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::* Alternative regimen (2): [[Levofloxacin]] 500–750 mg PO/IV daily {{withorwithout}} [[Rifampin]] 600–900 mg PO qd
::* Alternative regimen (2): [[Levofloxacin]] 500–750 mg PO/IV daily {{withorwithout}} [[Rifampin]] 600–900 mg PO qd
:*Penicillin-sensitive Streptococcus
:*Penicillin-sensitive Streptococcus
::* Preferred regimen: Penicillin G 20 MU/day IV continuously or q4h for 4–6 wk {{or}} Ceftriaxone 1–2 g IV/IM q24h for 4–6 wk {{or}} [[Cefazolin]] 1–2 g IV q8h for 4–6 wk
::* Preferred regimen: [[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 wk {{or}} [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 wk {{or}} [[Cefazolin]] 1–2 g IV q8h for 4–6 wk
::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk
::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk


:*Enterococcus or Streptococcus (MIC≥0.5 μg/mL) or Abiotrophia or Granulicatella
:*Enterococcus or Streptococcus (MIC≥0.5 μg/mL) or Abiotrophia or Granulicatella
::* Preferred regimen: Penicillin G 20 MU/day IV continuously or q4h for 4–6 wk {{withorwithout}} Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk {{or}} Ampicillin 12 g/day IV continuously or q4h for 4–6 wk {{withorwithout}} Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk
::* Preferred regimen: [[Penicillin G]] 20 MU/day IV continuously or q4h for 4–6 wk {{withorwithout}} [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk {{or}} [[Ampicillin]] 12 g/day IV continuously or q4h for 4–6 wk {{withorwithout}} [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk


::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{withorwithout}} Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk
::* Alternative regimen: [[Vancomycin]] 15 mg/kg IV q12h for 4–6 wk {{withorwithout}} [[Gentamicin]] 1 mg/kg IV or IM q8h for 1–2 wk
:*Enterobacteriaceae
:*Enterobacteriaceae
::* Preferred regimen: Ceftriaxone 1–2 g IV/IM q24h for 4–6 wk {{or}} Ertapenem 1 g IV q24h
::* Preferred regimen: [[Ceftriaxone]] 1–2 g IV/IM q24h for 4–6 wk {{or}} [[Ertapenem]] 1 g IV q24h
::* Alternative regimen: [[Levofloxacin]] 500–750 mg PO q24h {{or}} Ciprofloxacin 500–750 mg PO q12h for 4–6 wk
::* Alternative regimen: [[Levofloxacin]] 500–750 mg PO q24h {{or}} [[Ciprofloxacin]] 500–750 mg PO q12h for 4–6 wk
:*Pseudomonas aeruginosa
:*Pseudomonas aeruginosa
::* Preferred regimen: Cefepime 2 g IV q12h {{or}} Meropenem 1 g IV q8h {{or}} Imipenem 500 mg IV q6h for 4–6 wk
::* Preferred regimen: [[Cefepime]] 2 g IV q12h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Imipenem]] 500 mg IV q6h for 4–6 wk
::* Alternative regimen: Ciprofloxacin 750 mg PO q12h {{or}} Ceftazidime 2 g IV q8h for 4–6 wk
::* Alternative regimen: [[Ciprofloxacin]] 750 mg PO q12h {{or}} [[Ceftazidime]] 2 g IV q8h for 4–6 wk


* Chronic Osteomyelitis in Children – Pathogen-Based Therapy
* Chronic Osteomyelitis in Children – Pathogen-Based Therapy
:* ''Group A beta-hemolytic Streptococcus, Haemophilus influenzae type b, andStreptococcus pneumoniae''
:* ''Group A beta-hemolytic Streptococcus, Haemophilus influenzae type b, andStreptococcus pneumoniae''
::* Preferred regimen: Ampicillin 150–200 mg/kg/day administered in 4 equal doses {{or}} Amoxicillin 150–200 mg/kg/day administered in 4 equal doses
::* Preferred regimen: [[Ampicillin]] 150–200 mg/kg/day administered in 4 equal doses {{or}} [[Amoxicillin]] 150–200 mg/kg/day administered in 4 equal doses


::* Alternative regimen: Chloramphenicol 75 mg/kg/day administered in 3 equal doses
::* Alternative regimen: [[Chloramphenicol]] 75 mg/kg/day administered in 3 equal doses


===Osteomyelitis, contiguous with vascular insufficiency===
===Osteomyelitis, contiguous with vascular insufficiency===
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===Osteomyelitis, diabetic foot===
===Osteomyelitis, diabetic foot===
* Chronic Infection or Recent Antibiotic Use
* Chronic Infection or Recent Antibiotic Use
:* Preferred regimen: [[Levofloxacin]] 750 mg IV/PO q24h {{or}} Cefoxitin 1 g IV q4h (or 2 g IV q6–8h) {{or}} Ceftriaxone 1–2 g/day IV/IM q12–24h {{or}} Ampicillin–Sulbactam 1.5–3 g IV/IM q6h {{or}} Moxifloxacin 400 mg IV/PO q24h {{or}} Ertapenem 1 g IV/IM q24h {{or}} Tigecycline 100 mg IV, then 50 mg IV q12h (active against MRSA) {{or}} Imipenem–Cilastatin 0.5–1 g IV q6–8h (Not active against MRSA; consider when ESBL-producing pathogens suspected)
:* Preferred regimen: [[Levofloxacin]] 750 mg IV/PO q24h {{or}} Cefoxitin 1 g IV q4h (or 2 g IV q6–8h) {{or}} [[Ceftriaxone]] 1–2 g/day IV/IM q12–24h {{or}} [[Ampicillin]]–Sulbactam 1.5–3 g IV/IM q6h {{or}} [[Moxifloxacin]] 400 mg IV/PO q24h {{or}} [[Ertapenem]] 1 g IV/IM q24h {{or}} [[Tigecycline]] 100 mg IV, then 50 mg IV q12h (active against MRSA) {{or}} [[Imipenem]]–Cilastatin 0.5–1 g IV q6–8h (Not active against MRSA; consider when ESBL-producing pathogens suspected)


:* Alternative regimen (1): [[Levofloxacin]] 750 mg IV/PO q24h {{and}} Clindamycin 150–300 mg PO qid
:* 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 (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 (for more severe cases) {{and}} Clindamycin 150–300 mg PO qid
:* Alternative regimen (3): [[Ciprofloxacin]] 1200–2700 mg IV q6–12h (for more severe cases) {{and}} [[Clindamycin]] 150–300 mg PO qid


* High Risk for MRSA
* High Risk for MRSA
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* High Risk for ''Pseudomonas aeruginosa''
* High Risk for ''Pseudomonas aeruginosa''


