Chapter 120. Osteomyelitis (Part 5)

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Table 120-2 Selection of Antibiotics for Treatment of Acute Osteomyelitis Suggested Regimena Organism Primary Alternativesb Staphylococcus aureus Penicillin- Nafcillin or oxacillin, 2 g Cefazolin, 1 g IV resistant, methicillin- IV q4h q8h; ceftriaxone, 1 g IV q24h; clindamycin, 900 mg IV q8hc sensitive (MSSA) Penicillinsensitive Penicillin, 3–4 million U IV q4h Cefazolin, ceftriaxone, clindamycin (as above) Methicillinresistant (MRSA) Vancomycin, 15 mg/kg Clindamycinc (as IV q12h; rifampin, 300 mg PO above); linezolid, 600 q12h (see text) mg IV or PO q12hd; daptomycin, 4–6 mg/kg IV q24hd Streptococci (including S. milleri, bhemolytic streptococci) Penicillin (as above) Cefazolin, ceftriaxone, clindamycin (as above) Gram-negative aerobic bacilli Escherichia Ampicillin, 2 g IV q4h; Ceftriaxone, 1 g IV q24h; parenteral or oral fluoroquinolone ...

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Chapter 120. Osteomyelitis (Part 5) Table 120-2 Selection of Antibiotics for Treatment of Acute Osteomyelitis Suggested Regimena Organism Primary Alternativesb Staphylococcus aureus Penicillin- Nafcillin or oxacillin, 2 g Cefazolin, 1 g IV
resistant, methicillin- IV q4h q8h; ceftriaxone, 1 g IV sensitive (MSSA) q24h; clindamycin, 900 mg IV q8hc Penicillin- Penicillin, 3–4 million U Cefazolin, sensitive IV q4h ceftriaxone, clindamycin (as above) Methicillin- Vancomycin, 15 mg/kg Clindamycinc (as resistant (MRSA) IV q12h; rifampin, 300 mg PO above); linezolid, 600 q12h (see text) mg IV or PO q12hd; daptomycin, 4–6 mg/kg IV q24hd Streptococci Penicillin (as above) Cefazolin, (including S. milleri, b- ceftriaxone, clindamycin hemolytic (as above) streptococci)
Gram-negative aerobic bacilli Escherichia Ampicillin, 2 g IV q4h; Ceftriaxone, 1 g coli, other "sensitive" cefazolin, 1 g IV q8h IV q24h; parenteral or species oral fluoroquinolone (e.g., ciprofloxacin, 400 mg IV or 750 mg PO q12h)e Pseudomonas Extended-spectrum b- May substitute aeruginosa lactam agent (e.g., piperacillin, parenteral or oral 3–4 g IV q4–6h; or ceftazidime, fluoroquinolone for b- 2 g IV q12h) plus tobramycin, lactam agents (if patient 5–7 mg/kg q24hf is allergic) or for tobramycin (in relation to nephrotoxicity) Enterobacter Extended-spectrum b-
spp., other "resistant" lactam agent IV or species fluoroquinolone IV or POe (as above) Mixed infections Ampicillin/sulbactam, Carbapenem possibly involving 1.5–3 g IV q6h; antibiotic or a anaerobic bacteria piperacillin/tazobactam, 3.375 g combination of a IV q6h fluoroquinolone plus clindamycin (as above) or metronidazole, 500 mg PO tid a Duration of treatment is discussed in the text. b Cephalosporins may be used for the treatment of patients allergic to penicillin whose reaction did not consist of anaphylaxis or urticaria (immediate- type hypersensitivity). c Because of the possibility of inducible resistance, clindamycin must be used with caution for the treatment of strains resistant to erythromycin. Consult
clinical microbiology laboratory. d Experience is limited; there are anecdotal reports of efficacy. e Oral fluoroquinolones must not be coadministered with divalent cations (calcium, magnesium, iron, aluminum), which block the drugs' absorption. f Tobramycin levels and renal function must be monitored closely to minimize the risks of nephro- and ototoxicity.