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Table 84-2

Antibiotic Therapy for Osteomyelitis in Adults Without Implantsa

MicroorganismAntimicrobial Agent (Dose,b Route)
Staphylococcus spp.
Methicillin-susceptibleNafcillinor oxacillinc (2 g IV q6h)
followed by

Rifampin (300-450 mg PO q12h)

plus

levofloxacin (750 mg PO q24h or 500 mg PO q12h)

Methicillin-resistantVancomycind (15 mg/kg IV q12h) or daptomycin (>6-8 mg/kg IV q24h)
followed by
Rifampin (300-450 mg PO q12h)
plus
Levofloxacin (750 mg PO q24h or 500 mg PO q12h) or TMP-SMXe (1 double-strength tablet PO q8h) or fusidic acid (500 mg PO q8h)
Streptococcus spp.Penicillin Gc (5 million units IV q6h) or ceftriaxone (2 g IV q24h)
Enterobacteriaceae
Quinolone-susceptibleCiprofloxacin (750 mg PO q24h)
Quinolone-resistantfImipenem (500 mg IV q6h)
Pseudomonas aeruginosa

Cefepimeorceftazidime (2 g IV q8h)

plus

an aminoglycosideg

or

Piperacillin-tazobactam (4.5 g IV q8h)

plus

an aminoglycosideg for 2-4 weeks

followed by
Ciprofloxacinh (750 mg PO q12h)
AnaerobesClindamycin (600 mg IV q6-8h) for 2-4 weeks
followed by
Clindamycini (300 mg PO q6h)

aUnless otherwise indicated, the total duration of antimicrobial treatment is generally 6 weeks.

bAll dosages are for adults with normal renal function.

cWhen the pt has delayed-type penicillin hypersensitivity, cefuroxime (1.5 g IV q6-8h) can be administered. When the pt has immediate-type penicillin hypersensitivity, the penicillin should be replaced by vancomycin (1 g IV q12h).

dTarget vancomycin trough level: 15-20 µg/mL.

eTrimethoprim-sulfamethoxazole. A double-strength tablet contains 160 mg of trimethoprim and 800 mg of sulfamethoxazole.

f Including isolates producing extended-spectrum β-lactamase.

gThe need for addition of an aminoglycoside has not yet been proven. However, this addition may decrease the risk of emergence of resistance to the β-lactam.

hThe rationale for starting ciprofloxacin treatment only after pretreatment with a β-lactam is the increased risk of emergence of quinolone resistance in the presence of a heavy bacterial load.

iAlternatively, penicillin G (5 million units IV q6h) or ceftriaxone (2 g IV q24h) can be used against gram-positive anaerobes (e.g., Propionibacterium acnes), and metronidazole (500 mg IV/PO q8h) can be used against gram-negative anaerobes (e.g., Bacteroides spp.).

Source: From W Zimmerli: N Engl J Med 362:1022, 2010. © Massachusetts Medical Society. Reprinted with permission.