:* Preferred regimen: Piperacillin–Tazobactam 3.375 g IV q6–8h
:* Preferred regimen: [[Piperacillin–Tazobactam]] 3.375 g IV q6–8h


* Polymicrobial Infection
* 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)
:* 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
:* 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


===Osteomyelitis, foot bone===
===Osteomyelitis, foot bone===
* Foot bone osteomyelitis due to nail through tennis shoe  
* Foot bone osteomyelitis due to nail through tennis shoe  
:* Preferred regimen: Ciprofloxacin 750 mg po bid {{or}} [[Levofloxacin]] 750 mg po q24h  
:* Preferred regimen: [[Ciprofloxacin]] 750 mg po bid {{or}} [[Levofloxacin]] 750 mg po q24h  
:* Alternative regimen: Ceftazidime 2 gm IV q8h {{or}} Cefepime 2 gm IV q12h
:* Alternative regimen: [[Ceftazidime]] 2 gm IV q8h {{or}} [[Cefepime]] 2 gm IV q12h


===Osteomyelitis, foot puncture wound===
===Osteomyelitis, foot puncture wound===
* Long bone, post-internal fixation of fracture
* Long bone, post-internal fixation of fracture
:* Preferred regimen: [[Vancomycin]] 1 gm IV q12h {{and}} (Ceftazidime {{or}} Cefepime)
:* Preferred regimen: [[Vancomycin]] 1 gm IV q12h {{and}} ([[Ceftazidime]] {{or}} Cefepime)


:* Alternative regimen (1): [[Linezolid]] 600 mg IV/po bid<sup>NAI</sup> {{and}} Ceftazidime  
:* Alternative regimen (1): [[Linezolid]] 600 mg IV/po bid<sup>NAI</sup> {{and}} [[Ceftazidime]]
:* Alternative regimen (2): [[Linezolid]] 600 mg IV/po bid<sup>NAI</sup> {{and}} Cefepime
:* Alternative regimen (2): [[Linezolid]] 600 mg IV/po bid<sup>NAI</sup> {{and}} [[Cefepime]]


: NOTE: If susceptible Gm-neg. bacillus, Ciprofloxacin 750 mg po bid {{or}} [[Levofloxacin]] 750 mg po q24h
: NOTE: If susceptible Gm-neg. bacillus, [[Ciprofloxacin]] 750 mg po bid {{or}} [[Levofloxacin]] 750 mg po q24h


===Osteomyelitis, hematogenous===
===Osteomyelitis, hematogenous===
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:::* Preferred regimen: [[Vancomycin]] 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
:::* Preferred regimen: [[Vancomycin]] 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
::* MRSA unlikely  
::* MRSA unlikely  
:::* Preferred regimen: Nafcillin {{or}} [[Oxacillin]] 2 gm IV q4h
:::* Preferred regimen: [[Nafcillin]] {{or}} [[Oxacillin]] 2 gm IV q4h


:* Children (>4 mos.)-Adult
:* Children (>4 mos.)-Adult
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:::* Preferred regimen: [[Vancomycin]] 40 div q6–8h  
:::* Preferred regimen: [[Vancomycin]] 40 div q6–8h  
::* MRSA unlikely  
::* MRSA unlikely  
:::* Preferred regimen: Nafcillin {{or}} [[Oxacillin]] 37 q6h (to max. 8–12 gm per day)  
:::* Preferred regimen: [[Nafcillin]] {{or}} [[Oxacillin]] 37 q6h (to max. 8–12 gm per day)  
::* NOTE: Add Ceftazidime 50 q8h or Cefepime 150 div q8h if Gm-neg. bacilli on Gram stain   
::* NOTE: Add [[Ceftazidime]] 50 q8h or [[Cefepime]] 150 div q8h if Gm-neg. bacilli on Gram stain   


:* Newborn (<4 mos.)
:* Newborn (<4 mos.)
::* MRSA possible
::* MRSA possible
:::* Preferred regimen: [[Vancomycin]] {{and}} (Ceftazidime 2 gm IV q8h or Cefepime 2 gm IV q12h)  
:::* Preferred regimen: [[Vancomycin]] {{and}} ([[Ceftazidime]] 2 gm IV q8h or [[Cefepime]] 2 gm IV q12h)  
::* MRSA unlikely  
::* MRSA unlikely  
:::* Preferred regimen: (Nafcillin {{or}} Oxacillin) {{and}} (Ceftazidime {{or}} Cefepime)  
:::* Preferred regimen: ([[Nafcillin]] {{or}} Oxacillin) {{and}} ([[Ceftazidime]] {{or}} Cefepime)  


* Specific therapy
* Specific therapy
:* MSSA
:* MSSA
::* Preferred regimen: Nafcillin {{or}} [[Oxacillin]] 2 gm IV q4h {{or}} [[Cefazolin]] 2 gm IV q8h  
::* Preferred regimen: [[Nafcillin]] {{or}} [[Oxacillin]] 2 gm IV q4h {{or}} [[Cefazolin]] 2 gm IV q8h  
::* Alternative regimen: [[Vancomycin]] 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
::* Alternative regimen: [[Vancomycin]] 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
:* MRSA
:* MRSA
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===Osteomyelitis, hemoglobinopathy===
===Osteomyelitis, hemoglobinopathy===
:* Preferred regimen: Ciprofloxacin 400 mg IV q12h
:* Preferred regimen: [[Ciprofloxacin]] 400 mg IV q12h


:* Alternative regimen: [[Levofloxacin]] 750 mg IV q24h
:* Alternative regimen: [[Levofloxacin]] 750 mg IV q24h
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::* Alternative regimen (2): [[Levofloxacin]] 500–750 mg PO/IV daily {{and}} [[Rifampin]] 600–900 mg PO qd
::* Alternative regimen (2): [[Levofloxacin]] 500–750 mg PO/IV daily {{and}} [[Rifampin]] 600–900 mg PO qd
:* Streptococcus
:* Streptococcus
::* Preferred regimen: Penicillin G 5 MU IV q6h
::* Preferred regimen: [[Penicillin G]] 5 MU IV q6h
::* Alternative regimen: Ceftriaxone 2 g IV q24h
::* Alternative regimen: [[Ceftriaxone]] 2 g IV q24h
:* Enterobacteriaceae, quinolone-susceptible
:* Enterobacteriaceae, quinolone-susceptible
::* Preferred regimen: Ciprofloxacin 750 mg PO q12h
::* Preferred regimen: [[Ciprofloxacin]] 750 mg PO q12h
::* Alternative regimen: Ceftriaxone 2 g IV q24h
::* Alternative regimen: [[Ceftriaxone]] 2 g IV q24h


