II. Management: General

  1. If possible, delay antibiotics until bone culture and sensitivity are available
  2. Bone biopsy and surgical Debridement
  3. Once obtaining surgical bone culture-based antibiotic sensitivities, oral antibiotics are as effective as parenteral
    1. Rombach (2019) N Engl J Med 380(5):425-36 [PubMed]

III. Management: Acute (Hematogenous Spread)

  1. Protocol
    1. Total antibiotic duration: 4 to 6 weeks (up to 3-6 months for prosthetic hip or knee)
      1. Parenteral antibiotics for first 1-2 weeks
      2. Oral antibiotics for remainder of course
    2. Obtain cultures before starting empiric antibiotics
    3. Revise antibiotic coverage upon culture results
  2. First-line antibiotics (choose 2)
    1. Antibiotic 1: Vancomycin
      1. Vancomycin substitutes: Linezolid, Daptomycin, Trimethoprim-Sulfamethoxazole or if sensitive, Clindamycin
      2. Cefazolin or Nafcillin may be considered instead in non-life threatening infecton if low MRSA risk (<10%)
    2. Antibiotic 2: Cephalosporin (Ceftriaxone, Ceftazidime, Cefepime, Cefotaxime)
      1. Cephalosporin substitutes: Aztreonam, or if over age 15 years, Ciprofloxacin or Levofloxacin
  3. Additional coverage in special circumstances
    1. Sickle Cell Anemia (include Salmonella coverage)
      1. Add Fluoroquinolone (not in children)
    2. IV Drug Abuse or Hemodialysis patient
      1. Add Ciprofloxacin
  4. Other specific management (based on cultures)
    1. Candida Albicans
      1. Surprisingly, most often occurs in immunocompetent patients
      2. Most common sites are Vertebrae in adults, the femur in children
      3. Surgical Debridement and hardware removal is typical
      4. Treated with Antifungals for 6-12 months
        1. IV for First 2 weeks: Echinocandin (e.g. Caspofungin), Fluconazole or Amphotericin B
        2. Next: Fluconazole for 6-12 months
      5. Gamaletsou (2012) Clin Infect Dis 55(10):1338-51 +PMID:22911646 [PubMed]

IV. Management: Contiguous Osteomyelitis

  1. No Vascular Insufficiency
    1. Bacterial causes
      1. Staphylococcus aureus
      2. Coagulase Negative Staphylococcus
      3. Gram Negative Rods
      4. Streptococcus
      5. Pseudomonas aeruginosa
    2. Empiric antibiotics (only in acutely ill patients, otherwise wait for culture results)
      1. Vancomycin (or Linezolid) AND
      2. Cephalosporin (Ceftazidime or Cefepime)
    3. Antibiotics after culture identifies Bacteria
      1. Methicillin sensitive Staphylococcus aureus
        1. First-line: Nafcillin, Oxacillin, Cefazolin
        2. Alternative: Quinolone (Ciprofloxacin or Levofloxacin) AND Rifampin
      2. Methicillin Resistant Staphylococcus Aureus
        1. First-line: Vancomycin
        2. Alternative: Linezolid
      3. Gram-Negative Bacteria
        1. Ciprofloxacin
        2. Levofloxacin
    4. Antibiotic course
      1. Duration if no hardware: 6-8 weeks
      2. Duration if hardware: 3-6 months (or until hardware removed)
  2. Vascular Insufficiency (Peripheral Arterial Disease or Diabetes Mellitus with Neuropathy)
    1. See Diabetic Foot Infection
    2. See Diabetic Foot Osteomyelitis
    3. Antibiotics for 6 weeks based on bone culture and sensitivity
    4. Empiric antibiotics (only in acutely ill patients, otherwise wait for culture results)
      1. Vancomycin AND Ertapenem (or Moxifloxacin)
    5. Other measures
      1. Consider revascularization

V. Management: Chronic Osteomyelitis

  1. Avoid Empiric antibiotics unless acute exacerbation
    1. Treat acute exacerbation as Acute Osteomyelitis
  2. Base management on culture and sensitivity
    1. Bone biopsy culture and sensitivity (preferred)
    2. Soft-tissue culture and sensitivity
  3. Antibiotic duration for 2 to 6 weeks
  4. Surgical Debridement with
    1. Careful and complete Debridement is critical
    2. Dead-space management
      1. Local myoplasty
      2. Free-tissue transfers
      3. Antibiotic impregnated beads

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