Osteomyelitis medical therapy: Difference between revisions

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__NOTOC__
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{{Osteomyelitis}}
{{Osteomyelitis}}
{{CMG}}
{{CMG}}; {{AE}} {{MehdiP}}


==Overview==
==Overview==
The mainstay of therapy for osteomyelitis typically involves complete surgical debridement followed by antimicrobial therapy against suspected pathogens. Antimicrobial therapy is based on predisposing host factors and local resistance patterns. The standard recommendation for the treatment of chronic osteomyelitis is ≥ 4–6 weeks of [[parenteral]] antibiotics. However, oral antimicrobial agents may achieve adequate concentrations in the bone with similar cure rates as compared to parental administration, and may be considered in selected cases.
The mainstay of therapy for osteomyelitis typically involves complete surgical debridement followed by antimicrobial therapy against suspected pathogens. Antimicrobial therapy is based on predisposing host factors and local resistance patterns. The standard recommendation for the treatment of chronic osteomyelitis is ≥ 4–6 weeks of [[parenteral]] antibiotics. However, oral antimicrobial agents may achieve adequate concentrations in the bone with similar cure rates as compared to parental administration, and may be considered in selected cases.
 
==Medical Therapy==
==Medical Therapy==
* The mainstay of therapy for osteomyelitis is [[antimicrobial]] therapy and [[surgical debridement]].
* The mainstay of therapy for osteomyelitis is [[antimicrobial]] therapy and [[surgical debridement]].
* [[Antibiotic]] regimens should be targeted whenever possible ([[blood culture]] or [[biopsy]] if blood cultures are negative or equivocal), or should be tailored to the clinical situation.
* [[Antibiotic]] regimens should be targeted whenever possible ([[blood culture]] or [[biopsy]], if blood cultures are negative or equivocal), or should be tailored to the clinical situation.


===Antimicrobial Regimens===
===Antimicrobial Regimens===
====Hematogenous Osteomyelitis====
====Acute Hematogenous Osteomyelitis====
*1. '''Empiric antimicrobial therapy''' <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>
The following table summarizes the treatment for acute hematogenous osteomyelitis.<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>
:*1.1 '''Adult (>21 yrs)'''
{| class="wikitable"
::*1.1.1 '''MRSA possible'''
! colspan="2" rowspan="2" |Pathogens
:::* Preferred regimen: [[Vancomycin]] 1 g IV q12h (if over 100 kg, 1.5 g IV q12h)
! colspan="2" |Age group specific therapy
::*1.1.2 '''MRSA unlikely'''
|-
:::* Preferred regimen: [[Nafcillin]] 2 g IV q4h {{or}} [[Oxacillin]] 2 g IV q4h
!Adult (>21 yr)
:*1.2 '''Children (>4 months)'''
!Children (4 m-21yr)
::*1.2.1 '''MRSA possible'''
|-
:::* Preferred regimen: [[Vancomycin]] 40 mg/kg/day IV q6–8h
| rowspan="2" |Empiric
::*1.2.2 '''MRSA unlikely'''
|[[Methicillin-resistant staphylococcus aureus|MRSA]] possible †
:::* Preferred regimen: [[Nafcillin]] 37 mg/kg IV q6h (maximum dose 8–12 g/day) {{or}} [[Oxacillin]] 37 mg/kg IV q6h (maximum dose 8–12 g/day)  
|[[Vancomycin]] 1 g IV q12h (if over 100 kg, 1.5 g IV q12h)
::* Note: Add [[Ceftazidime]] 50 mg/kg IV q8h or [[Cefepime]] 150 mg/kg/day IV q8h if Gram-negative bacilli on Gram stain.
|[[Vancomycin]] 40 mg/kg/day IV q6–8h
*2. '''Pathogen-directed antimicrobial therapy'''
|-
:*2.1 '''MSSA'''
|[[Methicillin-resistant staphylococcus aureus|MRSA]] unlikely
::* Preferred regimen: [[Nafcillin]] 2 g IV q4h {{or}} [[Oxacillin]] 2 g IV q4h {{or}} [[Cefazolin]] 2 g IV q8h  
|[[Nafcillin]] 2 g IV q4h '''<u>OR</u>''' [[Oxacillin]] 2 g IV q4h
::* Alternative regimen: [[Vancomycin]] 1 g IV q12h (if over 100 kg, 1.5 g IV q12h)
|[[Nafcillin]] 37 mg/kg IV q6h (maximum dose 8–12 g/day) '''<u>OR</u>''' [[Oxacillin]] 37 mg/kg IV q6h (maximum dose 8–12 g/day)
:*2.2 '''MRSA'''
|-
::* Preferred regimen: [[Vancomycin]] 1 g IV q12h
| rowspan="8" |Pathogen directed
::* Alternative regimen: [[Linezolid]] 600 mg q12h IV/PO {{withorwithout}} [[Rifampin]] 300 mg po/IV bid
|[[MSSA]]
|[[Nafcillin]] 2 g IV q4h <u>'''OR'''</u> [[Oxacillin]] 2 g IV q4h '''<u>OR</u>''' [[Cefazolin]] 2 g IV q8h
|[[Cefazolin]] (100 mg/kg/24 hr divided q8h IV) '''<u>OR</u>''' [[Nafcillin]] (150-200 mg/kg/24 hr divided q6h)
|-
|[[MRSA]]
|[[Vancomycin]] 1 g IV q12h
Alternative:
 
