Sandbox ID Musculoskeletal: Difference between revisions

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Latest revision as of 14:46, 31 July 2015

Bursitis

Olecranon bursitis or prepatellar bursitis ^[1]

1. Staphylococcus aureus, methicillin-susceptible (MSSA)

Preferred regimen (1): Nafcillin 2 g IV q4h

Preferred regimen (2): Oxacillin 2 g IV q4h

Preferred regimen (3): Dicloxacillin 500 mg PO qid

2. Staphylococcus aureus, methicillin-resistant (MRSA)

Preferred regimen (1): Vancomycin 1 g IV q12h

Preferred regimen (2): Linezolid 600 mg PO qd

Osteomyelitis, candidal

Osteomyelitis, candidal ^[2]

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 ^[3]

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 ^[4]

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 ^[5]

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 ^[6]

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 ^[7]

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 ^[8]

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 ^[9]

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

Osteomyelitis, spinal implant

1. Onset within 30 days ^[10] ^[11]

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 ^[12] ^[13]

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 ^[14]

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

Osteonecrosis of the jaw

1. Bacterial Infection ^[15]

Preferred regimen (1): Penicillin VK 500 mg PO q6–8h for 7–10 days (maintenance: 500 mg PO bid)

Preferred regimen (2): Amoxicillin 500 mg PO q8h for 7–10 days (maintenance: 500 mg PO bid)
Alternative regimen (1): Clindamycin 150–300 mg PO qid

Alternative regimen (2): Doxycycline 100 mg PO qd

Alternative regimen (3): Erythromycin 400 mg PO tid

Alternative regimen (4): Azithromycin 500 mg PO single dose THEN 250 mg PO qd for 4 days

Alternative regimen (5): Levofloxacin 500 mg PO qd

Alternative regimen (6): Moxifloxacin 400 mg PO qd

2. Fungal Infection

Preferred regimen (1): Nystatin oral suspension 5–15 mL swish qid

Preferred regimen (2): Fluconazole 200 mg PO qd THEN 100 mg q24h

Preferred regimen (3): Clotrimazole 10 mg PO tid for 7–10 days

3. Viral Infection

Preferred regimen (1): Acyclovir 400 mg PO bid

Preferred regimen (2): Valacyclovir 0.5–2.0 g PO bid

Reactive arthritis, post-streptococcal arthritis

Reactive arthritis, post-streptococcal arthritis ^[16]

Treat strep pharyngitis and then NSAIDs (Prednisone needed in some patients)

Reactive arthritis, Reiter's syndrome

Reactive arthritis, Reiter's syndrome ^[17]

Only treatment is non-steroidal anti-inflammatory drugs

Septic arthritis, Brucella melitensis

Septic arthritis, Brucella melitensis ^[18]

Preferred Regimen: Doxycycline 100 mg PO bid for ≥ 6 weeks AND Streptomycin 15 mg/kg IM qd for 2–3 weeks OR Rifampin 600–900 mg qd for ≥ 6 weeks
Alternative Regimen: Doxycycline 100 mg PO bid for ≥ 6 weeks AND Gentamicin 5 mg/kg IV qd for 7 days

Septic arthritis, candidal

Septic arthritis, candidal ^[2]

Preferred regimen (1): Fluconazole 400 mg/day (6 mg/kg/day) for at least 6 weeks

Preferred regimen (2): Amphotericin B 3–5 mg/kg/day for several weeks THEN Fluconazole to completion
Alternative regimen (1): Anidulafungin 200-mg loading dose THEN 100 mg/day

Alternative regimen (2): Caspofungin 70-mg loading dose THEN 50 mg/day

Alternative regimen (3): Micafungin 100 mg/day

Alternative regimen (4): Amphotericin B deoxycholate 0.5–1 mg/kg/day for several weeks THEN Fluconazole to completion
Note: Duration of therapy usually is for at least 6 weeks, but few data are available; Surgical debridement is recommended for all cases; For infected prosthetic joints, removal is recommended for most cases.

