University of Pennsylvania Medical Center Guidelines for Antibiotic Use

 

BONE AND JOINT INFECTIONS

Clinical Setting

Empiric Treatment

Likely Pathogens

Definitive Treatment

Dosage Regimen

Duration

Osteomyelitis1

Normal Host

nafcillin2 or cefazolin2

S. aureus

nafcillin2 or

cefazolin2

2gm IV q 4-6 hour

500mg IV q 8 hour

6 weeks minimum, then continue until ESR normal3,4

Enterobacteriaceae (occasionally)

TMP/SMX

8-10mg/kg/day TMP IV/PO in 3-4 divided doses

Intravenous Drug User

vancomycin + gentamicin

same as above + methicillin resistant S. aureus

same as empiric (if culture data not available)

gentamicin5 - see this link

2 weeks

vancomycin - see this link

6 weeks minimum, then continue until ESR normal4

Post-operative

TMP/SMX

S. aureus

nafcillin2 or

cefazolin2

2gm IV q 4-6 hour

500mg IV q 8 hour

6 weeks minimum, then continue until ESR normal3,4

coagulase negative staphylococcus

vancomycin

see this link

Enterobacteriaceae

TMP/SMX

8-10mg/kg/day TMP IV in 3-4 divided doses

P. aeruginosa

piperacillin ±

gentamicin

4 gm IV q 6 hour

see this link

Post- traumatic

ampicillin/ sulbactam6

same as above, including:

same as above

same as above

6 weeks minimum, then continue until ESR normal3,4

anaerobes (especially Clostridia spp.)

penicillin G

2mu IV q 4 hour

Contiguous with decubitus ulcer/ diabetic foot

TMP/SMX ± metronidazole7,8

polymicrobial

same as empiric

TMP/SMX 8-10mg/kg/day TMP IV in 3-4 divided doses

metronidazole 500mg IV/PO q 12 hour

6 weeks minimum, then continue until ESR normal3,4

 

1For optimal treatment, microorganism(s) should be identified by aspiration or bone biopsy; debridement will enhance cure rate

2If beta-lactam allergy use clindamycin or trimethoprim sulfamethoxazole; if MRSA-use vancomycin

3Should switch to oral therapy once clinical improvement occurs

4Use of ESR is controversial in this setting; if normal when therapy initiated, treat for 6 weeks

5Can switch to levofloxacin 500mg PO q 24 hour in combination with IV vancomycin

6Ampicillin/sulbactam dose=1.5gm IV q 6 hours

7Metronidazole: use if foul odor present

8Not for aggressive anaerobic infections in diabetic hosts

BONE AND JOINT INFECTIONS-Cont'd.

Clinical Setting

Empiric Treatment

Likely Pathogens

Definitive Treatment

Dosage Regimen

Duration

Septic Arthritis1

Normal Host

nafcillin2 or cefazolin2

S. aureus

nafcillin2 or

cefazolin2

2gm IV q 4-6 hour

500mg IV q 8 hour

4-6 weeks3

Enterobacteriaceae

TMP/SMX

8-10mg/kg/day TMP IV in 3-4 divided doses

group A streptococcus

penicillin G

8-12mu/d IV in 4-6 divided doses

Sexually Active

ceftriaxone

N. gonorrhoeae

ceftriaxone

1gm IV q 24 hour

7-10 days

+doxycycline

100mg PO BID

then cefixime4,5 + doxycycline

400mg PO q day

100mg PO BID

S. aureus

same as above

same as above

Prosthetic Joint6

vancomycin + gentamicin

coagulase negative staphylococcus

vancomycin

see this link

4-6 weeks7

S. aureus

nafcillin2 or

cefazolin2

2gm IV q 4-6 hour

500mg IV q 8 hour

P. aeruginosa

piperacillin ±

gentamicin

4 gm IV q 6 hour

see this link

Enterobacteriaceae

TMP/SMX

8-10mg/kg/day TMP IV in 3-4 divided doses

 

1Complete drainage required for adequate therapy

2If beta-lactam allergy use clindamycin or trimethoprim/sulfamethoxazole; if MRSA-use vancomycin

3Should switch to oral therapy once clinical improvement occurs

4Should switch to oral therapy after 3 days of IV or IM therapy

5Cefixime is a non-formulary agent: a nonformulary request form must be completed

6Removal of prosthesis may be required

7May require subsequent oral therapy to eradicate infection

updated 9/28/04 by Lori LaRosa

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