Sandbox ID Musculoskeletal

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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
  • Alternative regimen (1): (Anidulafungin 200-mg loading dose, then 100 mg/day OR Caspofungin, 70-mg loading dose, then 50 mg/day OR Micafungin 100 mg/day), then fluconazole for 6–12 months
  • Alternative regimen (2): Amphotericin B deoxycholate 0.5–1 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
  • Preferred regimen: Vancomycin 15 mg/kg IV q12h for 4–6 wk OR Daptomycin 6 mg/kg IV q24h
  • Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 6 wk ± Rifampin 600–900 mg PO qd
  • Alternative regimen (2): Levofloxacin 500–750 mg PO/IV daily ± Rifampin 600–900 mg PO qd
  • 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
  • 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
  • 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
  • Alternative regimen: 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, 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

Osteomyelitis, foot bone

Osteomyelitis, foot puncture wound

Osteomyelitis, hematogenous

Osteomyelitis, hemoglobinopathy

  • Preferred regimen: Ciprofloxacin 400 mg IV q12h
  • Alternative regimen: Levofloxacin 750 mg IV q24h

Osteomyelitis, prosthetic joint infection

Osteomyelitis, spinal implant

Osteomyelitis, vertebral

  • Vertebral Osteomyelitis – Pathogen-Based Therapy
  • OSSA or coagulase-negative staphylococci
  • Preferred regimen: Oxacillin 2 g IV q6h OR Cefazolin 1–2 g IV q8h
  • Alternative regimen: Levofloxacin 750 mg PO qd AND Rifampin 300 mg PO bid
  • ORSA
  • Preferred regimen: Vancomycin 1 g IV q12h
  • Alternative regimen (1): Daptomycin ≥ 6 mg/kg IV q24h
  • Alternative regimen (2): Levofloxacin 500–750 mg PO/IV daily AND Rifampin 600–900 mg PO qd
  • Streptococcus
  • Preferred regimen: Penicillin G 5 MU IV q6h
  • Alternative regimen: Ceftriaxone 2 g IV q24h
  • Enterobacteriaceae, quinolone-susceptible
  • Preferred regimen: Ciprofloxacin 750 mg PO q12h
  • Alternative regimen: Ceftriaxone 2 g IV q24h
  • Enterobacteriaceae, quinolone-resistant
  • Preferred regimen: Imipenem 500 mg IV q6h
  • 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
  • Alternative regimen: Piperacillin–Tazobactam 750 mg PO q12h x 2–4 wk, followed by Ciprofloxacin 750 mg PO bid
  • Anaerobes
  • 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 (2): Metronidazole 500 mg PO tid (against gram-negative anaerobes)

Osteomyelitis, sternal

  • Preferred regimen: Surgical debridement is necessary;

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
  • 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. ↑ 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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