Osteomyelitis medical therapy: Difference between revisions

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Revision as of 20:26, 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.

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@@ Line 6: / Line 6: @@
 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==
+==Antimicrobial Regimen==
-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/or streptococcal coverage should be administered based on local resistance data.
-==Acute Osteomyelitis in Children – Empiric Therapy==
+===Osteomyelitis, candidal===
-<span style="font-size: 85%;">
+* 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>
-'''Abbreviations''':
+:* Preferred regimen (1): [[Fluconazole]] 400 mg/day (6 mg/kg/day) PO for 6–12 months
-OSSA, oxacillin-sensitive ''Staphylococcus aureus'';
-ORSA, Oxacillin-resistant ''Staphylococcus aureus'';
-CRSA, Clindamycin-resistant ''Staphylococcus aureus''.</span><ref>{{Cite journal| doi = 10.1056/NEJMra1213956| issn = 1533-4406| volume = 370| issue = 4| pages = 352–360| last1 = Peltola| first1 = Heikki| last2 = Pääkkönen| first2 = Markus| title = Acute osteomyelitis in children| journal = The New England Journal of Medicine| date = 2014-01-23| pmid = 24450893}}</ref>
-===High prevalence of OSSA in community===
+:* Preferred regimen (2): [[Amphotericin B]] 3–5 mg/kg/day PO for several weeks {{then}} [[Fluconazole]] for 6–12 months
-{{rx|Preferred regimen}}
+:* Alternative regimen (1): [[Anidulafungin]] 200 mg loading dose {{then}} 100 mg/day PO
-* First-generation cephalosporin ([[Cefadroxil]], [[Cefazolin]], [[Cephalexin]]) ≥150 mg/kg/day administered in 4 equal doses
-</li>
-{{rx|Alternative regimen}}
-* Antistaphylococcal penicillin ([[Cloxacillin]], [[Flucloxacillin]], [[Dicloxacillin]], [[Nafcillin]], [[Oxacillin]]) ≤ 200 mg/kg/day administered in 4 equal doses
-</li>
-===High prevalence of ORSA with low prevalence of CRSA in community===
+:* Alternative regimen (2): [[Caspofungin]] 70mg loading dose {{then}} 50 mg/day PO
-{{rx|Preferred regimen}}
-* [[Clindamycin]] ≥ 40 mg/kg/day administered in 4 equal doses
-</li>
-===High prevalence of ORSA with high prevalence of CRSA in community===
+:* Alternative regimen (3): [[Micafungin]] 100 mg/day PO
-{{rx|Preferred regimen}}
+:* Alternative regimen (4): [[Amphotericin B]] deoxycholate 0.5–1 mg/kg/day PO for several weeks {{then}} [[Fluconazole]] for 6–12 months
-* [[Vancomycin]] ≤ 40 mg/kg/day administered in 4 equal doses, adjust dosage to trough of 15–20 mcg/mL
+:* Note: Duration of therapy usually is prolonged (6–12 months); Surgical debridement is frequently necessary
-</li>
-{{rx|Alternative regimen}}
-* [[Linezolid]] 30 mg/kg/day administered in 3 equal doses
-</li>
-==Chronic Osteomyelitis in Adults – Pathogen-Based Therapy==
+===Osteomyelitis, chronic===
+*1. '''Chronic Osteomyelitis in Adults – Pathogen-Based 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>
+:*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 {{withorwithout}} [[Rifampin]] 600–900 mg PO qd
+::* Alternative regimen (2): [[Levofloxacin]] 500–750 mg/day PO/IV {{withorwithout}} [[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
-===OSSA===
+::* Preferred regimen (2): [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 weeks
-{{rx|Preferred regimen}}
-* [[Oxacillin]] 1.5–2 g IV q4h for 4–6 wk {{or}} [[Cefazolin]] 1–2 g IV q8h for 4–6 wk
-</li>
-{{rx|Alternative regimen}}
-* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{or2}}
-* [[Oxacillin]] 1.5–2 g IV q4h for 4–6 wk {{and2}} [[Rifampin]] 600 mg PO qd
-</li>
-===ORSA===
+::* Preferred regimen (3): [[Cefazolin]] 1–2 g IV q8h for 4–6 weeks
-{{rx|Preferred regimen}}
+::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks
-* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{or}} [[Daptomycin]] 6 mg/kg IV q24h
+:*1.4 '''Enterococcus or Streptococcus (MIC≥ 0.5 μg/mL) or Abiotrophia or Granulicatella'''
-</li>
+::* 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
-{{rx|Alternative regimen}}
-* [[Linezolid]] 600 mg PO/IV q12h for 6 wk ± [[Rifampin]] 600–900 mg PO qd {{or2}}
-* [[Levofloxacin]] 500–750 mg PO/IV daily ± [[Rifampin]] 600–900 mg PO qd
-</li>
