Septic arthritis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Alejandro Lemor, M.D. [2]; Jumana Nagarwala, M.D., Senior Staff Physician, Department of Emergency Medicine, Henry Ford Hospital; Cafer Zorkun, M.D., Ph.D. [3]

Overview

The treatment for septic arthritis requires an adequate drainage of the joint fluid and appropriate antibiotic therapy. Empiric therapy should be started after the collection joint fluid and blood sample for culture. There are no indications for intra-articular antibiotic therapy.

Medical Therapy

Antibiotics are used to treat the infection and most of them achieve excellent bactericidal concentrations in the synovial fluid. The initial therapy depends on the clinical presentation, whether the patient is at risk for a Gonoccocal infection or not, and Gram stain of joint aspiration. The final therapy depends on the culture and sensitivity results. During the acute phase of the disease is important to keep the the joint still and raised, and the patient need to rest. Using cool compresses may help relieve pain. After the acute phase, exercise and physical therapy is important for the recovery process. Severe cases may need surgery to drain the infected joint fluid.

Duration of Antimicrobial Therapy

• The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.

Recommended Duration of Antimicrobial Therapy Based on Isolated Pathogen.

Microorganism	Duration of Therapy
▸ Staphylococcus aureus	3-4 weeks
▸ Streptococcus groups A, B, C, G	3-4 weeks
▸ Gram-negative bacilli	4 weeks
▸ Brucella	6 weeks
▸ Borrelia burgdorferi	30 days
▸ Mycobacterium tuberculosis	9 months
▸ Candida albicans	6 weeks

Special cases	Duration of Therapy
▸ Prosthetic joint infection	6 weeks
▸ Post intra-articular injection or post-arthroscopy infection	14 days

Empiric Therapy Adapted from Lancet 375:846, 2010.

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Pediatric     Newborns (< 1 week)   ▸  Newborns (1 -4 week)   ▸  Infants (1 - 3 months)   ▸  Children (3 mo - 14 yr)     Adults   ▸  Acute Monoarticular   ▸  Chronic Monoarticular   ▸  Polyarticular

Newborn (< 1 week) Preferred Regimen High suspicion of MRSA ▸ Vancomycin 18 mg/kg IV divided q12h PLUS ▸ Cefotaxime 50 mg/kg IV q12h Low suspicion of MRSA ▸ Nafcillin 25 mg/kg q8h OR ▸ Oxacillin 25 mg/kg q8h PLUS ▸ Cefotaxime 50 mg/kg IV q12h Alternative Regimen (For low suspicion of MRSA) ▸ Clindamycin 5mg/kg q8h Newborn (1 - 4 weeks) Preferred Regimen High suspicion of MRSA ▸ Vancomycin 22 mg/kg q12h PLUS ▸ Cefotaxime 50 mg/kg IV q8h Low suspicion of MRSA ▸ Nafcillin 37 mg/kg q6h OR ▸ Oxacillin 37 mg/kg q6h PLUS ▸ Cefotaxime 50 mg/kg IV q8h Alternative Regimen (For low suspicion of MRSA) ▸ Clindamycin 5mg/kg q6h Infants (1- 3 months) Preferred Regimen High suspicion of MRSA ▸ Vancomycin 40 mg/kg/day divided q6-8h PLUS ▸ Cefotaxime 50 mg/kg IV q8h Low suspicion of MRSA ▸ Nafcillin 37 mg/kg q6h (max 8-12 g/day) OR ▸ Oxacillin 37 mg/kg q6h (max 8-12 g/day) PLUS ▸ Cefotaxime 50 mg/kg IV q8h Alternative Regimen (For low suspicion of MRSA) ▸ Clindamycin 7.5mg/kg q6h Children (3 mo - 14 yr) Preferred Regimen ▸ Vancomycin 40 mg/kg/day IV q6-8h PLUS ▸ Cefotaxime 50 mg/kg IV q8h Alternative Regimen ▸ Linezolid 10 mg/kg IV q8h OR ▸ Clindamycin 7.5 mg/kg IV q6h PLUS ▸ Aztreonam 30 mg/kg IV q6h Acute Monoarticular Preferred Regimen At risk for Gonococcal infection ▸ Ceftriaxone 1 g IV q24h OR ▸ Cefotaxime 1 g IV q8h OR ▸ Ceftizoxime 1 g IV q8h Not at risk for Gonococcal infection ▸ Vancomycin 15-20 mg/kg IV q8-12h PLUS ▸ Ceftriaxone 1g IV q24h OR ▸ Cefepime 2g IV q8h Alternative Regimen (If not at risk for Gonococcal infection) ▸ Vancomycin 15-20 mg/kg IV q8-12h PLUS ▸ Ciprofloxacin 400 mg IV q12h OR ▸ Levofloxacin 750 mg IV q24h Chronic Monoarticular Empirical therapy is not recommended. Treatment should be addressed for the specific etiology Polyarticular Preferred Regimen ▸ Ceftriaxone 1 gm IV q24h

