4.01 - Bone and Joint Infections

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

 
Septic Arthritis
 S. aureus

 
Cloxacillin 2 gm IV q4 - 6H

Cefazolin 2 gm IV q6 - 8H

Penicillin allergy:
Clindamycin 600 mg IV q8H


Duration:
Initial IV therapy 2 weeks. 
Oral therapy (2 - 4 weeks)
Total duration: 4 - 6 weeks.

*For IV to oral conversion, see notes below.

 
Acute Osteomyelitis
S. aureus (80%)
Strep pyogenes
Gram Negative Bacilli (rare)
 
Cloxacillin 2 gm IV q6H
 
Cefazolin 2 gm IV q8H

Penicillin allergy:
Clindamycin 600 mg IV q8H
OR
Vancomycin 15 - 20 mg/kg IV q8 - 12H


Duration:
Initial IV therapy 2 weeks, followed by oral.

Total duration: Minimum 6 weeks.

Tailored to tissue culture and sensitivity as swab culture is not reliable.

*For IV to oral conversion, see notes below.
 
Chronic Osteomyelitis
(therapy should be based on bone biopsy culture)

Commenest: S. aureus


 
Co-amoxiclav 1.2 gm IV q8H
 
Piperacillin / Tazobactam 4.5 gm IV q8H
 
Duration:
Minimum duration 6 weeks.
To extend if clinical improvement not sufficient.

If osteomyelitis fully resected (i.e. amputation), stop antibiotics when operative wound is healing.

Ideally therapy should be based on bone biopsy culture as swab culture is not reliable. Culture from bone biopsy is vital for recurrent disease.
Surgical debridement of sequestra or foreign body.

 
Infection After Fracture (Hardware Retained)

Fracture Fixation Infection


 
Ceftazidime 2 gm IV q8H
+
Vancomycin 15 - 20 mg/kg IV q8 - 12H
±
Metronidazole IV 500 mg q8H
 

 
Debridement and tissue for culture. 

Duration:
Acute Infection (within 3 weeks after implant insertion):
Antibiotics required until bone union (minimum 6 weeks).
Delayed Infection (≥ 3 weeks after implant insertion):
Antibiotics required as long as implant is present.
Implant SHOULD be removed after bone union and continue the antibiotics for 1 week post removal.

Rifampicin should be added if there is staphylococcal infection.

 
Muscular, Skeletal and Soft Tissue Trauma, Crush Injuries, Stab Wounds

 
Cefazolin 2 gm IV q8H

Cefuroxime 1.5 gm IV single dose then 750 mg IV q8H
 
Duration: 5 - 10 days.

Add Metronidazole 500 mg IV q8H ± Gentamicin 3 - 5 mg/kg IV q24H if contaminated wound, abdominal injury or devitalized tissue.

 
Open Fractures
 
Cefazolin 2 gm IV q8H
 
Cefuroxime 1.5 gm IV single dose then q8H

 
No need to obtain cultures in the setting of superficial debridement of necrotic tissue.
If subsequent debridement is performed for suspected infection, bone and tissue culture is warranted

Gustillo type I and II open fractures: discontinue after 24 hours. 

Gustillo type III open fractures: discontinue after 72 hours or within a day after soft tissue injuries have been closed (5 - 10 days). 


Add Metronidazole 500 mg IV q8H ± Gentamicin 3 - 5 mg/kg IV q24H depending on severity and exposure causing wound contamination.

 
Flexor Tenosynovitis
S. aureus
Streptococcus
Gram negative rods

 
Cloxacillin 2 gm IV q6H
± Gentamicin 3 - 5 mg/kg IV q24H
 
Cefazolin 1- 2 gm IV q8H
 
Duration: 5 - 10 days.
(subject to clinical assesment)
 
Paronychia / Felon
 
Cloxacillin 2 gm IV q6H
 
Cefazolin 1 - 2 gm IV q8H
 
Duration: 5 - 10 days.

