Sandbox:omtx

# Overview

## Antimicrobial Regimens

### Hematogenous Osteomyelitis
- 1. Empiric antimicrobial therapy 
- 1.1 Adult (>21 yrs)
- 1.1.1 MRSA possible
- Preferred regimen: Vancomycin 1 g IV q12h (if over 100 kg, 1.5 g IV q12h)
- 1.1.2 MRSA unlikely
- Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h
- 1.2 Children (>4 months)
- 1.2.1 MRSA possible
- Preferred regimen: Vancomycin 40 mg/kg/day IV q68h
- 1.2.2 MRSA unlikely
- Preferred regimen: Nafcillin 37 mg/kg IV q6h (maximum dose 812 g/day) OR Oxacillin 37 mg/kg IV q6h (maximum dose 812 g/day)
- Note: Add Ceftazidime 50 mg/kg IV q8h or Cefepime 150 mg/kg/day IV q8h if Gram-negative bacilli on Gram stain.
- 2. Pathogen-directed antimicrobial therapy
- 2.1 MSSA
- Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h OR Cefazolin 2 g IV q8h
- Alternative regimen: Vancomycin 1 g IV q12h (if over 100 kg, 1.5 g IV q12h)
- 2.2 MRSA
- Preferred regimen: Vancomycin 1 g IV q12h
- Alternative regimen: Linezolid 600 mg q12h IV/PO  Rifampin 300 mg po/IV bid

### Contiguous Osteomyelitis with Vascular Insufficiency
- Osteomyelitis, contiguous with vascular insufficiency 
- Debride overlying ulcer and send bone specimen for histology and culture.
- No empiric antimicrobial therapy unless acutely ill.
- Antibiotic therapy should be based on culture results
- Treatment duration is at least 6 weeks.
- Revascularize if possible.

### Open Fracture Osteomyelitis
- Long bone, post-internal fixation of fracture 
- 1. S. aureus  or  P. aeruginosa
- Preferred regimen: Vancomycin 1 g IV q12h AND (Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8h)
- Alternative regimen (1): Linezolid 600 mg IV/PO bid AND Ceftazidime 2 g IV q8h
- Alternative regimen (2): Linezolid 600 mg IV/PO bid AND Cefepime 2 g IV q8h
- 2. Gram negative bacilli
- Preferred regimen (1): Ciprofloxacin 750 mg PO bid
- Preferred regimen (2): Levofloxacin 750 mg PO qd

### Diabetic Foot Osteomyelitis
- 1. Chronic infection or recent antibiotic use 
- Preferred regimen (1): Levofloxacin 750 mg IV/PO q24h
- Preferred regimen (2): Cefoxitin 1 g IV q4h (or 2 g IV q68h)
- Preferred regimen (3): Ceftriaxone 12 g/day IV/IM q1224h
- Preferred regimen (4): Ampicillin-Sulbactam 1.53 g IV/IM q6h
- Preferred regimen (5): Moxifloxacin 400 mg IV/PO q24h
- Preferred regimen (6): Ertapenem 1 g IV/IM q24h
- Preferred regimen (7): Tigecycline 100 mg IV THEN 50 mg IV q12h (active against MRSA)
- Preferred regimen (8): Imipenem-Cilastatin 0.51 g IV q68h (Not active against MRSA)
- Alternative regimen (1): Levofloxacin 750 mg IV/PO q24h AND Clindamycin 150300 mg PO qid
- Alternative regimen (2): Ciprofloxacin 6001200 mg/day IV q612h AND Clindamycin 150300 mg PO qid
- Alternative regimen (3): Ciprofloxacin 12002700 mg IV q612h  AND Clindamycin 150300 mg PO qid (for more severe cases)
- 2. High risk for MRSA
- Preferred regimen (1): Linezolid 600 mg IV/PO q12h
- Preferred regimen (2): Daptomycin 4 mg/kg IV q24h
- Preferred regimen (3): Vancomycin 1520 mg/kg IV q812h (trough: 1020 mg/L)
- 3. High risk for Pseudomonas aeruginosa
- Preferred regimen: PiperacillinTazobactam 3.375 g IV q68h
- 4. Polymicrobial infection
- Preferred regimen: (Vancomycin 1520 mg/kg IV q812h (trough: 1020 mg/L) OR Linezolid 600 mg IV/PO q12h OR Daptomycin 4 mg/kg IV q24h) AND (PiperacillinTazobactam 3.375 g IV q68h OR ImipenemCilastatin 0.51 g IV q68h OR Ertapenem 1 g IV/IM q24h OR Meropenem 1 g IV q8h)
- Alternative regimen: (Vancomycin 1520 mg/kg IV q812h (trough: 1020 mg/L) OR Linezolid 600 mg IV/PO q12h OR Daptomycin 4 mg/kg IV q24h) AND (Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8h OR Aztreonam 2 g IV q68h) AND Metronidazole 15 mg/kg IV, then 7.5 mg/kg IV q6h
-  Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843..mw-parser-output cite.citation{font-style:inherit}.mw-parser-output q{quotes:"\"""\"""'""'"}.mw-parser-output code.cs1-code{color:inherit;background:inherit;border:inherit;padding:inherit}.mw-parser-output .cs1-lock-free a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-lock-limited a,.mw-parser-output .cs1-lock-registration a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-lock-subscription a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-subscription,.mw-parser-output .cs1-registration{color:#555}.mw-parser-output .cs1-subscription span,.mw-parser-output .cs1-registration span{border-bottom:1px dotted;cursor:help}.mw-parser-output .cs1-hidden-error{display:none;font-size:100%}.mw-parser-output .cs1-visible-error{display:none;font-size:100%}.mw-parser-output .cs1-subscription,.mw-parser-output .cs1-registration,.mw-parser-output .cs1-format{font-size:95%}.mw-parser-output .cs1-kern-left,.mw-parser-output .cs1-kern-wl-left{padding-left:0.2em}.mw-parser-output .cs1-kern-right,.mw-parser-output .cs1-kern-wl-right{padding-right:0.2em}
-  Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
-  Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
-  Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG;  et al. (2013). "2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections". J Am Podiatr Med Assoc. 103 (1): 27. PMID 23328846.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)