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Disease / Etiology
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Preferred
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Alternative
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Comments
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Septic Arthritis
S. aureus
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Cloxacillin 2 gm IV q4 - 6H |
Cefazolin 2 gm IV q6 - 8H
Penicillin allergy:
Clindamycin 600 mg IV q8H
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Duration:
Initial IV therapy 2 weeks.
Oral therapy (2 - 4 weeks)
Total duration: 4 - 6 weeks.
*For IV to oral conversion, see notes below.
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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
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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
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Co-amoxiclav 1.2 gm IV q8H
Or
Ampicilin-Sulbactam 3gm IV q8H |
Piperacillin / Tazobactam 4.5 gm IV q6H |
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.
Suggest HPE of the clean margin if possible.
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.
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Infection After Fracture (Hardware Retained)
Fracture Fixation Infection
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Ceftazidime 2 gm IV q8H
+
Vancomycin 15 - 20 mg/kg IV q8 - 12H
±
Metronidazole IV 500 mg q8H |
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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.
Antibiotics required as long
as implant is present
Rifampicin should be added if there is staphylococcal infection after the wound is clean and dry(
after 5-7 days).
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Muscular, Skeletal and Soft Tissue Trauma, Crush Injuries, Stab Wounds
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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.
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Open Fractures |
Cefazolin 2 gm IV q8H
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Cefuroxime 1.5 gm IV single dose then q8H
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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.
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Flexor Tenosynovitis
S. aureus
Streptococcus
Gram negative rods
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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.
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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.
Suggest to obtain HPE of
clean margin of the OM if possible
Penicillin allergy: Vancomycin / Clindamycin, consider ID consult.
*For IV to oral conversion, see notes below.
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Spinal Implant Infection
(Antibiotic based on culture results)
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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 12 weeks. (maximum duration guided by clinical,
biochemical and radiological progress)
Late onset > 30 days
a) Debridement and remove hardware: minimum 2 weeks IV
antibiotic, minimum duration of total antibiotic 10 12 weeks. (Maximum duration guided by
clinical, biochemical and radiological progress)
b) Debridement and hardware retained: minimum 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). (maximum duration guided by clinical,
biochemical and radiological progress)
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* 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 favourable 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 (480mg) 4 tablets q12H or 10mg/kg/day of TMP dose in divided dose
Rifampicin 300 mg q12H or 600mg q24H (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 (collateral damage
means ecological adverse effects of antibiotic therapy;
like selection of drug-resistant organisms and the unwanted development of
colonization or infection with multidrug-resistant organisms and also
C.difficile infection). Besides, Fluoroquinolones are also
associated with a number of adverse effects like tendonitis, tendon rupture,
prolonged Qtc which in turns leading to arrhythmia, delirium, dysglycemia (high
or low sugar), peripheral neuropathy and associated with aortic aneurysm and
rupture. All are in the black box FDA warning.
Reserve
for use in patients who have no alternative treatment options.
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Prosthetic Joint
Infection Refer: Pocket Guide to Diagnosis & Treatment of Periprosthetic Joint Infection (PJI) ( Version 8-1 March 2018) in section 9.0 Clinical pathway Culture
negative: Ampicillin/Sulbactam
3gm IV q8H for 2 weeks, followed
by Rifampicin
600mg PO q24H (gram positive & biofilm coverage) + Co-trimoxazole
(480mg) 4 tabs PO q12H(gram negative coverage) Give antibiotics
(including surgical prophylaxis) only after collecting specimens.
*Rifampicin should only be
added for Staphylococcus aureus
infection only if the old prosthesis is retained or new prosthesis is
implanted. Add it to the intravenous treatment as soon as wound are dry and
drains has removed (after 5-7 days).
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MSSA
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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
Or
Cloxacillin 1000mg 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
Or
Cloxacillin 1000mg PO q6H |
Duration:
1-Stage Exchange Strategy / Debridement and Implant Retention:
Knee: Total duration
of antibiotic regimen for 6 months.
Hip and others: Total duration of antibiotic regimen for 3 months.
2-Stage Exchange Strategy:
Total duration of antibiotic would be for 6-12
weeks in between the 2 stage surgery. Tailor
treatment according to clinical, biochemical and radiological improvement
Decision
to treat, total duration and choice of antibiotic after the second stage
procedure would depend on the culture result of the second stage procedure.
