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Musculoskeletal
Osteomyelitis
Candidal osteomyelitis
- Fluconazole 400 mg (6 mg/kg) IV/po daily OR Lipid-based Amphotericin B 3-5 mg/kg daily for two weeks, followed by Fluconazole
- Caspofungin 70 mg loading dose, then 50 mg/day IV OR Micafungin 100 mg/day IV or Anidulafungin 200 mg IV loading dose, then 100 mg/day IV
Chronic osteomyelitis
- Systemic antibiotics per culture and susceptibility results AND
- Surgical debridement
Contiguous with vascular insufficiency
- Systemic antibiotics per culture and susceptibility results AND
- Surgical debridement AND
- Revascularization if possible
Contiguous without vascular insufficiency
- Vancomycin 1 gm IV q12h AND
- Ceftazidime 2 gm IV q8h OR Cefepime 2 gm IV q12h
- Linezolid 600 mg po/IV bid AND
- Ceftazidime 2 gm IV q8h OR Cefepime 2 gm IV q12h
- Ciprofloxacin 750 mg po bid OR Linezolid 600 mg po/IV bid
- Ciprofloxacin 750 mg po bid OR Levofloxacin 750 mg po once daily if susceptible AND
- Rifampin 300-450 mg po bid OR Rifampin 600 mg po once daily if susceptible
- Vancomycin 15-20 mg/kg IV q8-12h targeting trough concentrations of 15-20 mg/L
Diabetic foot
- 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 OR Imipenem-Cilastatin 0.5–1 g IV q6–8h
- 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 OR Imipenem-Cilastatin 0.5–1 g IV q6–8h
- Linezolid 600 mg IV/PO q12h OR Daptomycin 4 mg/kg IV q24h OR Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
- Piperacillin–Tazobactam 3.375 g IV q6–8h
- (Vancomycin 15–20 mg/kg IV q8–12h 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/IM q24h) OR (Metronidazole 15 mg/kg IV, then 7.5 mg/kg IV q6h PLUS Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8h OR Aztreonam 2 g IV q6–8h)
Foot bone
- Ciprofloxacin 750 mg po bid OR Levofloxacin 750 mg po q24h
- Ceftazidime 2 gm IV q8h OR Cefepime 2 gm IV q8h OR Meropenem 1 gm IV q8h
Foot puncture wound
- Cleanse wound AND
- Tetanus booster if due AND
- X-ray to exclude presence of radio-opaque foreign body
Hematogenous
- MRSA likely – Vancomycin 15–20 mg/kg IV q8–12h AND (Ceftriaxone 1–2 g/day IV/IM q12–24h OR Ceftazidime 2 gm IV q8h OR Cefepime 2 gm IV q12h)
- MRSA unlikely – (Nafcillin OR Oxacillin) AND (Ceftriaxone 1–2 g/day IV/IM q12–24h OR Ceftazidime 2 gm IV q8h OR Cefepime 2 gm IV q12h)
- Linezolid 600 mg po/IV bid OR Daptomycin 4 mg/kg IV q24h to replace vancomycin
- Ciprofloxacin 750 mg po bid OR Levofloxacin 750 mg IV/PO q24h OR Aztreonam 2 g IV q6–8h to replace a third-generation cephalosporin
Hemoglobinopathy
- Ciprofloxacin 400 mg IV q12h OR Ceftriaxone 2 gm IV q24h
- Ciprofloxacin 750 mg po bid for 6 weeks OR Levofloxacin 750 mg po q24h for 6 weeks
Prosthetic joint infection
- (Nafcillin 2 gm IV q4h OR Oxacillin 2 gm IV q4h IV) PLUS Rifampin 300 mg po bid
OR - Cefazolin 2 gm IV q8h PLUS Rifampin 300 mg po bid for 2-6 weeks followed by (Ciprofloxacin 750 mg po bid OR Levofloxacin 750 mg po q24h) PLUS Rifampin 300 mg po bid for 3-6 months
- Vancomycin 15-20 mg/kg IV q8-12h PLUS Rifampin 300 mg po bid for 2-6 weeks followed by (Ciprofloxacin 750 mg po bid OR Levofloxacin 750 mg po q24h) PLUS Rifampin 300 mg po bid for 3-6 months
- Penicillin G 20 million units IV continuous infusion q24h or in 6 divided doses OR Ceftriaxone 2 gm IV q24h x 4-6 weeks
- Penicillin-susceptible – Ampicillin 12 gm IV OR Penicillin G 20 million units IV continuous infusion q24h or in 6 divided doses x 4-6 weeks
- Penicillin-resistant – Vancomycin 15 mg/kg IV q12h x 4-6 week
- Penicillin G 20 million units IV continuous infusion or in 6 divided doses OR Ceftriaxone 2 gm IV q24h x 4-6 weeks
- Ertapenem 1 gm q24h IV OR Ceftriaxone 2 gm IV q24h OR Cefepime 2 gm IV q12h for 4-6 weeks
- Cefepime 2 gm IV q12h OR Meropenem 1 gm IV q8h for 4-6 weeks AND
- Tobramycin 5.1 mg/kg once daily IV for 4-6 weeks
Spinal implant
- (Nafcillin 2 gm IV q4h OR Oxacillin 2 gm IV q4h IV) PLUS Rifampin 300 mg po bid
OR - Cefazolin 2 gm IV q8h PLUS Rifampin 300 mg po bid for 2-6 weeks followed by (Ciprofloxacin 750 mg po bid OR Levofloxacin 750 mg po q24h) PLUS Rifampin 300 mg po bid for 3-6 months
- Vancomycin 15-20 mg/kg IV q8-12h PLUS Rifampin 300 mg po bid for 2-6 weeks followed by (Ciprofloxacin 750 mg po bid OR Levofloxacin 750 mg po q24h) PLUS Rifampin 300 mg po bid for 3-6 months
- Penicillin G 20 million units IV continuous infusion q24h or in 6 divided doses OR Ceftriaxone 2 gm IV q24h x 4-6 weeks
- Penicillin-susceptible – Ampicillin 12 gm IV OR Penicillin G 20 million units IV continuous infusion q24h or in 6 divided doses x 4-6 weeks
- Penicillin-resistant – Vancomycin 15 mg/kg IV q12h x 4-6 week
- Penicillin G 20 million units IV continuous infusion or in 6 divided doses OR Ceftriaxone 2 gm IV q24h x 4-6 weeks
- Ertapenem 1 gm q24h IV OR Ceftriaxone 2 gm IV q24h OR Cefepime 2 gm IV q12h for 4-6 weeks
- Cefepime 2 gm IV q12h OR Meropenem 1 gm IV q8h for 4-6 weeks AND
- Tobramycin 5.1 mg/kg once daily IV for 4-6 weeks
Sternal
- Vancomycin 15-30 mg/kg IV q 8-12h targeting trough of 15-20 μg/mL OR Nafcillin 2 gm IV q4h
- Linezolid 600 mg IV/po bid