 
Vetebral Osteomyelitis
S. aureus
 
Cloxacillin 2 gm IV q4H
 
Cefazolin 2 gm IV q6 - 8H
 
Total Duration:
Minimum 6 weeks.
Minimum 8 weeks if undrained paravertebral abscess(es) and / or infection due to drug-resistant organisms.
Up to 12 weeks if extensive bone destruction.

Penicillin allergy: Vancomycin / Clindamycin, consider ID consult.

*For IV to oral conversion, see notes below.

 
Spinal Implant Infection
(Antibiotic based on culture results)

 
Bone culture warranted prior starting antibiotics.

Early onset < 30 days
Debridement and retain hardware (90% success)
2 weeks IV antibiotic, minimum duration of total antibiotic 10 weeks

Late onset > 30 days
a) Debridement and remove hardware: 2 weeks IV antibiotic, minimum duration of total antibiotic 10 weeks.
b) Debridement and hardware retained: 2 weeks IV antibiotic and total duration of antibiotic is until there is fusion (the hardware will be removed if there is clinical sign of ongoing infection).

 
* IV to Oral Conversion:
Most require completion of treatment with parenteral therapy.
Completion of treatment with oral therapy following at least 2 weeks of parenteral therapy may be reasonable in the following circumstances:
  • The infection is uncomplicated and the patient has no significant comorbidities.
  • A favorable clinical response to initial parenteral therapy is observed (CRP reducing).
  • A suitable oral drug with proven susceptibility to the causative organism is available.
  • Compliance with oral therapy can be assured or carefully monitored.
  • Adequate source control.
Oral options for bone infection include:
        Clindamycin 600 mg q8H
        Doxycycline 100 mg q12H
        Co-Trimoxazole 4x (400 mg / 80 mg) q12H
        Rifampicin 300 mg q12H (Must always be used in combination)
        Fusidic Acid 500 mg q8H (Must always be used in combination)
        Metronidazole 400 mg q8H
        Cephalexin 500 mg 1 gm q6H
        Co-Amoxiclav 625 mg q8H
        Ampicillin / Sulbactam 750 mg q12H
        Linezolid 600 mg q12H
        Ciprofloxacin 750 mg q12H**
        
        ** Fluroquinolones is associated with collateral damage. Reserve for use in patients who have no alternative treatment options)
         

Prosthetic Joint Infection

Give antibiotics (including surgical prophylaxis) only after collecting specimens.

 
MSSA

 
Cloxacillin 2 gm IV q4 - 6H
+ Rifampicin 600 mg PO q24H for 2 - 6 weeks

Followed by: 
Rifampicin 600 mg PO q24H
+ Cephalexin 500 mg - 1000 mg PO q6H

 
Cefazolin 2 gm IV q8H
OR 
Clindamycin 600 mg IV q8H

Rifampicin 600 mg PO q24H for 2 - 6 weeks

Followed by: 
Rifampicin 600 mg PO q24H

+ Cephalexin 500 - 1000 mg PO q6H


Duration:
1-Stage Exchange Strategy / Debridement and Implant Retention:
Knee: IV / PO regimen for 6 months.
Hip and others: IV / PO regimen for 3 months.
2-Stage Exchange Strategy:
IV/PO regimen for 4 - 6 weeks.

If prolonged therapy needed (beyond 3 months), stop Rifampicin and continue with the other oral agent being used as monotherapy.

 
MRSA

 
Vancomycin 15 - 20 mg/kg IV q8 - 12H
Rifampicin 600 mg PO q24H

Followed by:
Rifampicin 600 mg PO q24H
+ Sodium Fusidate 500 mg PO q8H 

 
Duration:
1-Stage Exchange Strategy / Debridement and Implant Retention:

Knee: IV / PO regimen for 6 months.
Hip and others: IV / PO regimen for 3 months.
2-Stage Exchange Strategy:
IV/PO regimen for 4 - 6 weeks.


