Osteomyelitis: Difference between revisions
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+ | == Background == |
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+ | *Inflammation of the bone which involves the medullary cavity, in comparison to osteitis (a distinction made on MRI but not clinically relevant) |
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+ | *Classified by: |
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+ | **[[Acute osteomyelitis]] (1 to 2 weeks) versus [[chronic osteomyelitis]] (3 to 6 months), though this classification is not necessarily helpful |
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+ | **Etiology and location, including the [[Osteomyelitis with orthopedic hardware|presence of orthopedic hardware]] or [[Prosthetic joint infection|joint prosthesis]] |
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+ | **Cierny-Mader classification based on area of bone involvement<ref> |
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+ | |||
+ | Cierny G, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clinical Orthopaedics and Related Research. 2003;(414):7–24. doi: [https://doi.org/10.1097/01.blo.0000088564.81746.62 10.1097/01.blo.0000088564.81746.62]</ref> |
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+ | ***Type I: medullary |
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+ | ***Type II: superficial |
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+ | ***Type III: localized |
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+ | ***Type IV: diffuse |
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+ | **Immune status and frailty of host |
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+ | |||
+ | === Microbiology === |
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+ | |||
+ | * Based on [[CiteRef::masters2022sk]] |
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+ | |||
+ | {| class="wikitable" |
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+ | ! colspan="2" |Species |
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+ | !Upper Extremity |
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+ | !Vertebral |
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+ | !Lower Extremity PJI |
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+ | !Trauma of Fracture |
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+ | !Hematogenous |
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+ | !Foot and Ankle |
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+ | |- |
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+ | | rowspan="6" |[[Gram-positive bacteria]] |
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+ | |[[Staphylococcus aureus]] |
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+ | |10-40% |
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+ | |15-60% |
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+ | |20-30% |
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+ | |20-40% |
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+ | |40% |
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+ | |45-55% |
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+ | |- |
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+ | |[[Coagulase-negative staphylococci]] |
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+ | |10-20% |
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+ | |5-40% |
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+ | |25-35% |
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+ | |10-40% |
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+ | |<5% |
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+ | |<5% |
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+ | |- |
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+ | |[[Streptococcus]] species |
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+ | |5-10% |
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+ | |5-10% |
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+ | |<5% |
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+ | |5-10% |
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+ | |5-10% |
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+ | |5-20% |
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+ | |- |
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+ | |[[Enterococcus]] species |
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+ | |<5% |
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+ | |5-15% |
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+ | |<5% |
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+ | |5% |
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+ | |<5% |
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+ | |5% |
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+ | |- |
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+ | |[[Diphtheroids]] |
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+ | |<5% |
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+ | |5% |
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+ | |<5% |
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+ | |5% |
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+ | |<5% |
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+ | |<5% |
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+ | |- |
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+ | |[[Cutibacterium acnes]] |
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+ | |30-50% in shoulder |
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+ | |10-15% spinal fusion |
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+ | | |
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+ | | |
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+ | | |
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+ | | |
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+ | |- |
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+ | | rowspan="4" |[[Gram-negative bacteria]] |
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+ | |Overall |
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+ | |5-10% |
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+ | |10-40% |
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+ | |5-10% |
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+ | |20% |
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+ | |10-15% |
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+ | |35-55% |
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+ | |- |
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+ | |[[Pseudomonas]] species |
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+ | |<5% |
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+ | |5-10% |
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+ | |<5% |
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+ | |5-10% |