[[Linezolid]] 600 mg q12h IV/PO ± [[Rifampin]] 300 mg po/IV bid
|[[Vancomycin]] (60 mg/kg/24 hr divided q6h IV)
|-
|[[Streptococcus agalactiae]] (Group B Streptococcus)
|[[Penicillin]]
|[[Penicillin]] (250,000 to 400,000 units/kg per day divided in 4 to 6 doses; maximum dose 24 million units per day)
|-
|[[Streptococcus pyogenes]] (Group A Streptococcus)
|[[Penicillin]]
|[[Penicillin]] (250,000 to 400,000 units/kg per day divided in 4 to 6 doses; maximum dose 24 million units per day)
|-
|[[Streptococcus pneumoniae]] (Pneumococcus)
* Penicillin-susceptible
|[[Penicillin]]
 
|[[Penicillin]] (250,000 to 400,000 units/kg per day divided in 4 to 6 doses; maximum dose 24 million units per day)
|-
|[[Streptococcus pneumoniae]] (Pneumococcus)
* Penicillin-nonsusceptible
|[[Cefotaxime]] OR [[Ceftriaxone]] OR [[Clindamycin]] OR [[Linezolid]]
|[[Cefotaxime]] (150 to 200 mg/kg per day divided in 3 or 4 doses; maximum dose 12 g/day)
OR [[Ceftriaxone]] (80 to 100 mg/kg per day divided in 1 or 2 doses; maximum dose 4 g/day) OR [[Clindamycin]] (40 mg/kg per day divided in 3 or 4 doses; maximum dose 2.7 g/day)
 
OR [[Linezolid]] (<12 years: 30 mg/kg per day in 3 doses, ≥12 years: 600 mg twice per day)
|-
|[[Haemophilus influenzae type b]]
|[[Cefotaxime]] OR [[Ceftriaxone]] OR [[Cefuroxime]]
|[[Cefotaxime]] (150 to 200 mg/kg per day divided in 3 or 4 doses; maximum dose 12 g/day)
OR [[Ceftriaxone]] (80 to 100 mg/kg per day divided in 1 or 2 doses; maximum dose 4 g/day)


====Contiguous Osteomyelitis with Vascular Insufficiency====
OR [[Cefuroxime]]
* Osteomyelitis, contiguous with vascular insufficiency <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>
|-
:* Debride overlying ulcer and send bone specimen for histology and culture.
|Kingella kingae
:* No empiric antimicrobial therapy unless acutely ill.
|[[Penicillin]] OR [[Cefotaxime]] OR [[Ceftriaxone]]
:* Antibiotic therapy should be based on culture results
|[[Penicillin]] (250,000 to 400,000 units/kg per day divided in 4 to 6 doses; maximum dose 24 million units per day)
:* Treatment duration is at least 6 weeks.
OR [[Cefotaxime]] (150 to 200 mg/kg per day divided in 3 or 4 doses; maximum dose 12 g/day)
:* Revascularize if possible.


====Open Fracture Osteomyelitis====
OR [[Ceftriaxone]] (80 to 100 mg/kg per day divided in 1 or 2 doses; maximum dose 4 g/day)
* Long bone, post-internal fixation of fracture <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>
|}
:*1. '''S. aureus  or  P. aeruginosa'''
<sub>† Risk factors for MRSA include:</sub>
::* Preferred regimen: [[Vancomycin]] 1 g IV q12h {{and}} ([[Ceftazidime]] 2 g IV q8h {{or}} [[Cefepime]] 2 g IV q8h)
::* Alternative regimen (1): [[Linezolid]] 600 mg IV/PO bid {{and}} [[Ceftazidime]] 2 g IV q8h
::* Alternative regimen (2): [[Linezolid]] 600 mg IV/PO bid {{and}} [[Cefepime]] 2 g IV q8h
:*2. '''Gram negative bacilli'''
::* Preferred regimen (1): [[Ciprofloxacin]] 750 mg PO bid 
::* Preferred regimen (2): [[Levofloxacin]] 750 mg PO qd


====Diabetic Foot Osteomyelitis====
<sub>Recent hospitalization, residence in a long-term care facility, recent antibiotic therapy, HIV infection, men who have sex with men, injection drug use, hemodialysis, incarceration, military service, sharing needles, razors, or other sharp objects, sharing sports equipment, diabetes, prolonged hospital stay, swine farming</sub>
*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)
:* 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  {{and}} [[Clindamycin]] 150–300 mg PO qid (for more severe cases)
*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