Septic arthritis, gonococcal

Septic arthritis, gonococcal ^[19]

Preferred regimen: Ceftriaxone 1 g intramuscularly IM/IV q24h
Alternative regimen (1): Cefotaxime 1 g IV q8h

Alternative regimen (2): Ceftizoxime 1 g IV q8h

Alternative regimen (3): Spectinomycin 2 g IV q12h (Penicillin allergies)
Alternative regimen (4): Ciprofloxacin 500 mg IV q12h OR Ofloxacin 400 mg IV q12h (β-lactam-allergic patient)
Note: The tetracyclines (except in pregnant women) or penicillins may be used if the infecting organism is proven to be susceptible
Pediatric regimen:

>45 kg

Preferred regimen: Ceftriaxone 50 mg/kg (Maximum, 2 g/dose) IM/IV single dose for 10 to 14 days

<45 kg

Preferred regimen: Ceftriaxone 50 mg/kg (Maximum, 1 g/dose) IM/IV single dose for 7 days

Septic arthritis, Gram-negative bacilli

Septic arthritis, Gram-negative bacilli ^[20]

Preferred regimen (1): Ceftazidime 2 g IV q8h

Preferred regimen (2): Cefepime 2 g IV q8–12h

Preferred regimen (3): Piperacillin-Tazobactam 4.5 g IV q6h
Alternative regimen (1): Aztreonam 2 g IV q8h

Alternative regimen (2): Imipenem 500 mg IV q6h

Alternative regimen (3): Meropenem 1 g IV q8h

Alternative regimen (4): Doripenem 500 mg IV q8h

Alternative regimen (5): Carbapenems

Septic arthritis, Histoplasmosis

Septic arthritis, histoplasmosis^[21]

1. Mild disease

Preferred regimen: Nonsteroidal anti-inflammatory drug

2. Severe disease

Preferred regimen: Prednisone 0.5–1.0 mg/kg/day (Maximum, 80 mg/day) in tapering doses over 1–2 weeks AND Itraconazole 200 mg tid for 3 days, followed by qd or bid for 6–12 weeks

Septic arthritis, Lyme disease

Septic arthritis, Lyme disease ^[22]

1. Patients without clinical evidence of neurologic disease

Preferred regimen (1): Doxycycline 100 mg bid for 28 days

Preferred regimen (2): Amoxicillin 500 mg tid for 28 days

Preferred regimen (3): Cefuroxime axetil 500 mg bid for 28 days
Pediatric regimen (1): Amoxicillin 50 mg/kg/day tid (Maximum, 500 mg/dose)

Pediatric regimen (2): Cefuroxime axetil 30 mg/kg/day bid (Maximum, 500 mg/dose)

Pediatric regimen (3): (if the patient is ≥8 years of age) Doxycycline 4 mg/kg/day bid (Maximum, 100 mg/dose)

2. Patients with arthritis and objective evidence of neurologic disease

Preferred regimen: Ceftriaxone administered parenterally for 2–4 weeks
Alternative regimen: Cefotaxime OR Penicillin G administered parenterally
Pediatric regimen: Ceftriaxone OR Cefotaxime OR Penicillin G administered intravenously

Note (1): For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of Ceftriaxone IV
Note (2): If patients have no resolution of arthritis despite intravenous therapy and if PCR results for a sample of synovial fluid (and synovial tissue if available) are negative, symptomatic treatment is recommended, which consist of nonsteroidal anti-inflammatory agents, intra-articular injections of corticosteroids, or disease-modifying antirheumatic drugs (DMARDs), such as Hydroxychloroquine.

Septic arthritis, Mycobacterium tuberculosis

Septic arthritis, Mycobacterium tuberculosis^[23]

1. Septic arthritis caused by susceptible Mycobacterium tuberculosis

1.1 Adults

1.1.1 Intensive phase

Preferred regimen: Isoniazid 5 mg/kg (max, 300 mg) for 2 months AND Rifampin 10 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months

1.1.2 Continuation phase

Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 7 months AND Rifampin 10 mg/kg (max: 600 mg) for 7 months

1.2 Pediatric

1.2.1 Intensive phase

Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 2 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months

1.2.2 Continuation phase

Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 7 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 7 months

2. Specific considerations

2.1 Pregnancy and breastfeeding

With the exception of streptomycin, the first line anti-TB drugs are safe for use in pregnancy: Streptomycin is ototoxic to the fetus and should not be used during pregnancy.
After active TB in the baby is ruled out, the baby should be given 6 months of isoniazid preventive therapy, followed by BCG vaccination.
Pyridoxine supplementation is recommended for all pregnant or breastfeeding women taking isoniazid.

