Sandbox osteomyelitis

# Acute Osteomyelitis in Adults  Empiric Therapy
Although osteomyelitis in adults usually has a subacute or chronic course, acute hematogenous seeding may occur in elderly patients, intravenous drug users, or patients with indwelling catheters.  The most commonly isolated microorganisms are Staphylococcus aureus and Streptococcus pneumonia.  Empiric antibiotics with anti-staphylococcal and anti-streptococcal coverage should be administered based on local resistance data.

# Acute Osteomyelitis in Children  Empiric Therapy
Abbreviations:
OSSA, oxacillin-sensitive Staphylococcus aureus;
ORSA, Oxacillin-resistant Staphylococcus aureus;
CRSA, Clindamycin-resistant Staphylococcus aureus.

## High prevalence of OSSA in community
- Preferred regimen
First-generation cephalosporin (Cefadroxil, Cefazolin, Cephalexin) 150 mg/kg/day administered in 4 equal doses
- First-generation cephalosporin (Cefadroxil, Cefazolin, Cephalexin) 150 mg/kg/day administered in 4 equal doses
- Alternative regimen
Antistaphylococcal penicillin (Cloxacillin, Flucloxacillin, Dicloxacillin, Nafcillin, Oxacillin)  200 mg/kg/day administered in 4 equal doses
- Antistaphylococcal penicillin (Cloxacillin, Flucloxacillin, Dicloxacillin, Nafcillin, Oxacillin)  200 mg/kg/day administered in 4 equal doses

## High prevalence of ORSA with low prevalence of CRSA in community
- Preferred regimen
Clindamycin  40 mg/kg/day administered in 4 equal doses
- Clindamycin  40 mg/kg/day administered in 4 equal doses

## High prevalence of ORSA with high prevalence of CRSA in community
- Preferred regimen
Vancomycin  40 mg/kg/day administered in 4 equal doses, adjust dosage to trough of 1520 mcg/mL
- Vancomycin  40 mg/kg/day administered in 4 equal doses, adjust dosage to trough of 1520 mcg/mL
- Alternative regimen
Linezolid 30 mg/kg/day administered in 3 equal doses
- Linezolid 30 mg/kg/day administered in 3 equal doses

# Chronic Osteomyelitis in Adults  Pathogen-Based Therapy

## OSSA
- Preferred regimen
Oxacillin 1.52 g IV q4h for 46 wk OR Cefazolin 12 g IV q8h for 46 wk
- Oxacillin 1.52 g IV q4h for 46 wk OR Cefazolin 12 g IV q8h for 46 wk
- Alternative regimen
Vancomycin 15 mg/kg IV q12h for 46 wk OR
Oxacillin 1.52 g IV q4h for 46 wk AND Rifampin 600 mg PO qd
- Vancomycin 15 mg/kg IV q12h for 46 wk OR
- Oxacillin 1.52 g IV q4h for 46 wk AND Rifampin 600 mg PO qd

## ORSA
- Preferred regimen
Vancomycin 15 mg/kg IV q12h for 46 wk OR Daptomycin 6 mg/kg IV q24h
- Vancomycin 15 mg/kg IV q12h for 46 wk OR Daptomycin 6 mg/kg IV q24h
- Alternative regimen
Linezolid 600 mg PO/IV q12h for 6 wk  Rifampin 600900 mg PO qd OR
Levofloxacin 500750 mg PO/IV daily  Rifampin 600900 mg PO qd
- Linezolid 600 mg PO/IV q12h for 6 wk  Rifampin 600900 mg PO qd OR
- Levofloxacin 500750 mg PO/IV daily  Rifampin 600900 mg PO qd

## Penicillin-sensitive Streptococcus
- Preferred regimen
Penicillin G 20 MU/day IV continuously or q4h for 46 wk OR Ceftriaxone 12 g IV/IM q24h for 46 wk OR Cefazolin 12 g IV q8h for 46 wk
- Penicillin G 20 MU/day IV continuously or q4h for 46 wk OR Ceftriaxone 12 g IV/IM q24h for 46 wk OR Cefazolin 12 g IV q8h for 46 wk
- Alternative regimen
Vancomycin 15 mg/kg IV q12h for 46 wk
- Vancomycin 15 mg/kg IV q12h for 46 wk

## Enterococcus or Streptococcus (MIC  0.5 g/mL) or Abiotrophia or Granulicatella
- Preferred regimen
Penicillin G 20 MU/day IV continuously or q4h for 46 wk  Gentamicin 1 mg/kg IV or IM q8h for 12 wk OR
Ampicillin 12 g/day IV continuously or q4h for 46 wk  Gentamicin 1 mg/kg IV or IM q8h for 12 wk
- Penicillin G 20 MU/day IV continuously or q4h for 46 wk  Gentamicin 1 mg/kg IV or IM q8h for 12 wk OR
- Ampicillin 12 g/day IV continuously or q4h for 46 wk  Gentamicin 1 mg/kg IV or IM q8h for 12 wk
- Alternative regimen
Vancomycin 15 mg/kg IV q12h for 46 wk  Gentamicin 1 mg/kg IV or IM q8h for 12 wk
- Vancomycin 15 mg/kg IV q12h for 46 wk  Gentamicin 1 mg/kg IV or IM q8h for 12 wk

