Non-Vertebral Osteomyelitis

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Patient Population: Adult

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 Expected Duration

Non-vertebral osteomyelitis
Presumed hematogenous source or contiguous without vascular insufficiency (no hardware in place)

S. aureus
Streptococci
GNRs (rarely)

If patient is stable and has negative blood cultures, withhold antibiotics until bone biopsy and consult ID

Vancomycin

 N/A

If S. aureus is methicillin-susceptible then cefazolin 2g IV q8h or nafcillin 2g IV q4h are the antibiotics of choice

 ID consultation recommended

Non-vertebral osteomyelitis

with vascular insufficiency or Diabetes Mellitus (e.g. severe diabetic foot ulcer)

S. aureus Enterobacteriaceae Anaerobes

P. aeruginosa (rare without risk factors, see comments)

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

Vancomycin

PLUS

Ceftriaxone

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

For severe PCN allergy: Vancomycin

PLUS ONE OF:

Ciprofloxacin

OR

Aztreonam

WITH

Metronidazole (if patient critically ill)

Consider Pseudomonal coverage with Piperacillin-Tazobactam or Cefepime in patients with the following risk factors:

  • Macerated ulcer or warm (tropical) climate

Include anaerobic coverage with piperacillin-tazobactam in necrotic or gas forming infections (see SSTI guidance for NSTI management)

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

Once stable, switch to oral antibiotics based on susceptibility results

 ID consultation recommended