Synovial Fluid Gram Stain-Based Therapy Adapted from Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases

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Gram-Positive   ▸  Gram-Positive Cocci   ▸  Gram-Positive Bacilli Gram-Negative   ▸  Gram-Negative Cocci   ▸  Gram-Negative Rods Negative Gram Stain   ▸  Negative Gram Stain

Gram-Positive Cocci Preferred Regimen ▸ Vancomycin 15-20 mg/kg IV q8—12h (trough 15—20 μg/mL) Alternative Regimen (For patients allergic to vancomycin) ▸ Linezolid 600 mg PO/IV q12h OR ▸ Daptomycin 6 mg/kg IV q24h Gram-Positive Bacilli Preferred Regimen ▸ Penicillin G 2 MU IV q4h Alternative Regimen ▸ Vancomycin 15-20 mg/kg IV q8—12h (trough 15—20 μg/mL) OR ▸ Nafcillin 1.5-2 g IV q4h Gram-Negative Cocci Preferred Regimen ▸ Ceftriaxone 1 g IV q24h Gram-Negative Rods Preferred Regimen ▸ Ceftazidime 2 g IV q8h OR ▸ Cefepime 2g IV q12h OR ▸ Piperacillin-tazobactam 4.5 g q6h OR ▸ Imipenem 500 mg IV q6h OR ▸ Meropenem 1 g IV q8h Alternative Regimen (For patients allergic to cephalosporins) ▸ Aztreonam 2 g q8h OR ▸ Ciprofloxacin 400 mg IV q12h OR ▸ Levofloxacin 750 mg IV q24h Negative Gram Stain Preferred Regimen ▸ Vancomycin 15-20 mg/kg IV q8—12h PLUS ▸ Ceftazidime 2 g IV q8h Alternative Regimen ▸ Ciprofloxacin 750 mg IV q12h OR ▸ Levofloxacin 750 mg IV q24h OR ▸ Tobramycin 300mg q12h OR ▸ Gentamycin 5-7 mg/kg once daily or 5 mg/kg divided in 3 doses/day

Pathogen-Based Therapy — Bacteria Adapted from Lancet. 2010;375(9717):846-55. and Clin Microbiol Rev. 2002;15(4):527-44.

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Bacteria   ▸  Bacteroides fragilis   ▸  Brucella melitensis   ▸  Enterococcus spp.   ▸  Escherichia coli   ▸  Haemophilus influenzae   ▸  Morganella morganii   ▸  Neisseria gonorrhoeae   ▸  Proteus mirabilis   ▸  Proteus vulgaris, Proteus rettgeri   ▸  Pseudomonas aeruginosa   ▸  Serratia marcescens   ▸  Staphylococcus aureus   ▸  Staphylococcus epidermidis   ▸  Streptococcus agalactiae   ▸  Streptococcus pyogenes   ▸  Tropheryma whipplei Mycobacteria   ▸  Mycobacterium tuberculosis Spirochetes   ▸  Borrelia burgdorferi   ▸  Treponema pallidum

