Bone and Joint Infections

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 normal^3,4
		Enterobacteriaceae (occasionally)	TMP/SMX	8-10mg/kg/day TMP IV/PO in 3-4 divided doses	6 weeks minimum, then continue until ESR normal^3,4
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
Intravenous Drug User	vancomycin + gentamicin	same as above + methicillin resistant S. aureus	same as empiric (if culture data not available)	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 normal^3,4
		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 normal^3,4
		anaerobes (especially Clostridia spp.)	penicillin G	2mu IV q 4 hour	6 weeks minimum, then continue until ESR normal^3,4
Contiguous with decubitus ulcer/ diabetic foot	TMP/SMX ± metronidazole^7,8	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 normal^3,4

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 cefixime^4,5 + 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

Back to Table of Contents