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

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:

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)

† 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:

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

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)

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

Linezolid 600 mg IV/PO bid + Cefepime 2 g IV q8h

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

  1. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  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.
  3. 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.
  4. 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.
  5. 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.
  6. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  7. 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.