Sandbox osteomyelitis

Acute Osteomyelitis in Adults – Empiric Therapy

Although osteomyelitis in adults usually has a subacute or chronic course, acute hematogenous seeding may occur in elderly patients, intravenous drug users, or patients with indwelling catheters. The most commonly isolated microorganisms are Staphylococcus aureus and Streptococcus pneumonia. Empiric antibiotics with anti-staphylococcal and anti-streptococcal coverage should be administered based on local resistance data.

Acute Osteomyelitis in Children – Empiric Therapy

Abbreviations: OSSA, oxacillin-sensitive Staphylococcus aureus; ORSA, Oxacillin-resistant Staphylococcus aureus; CRSA, Clindamycin-resistant Staphylococcus aureus.

High prevalence of OSSA in community

• First-generation cephalosporin (Cefadroxil, Cefazolin, Cephalexin) ≥150 mg/kg/day administered in 4 equal doses

• Antistaphylococcal penicillin (Cloxacillin, Flucloxacillin, Dicloxacillin, Nafcillin, Oxacillin) ≤ 200 mg/kg/day administered in 4 equal doses

High prevalence of ORSA with low prevalence of CRSA in community

• Clindamycin ≥ 40 mg/kg/day administered in 4 equal doses

High prevalence of ORSA with high prevalence of CRSA in community

• Vancomycin ≤ 40 mg/kg/day administered in 4 equal doses, adjust dosage to trough of 15–20 mcg/mL

• Linezolid 30 mg/kg/day administered in 3 equal doses

Chronic Osteomyelitis in Adults – Pathogen-Based Therapy

OSSA

• Oxacillin 1.5–2 g IV q4h for 4–6 wk OR Cefazolin 1–2 g IV q8h for 4–6 wk

• Vancomycin 15 mg/kg IV q12h for 4–6 wk
  OR
• Oxacillin 1.5–2 g IV q4h for 4–6 wk AND Rifampin 600 mg PO qd

ORSA

• Vancomycin 15 mg/kg IV q12h for 4–6 wk OR Daptomycin 6 mg/kg IV q24h

• Linezolid 600 mg PO/IV q12h for 6 wk ± Rifampin 600–900 mg PO qd
  OR
• Levofloxacin 500–750 mg PO/IV daily ± Rifampin 600–900 mg PO qd

Penicillin-sensitive Streptococcus

• 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

• Vancomycin 15 mg/kg IV q12h for 4–6 wk

Enterococcus or Streptococcus (MIC ≥ 0.5 μg/mL) or Abiotrophia or Granulicatella

• 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

• Vancomycin 15 mg/kg IV q12h for 4–6 wk ± Gentamicin 1 mg/kg IV or IM q8h for 1–2 wk

Enterobacteriaceae

• Ceftriaxone 1–2 g IV/IM q24h for 4–6 wk OR Ertapenem 1 g IV q24h

• Levofloxacin 500–750 mg PO q24h OR Ciprofloxacin 500–750 mg PO q12h for 4–6 wk

Pseudomonas aeruginosa

• Cefepime 2 g IV q12h OR Meropenem 1 g IV q8h OR Imipenem 500 mg IV q6h for 4–6 wk

• Ciprofloxacin 750 mg PO q12h OR Ceftazidime 2 g IV q8h for 4–6 wk

Chronic Osteomyelitis in Children – Pathogen-Based Therapy

Group A beta-hemolytic Streptococcus, Haemophilus influenzae type b, and Streptococcus pneumoniae

• Ampicillin 150–200 mg/kg/day administered in 4 equal doses OR Amoxicillin 150–200 mg/kg/day administered in 4 equal doses

• Chloramphenicol 75 mg/kg/day administered in 3 equal doses

Vertebral Osteomyelitis

Abbreviations: OSSA, oxacillin-sensitive Staphylococcus aureus; ORSA, Oxacillin-resistant Staphylococcus aureus; CRSA, Clindamycin-resistant Staphylococcus aureus.

OSSA or coagulase-negative staphylococci

• Oxacillin 2 g IV q6h
  OR
• Cefazolin 1–2 g IV q8h

• Levofloxacin 750 mg PO qd AND Rifampin 300 mg PO bid

ORSA

• Vancomycin 1 g IV q12h

• Daptomycin ≥ 6 mg/kg IV q24h
  OR
• Levofloxacin 500–750 mg PO/IV daily AND Rifampin 600–900 mg PO qd

Streptococcus

• Penicillin G 5 MU IV q6h

• Ceftriaxone 2 g IV q24h

Enterobacteriaceae, quinolone-susceptible

• Ciprofloxacin 750 mg PO q12h

• Ceftriaxone 2 g IV q24h

Enterobacteriaceae, quinolone-resistant

• Imipenem 500 mg IV q6h

Pseudomonas aeruginosa

• Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h x 2–4 wk, followed by Ciprofloxacin 750 mg PO bid

• Piperacillin–Tazobactam 750 mg PO q12h x 2–4 wk, followed by Ciprofloxacin 750 mg PO bid

Anaerobes

• Clindamycin 300–600 mg IV q6–8h

• Penicillin G 5 MU IV q6h OR Ceftriaxone 2 g IV q24h (against gram-positive anaerobes) {{or2}]
• Metronidazole 500 mg PO tid (against gram-negative anaerobes)

Specific Considerations

Osteomyelitis in patients with diabetes mellitus

Osteomyelitis in patients with vascular insufficiency

SAPHO syndrome

Chronic recurrent multifocal osteomyelitis

Osteitis Pubis

Osteomyelitis of the Clavicle

Osteomyelitis in Hemodialysis Patients

Osteomyelitis in Patients with Sickle Cell Disease

Gaucher’s Disease

Osteomyelitis in Injection Drug Users

Skeletal Mycobacterial Infection

Fungal Osteomyelitis

Brodie’s Abscess

Culture-Negative Osteomyelitis