:* Enterobacteriaceae, quinolone-resistant
:* Enterobacteriaceae, quinolone-resistant
::* Preferred regimen: Imipenem 500 mg IV q6h
::* Preferred regimen: [[Imipenem]] 500 mg IV q6h


:* Pseudomonas aeruginosa
:* Pseudomonas aeruginosa
::* Preferred regimen: Cefepime 2 g IV q8h {{or}} Ceftazidime 2 g IV q8h x 2–4 wk, followed by Ciprofloxacin 750 mg PO bid
::* Preferred regimen: [[Cefepime]] 2 g IV q8h {{or}} [[Ceftazidime]] 2 g IV q8h x 2–4 wk, followed by [[Ciprofloxacin]] 750 mg PO bid
::* Alternative regimen: Piperacillin–Tazobactam 750 mg PO q12h x 2–4 wk, followed by Ciprofloxacin 750 mg PO bid
::* Alternative regimen: [[Piperacillin–Tazobactam]] 750 mg PO q12h x 2–4 wk, followed by [[Ciprofloxacin]] 750 mg PO bid
:* Anaerobes
:* Anaerobes
::* Preferred regimen: Piperacillin–Tazobactam 750 mg PO q12h x 2–4 wk, followed by Ciprofloxacin 750 mg PO bid
::* Preferred regimen: [[Piperacillin–Tazobactam]] 750 mg PO q12h x 2–4 wk, followed by [[Ciprofloxacin]] 750 mg PO bid
::* Alternative regimen (1): Penicillin G 5 MU IV q6h OR Ceftriaxone 2 g IV q24h (against gram-positive anaerobes)
::* Alternative regimen (1): [[Penicillin G]] 5 MU IV q6h OR [[Ceftriaxone]] 2 g IV q24h (against gram-positive anaerobes)


::* Alternative regimen (2): Metronidazole 500 mg PO tid (against gram-negative anaerobes)
::* Alternative regimen (2): [[Metronidazole]] 500 mg PO tid (against gram-negative anaerobes)


===Osteomyelitis, sternal===
===Osteomyelitis, sternal===
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===Osteonecrosis of the jaw===
===Osteonecrosis of the jaw===
* Bacterial Infection
* Bacterial Infection
:* Preferred regimen:  Penicillin VK 500 mg PO q6–8h for 7–10 days (maintenance: 500 mg PO bid) {{or}} Amoxicillin 500 mg PO q8h for 7–10 days (maintenance: 500 mg PO bid)
:* Preferred regimen:  Penicillin VK 500 mg PO q6–8h for 7–10 days (maintenance: 500 mg PO bid) {{or}} [[Amoxicillin]] 500 mg PO q8h for 7–10 days (maintenance: 500 mg PO bid)


:* Alternative regimen: Clindamycin 150–300 mg PO qid {{or}} Doxycycline 100 mg PO qd {{or}} Erythromycin 400 mg PO tid {{or}} Azithromycin 500 mg PO for 1 dose, then 250 mg PO qd for 4 days {{or}} [[Levofloxacin]] 500 mg PO qd {{or}} Moxifloxacin 400 mg PO qd
:* Alternative regimen: [[Clindamycin]] 150–300 mg PO qid {{or}} [[Doxycycline]] 100 mg PO qd {{or}} [[Erythromycin]] 400 mg PO tid {{or}} [[Azithromycin]] 500 mg PO for 1 dose, then 250 mg PO qd for 4 days {{or}} [[Levofloxacin]] 500 mg PO qd {{or}} [[Moxifloxacin]] 400 mg PO qd
* Fungal Infection
* Fungal Infection


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* Viral Infection
* Viral Infection


:* Preferred regimen: Acyclovir 400 mg PO bid {{or}} Valacyclovir 0.5–2.0 g PO bid
:* Preferred regimen: [[Acyclovir]] 400 mg PO bid {{or}} Val[[Acyclovir]] 0.5–2.0 g PO bid


===Reactive arthritis, post-streptococcal  arthritis===
===Reactive arthritis, post-streptococcal  arthritis===
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===Septic arthritis, Brucella melitensis===
===Septic arthritis, Brucella melitensis===
:* Preferred Regimen: Doxycycline 100 mg PO bid for ≥ 6 weeks {{and}} Streptomycin 15 mg/kg IM qd for 2–3 weeks OR [[Rifampin]] 600–900 mg qd for ≥ 6 weeks
:* Preferred Regimen: [[Doxycycline]] 100 mg PO bid for ≥ 6 weeks {{and}} 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 {{and}} Gentamicin 5 mg/kg IV qd for 7 days
:* Alternative Regimen: [[Doxycycline]] 100 mg PO bid for ≥ 6 weeks {{and}} [[Gentamicin]] 5 mg/kg IV qd for 7 days


===Septic arthritis, candidal===
===Septic arthritis, candidal===
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===Septic arthritis, gonococcal===
===Septic arthritis, gonococcal===
:* Preferred regime<ref name="pmid12364368">{{cite journal| author=Shirtliff ME, Mader JT| title=Acute septic arthritis. | journal=Clin Microbiol Rev | year= 2002 | volume= 15 | issue= 4 | pages= 527-44 | pmid=12364368 | doi= | pmc=PMC126863 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12364368  }} </ref>: Ceftriaxone 1 g intramuscularly IM/IV every 24 h
:* Preferred regime<ref name="pmid12364368">{{cite journal| author=Shirtliff ME, Mader JT| title=Acute septic arthritis. | journal=Clin Microbiol Rev | year= 2002 | volume= 15 | issue= 4 | pages= 527-44 | pmid=12364368 | doi= | pmc=PMC126863 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12364368  }} </ref>: [[Ceftriaxone]] 1 g intramuscularly IM/IV every 24 h
:* Alternative regime: Cefotaxime 1 g IV every 8 hours {{or}} Ceftizoxime 1 g IV every 8 hours
:* Alternative regime: Cefotaxime 1 g IV every 8 hours {{or}} Ceftizoxime 1 g IV every 8 hours
:* NOTE: The tetracyclines (except in pregnant women) or penicillins may be used if the infecting organism is proven to be susceptible; Penicillin allergies should be given Spectinomycin (2 g IV every 12 h);Alternative antibiotics in the β-lactam-allergic patient may be Ciprofloxacin (500 mg IV every 12 h) or Ofloxacin (400 mg IV every 12 h)
:* NOTE: The tetracyclines (except in pregnant women) or penicillins may be used if the infecting organism is proven to be susceptible; Penicillin allergies should be given Spectinomycin (2 g IV every 12 h);Alternative antibiotics in the β-lactam-allergic patient may be [[Ciprofloxacin]] (500 mg IV every 12 h) or Ofloxacin (400 mg IV every 12 h)
:* Pediatric regime: (>45 kg) single daily dose of Ceftriaxone (50 mg/kg and a maximum dose of 2 g, IM or IV) for 10 to 14 days; (<45 kg) Ceftriaxone (50 mg/kg and a maximum dose of 1 g, IM or IV in a single daily dose for 7 days)
:* Pediatric regime: (>45 kg) single daily dose of [[Ceftriaxone]] (50 mg/kg and a maximum dose of 2 g, IM or IV) for 10 to 14 days; (<45 kg) [[Ceftriaxone]] (50 mg/kg and a maximum dose of 1 g, IM or IV in a single daily dose for 7 days)


