelitis, diabetic foot

1. Chronic Infection or Recent Antibiotic Use ^[4]

Preferred regimen (1): Levofloxacin 750 mg IV/PO q24h
Preferred regimen (2): Cefoxitin 1 g IV q4h (or 2 g IV q6–8h)
Preferred regimen (3): Ceftriaxone 1–2 g/day IV/IM q12–24h
Preferred regimen (4): Ampicillin-Sulbactam 1.5–3 g IV/IM q6h
Preferred regimen (5): Moxifloxacin 400 mg IV/PO q24h
Preferred regimen (6): Ertapenem 1 g IV/IM q24h
Preferred regimen (7): Tigecycline 100 mg IV THEN 50 mg IV q12h (active against MRSA)
Preferred regimen (8): Imipenem-Cilastatin 0.5–1 g IV q6–8h (Not active against MRSA; consider when ESBL-producing pathogens suspected)
Alternative regimen (1): Levofloxacin 750 mg IV/PO q24h AND Clindamycin 150–300 mg PO qid
Alternative regimen (2): Ciprofloxacin 600–1200 mg/day IV q6–12h AND Clindamycin 150–300 mg PO qid
Alternative regimen (3): Ciprofloxacin 1200–2700 mg IV q6–12h (for more severe cases) AND Clindamycin 150–300 mg PO qid

2. High Risk for MRSA

Preferred regimen (1): Linezolid 600 mg IV/PO q12h
Preferred regimen (2): Daptomycin 4 mg/kg IV q24h
Preferred regimen (3): Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)

3. High Risk for Pseudomonas aeruginosa

Preferred regimen: Piperacillin–Tazobactam 3.375 g IV q6–8h

4. Polymicrobial Infection

Preferred regimen: (Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L) OR Linezolid 600 mg IV/PO q12h OR Daptomycin 4 mg/kg IV q24h) AND (Piperacillin–Tazobactam 3.375 g IV q6–8h OR Imipenem–Cilastatin 0.5–1 g IV q6–8h OR Ertapenem 1 g IV/IM q24h OR Meropenem 1 g IV q8h)
Alternative regimen: (Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L) OR Linezolid 600 mg IV/PO q12h OR Daptomycin 4 mg/kg IV q24h) AND (Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8h OR Aztreonam 2 g IV q6–8h) AND Metronidazole 15 mg/kg IV, then 7.5 mg/kg IV q6h

Osteomyelitis, foot bone

Foot bone osteomyelitis due to nail through tennis shoe ^[5]

Preferred regimen (1): Ciprofloxacin 750 mg PO bid
Preferred regimen (2): Levofloxacin 750 mg PO q24h
Alternative regimen (1): Ceftazidime 2 g IV q8h
Alternative regimen (2): Cefepime 2 g IV q12h

Osteomyelitis, foot puncture wound

Long bone, post-internal fixation of fracture ^[6]

1. S. aureus or P. aeruginosa

Preferred regimen: Vancomycin 1 g IV q12h AND (Ceftazidime OR Cefepime)
Alternative regimen (1): Linezolid 600 mg IV/PO bid^NAI AND Ceftazidime
Alternative regimen (2): Linezolid 600 mg IV/PO bid^NAI AND Cefepime

2. Gm-neg. bacilli

Preferred regimen (1): Ciprofloxacin 750 mg po bid
Preferred regimen (2): Levofloxacin 750 mg po qd

Osteomyelitis, hematogenous

1. Empiric therapy ^[7]

1.1 Adult (>21 yrs)

1.1.1 MRSA possible

Preferred regimen: Vancomycin 1 g IV q12h (if over 100 kg, 1.5 g IV q12h)

1.1.2 MRSA unlikely

Preferred regimen: Nafcillin OR Oxacillin 2 g IV q4h

1.2 Children (>4 mos.)-Adult

1.2.1 MRSA possible

Preferred regimen: Vancomycin 40 div q6–8h

1.2.2 MRSA unlikely

Preferred regimen: Nafcillin OR Oxacillin 37 q6h (to max. 8–12 g per day)