2.2 Liver disorders

Two hepatotoxic drugs (rather than the three in the standard regimen):

9 months of Isoniazid AND Rifampicin AND Ethambutol (until or unless Isoniazid susceptibility is documented).
2 months of Isoniazid AND Rifampicin AND Streptomycin AND Ethambutol, followed by 6 months of Isoniazid AND Rifampicin.
6–9 months of Rifampicin AND Pyrazinamide AND Ethambutol

One hepatotoxic drug:

2 months of Isoniazid AND Ethambutol AND Streptomycin, followed by 10 months of Isoniazid AND Ethambutol

No hepatotoxic drugs:

18–24 months of Streptomycin AND Ethambutol AND a Fluoroquinolone

2.3 Renal failure and severe renal insufficiency

The recommended initial TB treatment regimen for patients with renal failure or severe renal insufficiency is 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampicin.
There is significant renal excretion of ethambutol and metabolites of pyrazinamide, and doses should therefore be adjusted.
Three times per week administration of these two drugs at the following doses is recommended: pyrazinamide (25 mg/kg), and ethambutol (15 mg/kg)
While receiving isoniazid, patients with severe renal insufficiency or failure should also be given pyridoxine in order to prevent peripheral neuropathy.
Because of an increased risk of nephrotoxicity and ototoxicity, Streptomycin should be avoided in patients with renal failure. If Streptomycin must be used, the dosage is 15 mg/kg, two or three times per week, to a maximum of 1 gram per dose, and serum levels of the drug should be monitored.

2.4 Previously treated patients in settings with rapid DST

TB patients whose treatment has failed or other patient groups with high likelihood of multidrug-resistant TB (MDR) should be started on an empirical MDR regimen.
TB patients returning after defaulting or relapsing from their first treatment course may receive the retreatment regimen containing first-line drugs 2HRZES/1HRZE/5HRE if country-specific data show low or medium levels of MDR in these patients or if such data are not available.

2.5 TB treatment in people living with HIV

TB patients with known positive HIV status and all TB patients living in HIV prevalent settings should receive daily TB treatment at least during the intensive phase.
For the continuation phase, the optimal dosing frequency is also daily for these patients.
If a daily continuation phase is not possible for these patients, three times weekly dosing during the continuation phase is an acceptable alternative.
It is recommended that TB patients who are living with HIV should receive at least the same duration of TB treatment as HIV-negative TB patients.

Septic arthritis, pneumococcal

Septic arthritis, post-intraarticular injection

Septic arthritis, post-intraarticular injection ^[24]

NO empiric therapy.

Septic arthritis, prosthetic joint infection

Septic arthritis, prosthetic joint infection (device-related osteoarticular infections) ^[25]

1. Empiric antimicrobial therapy

It is preferable to delay antibiotic therapy until specimens for culture are obtained by joint aspiration, joint debridement, and/or prosthesis removal.

2. Pathogen-directed antimicrobial therapy

2.1 Staphylococcus aureus, methicillin-susceptible (MSSA)

Preferred regimen (1): Nafcillin 2 g IV q4–6h

Preferred regimen (2): Oxacillin 2 g IV q4–6h
Alternative regimen (1): Cefazolin 1–2 g IV q8h

Alternative regimen (2): Ceftriaxone 2 g IV q24h
Alternative regimen (3): (if allergic to penicillins) Clindamycin 900 mg IV q8h

Alternative regimen (4): (if allergic to penicillins) Vancomycin 15–20 mg/kg IV q8–12h (Maximum, 2 g/dose)

2.2 Staphylococcus, methicillin-resistant (MRSA)

2.2.1 Early-onset or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)

Preferred regimen: Vancomycin AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
Alternative regimen: (Daptomycin 6 mg/kg IV q24h OR Linezolid 600 IV q8h) AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
Note: The above regimen should be followed by Rifampin plus a fluoroquinolone, TMP/SMX, a tetracycline or Clindamycin for 3 or 6 months for hips and knees, respectively.