-===Penicillin-sensitive ''Streptococcus''===
+::* 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
-{{rx|Preferred regimen}}
+::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 weeks {{withorwithout}} [[Gentamicin]] 1 mg/kg IV/IM q8h for 1–2 weeks
-* [[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
+:*1.5 '''Enterobacteriaceae'''
-</li>
+::* Preferred regimen (1): [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 weeks
-{{rx|Alternative regimen}}
-* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk
-</li>
-===''Enterococcus'' or ''Streptococcus'' (MIC ≥ 0.5 μg/mL) or ''Abiotrophia'' or ''Granulicatella''===
+::* Preferred regimen (2): [[Ertapenem]] 1 g IV q24h
-{{rx|Preferred regimen}}
+::* Alternative regimen (1): [[Levofloxacin]] 500–750 mg PO qd
-* [[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 {{or2}}
-* [[Ampicillin]] 12 g/day IV continuously or q4h for 4–6 wk ± [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk
-</li>
-{{rx|Alternative regimen}}
-* [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk ± [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk
-</li>
-===''Enterobacteriaceae''===
+::* Alternative regimen (2): [[Ciprofloxacin]] 500–750 mg PO bid for 4–6 weeks
-{{rx|Preferred regimen}}
+:*1.6 '''Pseudomonas aeruginosa'''
-* [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 wk {{or}} [[Ertapenem]] 1 g IV q24h
+::* Preferred regimen (1): [[Cefepime]] 2 g IV q12h
-</li>
-{{rx|Alternative regimen}}
-* [[Levofloxacin]] 500–750 mg PO q24h {{or}} [[Ciprofloxacin]] 500–750 mg PO q12h for 4–6 wk
-</li>
-===''Pseudomonas aeruginosa''===
+::* Preferred regimen (2): [[Meropenem]] 1 g IV q8h
-{{rx|Preferred regimen}}
-* [[Cefepime]] 2 g IV q12h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Imipenem]] 500 mg IV q6h for 4–6 wk
-</li>
-{{rx|Alternative regimen}}
-* [[Ciprofloxacin]] 750 mg PO q12h {{or}} [[Ceftazidime]] 2 g IV q8h for 4–6 wk
-</li>
-==Chronic Osteomyelitis in Children – Pathogen-Based Therapy ==
+::* Preferred regimen (3): [[Imipenem]] 500 mg IV q6h for 4–6 weeks
+::* Alternative regimen (1): [[Ciprofloxacin]] 750 mg PO q12h
-===Group A beta-hemolytic ''Streptococcus'', ''Haemophilus influenzae'' type b, and ''Streptococcus pneumoniae''===
+::* Alternative regimen (2): [[Ceftazidime]] 2 g IV q8h for 4–6 weeks
-{{rx|Preferred regimen}}
-* [[Ampicillin]] 150–200 mg/kg/day administered in 4 equal doses {{or}} [[Amoxicillin]] 150–200 mg/kg/day administered in 4 equal doses
-</li>
-{{rx|Alternative regimen}}
-* [[Chloramphenicol]] 75 mg/kg/day administered in 3 equal doses
-</li>
-==Vertebral Osteomyelitis – Pathogen-Based Therapy==
+*2. '''Chronic Osteomyelitis in Children – Pathogen-Based Therapy'''
-<span style="font-size: 85%;">
+:* ''Group A beta-hemolytic Streptococcus, Haemophilus influenzae type B and Streptococcus pneumoniae''
-'''Abbreviations''':
+::* Preferred regimen (1): [[Ampicillin]] 150–200 mg/kg/day q6h
-OSSA, oxacillin-sensitive ''Staphylococcus aureus'';
-ORSA, Oxacillin-resistant ''Staphylococcus aureus''.</span><ref>{{Cite journal| doi = 10.1056/NEJMcp0910753| issn = 1533-4406| volume = 362| issue = 11| pages = 1022–1029| last = Zimmerli| first = Werner| title = Clinical practice. Vertebral osteomyelitis| journal = The New England Journal of Medicine| date = 2010-03-18| pmid = 20237348}}</ref>
-===OSSA or coagulase-negative staphylococci===
+::* Preferred regimen (2): [[Amoxicillin]] 150–200 mg/kg/day q6h
-{{rx|Preferred regimen}}
+::* Alternative regimen: [[Chloramphenicol]] 75 mg/kg/day q8h
-* [[Oxacillin]] 2 g IV q6h {{or2}}
-* [[Cefazolin]] 1–2 g IV q8h
-</li>
-{{rx|Alternative regimen}}
-* [[Levofloxacin]] 750 mg PO qd {{and2}} [[Rifampin]] 300 mg PO bid
-</li>
-===ORSA===
+===Osteomyelitis, contiguous with vascular insufficiency===
-{{rx|Preferred regimen}}
-* [[Vancomycin]] 1 g IV q12h
-</li>
-{{rx|Alternative regimen}}
-* [[Daptomycin]] ≥ 6 mg/kg IV q24h {{or2}}
-* [[Levofloxacin]] 500–750 mg PO/IV daily {{and2}} [[Rifampin]] 600–900 mg PO qd
-</li>
-===''Streptococcus''===
+* 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>
-{{rx|Preferred regimen}}
+:* Debride overlying ulcer and send bone specimen for histology and culture.