Note: Add Ceftazidime 50 q8h or Cefepime 150 div q8h if Gm-neg. bacilli on Gram stain

1.3 Newborn (<4 mos.)

1.3.1 MRSA possible

Preferred regimen: Vancomycin AND (Ceftazidime 2 g IV q8h or Cefepime 2 g IV q12h)

1.3.2 MRSA unlikely

Preferred regimen: (Nafcillin OR Oxacillin) AND (Ceftazidime OR Cefepime)

2. Specific therapy

2.1 MSSA

Preferred regimen: Nafcillin OR Oxacillin 2 g IV q4h OR Cefazolin 2 g IV q8h
Alternative regimen: Vancomycin 1 g IV q12h (if over 100 kg, 1.5 g IV q12h)

2.2 MRSA

Preferred regimen: Vancomycin 1 g IV q12h
Alternative regimen: Linezolid 600 mg q12h IV/po ± Rifampin 300 mg po/IV bid

Osteomyelitis, hemoglobinopathy

Osteomyelitis, hemoglobinopathy ^[8]

Preferred regimen: Ciprofloxacin 400 mg IV q12h
Alternative regimen: Levofloxacin 750 mg IV q24h

Osteomyelitis, spinal implant

1. Onset within 30 days ^[9] ^[10]

Culture, treat & then suppress until fusion occurs

Main parenteral antimicrobial therapy

Preferred regimen: Beta-lactam antibiotic OR Vancomycin

Suppressive antimicrobial therapy strategy

Preferred regimen: Beta-lactam antibiotic OR Minocycline

2. Onset after 30 days

Remove implant, culture & treat

Main parenteral antimicrobial therapy

Preferred regimen: Beta-lactam antibiotic OR Vancomycin OR Combination therapy

Suppressive antimicrobial therapy strategy

Preferred regimen: Combination therapy OR Minocycline

Osteomyelitis, vertebral

Vertebral Osteomyelitis – Pathogen-Based Therapy ^[11] ^[12]

1. OSSA or coagulase-negative staphylococci

Preferred regimen (1): Oxacillin 2 g IV q6h
Preferred regimen (2): Cefazolin 1–2 g IV q8h
Alternative regimen: Levofloxacin 750 mg PO qd AND Rifampin 300 mg PO bid

2. ORSA

Preferred regimen: Vancomycin 1 g IV q12h
Alternative regimen (1): Daptomycin 6 mg/kg IV q24h
Alternative regimen (2): Levofloxacin 500–750 mg/day PO/IV AND Rifampin 600–900 mg PO qd

3. Streptococcus

Preferred regimen: Penicillin G 5 MU IV q6h
Alternative regimen: Ceftriaxone 2 g IV q24h

4. Enterobacteriaceae, quinolone-susceptible

Preferred regimen: Ciprofloxacin 750 mg PO q12h
Alternative regimen: Ceftriaxone 2 g IV q24h

5. Enterobacteriaceae, quinolone-resistant

Preferred regimen: Imipenem 500 mg IV q6h

6. Pseudomonas aeruginosa

Preferred regimen: (Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h for 2–4 weeks), followed by Ciprofloxacin 750 mg PO bid
Alternative regimen: Piperacillin–Tazobactam 750 mg PO q12h for 2–4 weeks, followed by Ciprofloxacin 750 mg PO bid

7. Anaerobes

Preferred regimen: Piperacillin–Tazobactam 750 mg PO q12h for 2–4 weeks, followed by Ciprofloxacin 750 mg PO bid
Alternative regimen (1): Penicillin G 5 MU IV q6h
Alternative regimen (2): Ceftriaxone 2 g IV q24h (against gram-positive anaerobes)
Alternative regimen (3): Metronidazole 500 mg PO tid (against gram-negative anaerobes)