====Chronic Osteomyelitis====
====Chronic Osteomyelitis====
*1. '''Pathogen-directed antimicrobial therapy''' <ref name="pmid22157324">{{cite journal| author=Spellberg B, Lipsky BA| title=Systemic antibiotic therapy for chronic osteomyelitis in adults. | journal=Clin Infect Dis | year= 2012 | volume= 54 | issue= 3 | pages= 393-407 | pmid=22157324 | doi=10.1093/cid/cir842 | pmc=PMC3491855 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22157324  }} </ref>
Treatment options for chronic ostemyelitis (based on pathogen) in children include:
:*1.1 '''MSSA'''
:* Preferred regimen (1): [[Ampicillin]] 150–200 mg/kg/day q6h
::* Preferred regimen (1): [[Oxacillin]] 1.5–2 g IV q4h for 4–6 weeks  
:* Preferred regimen (2): [[Amoxicillin]] 150–200 mg/kg/day q6h
::* Preferred regimen (2): [[Cefazolin]] 1–2 g IV q8h for 4–6 weeks
:* Alternative regimen: [[Chloramphenicol]] 75 mg/kg/day q8h
::* 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
The table below summarizes the treatment options for chronic osteomyelitis in adults.<ref name="pmid22157324">{{cite journal| author=Spellberg B, Lipsky BA| title=Systemic antibiotic therapy for chronic osteomyelitis in adults. | journal=Clin Infect Dis | year= 2012 | volume= 54 | issue= 3 | pages= 393-407 | pmid=22157324 | doi=10.1093/cid/cir842 | pmc=PMC3491855 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22157324  }} </ref>
:*1.2 '''MRSA'''
 
::* Preferred regimen (1): [[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks  
{| class="wikitable"
::* Preferred regimen (2): [[Daptomycin]] 6 mg/kg IV q24h
! colspan="3" |Chronic osteomyelitis
::* Alternative regimen (1): [[Linezolid]] 600 mg PO/IV q12h for 6 weeks {{withorwithout}} [[Rifampin]] 600–900 mg PO qd
|-
::* Alternative regimen (2): [[Levofloxacin]] 500–750 mg/day PO/IV {{withorwithout}} [[Rifampin]] 600–900 mg PO qd
!Pathogen
:*1.3 '''Penicillin-sensitive Streptococcus'''
!Preferred regimen
::* Preferred regimen (1): [[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 weeks 
!Alternative regimen
::* 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
|'''MSSA'''
::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks
|[[Oxacillin]] 1.5–2 g IV q4h for 4–6 weeks
:*1.4 '''Enterococcus or Streptococcus (MIC≥ 0.5 μg/mL) or Abiotrophia or Granulicatella'''
OR
::* 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
[[Cefazolin]] 1–2 g IV q8h for 4–6 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
|[[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks
:*1.5 '''Enterobacteriaceae'''
OR
::* Preferred regimen (1): [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 weeks
 
::* Preferred regimen (2): [[Ertapenem]] 1 g IV q24h
[[Oxacillin]] 1.5–2 g IV q4h for 4–6 weeks AND [[Rifampin]] 600 mg PO qd
::* Alternative regimen (1): [[Levofloxacin]] 500–750 mg PO qd 
|-
::* Alternative regimen (2): [[Ciprofloxacin]] 500–750 mg PO bid for 4–6 weeks
|'''MRSA'''
:*1.6 '''Pseudomonas aeruginosa'''
|[[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks
::* Preferred regimen (1): [[Cefepime]] 2 g IV q12h 
OR
::* Preferred regimen (2): [[Meropenem]] 1 g IV q8h 
 
::* Preferred regimen (3): [[Imipenem]] 500 mg IV q6h for 4–6 weeks
[[Daptomycin]] 6 mg/kg IV q24h
::* Alternative regimen (1): [[Ciprofloxacin]] 750 mg PO q12h 
 
::* Alternative regimen (2): [[Ceftazidime]] 2 g IV q8h for 4–6 weeks
OR
*2. '''Chronic Osteomyelitis in Children – Pathogen-Based Therapy'''
:*2.1 '''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