## Enterobacteriaceae
- Preferred regimen
Ceftriaxone 12 g IV/IM q24h for 46 wk OR Ertapenem 1 g IV q24h
- Ceftriaxone 12 g IV/IM q24h for 46 wk OR Ertapenem 1 g IV q24h
- Alternative regimen
Levofloxacin 500750 mg PO q24h OR Ciprofloxacin 500750 mg PO q12h for 46 wk
- Levofloxacin 500750 mg PO q24h OR Ciprofloxacin 500750 mg PO q12h for 46 wk

## Pseudomonas aeruginosa
- Preferred regimen
Cefepime 2 g IV q12h OR Meropenem 1 g IV q8h OR Imipenem 500 mg IV q6h for 46 wk
- Cefepime 2 g IV q12h OR Meropenem 1 g IV q8h OR Imipenem 500 mg IV q6h for 46 wk
- Alternative regimen
Ciprofloxacin 750 mg PO q12h OR Ceftazidime 2 g IV q8h for 46 wk
- Ciprofloxacin 750 mg PO q12h OR Ceftazidime 2 g IV q8h for 46 wk

# Chronic Osteomyelitis in Children  Pathogen-Based Therapy

## Group A beta-hemolytic Streptococcus, Haemophilus influenzae type b, and Streptococcus pneumoniae
- Preferred regimen
Ampicillin 150200 mg/kg/day administered in 4 equal doses OR Amoxicillin 150200 mg/kg/day administered in 4 equal doses
- Ampicillin 150200 mg/kg/day administered in 4 equal doses OR Amoxicillin 150200 mg/kg/day administered in 4 equal doses
- Alternative regimen
Chloramphenicol 75 mg/kg/day administered in 3 equal doses
- Chloramphenicol 75 mg/kg/day administered in 3 equal doses

# Vertebral Osteomyelitis
Abbreviations:
OSSA, oxacillin-sensitive Staphylococcus aureus;
ORSA, Oxacillin-resistant Staphylococcus aureus;
CRSA, Clindamycin-resistant Staphylococcus aureus.

## OSSA or coagulase-negative staphylococci
- Preferred regimen
Oxacillin 2 g IV q6h OR
Cefazolin 12 g IV q8h
- Oxacillin 2 g IV q6h OR
- Cefazolin 12 g IV q8h
- Alternative regimen
Levofloxacin 750 mg PO qd AND Rifampin 300 mg PO bid
- Levofloxacin 750 mg PO qd AND Rifampin 300 mg PO bid

## ORSA
- Preferred regimen
Vancomycin 1 g IV q12h
- Vancomycin 1 g IV q12h
- Alternative regimen
Daptomycin  6 mg/kg IV q24h OR
Levofloxacin 500750 mg PO/IV daily AND Rifampin 600900 mg PO qd
- Daptomycin  6 mg/kg IV q24h OR
- Levofloxacin 500750 mg PO/IV daily AND Rifampin 600900 mg PO qd

## Streptococcus
- Preferred regimen
Penicillin G 5 MU IV q6h
- Penicillin G 5 MU IV q6h
- Alternative regimen
Ceftriaxone 2 g IV q24h
- Ceftriaxone 2 g IV q24h

## Enterobacteriaceae, quinolone-susceptible
- Preferred regimen
Ciprofloxacin 750 mg PO q12h
- Ciprofloxacin 750 mg PO q12h
- Alternative regimen
Ceftriaxone 2 g IV q24h
- Ceftriaxone 2 g IV q24h

## Enterobacteriaceae, quinolone-resistant
- Preferred regimen
Imipenem 500 mg IV q6h
- Imipenem 500 mg IV q6h

## Pseudomonas aeruginosa
- Preferred regimen
Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h x 24 wk, followed by Ciprofloxacin 750 mg PO bid
- Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h x 24 wk, followed by Ciprofloxacin 750 mg PO bid
- Alternative regimen
PiperacillinTazobactam 750 mg PO q12h x 24 wk, followed by Ciprofloxacin 750 mg PO bid
- PiperacillinTazobactam 750 mg PO q12h x 24 wk, followed by Ciprofloxacin 750 mg PO bid

## Anaerobes
- Preferred regimen
Clindamycin 300600 mg IV q68h
- Clindamycin 300600 mg IV q68h
- Alternative regimen
Penicillin G 5 MU IV q6h OR Ceftriaxone 2 g IV q24h (against gram-positive anaerobes) {{or2}]
Metronidazole 500 mg PO tid (against gram-negative anaerobes)
- Penicillin G 5 MU IV q6h OR Ceftriaxone 2 g IV q24h (against gram-positive anaerobes) {{or2}]
- Metronidazole 500 mg PO tid (against gram-negative anaerobes)

# Specific Considerations
Osteomyelitis in patients with diabetes mellitus
Osteomyelitis in patients with vascular insufficiency
SAPHO syndrome
Chronic recurrent multifocal osteomyelitis
Osteitis Pubis
Osteomyelitis of the Clavicle
Osteomyelitis in Hemodialysis Patients
Osteomyelitis in Patients with Sickle Cell Disease
Gauchers Disease
Osteomyelitis in Injection Drug Users
Skeletal Mycobacterial Infection
Fungal Osteomyelitis
Brodies Abscess
Culture-Negative Osteomyelitis