Antibiotic Therapy for Osteomyelitis in Adults Without Implantsa | |
| MICROORGANISM | ANTIMICROBIAL AGENT (DOSE,b ROUTE) |
|---|---|
| Staphylococcus spp. | |
| Methicillin-susceptible | Nafcillin or 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-resistant | Vancomycind (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-susceptible Quinolone-resistantf | Ciprofloxacin (750 mg PO q24h) Imipenem (500 mg IV q6h) |
| Pseudomonas aeruginosa | Cefepime or ceftazidime (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) |
| Anaerobes | Clindamycin (600 mg IV q6-8h) for 2-4 weeks followed by Clindamycini (300 mg PO q6h) |
a Unless otherwise indicated, the total duration of antimicrobial treatment is generally 6 weeks.
b All dosages are for adults with normal renal function.
c When 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).
d Target 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.
g The 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.
h The 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.
i Alternatively, 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 Zimmerli W: Vertebral Osteomyelitis. N Engl J Med 362:1022, 2010. © Massachusetts Medical Society. Reprinted with permission.