====Vertebral Osteomyelitis====
[[Teicoplanin]] 6 to 12 mg/kg IV once daily
* '''Pathogen-directed antimicrobial therapy''' <ref name="pmid26229122">{{cite journal| author=Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK et al.| title=2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adultsa. | journal=Clin Infect Dis | year= 2015 | volume= 61 | issue= 6 | pages= e26-46 | pmid=26229122 | doi=10.1093/cid/civ482 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26229122  }} </ref>
|[[Ceftaroline]] 600 mg IV every 12 hours
:*1. '''OSSA or coagulase-negative staphylococci'''
OR
::*Preferred regimen (1): [[Nafcillin]] sodium or [[Oxacillin]] 1.5–2 g IV q4–6 h or continuous infusion for 6 weeks
::*Preferred regimen (2): [[Cefazolin]] 1–2 g IV q8 h for 6 weeks
::*Preferred regimen (3): [[Ceftriaxone]] 2 g IV q24 h for 6 weeks
::*Alternative regimen (1): [[Vancomycin]] IV 15–20 mg/kg q12 hd for 6 weeks
::*Alternative regimen (2): [[Daptomycin]] 6–8 mg/kg IV q24h for 6 weeks
::*Alternative regimen (3): [[Linezolid]] 600 mg PO/IV q12 h for 6 weeks
::*Alternative regimen (4): [[Levofloxacin]] 500–750 mg PO q24h for 6 weeks
::*Alternative regimen (5): [[Rifampin]] PO 600 mg daily for 6 weeks
::*Alternative regimen (6): [[Clindamycin]] IV 600–900 mg q8h for 6 weeks
:*2. '''ORSA'''
::*Preferred regimen: [[Vancomycin]] IV 15–20 mg/kg q12 h for 6 weeks
::*Alternative regimen: [[Daptomycin]] 6–8 mg/kg IV q24 h '''<u>OR</u>''' [[Linezolid]] 600 mg PO/IV q12 h '''<u>OR</u>''' [[Levofloxacin]] PO 500–750 mg PO q24 h '''<u>AND</u>''' [[Rifampin]] PO 600 mg q24h for 6 weeks
:*3. '''β-hemolytic Streptococci'''
::*Preferred regimen: [[Penicillin]] G 20–24 million units IV q24h continuously or in 6 divided doses for 6 weeks
::*Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 6 weeks
::*Alternative regimen: [[Vancomycin]] IV 15–20 mg/kg q12h for 6 weeks
:*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) {{then}} [[Ciprofloxacin]] 750 mg PO bid
::* Alternative regimen: [[Piperacillin–Tazobactam]] 750 mg PO q12h for 2–4 weeks {{then}} [[Ciprofloxacin]] 750 mg PO bid
:*7. '''Anaerobes'''
::* Preferred regimen: [[Piperacillin–Tazobactam]] 750 mg PO q12h for 2–4 weeks {{then}} [[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)


====Sternal Osteomyelitis====
[[Linezolid]] 600 mg PO/IV q12h for 6 weeks ± [[Rifampin]] 600–900 mg PO qd
* Osteomyelitis, sternal <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: [[Vancomycin]] 1 g IV q12h (If over 100kg, 1.5 g IV q12h)
:* Alternative regimen:  [[Linezolid]] 600 mg PO/IV bid


====Candidal Osteomyelitis====
OR
* 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
:* Note: Duration of therapy usually is prolonged (6–12 months); Surgical debridement is frequently necessary


====Hemoglobinopathy-Associated Osteomyelitis====
[[Levofloxacin]] 500–750 mg/day PO/IV ± [[Rifampin]] 600–900 mg PO qd
|-
|'''Penicillin-sensitive Streptococcus'''
|[[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 weeks
OR
 
[[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 weeks
|[[Cefazolin]] 1–2 g IV q8h for 4–6 weeks
OR
 
[[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks
|-
|'''Enterococcus or Streptococcus (MIC≥ 0.5 μg/mL) or'''
'''Abiotrophia or Granulicatella'''
|[[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 weeks
OR
 
[[Ertapenem]] 1 g IV q24h
|[[Levofloxacin]] 500–750 mg PO qd
OR
 
[[Ciprofloxacin]] 500–750 mg PO bid for 4–6 weeks
|-
|'''Pseudomonas aeruginosa'''
|[[Cefepime]] 2 g IV q12h
OR
 
[[Meropenem]] 1 g IV q8h
 
OR
 
[[Imipenem]] 500 mg IV q6h for 4–6 weeks
|[[Ciprofloxacin]] 750 mg PO q12h
OR
 
[[Ceftazidime]] 2 g IV q8h for 4–6 weeks
|-
|'''Enterobacteriaceae'''
|[[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 weeks
OR
 
[[Ertapenem]] 1 g IV q24h
|[[Levofloxacin]] 500–750 mg PO qd
OR
 
[[Ciprofloxacin]] 500–750 mg PO bid for 4–6 weeks
|}
 
 
====Diabetic foot osteomyelitis====
This table describes the treatment options for diabetic foot ostemyelitis.<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><ref name="pmid8075257">{{cite journal |vauthors=Grayson ML, Gibbons GW, Habershaw GM, Freeman DV, Pomposelli FB, Rosenblum BI, Levin E, Karchmer AW |title=Use of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients |journal=Clin. Infect. Dis. |volume=18 |issue=5 |pages=683–93 |year=1994 |pmid=8075257 |doi= |url=}}</ref>
{| class="wikitable"
! rowspan="2" |Specific group
! colspan="2" |
 
==== Diabetic Foot Osteomyelitis ====
|-
!Preferred regimen
!Alternative regimen
|-
|'''Mild to moderate infection'''
|[[Clindamycin]] (300 to 450 mg every 6 to 8 hours)
'''<u>OR</u>'''
 
[[Linezolid]] (600 mg every 12 hours)
 
'''<u>OR</u>'''
 
[[Penicillin]] '''or''' [[cephalexin]] '''or''' [[dicloxacillin]]
 
'''+'''
[[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] '''or''' [[doxycycline]]
 
|[[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]]
'''+'''
 
[[Amoxicillin-Clavulanate|Amoxicillin-clavulanate]]
 
'''<u>OR</u>'''
 
[[Clindamycin]]
 
'''+'''
[[Ciprofloxacin]] '''or''' [[levofloxacin]] '''or''' [[moxifloxacin]]
|-
|'''Severe infection ¶'''
|[[Ampicillin-Sulbactam|Ampicillin-sulbactam]] (3 g every 6 hours)
OR
 
