II. Management: General

  1. If possible, delay antibiotics until bone culture and sensitivity are available
  2. Bone biopsy and surgical debridement

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. Age under 4 months
    1. Nafcillin or Oxacillin (or Vancomycin) and
    2. Cefotaxime or Ceftriaxone
  3. Age 4 months to 21 years
    1. Nafcillin or Oxacillin (or Vancomycin or Clindamycin)
    2. Add Cefotaxime or Ceftriaxone for Gram Stain with G-
  4. Age over 21 years
    1. Nafcillin or Oxacillin or Cefazolin (or Vancomycin)

IV. Management: Acute Osteomyelitis Special Circumstances

V. Management: Contiguous Osteomyelitis

  1. No Vascular Insufficiency
    1. Post-op ORIF Fracture
      1. Nafcillin and Ciprofloxacin or
      2. Vancomycin with Cefotaxime or Ceftriaxone
    2. Post-op Sternotomy
      1. Vancomycin and Rifampin
    3. Post-nail puncture of foot via tennis shoe
      1. Ceftazidime or Cefepime (or Ciprofloxacin)
  2. Vascular Insufficiency
    1. Mild (Outpatient Management)
      1. Augmentin
    2. Severe (Inpatient Management)
      1. Imipenem or meropenem or
      2. Timentin or Zosyn or
      3. Unasyn or
      4. Trovafloxacin

VI. 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

VII. Management: Osteomyelitis due to Staphylococcus aureus

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