Osteomyelitis, sternal

Osteomyelitis, sternal ^[13]

Preferred regimen: Vancomycin 1 g IV q12h (If over 100kg, 1.5 g IV q12h)
Alternative regimen: Linezolid 600 mg po/IV^NAI bid

References

↑ Pappas PG, Kauffman CA, Andes D, Benjamin DK, Calandra TF, Edwards JE; et al. (2009). "Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America". Clin Infect Dis. 48 (5): 503–35. doi:10.1086/596757. PMID 19191635.
↑ Spellberg B, Lipsky BA (2012). "Systemic antibiotic therapy for chronic osteomyelitis in adults". Clin Infect Dis. 54 (3): 393–407. doi:10.1093/cid/cir842. PMC 3491855. PMID 22157324.CS1 maint: PMC format (link)
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2013). "2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections". J Am Podiatr Med Assoc. 103 (1): 2–7. PMID 23328846.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Kowalski TJ, Berbari EF, Huddleston PM, Steckelberg JM, Mandrekar JN, Osmon DR (2007). "The management and outcome of spinal implant infections: contemporary retrospective cohort study". Clin Infect Dis. 44 (7): 913–20. doi:10.1086/512194. PMID 17342641.
↑ Gentry LO (1991). "Oral antimicrobial therapy for osteomyelitis". Ann Intern Med. 114 (11): 986–7. PMID 2024868.
↑ Marschall J, Bhavan KP, Olsen MA, Fraser VJ, Wright NM, Warren DK (2011). "The impact of prebiopsy antibiotics on pathogen recovery in hematogenous vertebral osteomyelitis". Clin Infect Dis. 52 (7): 867–72. doi:10.1093/cid/cir062. PMC 3106232. PMID 21427393.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[pmid19191635-1] Pappas PG, Kauffman CA, Andes D, Benjamin DK, Calandra TF, Edwards JE; et al. (2009). "Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America". Clin Infect Dis. 48 (5): 503–35. doi:10.1086/596757. PMID 19191635.

[pmid22157324-2] Spellberg B, Lipsky BA (2012). "Systemic antibiotic therapy for chronic osteomyelitis in adults". Clin Infect Dis. 54 (3): 393–407. doi:10.1093/cid/cir842. PMC 3491855. PMID 22157324.CS1 maint: PMC format (link)

[3] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[pmid23328846-4] Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2013). "2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections". J Am Podiatr Med Assoc. 103 (1): 2–7. PMID 23328846.

[5] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[6] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[7] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[8] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[9] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[pmid17342641-10] Kowalski TJ, Berbari EF, Huddleston PM, Steckelberg JM, Mandrekar JN, Osmon DR (2007). "The management and outcome of spinal implant infections: contemporary retrospective cohort study". Clin Infect Dis. 44 (7): 913–20. doi:10.1086/512194. PMID 17342641.

[pmid2024868-11] Gentry LO (1991). "Oral antimicrobial therapy for osteomyelitis". Ann Intern Med. 114 (11): 986–7. PMID 2024868.

[pmid21427393-12] Marschall J, Bhavan KP, Olsen MA, Fraser VJ, Wright NM, Warren DK (2011). "The impact of prebiopsy antibiotics on pathogen recovery in hematogenous vertebral osteomyelitis". Clin Infect Dis. 52 (7): 867–72. doi:10.1093/cid/cir062. PMC 3106232. PMID 21427393.