[[Piperacillin-tazobactam]] (4.5 g every 6 to 8 hours)
 
OR
 
[[Imipenem-Cilastatin|Imipenem-cilastatin]] (500 mg every 6 hours)
 
OR
 
[[Meropenem]] (1 g every 8 hours)
 
OR
 
[[Ertapenem]] (1 g every 24 hours)
 
OR
 
[[Moxifloxacin]] (400 mg IV every 24 hours)
 
If MRSA is suspected add one of the following agents
 
[[Vancomycin]] (15 to 20 mg/kg every 8 to 12 hours)
 
OR
 
[[Linezolid]] (600 mg IV every 12 hours)
 
OR
 
[[Daptomycin]] (4 to 6 mg/kg every 24 hours)
|
|}
¶ <sub>Severe infection defined as:</sub>
 
<sub>Extensive infections that involve deep tissues, limb-threatening diabetic foot infections and those that are associated with systemic toxicity.</sub>
 
====Vertebral osteomyelitis====
Pathogen directed based treatment for vertebral osteomyelitis.<ref name="pmid26229122">{{cite journal| author=Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK et al.| title=2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adultsa. | journal=Clin Infect Dis | year= 2015 | volume= 61 | issue= 6 | pages= e26-46 | pmid=26229122 | doi=10.1093/cid/civ482 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26229122  }} </ref>
 
{| class="wikitable"
! colspan="2" rowspan="2" |Specific group
! colspan="2" |
==== Vertebral Osteomyelitis ====
|-
!Preferred regimen
!Alternative regimen
|-
| colspan="2" |'''Oxacillin sensitive staphylococcus aureus'''
'''(OSSA) or coagulase-negative staphylococci'''
 
|[[Nafcillin]] sodium or [[Oxacillin]] 1.5-2 g IV q4-6h or continuous infusion for 6 weeks
'''<u>OR</u>'''
 
[[Cefazolin]] 1-2 g IV q8h for 6 weeks
 
'''<u>OR</u>'''
 
[[Ceftriaxone]] 2 g IV q24h for 6 weeks
 
|[[Vancomycin]] IV 15-20 mg/kg q12 hd for 6 weeks
OR
 
[[Daptomycin]] 6-8 mg/kg IV q24h for 6 weeks
 
OR
 
[[Linezolid]] 600 mg PO/IV q12h for 6 weeks
 
OR
 
[[Levofloxacin]] 500-750 mg PO q24h for 6 weeks
 
OR
 
[[Clindamycin]] IV 600-900 mg q8h for 6 weeks
|-
| colspan="2" |'''Oxacillin resistant staphylococcus aureus'''
'''(ORSA)'''
|[[Vancomycin]] IV 15-20 mg/kg q12h for 6 weeks
|[[Daptomycin]] 6-8 mg/kg IV q24h '''OR''' [[Linezolid]] 600 mg PO/IV q12 h
 
'''OR''' [[Levofloxacin]] PO 500–750 mg PO q24 h
 
+
 
[[Rifampin]] PO 600 mg q24h for 6 weeks
|-
| colspan="2" |'''β-hemolytic Streptococci'''
|[[Penicillin]] G 20-24 million units IV q24h continuously or in 6 divided doses for 6 weeks
OR
 
[[Ceftriaxone]] 2 g IV q24h for 6 weeks
|[[Vancomycin]] IV 15-20 mg/kg q12h for 6 weeks
|-
| colspan="2" |'''Enterobacteriaceae'''
|[[Cefepime]] 2 g IV q12h for 6 weeks
OR
 
[[Ertapenem]] 1 g IV q24h for 6 weeks
|[[Ciprofloxacin]] 500-750 mg PO q12h or 400 mg IV q12h for 6 weeks
|-
| colspan="2" |'''Pseudomonas aeruginosa'''
|[[Cefepime]] 2 g IV q8-12h for 6 weeks
OR
 
[[Meropenem]] 1 g IV q8h for 6 weeks
 
OR
 
[[Doripenem]] 500 mg IV q8h for 6 weeks
|[[Ciprofloxacin]] 750 mg PO q12h or 400 mg IV q8h) for 6 weeks
OR
 
[[Aztreonam]] 2 g IV q8h for 6 weeks
 
OR
 
[[Ceftazidime]] 2 g IV q8h for 6 weeks
|-
| rowspan="2" |'''Enterococcus'''
|Penicillin susceptible
|[[Penicillin G]] 20-24 million units IV q24h continuously or in 6 divided doses
OR
 
[[Ampicillin]] sodium 12 g IV q24h continuously or in 6 divided doses
|[[Vancomycin]] 15-20 mg/kg IV q12h
OR
 
[[Daptomycin]] 6 mg/kg IV q24h
 
OR
 
[[Linezolid]] 600 mg PO or IV q12h
|-
|Penicillin resistant
|[[Vancomycin]] IV 15-20 mg/kg q12h
|[[Daptomycin]] 6 mg/kg IV q24h
OR
 