===Septic arthritis, Gram-negative  bacilli===
===Septic arthritis, Gram-negative  bacilli===
:* Preferred regime: Ceftazidime 2 g IV q8h {{or}} Cefepime 2 g IV q8–12h {{or}} Piperacillin-Tazobactam 4.5 g IV q6h
:* Preferred regime: [[Ceftazidime]] 2 g IV q8h {{or}} [[Cefepime]] 2 g IV q8–12h {{or}} Piperacillin-Tazobactam 4.5 g IV q6h


:* Alternative regime: Aztreonam 2 g IV q8h {{or}} Imipenem 500 mg IV q6h {{or}} Meropenem 1 g IV q8h {or}} Doripenem 500 mg IV q8h {{or}} Carbapenems
:* Alternative regime: [[Aztreonam]] 2 g IV q8h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h {or}} Doripenem 500 mg IV q8h {{or}} Carbapenems


===Septic arthritis, Histoplasmosis===
===Septic arthritis, Histoplasmosis===
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* Septic arthritis, Lyme disease <ref name="pmid17029130">{{cite journal| author=Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS et al.| title=The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2006 | volume= 43 | issue= 9 | pages= 1089-134 | pmid=17029130 | doi=10.1086/508667 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17029130  }} </ref>
* Septic arthritis, Lyme disease <ref name="pmid17029130">{{cite journal| author=Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS et al.| title=The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2006 | volume= 43 | issue= 9 | pages= 1089-134 | pmid=17029130 | doi=10.1086/508667 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17029130  }} </ref>
:* Patients without clinical evidence of neurologic disease
:* Patients without clinical evidence of neurologic disease
::* Preferred regime: Doxycycline 100 mg twice per day {{or}} Amoxicillin 500 mg 3 times per day {{or}} Cefuroxime Axetil 500 mg twice per day for 28 days
::* Preferred regime: [[Doxycycline]] 100 mg twice per day {{or}} [[Amoxicillin]] 500 mg 3 times per day {{or}} Cefuroxime Axetil 500 mg twice per day for 28 days
::* Pediatric regime: Amoxicillin 50 mg/kg per day in 3 divided doses maximum of 500 mg per dose {{or}} Cefuroxime Axetil 30 mg/kg per day in 2 divided doses maximum of 500 mg per dose {{or}} (if the patient is ≥8 years of age) Doxycycline 4 mg/ kg per day in 2 divided doses (maximum of 100 mg per dose)
::* Pediatric regime: [[Amoxicillin]] 50 mg/kg per day in 3 divided doses maximum of 500 mg per dose {{or}} Cefuroxime Axetil 30 mg/kg per day in 2 divided doses maximum of 500 mg per dose {{or}} (if the patient is ≥8 years of age) [[Doxycycline]] 4 mg/ kg per day in 2 divided doses (maximum of 100 mg per dose)
:* Patients with arthritis and objective evidence of neurologic disease
:* Patients with arthritis and objective evidence of neurologic disease
::* Preferred regime: Ceftriaxone administered parenterally for 2–4 weeks
::* Preferred regime: [[Ceftriaxone]] administered parenterally for 2–4 weeks
::* Alternative regime: Cefotaxime {{or}} Penicillin G administered parenterally
::* Alternative regime: Cefotaxime {{or}} [[Penicillin G]] administered parenterally
::* Pediatric regime: Ceftriaxone {{or}} Cefotaxime {{or}} Penicillin G administered intravenously
::* Pediatric regime: [[Ceftriaxone]] {{or}} Cefotaxime {{or}} [[Penicillin G]] administered intravenously
:* NOTE (1): For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of Ceftriaxone IV
:* NOTE (1): For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of [[Ceftriaxone]] IV
:* NOTE (2): If patients have no resolution of arthritis despite intravenous therapy and if PCR results for a sample of synovial fluid (and synovial tissue if available) are negative, symptomatic treatment is recommended, which consist of nonsteroidal anti-inflammatory agents, intra-articular injections of corticosteroids, or disease-modifying antirheumatic drugs (DMARDs), such as Hydroxychloroquine.
:* NOTE (2): If patients have no resolution of arthritis despite intravenous therapy and if PCR results for a sample of synovial fluid (and synovial tissue if available) are negative, symptomatic treatment is recommended, which consist of nonsteroidal anti-inflammatory agents, intra-articular injections of corticosteroids, or disease-modifying antirheumatic drugs (DMARDs), such as Hydroxychloroquine.


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::::* Preferred regimen: [[Vancomycin]] {{and}} [[Rifampin]] 600 mg PO qd or 300–450 mg PO bid for 2 weeks
::::* Preferred regimen: [[Vancomycin]] {{and}} [[Rifampin]] 600 mg PO qd or 300–450 mg PO bid for 2 weeks
::::* Alternative regimen: ([[Daptomycin]] 6 mg/kg IV q24h {{or}} [[Linezolid]] 600 IV q8h) {{and}} [[Rifampin]] 600 mg PO qd or 300–450 mg PO bid for 2 weeks
::::* Alternative regimen: ([[Daptomycin]] 6 mg/kg IV q24h {{or}} [[Linezolid]] 600 IV q8h) {{and}} [[Rifampin]] 600 mg PO qd or 300–450 mg PO bid for 2 weeks
::::: Note: The above regimen should be followed by [[Rifampin]] plus a fluoroquinolone, TMP/SMX, a tetracycline or clindamycin for 3 or 6 months for hips and knees, respectively.
::::: Note: The above regimen should be followed by [[Rifampin]] plus a fluoroquinolone, TMP/SMX, a tetracycline or [[Clindamycin]] for 3 or 6 months for hips and knees, respectively.