Bacteroides fragilis Preferred Regimen ▸ Clindamycin 900 mg IV/IM q8h OR ▸ Metronidazole 500 mg IV q8h Alternative Regimen ▸ Ampicillin-Sulbactam 3 g IV q6h OR ▸ Ticarcillin-Clavulanate 3.1 g IV q4–6h Morganella morganii Preferred Regimen ▸ Cefotaxime 2 g IV q6h OR ▸ Imipenem 500 mg IV q6h OR ▸ Levofloxacin 500 mg IV/PO q24h Alternative Regimen ▸ Gentamicin 3–5 mg/kg/day IV q6–8h OR ▸ Ticarcillin-Clavulanate 3.1 g IV q4–6h Proteus vulgaris, Proteus rettgeri Preferred Regimen ▸ Cefotaxime 2 g IV q6h OR ▸ Imipenem 500 mg IV q6h OR ▸ Levofloxacin 500 mg IV/PO q24h Alternative Regimen ▸ Gentamicin 3–5 mg/kg/day IV q6–8h OR ▸ Ticarcillin-Clavulanate 3.1 g IV q4–6h Serratia marcescens Preferred Regimen ▸ Cefotaxime 2 g IV q6h Alternative Regimen ▸ Levofloxacin 500 mg IV/PO q24h OR ▸ Gentamicin 3–5 mg/kg/day IV q6–8h OR ▸ Imipenem 500 mg IV q6h Brucella melitensis Preferred Regimen ▸ Doxycycline 100 mg PO bid for ≥6 weeks PLUS ▸ Streptomycin 15 mg/kg IM qd for 2–3 weeks OR ▸ Rifampin 600–900 mg qd for ≥6 weeks Alternative Regimen ▸ Doxycycline 100 mg PO bid for ≥6 weeks PLUS ▸ Gentamicin 5 mg/kg IV qd for 7 days Adapted from PLoS Med. 2007;4(12):e317. and Lancet Infect Dis. 2007;7(12):775-86. and Cochrane Database Syst Rev. 2012;10:CD007179. Methicillin-Sensitive S. aureus Preferred Regimen ▸ Nafcillin 2 g IV q6h OR ▸ Clindamycin 900 mg IV q8h Alternative Regimen ▸ Cefazolin 0.25–1 g IV/IM q6–8h OR ▸ Vancomycin 500 mg IV q6h (or 1 g IV q12h) Methicillin-Resistant S. aureus (Adult) Preferred Regimen ▸ Vancomycin 15–20 mg/kg IV q8–12h OR ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Alternative Regimen 1 ▸ TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h (TMP component) PLUS ▸ Rifampin 300–600 mg PO/IV q12h Alternative Regimen 2 ▸ Clindamycin 600 mg IV/IM q8h Methicillin-Resistant S. aureus (Pediatric) Preferred Regimen ▸ Vancomycin 15 mg/kg IV q6h OR ▸ Clindamycin 10 mg/kg PO/IV q6h (or 13 mg/kg PO/IV q8h) Alternative Regimen ▸ Daptomycin 6–10 mg/kg IV q24h OR ▸ Linezolid 10 mg/kg PO/IV q8h (Maximum: 600 mg/dose) Adapted from Clin Infect Dis. 2011;52(3):e18-55. Methicillin-Sensitive S. epidermidis Preferred Regimen ▸ Nafcillin 2 g IV q6h OR ▸ Clindamycin 900 mg IV/IM q8h Alternative Regimen ▸ Cefazolin 0.25–1 g IV/IM q6–8h OR ▸ Vancomycin 500 mg IV q6h (or 1 g IV q12h) Methicillin-Resistant S. epidermidis Preferred Regimen ▸ Vancomycin 500 mg IV q6h (or 1 g IV q12h) OR ▸ Linezolid 600 mg IV q12h Alternative Regimen 1 ▸ TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h (TMP component) OR ▸ Minocycline 200 mg PO x 1 dose, then 100 mg PO q12h PLUS ▸ Rifampin 300–600 mg PO/IV q12h Alternative Regimen 2 ▸ Clindamycin 900 mg IV/IM q8h Streptococcus agalactiae Preferred Regimen ▸ Penicillin G 2 MU IV/IM q4h OR ▸ Ampicillin 2 g IV q6h Alternative Regimen ▸ Clindamycin 600–1200 mg/day IV/IM q6–12h OR ▸ Cefazolin 0.25–1 g IV/IM q6–8h Streptococcus pyogenes Preferred Regimen ▸ Penicillin G 2 MU IV/IM q4h OR ▸ Ampicillin 2 g IV q6h Alternative Regimen ▸ Clindamycin 600–1200 mg/day IV/IM q6–12h OR ▸ Cefazolin 0.25–1 g IV/IM q6–8h Escherichia coli Preferred Regimen ▸ Ampicillin-Sulbactam 3 g IV q6h Alternative Regimen ▸ Cefazolin 0.25–1 g IV/IM q6–8h OR ▸ Levofloxacin 500–750 mg IV/PO q24h OR ▸ Gentamicin 3–5 mg/kg/day IV q6–8h OR ▸ TMP-SMX 8–10 mg/kg/day IV/PO q6–12h (TMP component) Pseudomonas aeruginosa Preferred Regimen ▸ Cefepime 2 g IV q12h OR ▸ Piperacillin 3–4 g IV q4–6h OR ▸ Imipenem 500 mg IV q6h Alternative Regimen ▸ Ticarcillin-Clavulanate 3.1 g IV q4–6h OR ▸ Tobramycin 3-5 mg/kg/day IV q6–8h OR ▸ Amikacin 15 mg/kg/day IV/IM q8–12h OR ▸ Ciprofloxacin 400 mg IV q8–12h Neisseria gonorrhoeae Preferred Regimen ▸ Ceftriaxone 2 g IV q24h OR ▸ Cefotaxime 1 g IV q8h Alternative Regimen ▸ Levofloxacin 500 mg IV/PO q24h OR ▸ Ampicillin 2 g IV q6h Haemophilus influenzae Preferred Regimen ▸ Amoxicillin-clavulanate 875/125 mg PO q12h OR ▸ Cefprozil 500 mg PO q12h OR ▸ Cefuroxime 500 mg PO q12h OR ▸ Cefdinir 600 mg PO q24h Alternative Regimen ▸ Levofloxacin 750 mg IV/PO q24h OR ▸ Moxifloxacin 400 mg IV/PO q24h OR ▸ Clarithromycin 500 mg PO q12h Mycobacterium tuberculosis Intensive Phase ▸ Isoniazid 5mg/kg PO q24h for 2 months OR ▸ Isoniazid 10 mg/kg PO 3 times per week × 2 months PLUS ▸ Rifampicin 10 mg/kg PO q24h for 2 months OR ▸ Rifampicin 10 mg/kg PO 3 times per week × 2 months PLUS ▸ Pyrazinamide 25mg/kg PO q24h for 2 months OR ▸ Pyrazinamide 35 mg/kg PO 3 times per week × 2 months PLUS ▸ Ethambutol 15mg/kg PO q24h for 2 months Continuation Phase ▸ Isoniazid 5mg/kg PO for 4-7 months OR ▸ Isoniazid 10 mg/kg PO 3 times per week × 4-7 months PLUS ▸ Rifampicin 10 mg/kg PO q24h for 4-7 months OR ▸ Rifampicin 10 mg/kg PO 3 times per week for 4-7 months Adapted from Treatment of Tuberculosis: Guidelines. Borrelia burgdorferi Preferred Regimen ▸ Amoxicillin 500 mg q8h for 28 days OR ▸ Doxycycline 100 mg q12h for 28 days OR ▸ Cefuroxime 500 mg q12h for 28 days Alternative Regimen ▸ Azithromycin 500 mg PO q24h for 7–10 days OR ▸ Clarithromycin 500 mg PO q12h for 14–21 days OR ▸ Erythromycin 500 mg PO q6h for 14–21 days Adapted from IDSA Guidelines: The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Treponema pallidum Preferred Regimen ▸ Penicillin G 2.4 MU IM single dose Alternative Regimen ▸ Doxycycline 100 mg PO q12h x 14 days OR ▸ Tetracycline 500 mg PO q6h x 14 days OR ▸ Ceftriaxone 1 g IM/IV q24h x 10 -14 days Adapted from MMWR Recomm Rep. 2006;55(RR-11):1-94 Tropheryma whipplei Preferred Regimen ▸ Penicillin G 2 MU IV q4h for 2 weeks PLUS ▸ Streptomycin 1 g IM/IV q24h for 2 weeks FOLLOWED BY ▸ Trimethoprim/Sulfamethoxazole 160mg/800mg PO q24h for 1 year Alternative Regimen ▸ Ceftriaxone 2 g IV q24h FOLLOWED BY ▸ Trimethoprim/Sulfamethoxazole 160mg/800mg PO q24h for 1 year Adapted from N Engl J Med 2007; 356:55-66 Enterococcus spp. Preferred Regimen ▸ Ampicillin 2 g IV q6h OR ▸ Vancomycin 1 g IV q12h Alternative Regimen ▸ Ampicillin-Sulbactam 3 g IV q6h OR ▸ Linezolid 600 mg PO/IV q12h Proteus mirabilis Preferred Regimen ▸ Ampicillin 2 g IV q6h OR ▸ Levofloxacin 500 mg IV/PO q24h Alternative Regimen ▸ Cefazolin 0.25–1 g IV/IM q6–8h OR ▸ TMP-SMX 8–10 mg/kg/day IV/PO q6–12h (TMP component) OR ▸ Gentamicin 3–5 mg/kg/day IV q6–8h