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+ | |5-10% |
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+ | |10-20% |
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+ | |- |
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+ | |[[Enterobacteriaceae]] |
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+ | |<5% |
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+ | |10-20% |
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+ | |<5% |
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+ | |5-20% |
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+ | |5% |
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+ | |10-15% |
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+ | |- |
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+ | |[[HACEK group]] |
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+ | |<5% |
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+ | |<5% |
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+ | |<5% |
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+ | |<5% |
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+ | |<5% |
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+ | |<5% |
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+ | |- |
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+ | | colspan="2" |Polymicrobial bacteria |
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+ | |10-25% |
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+ | |15-30% |
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+ | |10-20% |
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+ | |20-30% |
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+ | |20 |
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+ | |30-80% |
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+ | |- |
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+ | | colspan="2" |[[Fungi]] |
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+ | |<5% |
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+ | |<5% |
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+ | |<5% |
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+ | |<5% |
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+ | |<5% |
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+ | |<5% |
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+ | |} |
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+ | |||
+ | * Polymicrobial infections are more common in trauma-related OM, PJI, and diabetic foot infections |
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+ | ** Poorer outcomes |
||
+ | ** Commonly involves [[Staphylococcus aureus]] iwht a mix of other bacteria |
||
+ | |||
+ | == Diagnosis == |
||
+ | |||
+ | * Bone biopsy for histology and culture is the gold standard |
||
+ | * However, diagnosis is usually made based on a combination of physical exam, lab tests, and imaging |
||
+ | ** Physical exam findings: fever, constitutional symptoms, sinus tract, joint pain and swelling, cellulitis at the site |
||
+ | ** Blood tests: elevated WBC or CRP, positive blood cultures |
||
+ | *** Novel tests: alpha-defensin, D-dimer, synolvial IL-6, and synovial CRP |
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+ | ** [[Imaging in osteomyelitis|Imaging]]: MRI is the most sensitive; can also use bone scan and labelled WBC scan, or plain film x-ray or CT (if more chronic) |
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+ | |||
+ | ==Management== |
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+ | |||
+ | *No clinically meaningful differences in bone penetration between classes of antibiotics exist[[CiteRef::landersdorfer2009pe]] |
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+ | *Bioavailability likely still important |
||
+ | *Empiric antimicrobials should generally cover MRSA, susceptible Gram-positives, and common Gram-negatives |
||
+ | **For example, [[vancomycin]] plus [[ceftriaxone]] |
||
+ | |||
+ | ===Parenteral Antimicrobials=== |
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+ | {| class="wikitable" |
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+ | !Organism |
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+ | !Antimicrobial Options |
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+ | |- |
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+ | | rowspan="5" |[[MSSA]] |
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+ | |[[nafcillin]] 2 g IV q4h |
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+ | |- |
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+ | |[[oxacillin]] 2 g IV q4h |
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+ | |- |
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+ | |[[cefazolin]] 2 g IV q8h |
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+ | |- |
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+ | |[[flucloxacillin]] 2 g IV q6h |
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+ | |- |
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+ | |[[ceftriaxone]] 2 g IV q24h |
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+ | |- |
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+ | | rowspan="3" |[[MRSA]] |
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+ | |[[vancomycin]] 20 mg/kg load followed by 15-20 mg IV q8-12h |
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+ | |- |
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+ | |[[daptomycin]] 6 to 10 mg/kg IV daily |
||
+ | |- |
||
+ | |[[teicoplanin]] 12 mg/kg IV q12h for 3 to 5 doses followed by q24h |
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+ | |- |
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+ | | rowspan="2" |Adjunctive staphylococcal agent |
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+ | |[[rifampin]] 300 to 450 mg PO bid |
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+ | |- |
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+ | |[[fusidic acid]] 500 mg PO tid |
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+ | |- |
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+ | | rowspan="7" |[[Gram-negative bacteria]] |
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+ | |[[ciprofloxacin]] 750 mg PO big to 400 mg IV q12h |
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+ | |- |
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+ | |[[levofloxacin]] 750 mg PO/IV daily |
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+ | |- |
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+ | |[[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 |
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+ | |- |
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+ | |[[Pseudomonas aeruginosa]] |
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+ | |[[ciprofloxacin]] 400 mg IV q8h |