:::* Early-onset spinal implant infections (&lt; 30 days after surgery), or implants in an actively infected site
:::* Early-onset spinal implant infections (&lt; 30 days after surgery), or implants in an actively infected site
Line 311: Line 311:
::* Enterococci
::* Enterococci
:::* Monotherapy
:::* Monotherapy
::::* Preferred regimen (1): Ampicillin 6 to 12 g per 24 hours in four to six equally divided doses
::::* Preferred regimen (1): [[Ampicillin]] 6 to 12 g per 24 hours in four to six equally divided doses
::::* Preferred regimen (2): Penicillin G 18 to 30 million units per 24 hours either continuously or in six equally divided doses
::::* Preferred regimen (2): [[Penicillin G]] 18 to 30 million units per 24 hours either continuously or in six equally divided doses
::::* Preferred regimen (3): [[Vancomycin]] 15 to 20 mg/kg/dose every 8 to 12 hours, not to exceed 2 g per dose
::::* Preferred regimen (3): [[Vancomycin]] 15 to 20 mg/kg/dose every 8 to 12 hours, not to exceed 2 g per dose


Line 322: Line 322:
::* Gram-negative bacilli
::* Gram-negative bacilli
:::* Patients susceptible to fluoroquinolones
:::* Patients susceptible to fluoroquinolones
::::* Preferred regimen: Ciprofloxacin 500 to 750 mg bid
::::* Preferred regimen: [[Ciprofloxacin]] 500 to 750 mg bid
:::* ''P. aeruginosa''
:::* ''P. aeruginosa''
::::* Preferred regimen: Cefepime 2 g intravenously every 12 hours {{or}} Meropenem 1 g intravenously every 8 hours  
::::* Preferred regimen: [[Cefepime]] 2 g intravenously every 12 hours {{or}} [[Meropenem]] 1 g intravenously every 8 hours  
::::* Alternative regimen (1): Ciprofloxacin 750 mg orally every 12 hours Ceftazidime 2 g intravenously every 8 hours (alternative)
::::* Alternative regimen (1): [[Ciprofloxacin]] 750 mg orally every 12 hours [[Ceftazidime]] 2 g intravenously every 8 hours (alternative)
::::* Alternative regimen (2): Ceftazidime 2 g intravenously every 8 hours
::::* Alternative regimen (2): [[Ceftazidime]] 2 g intravenously every 8 hours


::* Anaerobes
::* Anaerobes
::''Propionibacterium acnes''
::''Propionibacterium acnes''
:::* Preferred regimen: Penicillin 24 million units intravenously every 24 hours given in six equally divided doses or as continuous infusion {{or}} Ceftriaxone 1 to 2 g intravenously once daily
:::* Preferred regimen: Penicillin 24 million units intravenously every 24 hours given in six equally divided doses or as continuous infusion {{or}} [[Ceftriaxone]] 1 to 2 g intravenously once daily
:::* Alternative regimen: [[Vancomycin]] {{or}} Clindamycin
:::* Alternative regimen: [[Vancomycin]] {{or}} Clindamycin
:: Not ''Propionibacterium acnes''
:: Not ''Propionibacterium acnes''
:::* Preferred regimen: Metronidazole 500 mg orally three times a day.  
:::* Preferred regimen: [[Metronidazole]] 500 mg orally three times a day.  


::* Mycobacterium tuberculosis
::* Mycobacterium tuberculosis
Line 342: Line 342:


::* Culture negative
::* Culture negative
:::* Preferred regimen:  [[Vancomycin]] {{and}} Ciprofloxacin {{or}} [[Cefazolin]] {{and}} Ciprofloxacin
:::* Preferred regimen:  [[Vancomycin]] {{and}} [[Ciprofloxacin]] {{or}} [[Cefazolin]] {{and}} Ciprofloxacin


===Septic arthritis, staphylococcal===
===Septic arthritis, staphylococcal===
Line 351: Line 351:
:* Alternative regimen (2): [[Linezolid]] 600 mg PO/IV q12h
:* Alternative regimen (2): [[Linezolid]] 600 mg PO/IV q12h


:* Alternative regimen (3): Clindamycin 600 mg PO/IV q8h
:* Alternative regimen (3): [[Clindamycin]] 600 mg PO/IV q8h
:* Alternative regimen (4): TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h  
:* Alternative regimen (4): TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h  


:* Pediatric regime: [[Vancomycin]] 15 mg/kg IV q6h {{or}} [[Daptomycin]] 6–10 mg/kg IV q24h {{or}} [[Linezolid]] 10 mg/kg PO/IV q8h {{or}} Clindamycin 10–13 mg/kg/dose PO/IV q6–8h
:* Pediatric regime: [[Vancomycin]] 15 mg/kg IV q6h {{or}} [[Daptomycin]] 6–10 mg/kg IV q24h {{or}} [[Linezolid]] 10 mg/kg PO/IV q8h {{or}} [[Clindamycin]] 10–13 mg/kg/dose PO/IV q6–8h
    
    
''Staphylococcus aureus (methicillin-susceptible)''
''Staphylococcus aureus (methicillin-susceptible)''
:* Preferred regime: Nafcillin 2 g IV q6h OR Clindamycin 900 mg IV q8h
:* Preferred regime: [[Nafcillin]] 2 g IV q6h OR [[Clindamycin]] 900 mg IV q8h
:* Alternative regime: [[Cefazolin]] 0.25–1 g IV/IM q6–8h {{or}} [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
:* Alternative regime: [[Cefazolin]] 0.25–1 g IV/IM q6–8h {{or}} [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h


Line 365: Line 365:


''Staphylococcus epidermidis (methicillin-susceptible)''
''Staphylococcus epidermidis (methicillin-susceptible)''
:* Preferred regime: Nafcillin 2 g IV q6h OR Clindamycin 900 mg IV q8h
:* Preferred regime: [[Nafcillin]] 2 g IV q6h OR [[Clindamycin]] 900 mg IV q8h
:* Alternative regime: [[Cefazolin]] 0.25–1 g IV/IM q6–8h {{or}} [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
:* Alternative regime: [[Cefazolin]] 0.25–1 g IV/IM q6–8h {{or}} [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h


===Septic arthritis, streptococcal===
===Septic arthritis, streptococcal===
''Streptococcus agalactiae''
''Streptococcus agalactiae''
:* Preferred regime: Penicillin G 2 MU IV/IM q4h {{or}} Ampicillin 2 g IV q6h
:* Preferred regime: [[Penicillin G]] 2 MU IV/IM q4h {{or}} [[Ampicillin]] 2 g IV q6h