2.2.2 Early-onset spinal implant infections or implants in an actively infected site

Initial parenteral therapy plus Rifampin followed by prolonged oral therapy is recommended.
Long-term oral suppressive antibiotics (eg, TMP-SMX, a tetracycline, a fluoroquinolone [which should be given in conjunction with Rifampin due to the potential emergence of fluoroquinolone resistance)

2.3 Streptococci, beta-hemolytic

Preferred regimen (1): Penicillin 12–18 MU/day IV q6h

Preferred regimen (2): Ampicillin 2 g IV q6h

Preferred regimen (3): Ceftriaxone 1–2 g IV q24h
Alternative regimen (1): (if allergic to penicillins) Clindamycin 900 mg IV q8h
Alternative regimen (2): (if allergic to penicillins) Vancomycin 15–20 mg/kg IV q8–12h (Maximum, 2 g/dose)

2.4 Enterococci

2.4.1 Monotherapy

Preferred regimen (1): Ampicillin 6-12 g/day q4-6h
Preferred regimen (2): Penicillin G 18-30 MU/day continuously or q4h
Preferred regimen (3): Vancomycin 15-20 mg/kg/dose q8-12h (Maximum, 2 g/dose)

2.4.2 Combination therapy (one of the monotherapy agents, and one of the following agents)

Preferred regimen (1): Gentamicin 1 mg/kg IV q8h
Preferred regimen (2): Streptomycin 7.5 mg/kg IV q12h
Preferred regimen (3): Ampicillin 2 g/day IV q6h AND Ceftriaxone 2 g IV q12h

2.5 Gram-negative bacilli

Patients susceptible to fluoroquinolones

Preferred regimen: Ciprofloxacin 500-750 mg bid

2.5.1 P. aeruginosa

Preferred regimen (1): Cefepime 2 g IV q12h

Preferred regimen (2): Meropenem 1 g IV q8h
Alternative regimen (1): Ciprofloxacin 750 mg PO bid
Alternative regimen (2): Ceftazidime 2 g IV q8h

2.6 Anaerobes

2.6.1Propionibacterium acnes

Preferred regimen (1): Penicillin 24 MU/day IV q4h or continuously

Preferred regimen (2): Ceftriaxone 1-2 g/day IV
Alternative regimen: Vancomycin OR Clindamycin

2.6.2 Not Propionibacterium acnes
Preferred regimen: Metronidazole 500 mg PO tid

2.7 Mycobacterium tuberculosis

Preferred regimen: see (Septic arthritis, Mycobacterium tuberculosis)

2.8 Fungi

Preferred regimen: see (Septic arthritis, candidal)

2.9 Culture negative

Preferred regimen: Vancomycin AND Ciprofloxacin OR Cefazolin AND Ciprofloxacin

Septic arthritis, staphylococcal

1.Staphylococcus aureus (methicillin-resistant)^[26]^[27]

Preferred regime: Vancomycin 15–20 mg/kg IV q8–12h
Alternative regimen (1): Daptomycin 6 mg/kg IV q24h
Alternative regimen (2): Linezolid 600 mg PO/IV q12h
Alternative regimen (3): Clindamycin 600 mg PO/IV q8h
Alternative regimen (4): TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h
Pediatric regimen（1): Vancomycin 15 mg/kg IV q6h
Pediatric regimen（1): Daptomycin 6–10 mg/kg IV q24h
Pediatric regimen（1): Linezolid 10 mg/kg PO/IV q8h
Pediatric regimen（1): Clindamycin 10–13 mg/kg/dose PO/IV q6–8h

2. Staphylococcus aureus (methicillin-susceptible)

Preferred regimen (1): Nafcillin 2 g IV q6h

Preferred regimen (2): Clindamycin 900 mg IV q8h
Alternative regimen (1): Cefazolin 0.25–1 g IV/IM q6–8h
Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h

3. Staphylococcus epidermidis (methicillin-resistant)

Preferred regimen (1): Vancomycin 500 mg IV q6h or 1 g IV q12h
Preferred regimen (2): Linezolid 600 mg IV q12h
Alternative regimen: (TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h (TMP component) OR Minocycline 200 mg PO single dose THEN 100 mg PO q12h) AND Rifampin 300–600 mg PO/IV q12h

4. Staphylococcus epidermidis (methicillin-susceptible)

Preferred regimen (1): Nafcillin 2 g IV q6h
Preferred regimen (2): Clindamycin 900 mg IV q8h
Alternative regimen (1): Cefazolin 0.25–1 g IV/IM q6–8h
Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h

