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Osteomyelitis Microchapters

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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

Antimicrobial Regimens

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)

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

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

Pathogens 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]
  • 1.1 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
  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.