Osteomyelitis medical therapy

Jump to navigation Jump to search

Osteomyelitis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Osteomyelitis from Other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications, and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

X Ray

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Osteomyelitis medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Osteomyelitis medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Osteomyelitis medical therapy

CDC on Osteomyelitis medical therapy

Osteomyelitis medical therapy in the news

Blogs on Osteomyelitis medical therapy

Directions to Hospitals Treating Osteomyelitis

Risk calculators and risk factors for Osteomyelitis medical therapy

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

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

Hematogenous Osteomyelitis

  • 1. Empiric antimicrobial therapy [1]
  • 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
  • 1.2 Children (>4 months)
  • 1.2.1 MRSA possible
  • Preferred regimen: Vancomycin 40 mg/kg/day IV q6–8h
  • 1.2.2 MRSA unlikely
  • 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)
  • Note: Add Ceftazidime 50 mg/kg IV q8h or Cefepime 150 mg/kg/day IV q8h if Gram-negative bacilli on Gram stain.
  • 2. Pathogen-directed antimicrobial therapy
  • 2.1 MSSA
  • 2.2 MRSA

Contiguous Osteomyelitis with Vascular Insufficiency

  • Osteomyelitis, contiguous with vascular insufficiency [2]
  • 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
  • Treatment duration is at least 6 weeks.
  • Revascularize if possible.

Open Fracture Osteomyelitis

  • Long bone, post-internal fixation of fracture [3]
  • 1. S. aureus or P. aeruginosa
  • 2. Gram negative bacilli

Diabetic Foot Osteomyelitis

  • 1. Chronic infection or recent antibiotic use [4]
  • 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
  • 4. Polymicrobial infection

Chronic Osteomyelitis

  • 1. Pathogen-directed antimicrobial therapy [5]
  • 1.1 MSSA
  • 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 MRSA
  • 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
  • 2.1 Group A beta-hemolytic Streptococcus, Haemophilus influenzae type B and Streptococcus pneumoniae

Vertebral Osteomyelitis

  • Pathogen-directed antimicrobial therapy [6]
  • 1. OSSA or coagulase-negative staphylococci
  • 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 q24h for 6 weeks
  • Alternative regimen (6): Clindamycin IV 600–900 mg q8h for 6 weeks
  • 2. ORSA
  • 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
  • Preferred regimen: Cefepime 2 g IV q12h for 6 weeks
  • Preferred regimen: Ertapenem 1 g IV q24h for 6 weeks
  • Alternative regimen: Ciprofloxacin 500–750 mg PO q12h or 400 mg IV q12h for 6 weeks
  • 5. Pseudomonas aeruginosa
  • Preferred regimen: Cefepime 2 g IV q8-12h for 6 weeks
  • Preferred regimen: Meropenem 1 g IV q8h for 6 weeks
  • Preferred regimen: Doripenem 500 mg IV q8h for 6 weeks
  • Alternative regimen: Ciprofloxacin 750 mg PO q12 h (or 400 mg IV q8 h)
  • Alternative regimen: Aztreonam 2 g IV q8h
  • Alternative regimen: Ceftazidime 2 g IV q8h
  • 7. Anaerobes

Sternal Osteomyelitis

  • Osteomyelitis, sternal [7]
  • 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

  • Osteomyelitis, candidal [8]
  • 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

  • Osteomyelitis, hemoglobinopathy [9]

References

  1. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  2. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  3. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  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. 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.
  6. 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.
  7. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  8. 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.
  9. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.