[13] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[1]

[2]

[3]

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@@ Line 11: / Line 11: @@
 * Osteomyelitis, candidal <ref name="pmid19191635">{{cite journal| author=Pappas PG, Kauffman CA, Andes D, Benjamin DK, Calandra TF, Edwards JE et al.| title=Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2009 | volume= 48 | issue= 5 | pages= 503-35 | pmid=19191635 | doi=10.1086/596757 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19191635  }} </ref>
 :* Preferred regimen (1): [[Fluconazole]] 400 mg/day (6 mg/kg/day) PO for 6–12 months
 :* Preferred regimen (2): [[Amphotericin B]] 3–5 mg/kg/day PO for several weeks {{then}} [[Fluconazole]] for 6–12 months
 :* Alternative regimen (1): [[Anidulafungin]] 200 mg loading dose {{then}} 100 mg/day PO
 :* Alternative regimen (2): [[Caspofungin]] 70mg loading dose {{then}} 50 mg/day PO
 :* Alternative regimen (3): [[Micafungin]] 100 mg/day PO
 :* Alternative regimen (4): [[Amphotericin B]] deoxycholate 0.5–1 mg/kg/day PO for several weeks {{then}} [[Fluconazole]] for 6–12 months
@@ Line 35: / Line 32: @@
 :*1.3 '''Penicillin-sensitive Streptococcus'''
 ::* Preferred regimen (1): [[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 weeks
 ::* Preferred regimen (2): [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 weeks
 ::* Preferred regimen (3): [[Cefazolin]] 1–2 g IV q8h for 4–6 weeks
 ::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks
 :*1.4 '''Enterococcus or Streptococcus (MIC≥ 0.5 μg/mL) or Abiotrophia or Granulicatella'''
 ::* Preferred regimen (1): [[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 weeks {{withorwithout}} [[Gentamicin]] 1 mg/kg IV/IM q8h for 1–2 weeks
 ::* Preferred regimen (2): [[Ampicillin]] 12 g/day IV continuously or q4h for 4–6 weeks {{withorwithout}} [[Gentamicin]] 1 mg/kg IV/IM q8h for 1–2 weeks
 ::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks {{withorwithout}} [[Gentamicin]] 1 mg/kg IV/IM q8h for 1–2 weeks
 :*1.5 '''Enterobacteriaceae'''
 ::* Preferred regimen (1): [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 weeks
 ::* Preferred regimen (2): [[Ertapenem]] 1 g IV q24h
 ::* Alternative regimen (1): [[Levofloxacin]] 500–750 mg PO qd
 ::* Alternative regimen (2): [[Ciprofloxacin]] 500–750 mg PO bid for 4–6 weeks
 :*1.6 '''Pseudomonas aeruginosa'''
 ::* Preferred regimen (1): [[Cefepime]] 2 g IV q12h
 ::* Preferred regimen (2): [[Meropenem]] 1 g IV q8h
 ::* Preferred regimen (3): [[Imipenem]] 500 mg IV q6h for 4–6 weeks
 ::* Alternative regimen (1): [[Ciprofloxacin]] 750 mg PO q12h
 ::* Alternative regimen (2): [[Ceftazidime]] 2 g IV q8h for 4–6 weeks
 *2. '''Chronic Osteomyelitis in Children – Pathogen-Based Therapy'''
 :* ''Group A beta-hemolytic Streptococcus, Haemophilus influenzae type B and Streptococcus pneumoniae''
 ::* Preferred regimen (1): [[Ampicillin]] 150–200 mg/kg/day q6h
 ::* Preferred regimen (2): [[Amoxicillin]] 150–200 mg/kg/day q6h
 ::* Alternative regimen: [[Chloramphenicol]] 75 mg/kg/day q8h
@@ Line 80: / Line 67: @@
