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Hospitalized patients

Infection Organisms First DOC Alternative
Osteomyelitis Presumed hematogenous source or contiguous without vascular insufficiency S. aureus Vancomycin Vanc If S. aureus is methicillin-susceptible then cefazolin 2 g IV q8h or nafcillin 2 g IV q4h are the antibiotics of choice.

Obtain bone biopsy to determine microbiologic cause prior to initiation of antimicrobial therapy if blood cultures are negative and patient clinically stable.

With vascular insufficiency or diabetes mellitus (e.g. severe diabetic foot ulcer) S. aureus 

Enterobacteriaceae

Anaerobes

Vancomycin

PLUS ONE OF:

Piperacillin/Tazobactam 4.5 g IV q6-8h

OR

Ertapenem 1 g IV daily

For severe PCN allergy:

Vancomycin

PLUS ONE OF:

Ciprofloxacin400 mg IV q12h

OR

Levofloxacin 750 mg IV daily

OR

Aztreonam 2 g IV q8h

ALL WITH OR WITHOUT:

Metronidazole500 mg IV q8h (if patient critically ill)

Other organisms are possible, esp. with hardware microbiologic diagnosis and ID consultation recommended

Obtain bone biopsy to determine microbiologic cause prior to initiation of antimicrobial therapy if patient clinically stable

Once stable, switch to oral antibiotics based on susceptibility results.

Septic Arthritis S. aureus

Streptococci spp.

N. gonorrhoeae

Enterobacteriaceae (rarely)

Vancomycin

PLUS

Ceftriaxone1 g IV daily

For severe PCN allergy:

Vancomycin

PLUS ONE OF:

Ciprofloxacin 400 mg IV q12h

OR

Levofloxacin 500 mg IV daily

OR

Aztreonam g IV q8h if gonococcus is strongly suspected

Gram stain recommended to guide therapy.

Narrow coverage to microbiologically confirmed pathogens.

Brain abscess Streptococci (anaerobic or aerobic)

Bacteroides spp

Prevotella spp

Enterobacteriacea

Ceftriaxone

2 g IV q12h

PLUS

Metronidazole 500 mg PO/IV q8h

WITH OR WITHOUT*:

Vancomycin

Aztreonam

2 g IV q8h

PLUS

Vancomycin

PLUS

Metronidazole 500 mg PO/IV q8h

Consider expanded Gram-positive coverage if patient at risk for drug-resistant streptococci or MRSA
Meningitis

Community-onset

S. pneumoniae

Neisseria meningitidis

Listeria (especially in immuno-compromised, elderly patients, and alcoholics)

ceftriaxone

2 g IV q12h

PLUS

Vancomycin

WITH OR WITHOUT* one of:

TMP/SMX 15 mg/kg/day (in divided doses)

OR

'Ampicillin' 2 g IV q4h

For severe PCN allergy:

Vancomycin

PLUS

Aztreonam2 g IV q6h-q8h

WITH OR WITHOUT*:

TMP/SMX (if Listeria) 15 mg/kg/day (in divided doses)

Therapy should be guided by Gram stain.

If bacterial meningitis suspected, dexamethasone 10 mg PO/IV q6h x 4 days given before or with initial dose of antibiotics. 

*Coverage for Listeria with TMP/SMX or ampicillin should be added for patients who are <2 or >50 years of age or immunocompromised.

Meningitis

Post-neurosurgical or device associated

S. aureus

Coagulase negative

Staphylococci

Gram negative rods

Cefepime

PLUS

'Vancomycin' 

For severe PCN allergy:

Aztreonam 2 g IV q6h-q8h

PLUS

Vancomycin