Sandbox:omtx

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
Sandbox:omtx On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Sandbox:omtx All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Sandbox:omtx
CDC on Sandbox:omtx
Sandbox:omtx in the news
Blogs on Sandbox:omtx
Directions to Hospitals Treating Osteomyelitis
Risk calculators and risk factors for Sandbox:omtx

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

Overview

Antimicrobial Regimens

			Hematogen
			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)

Hematogenous Osteomyelitis

• 1. Empiric antimicrobial therapy

• 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 2 g IV q4h OR Oxacillin 2 g IV q4h

• 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

• Preferred regimen: Nafcillin 2 g IV q4h 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

Contiguous Osteomyelitis with Vascular Insufficiency

• Osteomyelitis, contiguous with vascular insufficiency

• 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

• 1. S. aureus or P. aeruginosa

• 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

• 1. Chronic infection or recent antibiotic use

• 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