Hospitalized Adults: Bone & Joint Infections: Osteomyelitis

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Doses provided in this table are for patients with normal renal and hepatic function. Click on drug link to go to dosing guidelines.  Some antimicrobials are restricted (ID-R).  Click on link for guidelines on obtaining authorization.

Diagnosis

Common Pathogens

Drug(s) of First Choice

Alternative Drug(s)

Comments

Osteomyelitis

Presumed hematogenous source or contiguous without vascular insufficiency

S. aureus

 

Vancomycin

 

Vancomycin

 

 

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.

Osteomyelitis

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

 

S. aureus

Enterobacteriaceae

Anaerobes 

Vancomycin

PLUS ONE OF:

Piperacillin/TazobactamID-R: SFGH 4.5 g IV q6-8h

OR

Ertapenem 1 g IV daily

For severe PCN allergy:

Vancomycin

PLUS ONE OF:

CiprofloxacinID-R: VASF 400 mg IV q12h

OR

Levofloxacin ID-R: VASF 750 mg IV daily

OR

Aztreonam ID-R: SFGH 2 g IV q8h

ALL WITH OR WITHOUT:

Metronidazole 500 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.

References:

Lipsky BA, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:132-173