Osteomyelitis
From IDWiki
Background
Microbiology
| Species | Upper Extremity | Vertebral | Lower Extremity PJI | Trauma of Fracture | Hematogenous | Foot and Ankle | |
|---|---|---|---|---|---|---|---|
| Gram-positive | |||||||
| Staphylococcus aureus | 10-40% | 15-60% | 20-30% | 20-40% | 40% | 45-55% | |
| Coagulase-negative staphylococci | 10-20% | 5-40% | 25-35% | 10-40% | <5% | <5% | |
| Streptococcus species | 5-10% | 5-10% | <5% | 5-10% | 5-10% | 5-20% | |
| Enterococcus species | <5% | 5-15% | <5% | 5% | <5% | 5% | |
| Diphtheroids | <5% | 5% | <5% | 5% | <5% | <5% | |
| Cutibacterium acnes | 30-50% in shoulder | 10-15% spinal fusion | |||||
| Gram-negatives | 5-10% | 10-40% | 5-10% | 20% | 10-15% | 35-55% | |
| Pseudomonas species | <5% | 5-10% | <5% | 5-10% | 5-10% | 10-20% | |
| Enterobacteriaceae | <5% | 10-20% | <5% | 5-20% | 5% | 10-15% | |
| HACEK group | <5% | <5% | <5% | <5% | <5% | <5% | |
| Fungal | <5% | <5% | <5% | <5% | <5% | <5% | |
| Polymicrobial | 10-25% | 15-30% | 10-20% | 20-30% | 20 | 30-80% | |
Management
- No clinically meaningful differences in bone penetration between classes of antibiotics exist1
- Bioavailability likely still important
- Empiric antimicrobials should generally cover MRSA, susceptible Gram-positives, and common Gram-negatives
- For example, vancomycin plus ceftriaxone
Parenteral Antimicrobials
| Organism | Antimicrobial Options |
|---|---|
| MSSA | nafcillin 2 g IV q4h |
| oxacillin 2 g IV q4h | |
| cefazolin 2 g IV q8h | |
| flucloxacillin 2 g IV q6h | |
| ceftriaxone 2 g IV q24h | |
| MRSA | vancomycin 20 mg/kg load followed by 15-20 mg IV q8-12h |
| daptomycin 6 to 10 mg/kg IV daily | |
| teicoplanin 12 mg/kg IV q12h for 3 to 5 doses followed by q24h | |
| Adjunctive staphylococcal agent | rifampin 300 to 450 mg PO bid |
| fusidic acid 500 mg PO tid | |
| Gram-negative bacteria | ciprofloxacin 750 mg PO big to 400 mg IV q12h |
| levofloxacin 750 mg PO/IV daily | |
| ceftriaxone 2 g IV q24h | |
| ceftazidime 2 g IV q8h | |
| cefepime 2 g IV q8-12h | |
| ertapenem 1 g IV q24h | |
| meropenem 1 g IV q8h | |
| Pseudomonas aeruginosa | ciprofloxacin 400 mg IV q8h |
| Enterococcus | ampicillin 12 g continuous IV q24h |
| ampicillin 2 g IV q4h | |
| penicillin G 20 to 24 million units continuous IV q24h | |
| penicillin G 3-4 million units IV q4h | |
| vancomycin 20 mg/kg IV load followed by 15 mg/kg IV q12h (max 2 g per dose) | |
| daptomycin 6 to 10 mg/kg IV daily | |
| teicoplanin 12 mg/kg IV q12h for 3 to 5 doses, followed by q24h | |
| ampicillin as above, PLUS ceftriaxone 2 g IV q12-24h | |
| penicillin-susceptible streptococci | ampicillin 12 g continuous IV q24h |
| ampicillin 2 g IV q4h | |
| penicillin G 20 to 24 million units continuous IV q24h | |
| penicillin G 3-4 million units IV q4h | |
| ceftriaxone 2 g IV q24h | |
| vancomycin 20 mg/kg IV load followed by 15 mg/kg IV q12h (max 2 g per dose) | |
| Cutibacterium acnes | penicillin G 20 to 24 million units continuous IV q24h |
| penicillin G 3-4 million units IV q4h | |
| ceftriaxone 2 g IV q24h |
Oral Antimicrobials
| Organism | Antibiotic Options |
|---|---|
| MSSA | cefadroxil 500 to 1000 mg PO bid |
| cephalexin 500 mg PO tid to qid, or 1000 mg PO bid to tid | |
| dicloxacillin 500 mg PO tid to qid | |
| flucloxaxillin 500 mg PO tid to qid | |
| MRSA | TMP-SMX DS 1 tablet PO bid |
| doxycycline 100 mg PO bid | |
| minocycline 100 mg PO bid | |
| clindamycin 600 mg PO tid | |
| Gram-negative bacteria | TMP-SMX DS 1 tablet PO bid |
| ciprofloxacin 500 mg PO bid | |
| levofloxacin 500 mg PO daily | |
| penicillin-susceptible streptococci and enterococci | amoxicillin 500 mg PO bid to tid |
| penicillin VK 500 mg PO bid to tid | |
| Cutibacterium acnes | amoxicillin 500 mg PO bid to tid |
| penicillin VK 500 mg PO bid to tidO |
OVIVA Trial
- Oral therapy non-inferior to intravenous therapy for bone and joint infections requiring 6+ weeks of therapy
- Oral regimens included fluoroquinolones (41%), combination with cipro/clinda or cipro/doxy (14%), beta lactams (15%), macrolides or lincosamides (11%), tetracyclines (9%), and other antibiotics (9%)
References
- ^ Cornelia B. Landersdorfer, Jürgen B. Bulitta, Martina Kinzig, Ulrike Holzgrabe, Fritz Sörgel. Penetration of Antibacterials into Bone. Clinical Pharmacokinetics. 2009;48(2):89-124. doi:10.2165/00003088-200948020-00002.