Pathogen-Based Therapy — Fungi

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Fungi   ▸  Aspergillus spp.   ▸  Blastomyces dermatitidis   ▸  Candida spp.   ▸  Coccidioides immitis   ▸  Histoplasma   ▸  Sporothrix

Aspergillus spp.† Preferred Regimen ▸ Voriconazole 6 mg/kg IV q12h on day 1 FOLLOWED BY ▸ Voriconazole 4 mg/kg IV q12h (goal trough: 1.0–5.5 mg/L)‡ OR ▸ Voriconazole 200 mg PO q12h (for body weight ≥40 kg) OR ▸ Voriconazole 100 mg PO q12h (for body weight <40 kg) Alternative Regimen ▸ Liposomal amphotericin B 3-5 mg/kg/day IV OR ▸ Amphotericin B lipid complex 5 mg/kg/day IV OR ▸ Caspofungin 70 mg IV on day 1, then 50 mg IV q24h OR ▸ Micafungin 100 mg IV q12h (or 250 mg IV q24h)¶ OR ▸ Itraconazole 200 mg PO tid for 3 days, then 200 mg PO bid † Adapted from Clin Infect Dis. 2008; 46:327–60. ‡ Adapted from Clin Infect Dis. 2012;55(8):1080-7. ¶ Adapted from J Antimicrob Chemother. 2009;64(4):840-4. Blastomyces dermatitidis Moderately Severe to Severe Disease ▸ Liposomal amphotericin B 3–5 mg/kg/day IV for 1–2 weeks OR ▸ Amphotericin B 0.7–1 mg/kg/day IV for 1–2 weeks FOLLOWED BY ▸ Itraconazole 200 mg PO tid for 3 days FOLLOWED BY ▸ Itraconazole 200 mg PO bid for ≥12 months totally Mild to Moderate Disease ▸ Itraconazole 200 mg PO tid for 3 days FOLLOWED BY ▸ Itraconazole 200 mg PO qd–bid for 6–12 months Adapted from Clin Infect Dis. 2008;46(12):1801-12. Candida spp. Preferred Regimen ▸ Fluconazole 400 mg/day (or 6 mg/kg/day) IV/PO for ≥2 weeks OR ▸ Lipid-based amphotericin B 3–5 mg/kg/day IV for ≥2 weeks FOLLOWED BY ▸ Fluconazole 400 mg/day IV/PO for ≥6 weeks totally Alternative Regimen ▸ Anidulafungin 200 mg IV on day 1, then 100 mg/day IV for ≥2 weeks OR ▸ Caspofungin 70 mg IV on day 1, then 50 mg IV q24h for ≥2 weeks OR ▸ Micafungin 100 mg IV q24h for ≥2 weeks OR ▸ Amphotericin B 0.5–1 mg/kg/day IV for ≥2 weeks FOLLOWED BY ▸ Fluconazole 400 mg/day IV/PO for ≥6 weeks totally Adapted from Clin Infect Dis. 2009;48(5):503-35. Coccidioides immitis Preferred Regimen ▸ Itraconazole 200 mg q12h (max: 800 mg/day) for ≥6 weeks OR ▸ Fluconazole 400-600 mg/day (max: 2000 mg/day) for ≥6 weeks OR ▸ Ketoconazole 400 mg/day for ≥6 weeks Alternative Regimen ▸ Amphotericin B 0.5–1.5 mg/kg/day Adapted from Clin Infect Dis. 2005;41(9):1217-23. and N Engl J Med 1995; 332:1077-1082 Histoplasma capsulatum Preferred Regimen Moderate Severe to Severe Disease ▸ Liposomal Amphotericin B 3 mg/kg/day IV × 1-2 weeks OR ▸ Amphotericin B deoxycholate 0.7-1 mg/kg/day IV × 1-2 weeks OR ▸ Amphotericin B lipid complex 5 mg/kg/day IV × 1-2 weeks FOLLOWED BY ▸ Itraconazole 200 mg PO q12h x ≥12 months Mild to Moderate Disease ▸ Itraconazole 200 mg PO q12h x ≥12 months Adapted from Clin Infect Dis. 2007;45(7):807-25. Sporothrix Preferred Regimen ▸ Itraconazole 200 mg q12h x 12 months Alternative Regimen ▸ Liposomal Amphotericin B 3-5 mg/kg/day IV × for 1-2 weeks OR ▸ Amphotericin B deoxycholate 0.7-1 mg/kg/day IV × 1-2 weeks FOLLOWED BY ▸ Itraconazole 200 mg PO q12h x 12 months Adapted from Clin Infect Dis. 2007; 45:1255–65