Septic arthritis, streptococcal

1. Streptococcus agalactiae ^[28]

Preferred regimen (1): Penicillin G 2 MU IV/IM q4h
Preferred regimen (2): Ampicillin 2 g IV q6h
Alternative regimen (1): Clindamycin 600–1200 mg/day IV/IM q6–12h
Alternative regimen (2): Cefazolin 0.25–1 g IV/IM q6–8h

2. Streptococcus pyogenes

Preferred regimen (1): Penicillin G 2 MU IV/IM q4h
Preferred regimen (2): Ampicillin 2 g IV q6h
Alternative regimen (1): Clindamycin 600–1200 mg/day IV/IM q6–12h
Alternative regimen (2): Cefazolin 0.25–1 g IV/IM q6–8h

References

↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ ^2.0 ^2.1 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.
↑ 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.
↑ 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.
↑ Corbel, Michael (2006). Brucellosis in humans and animals. Geneva: World Health Organization. ISBN 9241547138.
↑ Shirtliff ME, Mader JT (2002). "Acute septic arthritis". Clin Microbiol Rev. 15 (4): 527–44. PMC 126863. PMID 12364368.CS1 maint: PMC format (link)
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Wheat LJ, Freifeld AG, Kleiman MB, Baddley JW, McKinsey DS, Loyd JE; et al. (2007). "Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (7): 807–25. doi:10.1086/521259. PMID 17806045.
↑ Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS; et al. (2006). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clin Infect Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130.
↑ Treatment of Tuberculosis: Guidelines. WHO Guidelines Approved by the Guidelines Review Committee (4th ed.). Geneva: World Health Organization. 2010. ISBN 9789241547833. PMID 23741786. Retrieved 2015-06-08.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM; et al. (2013). "Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America". Clin Infect Dis. 56 (1): 1–10. doi:10.1093/cid/cis966. PMID 23230301.
↑ Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ; et al. (2011). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clin Infect Dis. 52 (3): e18–55. doi:10.1093/cid/ciq146. PMID 21208910.
↑ Sharff KA, Richards EP, Townes JM (2013). "Clinical management of septic arthritis". Curr Rheumatol Rep. 15 (6): 332. doi:10.1007/s11926-013-0332-4. PMID 23591823.
↑ "Clinical Management of Septic Arthritis" (PDF).

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

[pmid19191635-2] 2.0 ^2.1 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.

[pmid22157324-3] 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)

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

[pmid23328846-5] 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.

[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.

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

[pmid17342641-11] 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.

[pmid2024868-12] Gentry LO (1991). "Oral antimicrobial therapy for osteomyelitis". Ann Intern Med. 114 (11): 986–7. PMID 2024868.

[pmid21427393-13] 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.

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

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

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

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

[18] Corbel, Michael (2006). Brucellosis in humans and animals. Geneva: World Health Organization. ISBN 9241547138.

[pmid12364368-19] Shirtliff ME, Mader JT (2002). "Acute septic arthritis". Clin Microbiol Rev. 15 (4): 527–44. PMC 126863. PMID 12364368.CS1 maint: PMC format (link)

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

[pmid17806045-21] Wheat LJ, Freifeld AG, Kleiman MB, Baddley JW, McKinsey DS, Loyd JE; et al. (2007). "Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (7): 807–25. doi:10.1086/521259. PMID 17806045.

[pmid17029130-22] Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS; et al. (2006). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clin Infect Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130.

[23] Treatment of Tuberculosis: Guidelines. WHO Guidelines Approved by the Guidelines Review Committee (4th ed.). Geneva: World Health Organization. 2010. ISBN 9789241547833. PMID 23741786. Retrieved 2015-06-08.

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

[pmid23230301-25] Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM; et al. (2013). "Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America". Clin Infect Dis. 56 (1): 1–10. doi:10.1093/cid/cis966. PMID 23230301.

[pmid21208910-26] Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ; et al. (2011). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clin Infect Dis. 52 (3): e18–55. doi:10.1093/cid/ciq146. PMID 21208910.

[pmid23591823-27] Sharff KA, Richards EP, Townes JM (2013). "Clinical management of septic arthritis". Curr Rheumatol Rep. 15 (6): 332. doi:10.1007/s11926-013-0332-4. PMID 23591823.

[28] "Clinical Management of Septic Arthritis" (PDF).

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