[[Linezolid]] 600 mg PO or IV q12h
|-
| colspan="2" |'''Propionibacterium acnes'''
|[[Penicillin]] G 20 million units IV q24h continuously or in 6 divided doses for 6 weeks
OR
 
[[Ceftriaxone]] 2 g IV q24h for 6 weeks
|[[Clindamycin]] 600-900 mg IV q8h for 6 weeks
OR
 
[[Vancomycin]] IV 15-20 mg/kg q12h for 6 weeks
|-
| colspan="2" |'''Salmonella species'''
|[[Ciprofloxacin]] PO 500 mg q12h or IV 400 mg q12h for 6-8 weeks
|[[Ceftriaxone]] 2 g IV q24h for 6-8 weeks
|}
 
====Specific conditions====
The treatment of other rare types of osteomyelitis are summarized in the table below.<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><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>
{| class="wikitable"
! colspan="2" rowspan="2" |Specific condition
! colspan="2" |Anti-biotic  regimen
|-
!Preferred
!Alternative
|-
| rowspan="2" |
==== Open Fracture Osteomyelitis ====
|S. aureus or P. aeruginosa
|[[Vancomycin]] 1 g IV q12h
+
 
([[Ceftazidime]] 2 g IV q8h OR [[Cefepime]] 2 g IV q8h)
|[[Linezolid]] 600 mg IV/PO bid + [[Ceftazidime]] 2 g IV q8h
OR
 
[[Linezolid]] 600 mg IV/PO bid + [[Cefepime]] 2 g IV q8h
|-
|Gram negative bacilli
|[[Ciprofloxacin]] 750 mg PO bid
|[[Levofloxacin]] 750 mg PO qd
|-
| colspan="2" |
==== Sternal Osteomyelitis ====
|[[Vancomycin]] 1 g IV q12h (If over 100kg, 1.5 g IV q12h)
|[[Linezolid]] 600 mg PO/IV bid
|-
| colspan="2" |
==== Candidal Osteomyelitis ====
|[[Fluconazole]] 400 mg/day (6 mg/kg/day) PO for 6–12 months
|[[Anidulafungin]] 200 mg loading dose THEN 100 mg/day PO
OR
 
[[Caspofungin]] 70mg loading dose THEN 50 mg/day PO
 
OR
 
[[Micafungin]] 100 mg/day PO
 
|-
| colspan="2" |
==== Hemoglobinopathy-Associated Osteomyelitis ====
|[[Ciprofloxacin]] 400 mg IV q12h
|[[Levofloxacin]] 750 mg IV q24h
|}


* Osteomyelitis, hemoglobinopathy <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: [[Ciprofloxacin]] 400 mg IV q12h
:* Alternative regimen: [[Levofloxacin]] 750 mg IV q24h


==References==
==References==
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[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
[[Category:Skeletal disorders]]
[[Category:Skeletal disorders]]
[[Category:Infectious disease]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious Disease Project]]
[[Category:Infectious Disease Project]]
[[Category:Emergency mdicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Latest revision as of 23:28, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

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

Medical Therapy

Antimicrobial Regimens

Acute Hematogenous Osteomyelitis

The following table summarizes the treatment for acute hematogenous osteomyelitis.[1]

Pathogens Age group specific therapy
Adult (>21 yr) Children (4 m-21yr)
Empiric MRSA possible † Vancomycin 1 g IV q12h (if over 100 kg, 1.5 g IV q12h) Vancomycin 40 mg/kg/day IV q6–8h
MRSA unlikely Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h Nafcillin 37 mg/kg IV q6h (maximum dose 8–12 g/day) OR Oxacillin 37 mg/kg IV q6h (maximum dose 8–12 g/day)
Pathogen directed MSSA Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h OR Cefazolin 2 g IV q8h Cefazolin (100 mg/kg/24 hr divided q8h IV) OR Nafcillin (150-200 mg/kg/24 hr divided q6h)
MRSA Vancomycin 1 g IV q12h

Alternative:

Linezolid 600 mg q12h IV/PO ± Rifampin 300 mg po/IV bid

Vancomycin (60 mg/kg/24 hr divided q6h IV)
Streptococcus agalactiae (Group B Streptococcus) Penicillin Penicillin (250,000 to 400,000 units/kg per day divided in 4 to 6 doses; maximum dose 24 million units per day)
Streptococcus pyogenes (Group A Streptococcus) Penicillin Penicillin (250,000 to 400,000 units/kg per day divided in 4 to 6 doses; maximum dose 24 million units per day)
Streptococcus pneumoniae (Pneumococcus)
  • Penicillin-susceptible
 Penicillin Penicillin (250,000 to 400,000 units/kg per day divided in 4 to 6 doses; maximum dose 24 million units per day)
Streptococcus pneumoniae (Pneumococcus)
  • Penicillin-nonsusceptible
 Cefotaxime OR Ceftriaxone OR Clindamycin OR Linezolid Cefotaxime (150 to 200 mg/kg per day divided in 3 or 4 doses; maximum dose 12 g/day)

OR Ceftriaxone (80 to 100 mg/kg per day divided in 1 or 2 doses; maximum dose 4 g/day) OR Clindamycin (40 mg/kg per day divided in 3 or 4 doses; maximum dose 2.7 g/day)

