Osteomyelitis medical therapy
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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
The mainstay of therapy for osteomyelitis typically involves complete surgical debridement followed by antimicrobial therapy against suspected pathogens. Antimicrobial therapy is based on predisposing host factors and local resistance patterns. The standard recommendation for the treatment of chronic osteomyelitis is ≥ 4–6 weeks of parenteral antibiotics. However, oral antimicrobial agents may achieve adequate concentrations in the bone with similar cure rates as compared to parental administration, and may be considered in selected cases.
Medical Therapy
- The mainstay of therapy for osteomyelitis is antimicrobial therapy and surgical debridement.
- Antibiotic regimens should be targeted whenever possible (blood culture or biopsy, if blood cultures are negative or equivocal), or should be tailored to the clinical situation.
Antimicrobial Regimens
Acute Hematogenous Osteomyelitis
The following table summarizes the treatment for acute hematogenous osteomyelitis.[1]
Pathogens | Age group specific therapy | ||
---|---|---|---|
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: |
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 | 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)
|
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) |
† Risk factors for MRSA include:
Recent hospitalization, residence in a long-term care facility, recent antibiotic therapy, HIV infection, men who have sex with men, injection drug use, hemodialysis, incarceration, military service, sharing needles, razors, or other sharp objects, sharing sports equipment, diabetes, prolonged hospital stay, swine farming
Chronic Osteomyelitis
Treatment options for chronic ostemyelitis (based on pathogen) in children include:
- 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
The table below summarizes the treatment options for chronic osteomyelitis in adults.[2]
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 OR Teicoplanin 6 to 12 mg/kg IV once daily |
Ceftaroline 600 mg IV every 12 hours
OR 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 |
Diabetic foot osteomyelitis
This table describes the treatment options for diabetic foot ostemyelitis.[3][4]
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 |
Trimethoprim-sulfamethoxazole
+ OR + 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) |
¶ Severe infection defined as:
Extensive infections that involve deep tissues, limb-threatening diabetic foot infections and those that are associated with systemic toxicity.
Vertebral osteomyelitis
Pathogen directed based treatment for vertebral osteomyelitis.[5]
Specific group |
Vertebral Osteomyelitis | ||
---|---|---|---|
Preferred regimen | Alternative regimen | ||
Oxacillin sensitive staphylococcus aureus
(OSSA) or coagulase-negative staphylococci |
Nafcillin sodium or Oxacillin 1.5-2 g IV q4-6h or continuous infusion for 6 weeks
OR Cefazolin 1-2 g IV q8h for 6 weeks OR Ceftriaxone 2 g IV q24h for 6 weeks |
Vancomycin IV 15-20 mg/kg q12 hd for 6 weeks
OR Daptomycin 6-8 mg/kg IV q24h for 6 weeks OR Linezolid 600 mg PO/IV q12h for 6 weeks OR Levofloxacin 500-750 mg PO q24h for 6 weeks OR Clindamycin IV 600-900 mg q8h for 6 weeks | |
Oxacillin resistant staphylococcus aureus
(ORSA) |
Vancomycin IV 15-20 mg/kg q12h for 6 weeks | Daptomycin 6-8 mg/kg IV q24h OR Linezolid 600 mg PO/IV q12 h
OR Levofloxacin PO 500–750 mg PO q24 h + Rifampin PO 600 mg q24h for 6 weeks | |
β-hemolytic Streptococci | Penicillin G 20-24 million units IV q24h continuously or in 6 divided doses for 6 weeks
OR Ceftriaxone 2 g IV q24h for 6 weeks |
Vancomycin IV 15-20 mg/kg q12h for 6 weeks | |
Enterobacteriaceae | Cefepime 2 g IV q12h for 6 weeks
OR Ertapenem 1 g IV q24h for 6 weeks |
Ciprofloxacin 500-750 mg PO q12h or 400 mg IV q12h for 6 weeks | |
Pseudomonas aeruginosa | Cefepime 2 g IV q8-12h for 6 weeks
OR Meropenem 1 g IV q8h for 6 weeks OR Doripenem 500 mg IV q8h for 6 weeks |
Ciprofloxacin 750 mg PO q12h or 400 mg IV q8h) for 6 weeks
OR Aztreonam 2 g IV q8h for 6 weeks OR Ceftazidime 2 g IV q8h for 6 weeks | |
Enterococcus | Penicillin susceptible | Penicillin G 20-24 million units IV q24h continuously or in 6 divided doses
OR Ampicillin sodium 12 g IV q24h continuously or in 6 divided doses |
Vancomycin 15-20 mg/kg IV q12h
OR Daptomycin 6 mg/kg IV q24h OR Linezolid 600 mg PO or IV q12h |
Penicillin resistant | Vancomycin IV 15-20 mg/kg q12h | Daptomycin 6 mg/kg IV q24h
OR Linezolid 600 mg PO or IV q12h | |
Propionibacterium acnes | Penicillin G 20 million units IV q24h continuously or in 6 divided doses for 6 weeks
OR Ceftriaxone 2 g IV q24h for 6 weeks |
Clindamycin 600-900 mg IV q8h for 6 weeks
OR Vancomycin IV 15-20 mg/kg q12h for 6 weeks | |
Salmonella species | Ciprofloxacin PO 500 mg q12h or IV 400 mg q12h for 6-8 weeks | Ceftriaxone 2 g IV q24h for 6-8 weeks |
Specific conditions
The treatment of other rare types of osteomyelitis are summarized in the table below.[6][7]
Specific condition | Anti-biotic regimen | ||
---|---|---|---|
Preferred | Alternative | ||
Open Fracture Osteomyelitis |
S. aureus or P. aeruginosa | Vancomycin 1 g IV q12h
+ (Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8h) |
Linezolid 600 mg IV/PO bid + Ceftazidime 2 g IV q8h
OR |
Gram negative bacilli | Ciprofloxacin 750 mg PO bid | Levofloxacin 750 mg PO qd | |
Sternal Osteomyelitis |
Vancomycin 1 g IV q12h (If over 100kg, 1.5 g IV q12h) | Linezolid 600 mg PO/IV bid | |
Candidal Osteomyelitis |
Fluconazole 400 mg/day (6 mg/kg/day) PO for 6–12 months | Anidulafungin 200 mg loading dose THEN 100 mg/day PO
OR Caspofungin 70mg loading dose THEN 50 mg/day PO OR Micafungin 100 mg/day PO | |
Hemoglobinopathy-Associated Osteomyelitis |
Ciprofloxacin 400 mg IV q12h | Levofloxacin 750 mg IV q24h |
References
- ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
- ↑ 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.
- ↑ 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.
- ↑ Grayson ML, Gibbons GW, Habershaw GM, Freeman DV, Pomposelli FB, Rosenblum BI, Levin E, Karchmer AW (1994). "Use of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients". Clin. Infect. Dis. 18 (5): 683–93. PMID 8075257.
- ↑ Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK; et al. (2015). "2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adultsa". Clin Infect Dis. 61 (6): e26–46. doi:10.1093/cid/civ482. PMID 26229122.
- ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
- ↑ 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.