Pathogen-Based Therapy — Virus

The treatment for viral arthritis is symptomatic, with the use of analgesics and NSAID. No antimicrobial therapy is recommended for treating arthritis caused by a virus.
Vaccination and safe sex are the most important measures to avoid viral infections in the joint.

Pathogen-Based Therapy in Patients with Prosthetic Joint Adapted from Diagnosis and Management of Prosthetic Joint Infection CID 2013:56

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Bacteria   ▸  Staphylococci, oxacillin-susceptible   ▸  Staphylococci, oxacillin-resistant   ▸  Enterococcus spp, penicillin-susceptible   ▸  Enterococcus spp, penicillin-resistant   ▸  Pseudomonas aeruginosa   ▸  Enterobacter spp   ▸  Enterobacteriaceae   ▸  β-hemolytic streptococci   ▸  Propionibacterium acnes

Staphylococci, oxacillin-susceptible Preferred Regimen ▸ Nafcillin 1.5-2 g IV q4-6h OR ▸ Cefazolin 1–2 g IV q8 h OR ▸ Ceftriaxone 1–2 g IV q24h Alternative Regimen ▸ Vancomycin IV 15 mg/kg q12h OR ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Staphylococci, oxacillin-resistant Preferred Regimen ▸ Vancomycin 15 mg/kg IV q12h Alternative Regimen ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Enterococcus spp, penicillin-susceptible Preferred Regimen ▸ Penicillin G 20-40 MU IV q24h continuously or divided in 6 doses Alternative Regimen ▸ Vancomycin IV 15 mg/kg q12h OR ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Enterococcus spp, penicillin-resistant Preferred Regimen ▸ Vancomycin IV 15 mg/kg q12h Alternative Regimen ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Pseudomonas aeruginosa Preferred Regimen ▸ Cefepime 2 g IV q12 h OR ▸ Meropenem 1 g IV q8 h Alternative Regimen ▸ Ciprofloxacin 750 mg PO q12h or 400 mg IV q12h OR ▸ Ceftazidime 2 g IV q8h Enterobacter spp Preferred Regimen ▸ Cefepime 2 g IV q12h OR ▸ Ertapenem 1 g IV q24 h Alternative Regimen ▸ Ciprofloxacin 750 mg PO q12h or 400 mg IV q12h Enterobacteriaceae Preferred Regimen ▸ IV β-lactam based on in vitro susceptibilities OR ▸ Ciprofloxacin 750 mg PO q12h β-hemolytic streptococci Preferred Regimen ▸ Penicillin G 20-40 MU IV q24h continuously or divided in 6 doses OR ▸ Ceftriaxone 2 g IV q24h Alternative Regimen ▸ Vancomycin 15mg/kg IV q12h Propionibacterium acnes Preferred Regimen ▸ Penicillin G 20-40 MU IV q24h continuously or divided in 6 doses OR ▸ Ceftriaxone 2 g IV q24h Alternative Regimen ▸ Clindamycin 600–900 mg IV q8h OR ▸ Clindamycin300–450 mg PO q6h OR ▸ Vancomycin 15mg/kg IV q12h

References

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