:* Alternative regime: Clindamycin 600–1200 mg/day IV/IM q6–12h {{or}} [[Cefazolin]] 0.25–1 g IV/IM q6–8h
:* Alternative regime: [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h {{or}} [[Cefazolin]] 0.25–1 g IV/IM q6–8h
''Streptococcus pyogenes''
''Streptococcus pyogenes''
:* Preferred regime: Penicillin G 2 MU IV/IM q4h {{or}} Ampicillin 2 g IV q6h
:* Preferred regime: [[Penicillin G]] 2 MU IV/IM q4h {{or}} [[Ampicillin]] 2 g IV q6h


:* Alternative regime: Clindamycin 600–1200 mg/day IV/IM q6–12h {{or}} [[Cefazolin]] 0.25–1 g IV/IM q6–8h
:* Alternative regime: [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h {{or}} [[Cefazolin]] 0.25–1 g IV/IM q6–8h


==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 19:34, 15 June 2015

Bursitis

  • Olecranon bursitis or prepatellar bursitis
  • Staphylococcus aureus, methicillin-susceptible (MSSA)
  • Staphylococcus aureus, methicillin-resistant (MRSA)
Note: Initially aspirate q24h and treat for a minimum of 2–3 weeks.

Osteomyelitis, candidal

  • Osteomyelitis, candidal [1]
  • Preferred regimen: Fluconazole 400 mg (6 mg/kg) daily for 6–12 months OR lipid formulation of Amphotericin B 3–5 mg/kg daily for several weeks, then Fluconazole for 6–12 months
NOTE: Duration of therapy usually is prolonged (6–12 months); Surgical debridement is frequently necessary

Osteomyelitis, chronic

  • Chronic Osteomyelitis in Adults – Pathogen-Based Therapy
  • OSSA
  • Preferred regimen: Oxacillin 1.5–2 g IV q4h for 4–6 wk OR Cefazolin 1–2 g IV q8h for 4–6 wk
  • Alternative regimen (1): Vancomycin 15 mg/kg IV q12h for 4–6 wk
  • Alternative regimen (2): Oxacillin 1.5–2 g IV q4h for 4–6 wk AND Rifampin 600 mg PO qd
  • ORSA
  • Penicillin-sensitive Streptococcus
  • Preferred regimen: Penicillin G 20 MU/day IV continuously or q4h for 4–6 wk OR Ceftriaxone 1–2 g IV/IM q24h for 4–6 wk OR Cefazolin 1–2 g IV q8h for 4–6 wk
  • Alternative regimen: Vancomycin 15 mg/kg IV q12h for 4–6 wk
  • Enterococcus or Streptococcus (MIC≥0.5 μg/mL) or Abiotrophia or Granulicatella
  • Preferred regimen: Penicillin G 20 MU/day IV continuously or q4h for 4–6 wk ± Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk OR Ampicillin 12 g/day IV continuously or q4h for 4–6 wk ± Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk
  • Alternative regimen: Vancomycin 15 mg/kg IV q12h for 4–6 wk ± Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk
  • Enterobacteriaceae
  • Pseudomonas aeruginosa
  • Chronic Osteomyelitis in Children – Pathogen-Based Therapy
  • Group A beta-hemolytic Streptococcus, Haemophilus influenzae type b, andStreptococcus pneumoniae
  • Preferred regimen: Ampicillin 150–200 mg/kg/day administered in 4 equal doses OR Amoxicillin 150–200 mg/kg/day administered in 4 equal doses
  • Alternative regimen: Chloramphenicol 75 mg/kg/day administered in 3 equal doses

Osteomyelitis, contiguous with vascular insufficiency

  • Osteomyelitis, contiguous with vascular insufficiency
  • 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 and treat for 6 weeks.
  • Revascularize if possible.

Osteomyelitis, diabetic foot

  • Chronic Infection or Recent Antibiotic Use
  • Preferred regimen: Levofloxacin 750 mg IV/PO q24h OR Cefoxitin 1 g IV q4h (or 2 g IV q6–8h) OR Ceftriaxone 1–2 g/day IV/IM q12–24h OR Ampicillin–Sulbactam 1.5–3 g IV/IM q6h OR Moxifloxacin 400 mg IV/PO q24h OR Ertapenem 1 g IV/IM q24h OR Tigecycline 100 mg IV, then 50 mg IV q12h (active against MRSA) OR Imipenem–Cilastatin 0.5–1 g IV q6–8h (Not active against MRSA; consider when ESBL-producing pathogens suspected)
  • Alternative regimen (3): Ciprofloxacin 1200–2700 mg IV q6–12h (for more severe cases) AND Clindamycin 150–300 mg PO qid
  • High Risk for MRSA
  • High Risk for Pseudomonas aeruginosa
  • Polymicrobial Infection

Osteomyelitis, foot bone

  • Foot bone osteomyelitis due to nail through tennis shoe

Osteomyelitis, foot puncture wound

  • Long bone, post-internal fixation of fracture
NOTE: If susceptible Gm-neg. bacillus, Ciprofloxacin 750 mg po bid OR Levofloxacin 750 mg po q24h

Osteomyelitis, hematogenous

  • Empiric therapy
  • Adult (>21 yrs)
  • MRSA possible
  • Preferred regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
  • MRSA unlikely
  • Children (>4 mos.)-Adult
  • MRSA possible
  • MRSA unlikely
  • Newborn (<4 mos.)
  • MRSA possible
  • MRSA unlikely
  • Specific therapy
  • MSSA
  • MRSA

Osteomyelitis, hemoglobinopathy

Osteomyelitis, spinal implant

  • Onset within 30 days
  • Preferred regimen: Culture, treat & then suppress until fusion occurs
  • Onset after 30 days
  • Preferred regimen: Remove implant, culture & treat

Osteomyelitis, vertebral

  • Vertebral Osteomyelitis – Pathogen-Based Therapy
  • OSSA or coagulase-negative staphylococci
  • ORSA
  • Streptococcus
  • Enterobacteriaceae, quinolone-susceptible
  • Enterobacteriaceae, quinolone-resistant
  • Preferred regimen: Imipenem 500 mg IV q6h
  • Pseudomonas aeruginosa
  • Anaerobes
  • Alternative regimen (2): Metronidazole 500 mg PO tid (against gram-negative anaerobes)

Osteomyelitis, sternal

  • Preferred regimen: Vancomycin 1 gm IV q12h (If over 100kg, 1.5 gm IV q12h)
  • Alternative regimen: Linezolid 600 mg po/IVNAI bid

