II. Management: General
- If possible, delay antibiotics until bone culture and sensitivity are available
- Bone biopsy and surgical debridement
- Once obtaining surgical bone culture-based antibiotic sensitivities, oral antibiotics are as effective as parenteral
III. Management: Acute (Hematogenous Spread)
- Protocol
- Total antibiotic duration: 4 to 6 weeks (up to 3-6 months for prosthetic hip or knee)
- Parenteral antibiotics for first 1-2 weeks
- Oral antibiotics for remainder of course
- Obtain cultures before starting empiric antibiotics
- Revise antibiotic coverage upon culture results
- Total antibiotic duration: 4 to 6 weeks (up to 3-6 months for prosthetic hip or knee)
- First-line antibiotics (choose 2)
- Antibiotic 1: Vancomycin
- Vancomycin substitutes: Linezolid, Daptomycin, Trimethoprim-Sulfamethoxazole or if sensitive, Clindamycin
- Cefazolin or Nafcillin may be considered instead in non-life threatening infecton if low MRSA risk (<10%)
- Antibiotic 2: Cephalosporin (Ceftriaxone, Ceftazidime, Cefepime, Cefotaxime)
- Cephalosporin substitutes: Aztreonam, or if over age 15 years, Ciprofloxacin or Levofloxacin
- Antibiotic 1: Vancomycin
- Additional coverage in special circumstances
- Sickle Cell Anemia (include Salmonella coverage)
- Add Fluoroquinolone (not in children)
- IV Drug Abuse or Hemodialysis patient
- Add Ciprofloxacin
- Sickle Cell Anemia (include Salmonella coverage)
- Other specific management (based on cultures)
- Candida Albicans
- Surprisingly, most often occurs in immunocompetent patients
- Most common sites are Vertebrae in adults, the femur in children
- Surgical debridement and hardware removal is typical
- Treated with Antifungals for 6-12 months
- IV for First 2 weeks: Echinocandin (e.g. Caspofungin), Fluconazole or Amphotericin B
- Next: Fluconazole for 6-12 months
- Gamaletsou (2012) Clin Infect Dis 55(10):1338-51 +PMID:22911646 [PubMed]
- Candida Albicans
IV. Management: Contiguous Osteomyelitis
- No Vascular Insufficiency
- Bacterial causes
- Staphylococcus aureus
- Coagulase Negative Staphylococcus
- Gram Negative Rods
- Streptococcus
- Pseudomonas aeruginosa
- Empiric antibiotics (only in acutely ill patients, otherwise wait for culture results)
- Vancomycin (or Linezolid) AND
- Cephalosporin (Ceftazidime or Cefepime)
- Antibiotics after culture identifies Bacteria
- Methicillin sensitive Staphylococcus aureus
- First-line: Nafcillin, Oxacillin, Cefazolin
- Alternative: Quinolone (Ciprofloxacin or Levofloxacin) AND Rifampin
- Methicillin Resistant Staphylococcus Aureus
- First-line: Vancomycin
- Alternative: Linezolid
- Gram-Negative Bacteria
- Methicillin sensitive Staphylococcus aureus
- Antibiotic course
- Duration if no hardware: 6-8 weeks
- Duration if hardware: 3-6 months (or until hardware removed)
- Bacterial causes
- Vascular Insufficiency (Peripheral Arterial Disease or Diabetes Mellitus with Neuropathy)
- See Diabetic Foot Infection
- See Diabetic Foot Osteomyelitis
- Antibiotics for 6 weeks based on bone culture and sensitivity
- Empiric antibiotics (only in acutely ill patients, otherwise wait for culture results)
- Vancomycin AND Ertapenem (or Moxifloxacin)
- Other measures
- Consider revascularization
V. Management: Chronic Osteomyelitis
- Avoid Empiric antibiotics unless acute exacerbation
- Treat acute exacerbation as Acute Osteomyelitis
- Base management on culture and sensitivity
- Bone biopsy culture and sensitivity (preferred)
- Soft-tissue culture and sensitivity
- Antibiotic duration for 2 to 6 weeks
- Surgical debridement with
- Careful and complete debridement is critical
- Dead-space management
- Local myoplasty
- Free-tissue transfers
- Antibiotic impregnated beads
VI. References
- (2019) Sanford Guide, accessed on IOS 10/26/2019
- Bamberger (2005) Am Fam Physician 72:2471-81 [PubMed]
- Boutin (1998) Orthop Clin North Am 29:41-66 [PubMed]
- Carek (2001) Am Fam Physician 63(12):2413-20 [PubMed]
- Hatzenbuehler (2011) Am Fam Physician 84(9): 1027-33 [PubMed]
- Lew (1997) N Engl J Med 336:999-1007 [PubMed]
- Lipsky (1997) Clin Infect Dis 25:1318-26 [PubMed]