ID
Osteomyelitis Management
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Osteomyelitis Management
See Also
Osteomyelitis
Osteomyelitis Causes
Vertebral Osteomyelitis
Osteomyelitis Management in Diabetes Mellitus
Management
Gene
ral
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
Rombach (2019) N Engl J Med 380(5):425-36 [PubMed]
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
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
Additional coverage in special circumstances
Sickle Cell Anemia
(include
Salmonella
coverage)
Add
Fluoroquinolone
(not in children)
IV Drug Abuse
or
Hemodialysis
patient
Add
Ciprofloxacin
Other specific management (based on cultures)
Candida Albicans
Surprisingly, most often occurs in immunocompetent patients
Most common sites are
Vertebra
e in adults, the femur in children
Surgical debridement and hardware removal is typical
Treated with
Antifungal
s 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]
Management
Contiguous
Osteomyelitis
No Vascular Insufficiency
Bacteria
l causes
Staphylococcus aureus
Coagulase Negative
Staphylococcus
Gram Negative Rod
s
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
Ciprofloxacin
Levofloxacin
Antibiotic course
Duration if no hardware: 6-8 weeks
Duration if hardware: 3-6 months (or until hardware removed)
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
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
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]
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