Osteomyelitis medical therapy
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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.
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 pneumoniae. Empiric antibiotics with staphylococcal and 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
- First-generation cephalosporin (Cefadroxil, Cefazolin, Cephalexin) ≥150 mg/kg/day administered in 4 equal doses
- Antistaphylococcal penicillin (Cloxacillin, Flucloxacillin, Dicloxacillin, Nafcillin, Oxacillin) ≤ 200 mg/kg/day administered in 4 equal doses
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
- Vancomycin 15 mg/kg IV q12h for 4–6 wk
OR - Oxacillin 1.5–2 g IV q4h for 4–6 wk AND Rifampin 600 mg PO qd
ORSA
- Vancomycin 15 mg/kg IV q12h for 4–6 wk OR Daptomycin 6 mg/kg IV q24h
- Linezolid 600 mg PO/IV q12h for 6 wk ± Rifampin 600–900 mg PO qd
OR - Levofloxacin 500–750 mg PO/IV daily ± Rifampin 600–900 mg PO qd
Penicillin-sensitive Streptococcus
- 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
- Vancomycin 15 mg/kg IV q12h for 4–6 wk
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
- Vancomycin 15 mg/kg IV q12h for 4–6 wk ± Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk
Enterobacteriaceae
- Ceftriaxone 1–2 g IV/IM q24h for 4–6 wk OR Ertapenem 1 g IV q24h
- Levofloxacin 500–750 mg PO q24h OR Ciprofloxacin 500–750 mg PO q12h for 4–6 wk
Pseudomonas aeruginosa
- Ciprofloxacin 750 mg PO q12h OR Ceftazidime 2 g IV q8h for 4–6 wk
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
- Chloramphenicol 75 mg/kg/day administered in 3 equal doses
Vertebral Osteomyelitis
Abbreviations: OSSA, oxacillin-sensitive Staphylococcus aureus; ORSA, Oxacillin-resistant Staphylococcus aureus.[2]
OSSA or coagulase-negative staphylococci
- Levofloxacin 750 mg PO qd AND Rifampin 300 mg PO bid
ORSA
- Vancomycin 1 g IV q12h
- Daptomycin ≥ 6 mg/kg IV q24h
OR - Levofloxacin 500–750 mg PO/IV daily AND Rifampin 600–900 mg PO qd
Streptococcus
- Penicillin G 5 MU IV q6h
- Ceftriaxone 2 g IV q24h
Enterobacteriaceae, quinolone-susceptible
- Ciprofloxacin 750 mg PO q12h
- Ceftriaxone 2 g IV q24h
Enterobacteriaceae, quinolone-resistant
- Imipenem 500 mg IV q6h
Pseudomonas aeruginosa
- Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h x 2–4 wk, followed by Ciprofloxacin 750 mg PO bid
- Piperacillin–Tazobactam 750 mg PO q12h x 2–4 wk, followed by Ciprofloxacin 750 mg PO bid
Anaerobes
- Clindamycin 300–600 mg IV q6–8h
- 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)
References
- ↑ 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.
- ↑ 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.