Sandbox:omtx
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Osteomyelitis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Sandbox:omtx On the Web |
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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 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 | |
| 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 | |
| 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: |
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) | |
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
- 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.