 *1. '''Chronic Infection or Recent Antibiotic Use''' <ref name="pmid23328846">{{cite journal| author=Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG et al.| title=2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections. | journal=J Am Podiatr Med Assoc | year= 2013 | volume= 103 | issue= 1 | pages= 2-7 | pmid=23328846 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23328846  }} </ref>
 :* Preferred regimen (1): [[Levofloxacin]] 750 mg IV/PO q24h
 :* Preferred regimen (2): [[Cefoxitin]] 1 g IV q4h (or 2 g IV q6–8h)
 :* Preferred regimen (3): [[Ceftriaxone]] 1–2 g/day IV/IM q12–24h
 :* Preferred regimen (4): [[Ampicillin-Sulbactam]] 1.5–3 g IV/IM q6h
 :* Preferred regimen (5): [[Moxifloxacin]] 400 mg IV/PO q24h
 :* Preferred regimen (6): [[Ertapenem]] 1 g IV/IM q24h
 :* Preferred regimen (7): [[Tigecycline]] 100 mg IV {{then}} 50 mg IV q12h (active against MRSA)
 :* Preferred regimen (8): [[Imipenem-Cilastatin]] 0.5–1 g IV q6–8h (Not active against MRSA; consider when ESBL-producing pathogens suspected)
 :* Alternative regimen (1): [[Levofloxacin]] 750 mg IV/PO q24h {{and}} [[Clindamycin]] 150–300 mg PO qid
@@ Line 99: / Line 79: @@
 *2. '''High Risk for MRSA'''
 :* Preferred regimen (1): [[Linezolid]] 600 mg IV/PO q12h
 :* Preferred regimen (2): [[Daptomycin]] 4 mg/kg IV q24h
 :* Preferred regimen (3): [[Vancomycin]] 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
-*3. '''High Risk for ''Pseudomonas aeruginosa'''
+*3. High Risk for Pseudomonas aeruginosa
 :* Preferred regimen: [[Piperacillin–Tazobactam]] 3.375 g IV q6–8h
 *4. '''Polymicrobial Infection'''
@@ Line 112: / Line 90: @@
 * Foot bone osteomyelitis due to nail through tennis shoe <ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
 :* Preferred regimen (1): [[Ciprofloxacin]] 750 mg PO bid
 :* Preferred regimen (2): [[Levofloxacin]] 750 mg PO q24h
 :* Alternative regimen (1): [[Ceftazidime]] 2 g IV q8h
 :* Alternative regimen (2): [[Cefepime]] 2 g IV q12h
@@ Line 126: / Line 102: @@
 :*2. '''Gm-neg. bacilli '''
 ::* Preferred regimen (1): [[Ciprofloxacin]] 750 mg po bid
 ::* Preferred regimen (2): [[Levofloxacin]] 750 mg po qd
@@ Line 165: / Line 140: @@
 ::* Main parenteral antimicrobial therapy
 :::* Preferred regimen: [[Beta-lactam antibiotic]] {{or}} [[Vancomycin]]
 ::* Suppressive antimicrobial therapy strategy
 :::* Preferred regimen: [[Beta-lactam antibiotic]] {{or}} [[Minocycline]]
@@ Line 180: / Line 154: @@
 :*1. '''OSSA or coagulase-negative staphylococci'''
 ::* Preferred regimen (1): [[Oxacillin]] 2 g IV q6h
 ::* Preferred regimen (2): [[Cefazolin]] 1–2 g IV q8h
 ::* Alternative regimen: [[Levofloxacin]] 750 mg PO qd {{and}} [[Rifampin]] 300 mg PO bid
@@ Line 201: / Line 174: @@
 ::* Preferred regimen: [[Piperacillin–Tazobactam]] 750 mg PO q12h for 2–4 weeks, followed by [[Ciprofloxacin]] 750 mg PO bid
 ::* Alternative regimen (1): [[Penicillin G]] 5 MU IV q6h
 ::* Alternative regimen (2): [[Ceftriaxone]] 2 g IV q24h (against gram-positive anaerobes)
 ::* Alternative regimen (3): [[Metronidazole]] 500 mg PO tid (against gram-negative anaerobes)
@@ Line 209: / Line 181: @@
 :* Preferred regimen: [[Vancomycin]] 1 g IV q12h (If over 100kg, 1.5 g IV q12h)
 :* Alternative regimen:  [[Linezolid]] 600 mg po/IV<sup>NAI</sup> bid
 ==References==