 
β-Hemolytic Streptococci


Benzylpenicillin 20 – 24 MU IV daily divided q6H



 
Cefazolin 2 gm IV q8H
OR Clindamycin 600 mg IV q8H

 
Duration: Initial IV therapy 4 - 6 weeks.
 
Enterococcus

 
Benzylpenicillin 20 – 24 MU IV daily divided q6H 
OR
Ampicillin 2 gm IV q6H



 
Vancomycin 15 - 20 mg/kg IV q8 - 12H
 
Duration: Initial IV therapy 4 - 6 weeks.
 
Pseudomonas aeruginosa
 
Ceftazidime 2 gm IV q8H
+ Gentamicin 3 - 5 mg/kg IV q24H for 4 - 6 weeks



 
Piperacillin / Tazobactam
4.5 gm IV q8H for 4 - 6 weeks

 
Duration: Initial IV therapy 4 - 6 weeks.
 
Propionibacterium acnes
 
Benzylpenicillin 20 MU IV daily divided q4H for 4 - 6 weeks


 
Ceftriaxone 2 gm IV q24H
OR
Clindamycin 600 mg IV q8H or 450 mg PO q8H for 4 - 6 weeks

 
Duration: IV for 4 - 6 weeks.


B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

Septic Arthritis


Neonates:
Group B streptococcus
MSSA
Escherichia coli
Gram negatives
Candida albicans (on TPN )

 
Cefotaxime 50 mg/kg IV q12H (< 7 days of life);
50 mg/kg q6 - 8H (> 7 days of life)
+ Cloxacillin 50 mg/kg IV q12H (< 7 days of life);
q6H (> 7 days of life)


For term infant:
Clindamycin 15 - 20 mg/kg/day IV in 3 - 4 divided doses in penicillin allergy
 
Final choice of antibiotics depends on C&S of pus obtained from joint aspiration or at surgery.
 
Older Children:
MSSA
Group A Streptococcus
S pneumoniae
Haemophilus spp
(non-typable)
MRSA

Co-amoxiclav 25 mg/kg 
(Amoxicillin component) IV q8H 
OR
Cefuroxime 25 - 30 mg/kg IV (max 1.5 gm) q8H
± Cloxacillin 50 mg/kg IV q6H
 
For documented MRSA:
Sodium Fusidate 6 - 7 mg/kg (max 500 mg) IV q8H
given by infusion over q6 - 8H
+ Rifampicin 10 - 15 mg/kg (max 600 mg) PO q24H
OR
Linezolid 10 mg/kg IV (max 600 mg) q8H

 
Duration: at least 3 - 4 weeks; IV to oral switch permissible upon good clinical response.

Vancomycin penetrates poorly into synovial space. Cefotaxime and Ceftriaxone have poor effectiveness for Staph aureus.

IV Sodium Fusidate is not available in UMMC.

Osteomyelitis


Neonates:
Staph aureus
Group B Streptococci
Coliforms
Pseudomonas aeruginosa
Candida spp
 
Cloxacillin 50 mg/kg IV
q12H (< 7 days of life);
q6H (> 7 days of life)
+
Cefotaxime 50 mg/kg IV q12H (< 7 days of life);
50 mg/kg q6 - 8H (> 7 days of life)

 
For MRSA:
Linezolid 10 mg/kg IV (max 600 mg) q8H
 
Ceftazidime 50 mg/kg IV (max 2 gm) q8H or Aminoglycoside if Pseudomonas isolated.
 
Older Children:
Staph aureus
Group A Streptococcus
Haemophilus spp
S pneumoniae
Anaerobes

 
Cloxacillin 50 mg/kg IV q6H
 
Clindamycin 6 - 10 mg/kg IV (max 1.2 gm) q6H
 
Duration: 6 weeks

Adapted from w. zimmerli. Current concept.