Osteonecrosis of the jaw

  • Bacterial Infection
  • Preferred regimen: Penicillin VK 500 mg PO q6–8h for 7–10 days (maintenance: 500 mg PO bid) OR Amoxicillin 500 mg PO q8h for 7–10 days (maintenance: 500 mg PO bid)
  • Fungal Infection
  • Preferred regimen: Nystatin oral suspension 5–15 mL swish qid OR Fluconazole 200 mg PO qd, then 100 mg q24h OR Clotrimazole 10 mg PO tid for 7–10 days
  • Viral Infection

Reactive arthritis, post-streptococcal arthritis

  • Preferred regimen: Treat strep pharyngitis and then NSAIDs (Prednisone needed in some patients)

Reactive arthritis, Reiter's syndrome

  • Preferred regimen: Only treatment is non-steroidal anti-inflammatory drugs

Septic arthritis, Brucella melitensis

  • Preferred Regimen: Doxycycline 100 mg PO bid for ≥ 6 weeks AND 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 AND Gentamicin 5 mg/kg IV qd for 7 days

Septic arthritis, candidal

  • Preferred regime: Fluconazole 400 mg (6 mg/kg) daily for at least 6 weeks OR lipid formulation of Amphotericin B 3–5 mg/kg daily for several weeks, then Fluconazole to completion
  • Alternative regime: Anidulafungin 200-mg loading dose, then 100 mg/day OR Caspofungin 70-mg loading dose, then 50 mg/day OR Micafungin 100 mg/day OR Amphotericin B deoxycholate 0.5–1 mg/kg daily for several weeks then Fluconazole to completion
  • NOTE: Duration of therapy usually is for at least 6 weeks, but few data are available; Surgical debridement is recommended for all cases; For infected prosthetic joints, removal is recommended for most cases.

Septic arthritis, gonococcal

  • Preferred regime[2]: Ceftriaxone 1 g intramuscularly IM/IV every 24 h
  • Alternative regime: Cefotaxime 1 g IV every 8 hours OR Ceftizoxime 1 g IV every 8 hours
  • NOTE: The tetracyclines (except in pregnant women) or penicillins may be used if the infecting organism is proven to be susceptible; Penicillin allergies should be given Spectinomycin (2 g IV every 12 h);Alternative antibiotics in the β-lactam-allergic patient may be Ciprofloxacin (500 mg IV every 12 h) or Ofloxacin (400 mg IV every 12 h)
  • Pediatric regime: (>45 kg) single daily dose of Ceftriaxone (50 mg/kg and a maximum dose of 2 g, IM or IV) for 10 to 14 days; (<45 kg) Ceftriaxone (50 mg/kg and a maximum dose of 1 g, IM or IV in a single daily dose for 7 days)

Septic arthritis, Gram-negative bacilli

  • Preferred regime: Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8–12h OR Piperacillin-Tazobactam 4.5 g IV q6h
  • Alternative regime: Aztreonam 2 g IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h {or}} Doripenem 500 mg IV q8h OR Carbapenems

Septic arthritis, Histoplasmosis

  • Septic arthritis, histoplasmosis[3]
  • Mild disease
  • Severe disease
  • Preferred regimen: Prednisone 0.5–1.0 mg/kg/day (maximum: 80 mg daily) in tapering doses over 1–2 weeks AND Itraconazole 200 mg tid for 3 days, followed by qd or bid for 6–12 weeks

Septic arthritis, Lyme disease

  • Septic arthritis, Lyme disease [4]
  • Patients without clinical evidence of neurologic disease
  • Preferred regime: Doxycycline 100 mg twice per day OR Amoxicillin 500 mg 3 times per day OR Cefuroxime Axetil 500 mg twice per day for 28 days
  • Pediatric regime: Amoxicillin 50 mg/kg per day in 3 divided doses maximum of 500 mg per dose OR Cefuroxime Axetil 30 mg/kg per day in 2 divided doses maximum of 500 mg per dose OR (if the patient is ≥8 years of age) Doxycycline 4 mg/ kg per day in 2 divided doses (maximum of 100 mg per dose)
  • Patients with arthritis and objective evidence of neurologic disease
  • Preferred regime: Ceftriaxone administered parenterally for 2–4 weeks
  • Alternative regime: Cefotaxime OR Penicillin G administered parenterally
  • Pediatric regime: Ceftriaxone OR Cefotaxime OR Penicillin G administered intravenously
  • NOTE (1): For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of Ceftriaxone IV
  • NOTE (2): If patients have no resolution of arthritis despite intravenous therapy and if PCR results for a sample of synovial fluid (and synovial tissue if available) are negative, symptomatic treatment is recommended, which consist of nonsteroidal anti-inflammatory agents, intra-articular injections of corticosteroids, or disease-modifying antirheumatic drugs (DMARDs), such as Hydroxychloroquine.

Septic arthritis, Mycobacterium tuberculosis

  • Septic arthritis, Mycobacterium tuberculosis[5]
  • Septic arthritis caused by susceptible Mycobacterium tuberculosis
  • Intensive phase (adult)
  • Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 2 months AND Rifampin 10 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months
  • Continuation phase (adult)
  • Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 7 months AND Rifampin 10 mg/kg (max: 600 mg) for 7 months
  • Intensive phase (pediatric)
  • Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 2 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months
  • Continuation phase (pediatric)
  • Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 7 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 7 months
  • Specific considerations
  • Pregnancy and breastfeeding
  • With the exception of streptomycin, the first line anti-TB drugs are safe for use in pregnancy: streptomycin is ototoxic to the fetus and should not be used during pregnancy.
  • After active TB in the baby is ruled out, the baby should be given 6 months of isoniazid preventive therapy, followed by BCG vaccination.
  • Pyridoxine supplementation is recommended for all pregnant or breastfeeding women taking isoniazid.
  • Liver disorders
  • Two hepatotoxic drugs (rather than the three in the standard regimen):
  • 9 months of isoniazid and rifampicin, plus ethambutol (until or unless isoniazid susceptibility is documented).
  • 2 months of isoniazid, rifampicin, streptomycin and ethambutol, followed by 6 months of isoniazid and rifampicin.
  • 6–9 months of rifampicin, pyrazinamide and ethambutol.
  • One hepatotoxic drug:
  • 2 months of isoniazid, ethambutol and streptomycin, followed by 10 months of isoniazid and ethambutol.
  • No hepatotoxic drugs:
  • 18–24 months of streptomycin, ethambutol and a fluoroquinolone.
  • Renal failure and severe renal insufficiency
  • The recommended initial TB treatment regimen for patients with renal failure or severe renal insufficiency is 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampicin.
  • There is significant renal excretion of ethambutol and metabolites of pyrazinamide, and doses should therefore be adjusted.
  • Three times per week administration of these two drugs at the following doses is recommended: pyrazinamide (25 mg/kg), and ethambutol (15 mg/kg)
  • While receiving isoniazid, patients with severe renal insufficiency or failure should also be given pyridoxine in order to prevent peripheral neuropathy.
  • Because of an increased risk of nephrotoxicity and ototoxicity, streptomycin should be avoided in patients with renal failure. If streptomycin must be used, the dosage is 15 mg/kg, two or three times per week, to a maximum of 1 gram per dose, and serum levels of the drug should be monitored.
  • Previously treated patients in settings with rapid DST
  • TB patients whose treatment has failed or other patient groups with high likelihood of multidrug-resistant TB (MDR) should be started on an empirical MDR regimen.
  • TB patients returning after defaulting or relapsing from their first treatment course may receive the retreatment regimen containing first-line drugs 2HRZES/1HRZE/5HRE if country-specific data show low or medium levels of MDR in these patients or if such data are not available.
  • TB treatment in people living with HIV
  • TB patients with known positive HIV status and all TB patients living in HIV prevalent settings should receive daily TB treatment at least during the intensive phase.
  • For the continuation phase, the optimal dosing frequency is also daily for these patients.
  • If a daily continuation phase is not possible for these patients, three times weekly dosing during the continuation phase is an acceptable alternative.
  • It is recommended that TB patients who are living with HIV should receive at least the same duration of TB treatment as HIV-negative TB patients.

