Sandbox ID Musculoskeletal

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Bursitis

Osteomyelitis, candidal

Osteomyelitis, chronic

Osteomyelitis, contiguous with vascular insufficiency

Osteomyelitis, contiguous without vascular insufficiency

Osteomyelitis, diabetic foot

Osteomyelitis, foot bone

Osteomyelitis, foot puncture wound

Osteomyelitis, hematogenous

Osteomyelitis, hemoglobinopathy

Osteomyelitis, prosthetic joint infection

Osteomyelitis, spinal implant

Osteomyelitis, sternal

Reactive arthritis, post-streptococcal arthritis

Reactive arthritis, Reiter's syndrome

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[1]: 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[2]
  • 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 [3]
  • 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[4]
  • 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
  • Preferred regimen: Ciprofloxacin 500 to 750 mg bid
  • 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
  • Preferred regimen: vancomycin AND Ciprofloxacin OR Cefazolin AND Ciprofloxacin

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
  • 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)

  • 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

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)

  • 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

Septic arthritis, streptococcal

Streptococcus agalactiae

  • 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

Streptococcus pyogenes

  • 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

References

  1. Shirtliff ME, Mader JT (2002). "Acute septic arthritis". Clin Microbiol Rev. 15 (4): 527–44. PMC 126863. PMID 12364368.
  2. 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.
  3. 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.
  4. 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.