Sandbox:omtx

	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
Specific group	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
Pathogens		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
Empiric	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

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 ^[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

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 ^[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)
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

↑ 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.
↑ 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.

[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.

[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.

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Sandbox:omtx

Overview

Antimicrobial Regimens

Diabetic Foot Osteomyelitis

Hematogenous Osteomyelitis

Contiguous Osteomyelitis with Vascular Insufficiency

Open Fracture Osteomyelitis

Diabetic Foot Osteomyelitis

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