Septic arthritis, pneumococcal

Septic arthritis, post-intraarticular injection

  • NO empiric therapy.

Septic arthritis, prosthetic joint infection

  • Septic arthritis, prosthetic joint infection (device-related osteoarticular infections)
  • Empiric antimicrobial therapy
  • It is preferable to delay antibiotic therapy until specimens for culture are obtained by joint aspiration, joint debridement, and/or prosthesis removal.
  • Pathogen-directed antimicrobial therapy
  • Staphylococcus aureus, methicillin-susceptible (MSSA)
  • Alternative regimen: Cefazolin 1–2 g IV q8h OR Ceftriaxone 2 g IV q24h
  • Alternative regimen (if allergic to penicillins): Clindamycin 900 mg IV q8h OR Vancomycin 15–20 mg/kg IV q8–12 hours, not to exceed 2 g per dose
  • Staphylococcus, methicillin-resistant (MRSA)
  • Early-onset (< 2 months after surgery) or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)
  • Preferred regimen: Vancomycin AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
  • Alternative regimen: (Daptomycin 6 mg/kg IV q24h OR Linezolid 600 IV q8h) AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
Note: The above regimen should be followed by Rifampin plus a fluoroquinolone, TMP/SMX, a tetracycline or Clindamycin for 3 or 6 months for hips and knees, respectively.
  • Early-onset spinal implant infections (< 30 days after surgery), or implants in an actively infected site
  • Initial parenteral therapy plus Rifampin followed by prolonged oral therapy is recommended.
  • Long-term oral suppressive antibiotics (eg, TMP-SMX, a tetracycline, a fluoroquinolone [which should be given in conjunction with Rifampin due to the potential emergence of fluoroquinolone resistance)
  • Streptococci, beta-hemolytic
  • Enterococci
  • Monotherapy
  • Preferred regimen (1): Ampicillin 6 to 12 g per 24 hours in four to six equally divided doses
  • Preferred regimen (2): Penicillin G 18 to 30 million units per 24 hours either continuously or in six equally divided doses
  • Preferred regimen (3): Vancomycin 15 to 20 mg/kg/dose every 8 to 12 hours, not to exceed 2 g per dose
  • Combination therapy (one of the monotherapy agents, and one of the following agents)
  • Gram-negative bacilli
  • Patients susceptible to fluoroquinolones
  • P. aeruginosa
  • Preferred regimen: Cefepime 2 g intravenously every 12 hours OR Meropenem 1 g intravenously every 8 hours
  • Alternative regimen (1): Ciprofloxacin 750 mg orally every 12 hours Ceftazidime 2 g intravenously every 8 hours (alternative)
  • Alternative regimen (2): Ceftazidime 2 g intravenously every 8 hours
  • Anaerobes
Propionibacterium acnes
  • Preferred regimen: Penicillin 24 million units intravenously every 24 hours given in six equally divided doses or as continuous infusion OR Ceftriaxone 1 to 2 g intravenously once daily
  • Alternative regimen: Vancomycin OR Clindamycin
Not Propionibacterium acnes
  • Preferred regimen: Metronidazole 500 mg orally three times a day.
  • Mycobacterium tuberculosis
  • Preferred regimen: see (Septic arthritis, Mycobacterium tuberculosis)
  • Fungi
  • Preferred regimen: see (Septic arthritis, candidal)
  • Culture negative

Septic arthritis, staphylococcal

Staphylococcus aureus (methicillin-resistant)

  • Preferred regime: Vancomycin 15–20 mg/kg IV q8–12h
  • Alternative regimen (1): Daptomycin 6 mg/kg IV q24h in adults
  • Alternative regimen (2): Linezolid 600 mg PO/IV q12h
  • Alternative regimen (3): Clindamycin 600 mg PO/IV q8h
  • Alternative regimen (4): TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h

Staphylococcus aureus (methicillin-susceptible)

Staphylococcus epidermidis (methicillin-resistant)

  • Preferred regime: Vancomycin 500 mg IV q6h or 1 g IV q12h OR Linezolid 600 mg IV q12h
  • Alternative regime: 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 AND Rifampin 300–600 mg PO/IV q12h

Staphylococcus epidermidis (methicillin-susceptible)

Septic arthritis, streptococcal

Streptococcus agalactiae

  • Alternative regime: Clindamycin 600–1200 mg/day IV/IM q6–12h OR Cefazolin 0.25–1 g IV/IM q6–8h

Streptococcus pyogenes

  • Alternative regime: Clindamycin 600–1200 mg/day IV/IM q6–12h OR Cefazolin 0.25–1 g IV/IM q6–8h

References

  1. ↑ 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.
  2. ↑ Shirtliff ME, Mader JT (2002). "Acute septic arthritis". Clin Microbiol Rev. 15 (4): 527–44. PMC 126863. PMID 12364368.
  3. ↑ Wheat LJ, Freifeld AG, Kleiman MB, Baddley JW, McKinsey DS, Loyd JE; et al. (2007). "Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (7): 807–25. doi:10.1086/521259. PMID 17806045.
  4. ↑ Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS; et al. (2006). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clin Infect Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130.
  5. ↑ Treatment of Tuberculosis: Guidelines. WHO Guidelines Approved by the Guidelines Review Committee (4th ed.). Geneva: World Health Organization. 2010. ISBN 9789241547833. PMID 23741786. Retrieved 2015-06-08.
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