-* [[Penicillin G]] 5 MU IV q6h
+:* No empiric antimicrobial therapy unless acutely ill.
-</li>
+:* Antibiotic therapy should be based on culture results and treat for 6 weeks.
-{{rx|Alternative regimen}}
+:* Revascularize if possible.
-* [[Ceftriaxone]] 2 g IV q24h
-</li>
-===''Enterobacteriaceae'', quinolone-susceptible===
+===Osteomyelitis, diabetic foot===
-{{rx|Preferred regimen}}
+*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>
-* [[Ciprofloxacin]] 750 mg PO q12h
+:* Preferred regimen (1): [[Levofloxacin]] 750 mg IV/PO q24h
-</li>
-{{rx|Alternative regimen}}
-* [[Ceftriaxone]] 2 g IV q24h
-</li>
-===''Enterobacteriaceae'', quinolone-resistant===
+:* Preferred regimen (2): [[Cefoxitin]] 1 g IV q4h (or 2 g IV q6–8h)
-{{rx|Preferred regimen}}
-* [[Imipenem]] 500 mg IV q6h
-</li>
-===''Pseudomonas aeruginosa''===
+:* Preferred regimen (3): [[Ceftriaxone]] 1–2 g/day IV/IM q12–24h
-{{rx|Preferred regimen}}
-* [[Cefepime]] 2 g IV q8h {{or}} [[Ceftazidime]] 2 g IV q8h x 2–4 wk, followed by [[Ciprofloxacin]] 750 mg PO bid
+:* Preferred regimen (4): [[Ampicillin-Sulbactam]] 1.5–3 g IV/IM q6h
-</li>
-{{rx|Alternative regimen}}
+:* Preferred regimen (5): [[Moxifloxacin]] 400 mg IV/PO q24h
-* [[Piperacillin–Tazobactam]] 750 mg PO q12h x 2–4 wk, followed by [[Ciprofloxacin]] 750 mg PO bid
-</li>
+:* 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 <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
+===Osteomyelitis, foot puncture wound===
+* 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'''
+::* Preferred regimen: [[Vancomycin]] 1 g IV q12h {{and}} ([[Ceftazidime]] {{or}} [[Cefepime]])
+::* Alternative regimen (1): [[Linezolid]] 600 mg IV/PO bid<sup>NAI</sup> {{and}} [[Ceftazidime]]
+::* Alternative regimen (2): [[Linezolid]] 600 mg IV/PO bid<sup>NAI</sup> {{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''' <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)'''
+::*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 {{withorwithout}} [[Rifampin]] 300 mg po/IV bid
+===Osteomyelitis, hemoglobinopathy===
+* 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
+===Osteomyelitis, spinal implant===
+*1. '''Onset within 30 days''' <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="pmid17342641">{{cite journal| author=Kowalski TJ, Berbari EF, Huddleston PM, Steckelberg JM, Mandrekar JN, Osmon DR| title=The management and outcome of spinal implant infections: contemporary retrospective cohort study. | journal=Clin Infect Dis | year= 2007 | volume= 44 | issue= 7 | pages= 913-20 | pmid=17342641 | doi=10.1086/512194 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17342641  }} </ref>
+:* 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 <ref name="pmid2024868">{{cite journal| author=Gentry LO| title=Oral antimicrobial therapy for osteomyelitis. | journal=Ann Intern Med | year= 1991 | volume= 114 | issue= 11 | pages= 986-7 | pmid=2024868 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2024868  }} </ref> <ref name="pmid21427393">{{cite journal| author=Marschall J, Bhavan KP, Olsen MA, Fraser VJ, Wright NM, Warren DK| title=The impact of prebiopsy antibiotics on pathogen recovery in hematogenous vertebral osteomyelitis. | journal=Clin Infect Dis | year= 2011 | volume= 52 | issue= 7 | pages= 867-72 | pmid=21427393 | doi=10.1093/cid/cir062 | pmc=PMC3106232 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21427393  }} </ref>
+:*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 <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<sup>NAI</sup> bid
-===Anaerobes===
-{{rx|Preferred regimen}}
-* [[Clindamycin]] 300–600 mg IV q6–8h
-</li>
-{{rx|Alternative regimen}}
-* [[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)
-</li>
 ==References==