3.01 - Bone and Joint Infections [updated]

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


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.

 
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.
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).


 
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.

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.

 
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 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)


 

* 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.                 

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). 

 
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

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.

 
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: Total duration of antibiotic regimen for 6 weeks post re-implantation (depends on clinical, biochemical and radiological improvement)


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.

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.


 
β-Hemolytic Streptococci


Benzylpenicillin 20 – 24 MU IV daily divided q6H



 
Cefazolin 2 gm IV q8H
OR Clindamycin 600 mg IV q8H

 
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:
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.

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.

 
Enterococcus

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


 
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:
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.

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.

 
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:

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:
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.

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.

 
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:

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:
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.

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.


Antibiotic Cement implantation-

General concept: 

Add as much antibiotics with minimal compromise on mechanical strength.

Fixation - 5% antibiotics to dry weight of polymethylmethacrylate (PMMA).

Antibiotic spacers - 10% antibiotics to dry weight of PMMA

Vancomycin is preferred choice if organism not identified. High doses can be delivered through the cement, is bactericidal at those doses even for gram negatives. Once organism is identified, targeted local antibiotic therapy can be used.

Antibiotic

Dose per 40g cement (in gm)

Gentamicin

0.25-4.8

Cefazolin

1-2

Cefuroxime

1.5-2

Ceftazidime

2 – 4*

Ciprofloxacin

0.2-3

Vancomycin

0.5 –4

Clindamycin

1-2

Colistin

0.24

Linezolid

1.2

Meropenem

0.5-4

Voriconazole

300-600mg

Reference: https://icmphilly.com/questions/should-the-antibiotics-placed-in-a-cement-spacer-be-tailored-to-the-sensitivity-of-the-infective-organism/

*Hsu, Yung-Heng, et al. "Vancomycin and ceftazidime in bone cement as a potentially effective treatment for knee periprosthetic joint infection." JBJS 99.3 (2017): 223-231.



B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

Septic Arthritis


Neonates:
Group B streptococcus
MSSA
Gram negative enteric organism


Candida albicans (on TPN )

 
Cefotaxime 50 mg/kg/dose IV q12H (< 7 days of life)
q6H (> 7 days of life)

+

Cloxacillin 50 mg/kg/dose IV q12H (< 7 days of life)
q6H (> 7 days of life)


For term infant:
Clindamycin 10mg/kg/dose IV q8H 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)

Kingella kingae

 

MSSA


< 5 years old:

Co-amoxiclav 25 mg/kg/dose (Amoxicillin component) IV q8H 





> 5 years old:

Cloxacillin 50 mg/kg/dose IV q6H

 
Cefazolin 50mg/kg/dose IV q8H

OR

Cefuroxime 30 mg/kg/dose IV q8H



Cefazolin 50mg/kg/dose IV q8H

 
Duration: at least 2 weeks of IV followed by 2-4 weeks oral; IV to oral switch permissible upon good clinical response


Cefotaxime and Ceftriaxone have poor effectiveness for Staph aureus.


 

MRSA

 

*Sodium Fusidate 6 - 7 mg/kg/dose (max 500 mg) IV q8H
given by infusion over q6 – 8H

 

OR

 

Vancomycin 15mg/kg/dose IV q8H

+

Rifampicin 7.5-10 mg/kg/dose (max 600 mg/day) PO q12H

                                        Clindamycin 10mg/kg/dose IV q8H (for CA-MRSA only)

OR

Linezolid 10 mg/kg/dose IV (max 600 mg) q8H

 

Vancomycin penetrates poorly into synovial space.

 

*IV Sodium Fusidate is not available in UMMC.

Acute Osteomyelitis


Neonates:
Staph aureus
Group B Streptococci
Coliforms
Pseudomonas aeruginosa
Candida spp

 
Cloxacillin 50 mg/kg/dose IV q12H (< 7 days of life)
q6H (> 7 days of life)

AND

Cefotaxime 50 mg/kg/dose IV q12H (< 7 days of life)
q6H (> 7 days of life)

 
For MRSA:
Linezolid 10 mg/kg/dose IV (max 600 mg) q8H

 
Ceftazidime 50 mg/kg/dose 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/dose IV q6H

 
Cefazolin 50mg/kg/dose IV q8H

 

OR

 

Clindamycin 10 mg/kg/dose IV (max 1.2 gm) q6H

 

 

 

 

 

 
Duration: 6 weeks

 Chronic osteomyelitis

 

 Staph aureus (MSSA)

 CA-MRSA

Cloxacillin 25mg/kg/dose PO q6H

 

OR

 

Clindamycin 10mg/kg/dose PO q8H

 

Cephalexin 100mg/kg/day PO q8H

Surgical debridement is recommended. Consider adding rifampicin for prosthetic joint infection.

 

 


Adapted from w. zimmerli. Current concept.