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+ | |- |
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+ | | rowspan="8" |[[Enterococcus]] |
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+ | |[[ampicillin]] 12 g continuous IV q24h |
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+ | |- |
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+ | |[[ampicillin]] 2 g IV q4h |
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+ | |- |
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+ | |[[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 |
||
+ | |- |
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+ | | rowspan="6" |penicillin-susceptible [[streptococci]] |
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+ | |[[ampicillin]] 12 g continuous IV q24h |
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+ | |- |
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+ | |[[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) |
||
+ | |- |
||
+ | | rowspan="3" |[[Cutibacterium acnes]] |
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+ | |[[penicillin G]] 20 to 24 million units continuous IV q24h |
||
+ | |- |
||
+ | |[[penicillin G]] 3-4 million units IV q4h |
||
+ | |- |
||
+ | |[[ceftriaxone]] 2 g IV q24h |
||
+ | |} |
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+ | |||
+ | ===Oral Antimicrobials=== |
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+ | {| class="wikitable" |
||
+ | !Organism |
||
+ | !Antibiotic Options |
||
+ | |- |
||
+ | | rowspan="4" |[[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 |
||
+ | |- |
||
+ | | rowspan="4" |[[MRSA]] |
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+ | |[[TMP-SMX]] DS 1 tablet PO bid |
||
+ | |- |
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+ | |[[doxycycline]] 100 mg PO bid |
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+ | |- |
||
+ | |[[minocycline]] 100 mg PO bid |
||
+ | |- |
||
+ | |[[clindamycin]] 600 mg PO tid |
||
+ | |- |
||
+ | | rowspan="3" |[[Gram-negative bacteria]] |
||
+ | |[[TMP-SMX]] DS 1 tablet PO bid |
||
+ | |- |
||
+ | |[[ciprofloxacin]] 500 mg PO bid |
||
+ | |- |
||
+ | |[[levofloxacin]] 500 mg PO daily |
||
+ | |- |
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+ | | rowspan="2" |penicillin-susceptible [[Streptococcus species|streptococci]] and [[Enterococcus species|enterococci]] |
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+ | |[[amoxicillin]] 500 mg PO bid to tid |
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+ | |- |
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+ | |[[penicillin]] VK 500 mg PO bid to tid |
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+ | |- |
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+ | | rowspan="2" |[[Cutibacterium acnes]] |
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+ | |[[amoxicillin]] 500 mg PO bid to tid |
||
+ | |- |
||
+ | |[[penicillin]] VK 500 mg PO bid to tid |
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+ | |} |
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+ | |||
+ | === [https://www.wikijournalclub.org/wiki/OVIVA OVIVA Trial] === |
||
+ | |||
+ | * Oral therapy non-inferior to intravenous therapy for bone and joint infections requiring 6+ weeks of therapy[[CiteRef::li2019or]] |
||
+ | * Patients were randomized after at least 7 days of appropriate IV antibiotics |
||
+ | * Oral regimens included [[fluoroquinolones]] (41%), combination with [[ciprofloxacin]]/[[clindamycin]] or [[ciprofloxacin]]/[[doxycycline]] (14%), [[Beta lactam antibiotics|beta lactams]] (15%), [[macrolides]] or [[lincosamides]] (11%), [[tetracyclines]] (9%), and other antibiotics (9%) |
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+ | |||
[[Category:Bone and joint infections]] |
[[Category:Bone and joint infections]] |
Latest revision as of 13:29, 3 March 2023
Background
- Inflammation of the bone which involves the medullary cavity, in comparison to osteitis (a distinction made on MRI but not clinically relevant)
- Classified by:
- Acute osteomyelitis (1 to 2 weeks) versus chronic osteomyelitis (3 to 6 months), though this classification is not necessarily helpful
- Etiology and location, including the presence of orthopedic hardware or joint prosthesis
- Cierny-Mader classification based on area of bone involvement[1]
- Type I: medullary
- Type II: superficial
- Type III: localized
- Type IV: diffuse
- Immune status and frailty of host
Microbiology
- Based on 1
Species | Upper Extremity | Vertebral | Lower Extremity PJI | Trauma of Fracture | Hematogenous | Foot and Ankle | |
---|---|---|---|---|---|---|---|
Gram-positive bacteria | 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-negative bacteria | Overall | 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% | |
Polymicrobial bacteria | 10-25% | 15-30% | 10-20% | 20-30% | 20 | 30-80% | |
Fungi | <5% | <5% | <5% | <5% | <5% | <5% |
- Polymicrobial infections are more common in trauma-related OM, PJI, and diabetic foot infections
- Poorer outcomes
- Commonly involves Staphylococcus aureus iwht a mix of other bacteria
Diagnosis
- Bone biopsy for histology and culture is the gold standard
- However, diagnosis is usually made based on a combination of physical exam, lab tests, and imaging
- Physical exam findings: fever, constitutional symptoms, sinus tract, joint pain and swelling, cellulitis at the site
- Blood tests: elevated WBC or CRP, positive blood cultures
- Novel tests: alpha-defensin, D-dimer, synolvial IL-6, and synovial CRP
- Imaging: MRI is the most sensitive; can also use bone scan and labelled WBC scan, or plain film x-ray or CT (if more chronic)
Management
- No clinically meaningful differences in bone penetration between classes of antibiotics exist2
- 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 tid |
OVIVA Trial
- Oral therapy non-inferior to intravenous therapy for bone and joint infections requiring 6+ weeks of therapy3
- Patients were randomized after at least 7 days of appropriate IV antibiotics
- Oral regimens included fluoroquinolones (41%), combination with ciprofloxacin/clindamycin or ciprofloxacin/doxycycline (14%), beta lactams (15%), macrolides or lincosamides (11%), tetracyclines (9%), and other antibiotics (9%)
- ↑ Cierny G, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clinical Orthopaedics and Related Research. 2003;(414):7–24. doi: 10.1097/01.blo.0000088564.81746.62
References
- ^ Elysia A. Masters, Benjamin F. Ricciardi, Karen L. de Mesy Bentley, T. Fintan Moriarty, Edward M. Schwarz, Gowrishankar Muthukrishnan. Skeletal infections: microbial pathogenesis, immunity and clinical management. Nature Reviews Microbiology. 2022. doi:10.1038/s41579-022-00686-0.
- ^ 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.