II. Management: General
- If possible, delay antibiotics until bone culture and sensitivity are available
- Bone biopsy and surgical debridement
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)
- Age under 4 months
- Nafcillin or Oxacillin (or Vancomycin) and
- Cefotaxime or Ceftriaxone
- Age 4 months to 21 years
- Nafcillin or Oxacillin (or Vancomycin or Clindamycin)
- Add Cefotaxime or Ceftriaxone for Gram Stain with G-
- Age over 21 years
- Nafcillin or Oxacillin or Cefazolin (or Vancomycin)
IV. Management: Acute Osteomyelitis Special Circumstances
-
Sickle Cell Anemia
- Fluoroquinolone (not in children) or
- Cefotaxime or Ceftriaxone
-
IV Drug Abuse or Hemodialysis patient
- Nafcillin (or Vancomycin) and Ciprofloxacin
V. Management: Contiguous Osteomyelitis
- No Vascular Insufficiency
- Post-op ORIF Fracture
- Nafcillin and Ciprofloxacin or
- Vancomycin with Cefotaxime or Ceftriaxone
- Post-op Sternotomy
- Vancomycin and Rifampin
- Post-nail puncture of foot via tennis shoe
- Ceftazidime or Cefepime (or Ciprofloxacin)
- Post-op ORIF Fracture
- Vascular Insufficiency
- Mild (Outpatient Management)
- Severe (Inpatient Management)
- Imipenem or meropenem or
- Timentin or Zosyn or
- Unasyn or
- Trovafloxacin
VI. 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
VII. Management: Osteomyelitis due to Staphylococcus aureus
-
Methicillin sensitive Staphylococcus aureus
- First-line: Nafcillin, Cefazolin
- Alternative: Clindamycin, Quinolone with Rifampin
-
Methicillin Resistant Staphylococcus Aureus
- First-line: Vancomycin
- Alternative: Linezolid, Daptomycin, Trimethoprim Sulfamethoxazole, Minocycline
VIII. References
- Gilbert (2001) Sanford Guide Antimicrobial, p. 2-3
- 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]
