| Condition | Major Pathogens | First-choice Therapy | Alternative Therapy | Comments |
|---|---|---|---|---|
| Acute osteomyelitis in child > 3 months old without medical comorbidities or other exception criteria defined below |
Staphylococcus aureus Group A streptococcus Kingella kingae in children < 3 years |
Clinically stable (see note in Comments column about waiting for cultures if surgical debridement planned): Cefazolin 50 mg/kg/dose (max 2000 mg/dose) IV q8h ------------------------ Severely ill (hemodynamic instability, multiple sites involved, or rapid local progression) or known positive blood culture for gram-positive organism (while awaiting initial ID and susceptibility): Cefazolin 50 mg/kg/dose (max 2000 mg/dose) IV q8h AND (follow link for dosing & monitoring) Consult ID for therapy selection if blood culture is positive for a gram-negative organism |
Penicillin or cephalosporin allergy with higher risk for allergic reaction, or history of documented MRSA infection or carriage within the last 6 months (Please confirm clindamycin susceptibility if prior cultures are available, tailor antibiotics to past susceptibility): Clindamycin 13 mg/kg/dose (max 900 mg/dose) IV q8h Penicillin or cephalosporin allergy with higher risk for allergic reaction, severely ill (hemodynamic instability or rapid local progression) or known positive blood culture for gram-positive organism (while awaiting initial ID and susceptibility): Consult ID |
ID and Orthopedic Surgery consults recommended At initial evaluation, send ESR, CRP and blood culture Discuss with Orthopedic Surgery before starting antibiotics if the patient is hemodynamically stable. If surgical debridement is planned, may prefer to hold antibiotics until after operative cultures are sent Therapy should be tailored to the identified organism. Change from IV to PO and total duration of therapy should be determined in consultation with ID based on the patient's clinical course If cultures are positive, use results of preliminary diagnostic tests to target therapy Duration: Uncomplicated acute hematogenous osteomyelitis is usually treated for 4-6 weeks, guided by follow-up assessments |
| Chronic osteomyelitis | Variable based on risk factors | Antibiotic therapy should generally be withheld pending operative cultures from the involved site, and is selected based on individual patient risk factors - consult ID for guidance | ID and Orthopedic Surgery consults recommended | |
| Bone or joint infection in patient with significant medical comorbidities, age 0-3 months, penetrating trauma, orthopedic hardware involved, contiguous infection or other modifying factors | Variable based on risk factors | Consult ID for guidance before initiating empiric therapy | ID and Orthopedic Surgery consults recommended |
References:
Woods CR, et al. Clinical practice guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 guideline on diagnosis and management of acute hematogenous osteomyelitis in pediatrics. J Pediatr Infect Dis Soc 2021 (epub).
McBride S, et al. Comparison of empiric antibiotics for acute osteomyelitis in children. Hosp Pediatr 2018;8:280-287.
American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.