OR Linezolid (<12 years: 30 mg/kg per day in 3 doses, ≥12 years: 600 mg twice per day)

Haemophilus influenzae type b Cefotaxime OR Ceftriaxone OR Cefuroxime Cefotaxime (150 to 200 mg/kg per day divided in 3 or 4 doses; maximum dose 12 g/day)

OR Ceftriaxone (80 to 100 mg/kg per day divided in 1 or 2 doses; maximum dose 4 g/day)

OR Cefuroxime

Kingella kingae Penicillin OR Cefotaxime OR Ceftriaxone Penicillin (250,000 to 400,000 units/kg per day divided in 4 to 6 doses; maximum dose 24 million units per day)

OR Cefotaxime (150 to 200 mg/kg per day divided in 3 or 4 doses; maximum dose 12 g/day)

OR Ceftriaxone (80 to 100 mg/kg per day divided in 1 or 2 doses; maximum dose 4 g/day)

† Risk factors for MRSA include:

Recent hospitalization, residence in a long-term care facility, recent antibiotic therapy, HIV infection, men who have sex with men, injection drug use, hemodialysis, incarceration, military service, sharing needles, razors, or other sharp objects, sharing sports equipment, diabetes, prolonged hospital stay, swine farming

Chronic Osteomyelitis

Treatment options for chronic ostemyelitis (based on pathogen) in children include:

The table below summarizes the treatment options for chronic osteomyelitis in adults.[2]

Chronic osteomyelitis
Pathogen Preferred regimen Alternative regimen
MSSA Oxacillin 1.5–2 g IV q4h for 4–6 weeks

OR

Cefazolin 1–2 g IV q8h for 4–6 weeks

Vancomycin 15 mg/kg IV q12h for 4–6 weeks

OR

Oxacillin 1.5–2 g IV q4h for 4–6 weeks AND Rifampin 600 mg PO qd

MRSA Vancomycin 15 mg/kg IV q12h for 4–6 weeks

OR

Daptomycin 6 mg/kg IV q24h

OR

Teicoplanin 6 to 12 mg/kg IV once daily

Ceftaroline 600 mg IV every 12 hours

OR

Linezolid 600 mg PO/IV q12h for 6 weeks ± Rifampin 600–900 mg PO qd

OR

Levofloxacin 500–750 mg/day PO/IV ± Rifampin 600–900 mg PO qd

Penicillin-sensitive Streptococcus Penicillin G 20 MU/day IV continuously or q4h for 4–6 weeks

OR

Ceftriaxone 1–2 g IV/IM q24h for 4–6 weeks

Cefazolin 1–2 g IV q8h for 4–6 weeks

OR

Vancomycin 15 mg/kg IV q12h for 4–6 weeks

Enterococcus or Streptococcus (MIC≥ 0.5 μg/mL) or

Abiotrophia or Granulicatella

Ceftriaxone 1–2 g IV/IM q24h for 4–6 weeks

OR

Ertapenem 1 g IV q24h

Levofloxacin 500–750 mg PO qd

OR

Ciprofloxacin 500–750 mg PO bid for 4–6 weeks

Pseudomonas aeruginosa Cefepime 2 g IV q12h

OR

Meropenem 1 g IV q8h

OR

Imipenem 500 mg IV q6h for 4–6 weeks

Ciprofloxacin 750 mg PO q12h

OR

Ceftazidime 2 g IV q8h for 4–6 weeks

Enterobacteriaceae Ceftriaxone 1–2 g IV/IM q24h for 4–6 weeks

OR

Ertapenem 1 g IV q24h

Levofloxacin 500–750 mg PO qd

OR

Ciprofloxacin 500–750 mg PO bid for 4–6 weeks


Diabetic foot osteomyelitis

This table describes the treatment options for diabetic foot ostemyelitis.[3][4]

Specific group

Diabetic Foot Osteomyelitis

Preferred regimen Alternative regimen
Mild to moderate infection Clindamycin (300 to 450 mg every 6 to 8 hours)

OR

Linezolid (600 mg every 12 hours)

OR

Penicillin or cephalexin or dicloxacillin

+ Trimethoprim-sulfamethoxazole or doxycycline

Trimethoprim-sulfamethoxazole

+

Amoxicillin-clavulanate

OR

Clindamycin

+ Ciprofloxacin or levofloxacin or moxifloxacin

Severe infection ¶ Ampicillin-sulbactam (3 g every 6 hours)

OR

Piperacillin-tazobactam (4.5 g every 6 to 8 hours)

OR

Imipenem-cilastatin (500 mg every 6 hours)

OR

Meropenem (1 g every 8 hours)

OR

Ertapenem (1 g every 24 hours)

OR

Moxifloxacin (400 mg IV every 24 hours)

If MRSA is suspected add one of the following agents

Vancomycin (15 to 20 mg/kg every 8 to 12 hours)

OR

Linezolid (600 mg IV every 12 hours)

OR

Daptomycin (4 to 6 mg/kg every 24 hours)

Severe infection defined as:

Extensive infections that involve deep tissues, limb-threatening diabetic foot infections and those that are associated with systemic toxicity.