If prolonged therapy needed (beyond 3 months), stop Rifampicin and continue
with the other oral agent being used as monotherapy.
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MRSA
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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
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Duration:
1-Stage Exchange Strategy / Debridement and Implant Retention:
Knee: Total duration of antibiotic regimen for 6 weeks post re-implantation (depends on clinical, biochemical and radiological
improvement)
2-Stage Exchange Strategy:
Decision to treat, total duration
and choice of antibiotic after the second stage procedure would depend on the
culture result of the second stage procedure.
Post re-implantation, duration of
antibiotic should be minimum 6 weeks depending on clinical, biochemical and
radiological improvement.
If prolonged therapy needed
(beyond 3 months), stop Rifampicin and continue with the other oral agent being
used as mono-therapy.
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β-Hemolytic Streptococci
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Benzylpenicillin 20 – 24 MU IV daily divided q6H
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Cefazolin 2 gm IV q8H
OR Clindamycin 600 mg IV q8H
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Duration:
1-Stage Exchange Strategy / Debridement and Implant Retention:
Knee: Total
duration of antibiotic regimen for 6 weeks post re-implantation
(depends on clinical, biochemical and radiological improvement)
2-Stage Exchange Strategy:
Decision to treat, total duration
and choice of antibiotic after the second stage procedure would depend on the
culture result of the second stage procedure.
Post re-implantation, duration of
antibiotic should be minimum 6 weeks depending on clinical, biochemical and
radiological improvement.
If prolonged therapy needed
(beyond 3 months), stop Rifampicin and continue with the other oral agent being
used as mono-therapy.
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Enterococcus
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Benzylpenicillin 20 – 24 MU IV daily divided q6H
OR
Ampicillin 2 gm IV q6H
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Vancomycin 15 - 20 mg/kg IV q8 - 12H |
Duration:
1-Stage Exchange Strategy / Debridement and Implant Retention:
Knee: Total
duration of antibiotic regimen for 6 weeks post re-implantation
(depends on clinical, biochemical and radiological improvement)
2-Stage Exchange Strategy:
Decision to treat, total duration
and choice of antibiotic after the second stage procedure would depend on the
culture result of the second stage procedure.
Post re-implantation, duration of
antibiotic should be minimum 6 weeks depending on clinical, biochemical and
radiological improvement.
If prolonged therapy needed
(beyond 3 months), stop Rifampicin and continue with the other oral agent being
used as mono-therapy.
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Pseudomonas aeruginosa |
Ceftazidime 2 gm IV q8H
+ Gentamicin 3 - 5 mg/kg IV q24H for 4 - 6 weeks
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Piperacillin / Tazobactam
4.5 gm IV q8H for 4 - 6 weeks
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Duration:
1-Stage Exchange Strategy / Debridement and Implant Retention:
Knee: Total
duration of antibiotic regimen for 6 weeks post re-implantation
(depends on clinical, biochemical and radiological improvement)
2-Stage Exchange Strategy:
Decision to treat, total duration
and choice of antibiotic after the second stage procedure would depend on the
culture result of the second stage procedure.
Post re-implantation, duration of
antibiotic should be minimum 6 weeks depending on clinical, biochemical and
radiological improvement.
If prolonged therapy needed
(beyond 3 months), stop Rifampicin and continue with the other oral agent being
used as mono-therapy.
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Propionibacterium acnes |
Benzylpenicillin 20 MU IV daily divided q4H for 4 - 6 weeks
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Ceftriaxone 2 gm IV q24H
OR
Clindamycin 600 mg IV q8H or 450 mg PO q8H for 4 - 6 weeks
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Duration:
1-Stage Exchange Strategy / Debridement and Implant Retention:
Knee: Total
duration of antibiotic regimen for 6 weeks post re-implantation
(depends on clinical, biochemical and radiological improvement)
2-Stage Exchange Strategy:
Decision to treat, total duration
and choice of antibiotic after the second stage procedure would depend on the
culture result of the second stage procedure.
Post re-implantation, duration of
antibiotic should be minimum 6 weeks depending on clinical, biochemical and
radiological improvement.
If prolonged therapy needed
(beyond 3 months), stop Rifampicin and continue with the other oral agent being
used as mono-therapy.
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