Vertebral osteomyelitis

Pathogen directed based treatment for vertebral osteomyelitis.[5]

Specific group

Vertebral Osteomyelitis

Preferred regimen Alternative regimen
Oxacillin sensitive staphylococcus aureus

(OSSA) or coagulase-negative staphylococci

Nafcillin sodium or Oxacillin 1.5-2 g IV q4-6h or continuous infusion for 6 weeks

OR

Cefazolin 1-2 g IV q8h for 6 weeks

OR

Ceftriaxone 2 g IV q24h for 6 weeks

Vancomycin IV 15-20 mg/kg q12 hd for 6 weeks

OR

Daptomycin 6-8 mg/kg IV q24h for 6 weeks

OR

Linezolid 600 mg PO/IV q12h for 6 weeks

OR

Levofloxacin 500-750 mg PO q24h for 6 weeks

OR

Clindamycin IV 600-900 mg q8h for 6 weeks

Oxacillin resistant staphylococcus aureus

(ORSA)

Vancomycin IV 15-20 mg/kg q12h for 6 weeks Daptomycin 6-8 mg/kg IV q24h OR Linezolid 600 mg PO/IV q12 h

OR Levofloxacin PO 500–750 mg PO q24 h

+

Rifampin PO 600 mg q24h for 6 weeks

β-hemolytic Streptococci Penicillin G 20-24 million units IV q24h continuously or in 6 divided doses for 6 weeks

OR

Ceftriaxone 2 g IV q24h for 6 weeks

Vancomycin IV 15-20 mg/kg q12h for 6 weeks
Enterobacteriaceae Cefepime 2 g IV q12h for 6 weeks

OR

Ertapenem 1 g IV q24h for 6 weeks

Ciprofloxacin 500-750 mg PO q12h or 400 mg IV q12h for 6 weeks
Pseudomonas aeruginosa Cefepime 2 g IV q8-12h for 6 weeks

OR

Meropenem 1 g IV q8h for 6 weeks

OR

Doripenem 500 mg IV q8h for 6 weeks

Ciprofloxacin 750 mg PO q12h or 400 mg IV q8h) for 6 weeks

OR

Aztreonam 2 g IV q8h for 6 weeks

OR

Ceftazidime 2 g IV q8h for 6 weeks

Enterococcus Penicillin susceptible Penicillin G 20-24 million units IV q24h continuously or in 6 divided doses

OR

Ampicillin sodium 12 g IV q24h continuously or in 6 divided doses

Vancomycin 15-20 mg/kg IV q12h

OR

Daptomycin 6 mg/kg IV q24h

OR

Linezolid 600 mg PO or IV q12h

Penicillin resistant Vancomycin IV 15-20 mg/kg q12h Daptomycin 6 mg/kg IV q24h

OR

Linezolid 600 mg PO or IV q12h

Propionibacterium acnes Penicillin G 20 million units IV q24h continuously or in 6 divided doses for 6 weeks

OR

Ceftriaxone 2 g IV q24h for 6 weeks

Clindamycin 600-900 mg IV q8h for 6 weeks

OR

Vancomycin IV 15-20 mg/kg q12h for 6 weeks

Salmonella species Ciprofloxacin PO 500 mg q12h or IV 400 mg q12h for 6-8 weeks Ceftriaxone 2 g IV q24h for 6-8 weeks

Specific conditions

The treatment of other rare types of osteomyelitis are summarized in the table below.[6][7]

Specific condition Anti-biotic regimen
Preferred Alternative

Open Fracture Osteomyelitis

 S. aureus or P. aeruginosa Vancomycin 1 g IV q12h

+

(Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8h)

Linezolid 600 mg IV/PO bid + Ceftazidime 2 g IV q8h

OR

Linezolid 600 mg IV/PO bid + Cefepime 2 g IV q8h

Gram negative bacilli Ciprofloxacin 750 mg PO bid Levofloxacin 750 mg PO qd

Sternal Osteomyelitis

 Vancomycin 1 g IV q12h (If over 100kg, 1.5 g IV q12h) Linezolid 600 mg PO/IV bid

Candidal Osteomyelitis

 Fluconazole 400 mg/day (6 mg/kg/day) PO for 6–12 months Anidulafungin 200 mg loading dose THEN 100 mg/day PO

OR

Caspofungin 70mg loading dose THEN 50 mg/day PO

OR

Micafungin 100 mg/day PO

Hemoglobinopathy-Associated Osteomyelitis

 Ciprofloxacin 400 mg IV q12h Levofloxacin 750 mg IV q24h


References

  1. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  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.
  3. ↑ 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.
  4. ↑ Grayson ML, Gibbons GW, Habershaw GM, Freeman DV, Pomposelli FB, Rosenblum BI, Levin E, Karchmer AW (1994). "Use of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients". Clin. Infect. Dis. 18 (5): 683–93. PMID 8075257.
  5. ↑ Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK; et al. (2015). "2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adultsa". Clin Infect Dis. 61 (6): e26–46. doi:10.1093/cid/civ482. PMID 26229122.
  6. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  7. ↑ 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.
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