Bone and Joint Infections

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Acute Osteomyelitis

Common organisms:

Staphylococcus aureus (80%)

Streptococcus pyogenes

Rarely gram negative bacilli

Cloxacillin 2gm IV q6h

Penicillin allergy:

Cefazolin 2 gm IV q6-8h

OR

Clindamycin 600mg IV q6h then PO

OR

Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2gm/dose (if risk of MRSA)

Duration: Initial IV therapy for 2-4 weeks followed by oral therapy. Minimum 6 weeks.

Tailor therapy based on C&S reports.

Shorter duration can be considered if the osteomyelitis is fully resected

No surrounding soft tissue infection: 5days.

Evidence of soft tissue infection: 10-14 days.

Chronic Osteomyelitis or Chronic synovitis

Most common Organism:

Staphylococcus aureus

No Empirical treatment.

Duration: 6 weeks but usually > 3 months.

Treatments until inflammatory parameters are normal.

Thorough surgical debridement required

Vertebral Osteomyelitis Epidural Abscess

Common organisms:

Staphylococcus aureus (main)

Brucella spp.

Salmonella spp.

Gram negative bacilli

Cloxacillin 2gm IV q4h

Empirical therapy only if sepsis or  neurologic compromise

Cefazolin 2gm IV q6-8h

Empiric gram negative should be covered if patient had:

• Recent spinal hardware inserted or surgery
• Intra-abdominal infections
• Coexisting or synchronous genitourinary infection
• HIV infection.

Surgical therapy is necessary in:

• Spinal cord compression/ instability
• Persistence of epidural abscess despite adequate antibiotic
• Considering TB spine/MDR organisms

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.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Acute monoarticular

No risk factors of STD

Cloxacillin 2gm IV q4-6h

Duration:

Parenteral therapy 2-4 weeks

Oral therapy to complete total 4-6 weeks

Penicillin allergy:

Cefazolin 2gm IV q6-8h

OR

Clindamycin 600mg IV q6h, followed by oral therapy (same dose)

OR

**Vancomycin 15-20mg/ kg (actual body weight) IV q8-12h; not to exceed 2gm/dose

Duration:

Parenteral therapy 2-4 weeks

Oral therapy to complete total 4-6 weeks

Drainage, debridement and washout of infected joint are important to limit further damage.

Shorter duration possible if adequate surgical drainage.

**Vancomycin:

If suspected/confirmed MRSA. Consider loading dose 25-30mg/kg for critically ill/septic patient to achieve faster steady state.

Acute monoarticular

Risk factors of Sexually

Transmitted Infection (STI)

Ceftriaxone 2gm IV q24h for 1-2 weeks

PLUS

Doxycycline 100mg PO q12h for 7 days

OR

Azithromycin 1gm PO stat

Substitute Ceftriaxone with

Cefotaxime 2gm IV q8h for

1-2 weeks

Polyarticular

Neisseria gonorrhoeae

Ceftriaxone 2gm IV q24h for 7 days

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Prosthetic Joint Infections (Empirical)

Early: <3 months after surgery

Staphylococcus aureus

Gram negative bacilli

Delayed onset: from 3-12 months after surgery

Less virulent organism: CoNS/Enterococcus spp./ anaerobes

Late onset:> 12 months after surgery

Staphylococcus aureus

Enterobacteriaceae

β-hemolytic Streptococcus

Anaerobes

Empiric therapy ONLY if sepsis or unstable patients

Amoxicillin-clavulanate 625mg PO q8h

Treatment is based on C&S.

Rifampicin should never be used alone and should be started only after the clearance of bacteraemia. Treatment strategy and duration of treatment depends on surgical strategy.

Definitive Prosthetic Joint infection

Methicillin-susceptible Staphylococcus aureus

Initial Treatment:

Cloxacillin 2gm IV q4-6h

OR

Cefazolin 2gm IV q6-8h

PLUS

Rifampicin 600mg PO q24h or 450 PO q12h

Penicillin allergy:

Cefazolin 2gm IV q6-8h

OR

Clindamycin 600mg IV q6h, followed by oral therapy (same dose)

PLUS

Rifampicin 600mg PO q24h or 450 PO q12h

Duration: 2-6 weeks. (Parenteral 2-4 weeks, oral therapy for the rest of 4-6 weeks).

Followed by an oral combination therapy according to susceptibility. Rifampicin should be included if implant is in situ.

Definitive Prosthetic Joint infection

Methicillin-resistant Staphylococcus aureus

Initial Treatment:

Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2gm/dose

PLUS

Rifampicin 300-450mg PO q12h

Teicoplanin 400mg IV q12h for 3 doses then 400mg IV q24h

Duration: 2-6 weeks.

Followed by an oral combination therapy according to susceptibility. Rifampicin should be included if implant is in situ.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Muscular, skeletal and soft

tissue trauma, crush injuries

and stab wounds

Cloxacillin/Flucloxacillin 2gm IV q6h

PLUS*

Metronidazole 500mg IV q8h

PLUS**

Gentamicin 5mg/kg IV q24h

Cefazolin 2gm IV q6-8h

OR

Cefuroxime 1.5gm as a loading dose, followed by 750mg IV q8h

PLUS

Metronidazole 500mg IV q8h

*Metronidazole: In soil/ rust contamination or heavy machinery.

**Gentamicin: If there’s extensive skin and soft tissue involvement.

Thorough surgical debridement and fracture stabilization.

For severe penetrating injuries, especially those involving joints and/or tendons, antibiotics must be given for at least 5 days.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Compound fractures: Antibiotics are administered as prophylaxis within 3 hours of injury.

Gustilo 1 and 2 fractures

Cefazolin 1-2gm IV q8h

OR

Amoxicillin-clavulanate 1.2gm IV q8h

Cefuroxime 1.5gm IV q8h

Pre-debridement and post debridement cultures are not representative of actual infection.

Duration of antibiotic for open fractures classification

Gustilo type I : stop after 24 hours

Gustilo type II: discontinue after 24 hours to 48 hours

Gustilo type III: 24 hours after wound closure or up to a maximum of 72 hours (whichever is earlier)

*Gentamicin: If initial debridement is expected to last more than 2 hours will need higher dose of Gentamicin 5mg/kg IV stat dose.

*Metronidazole: In soil/ rust contamination or heavy machinery.

If soft tissue injury is of concern, to follow antibiotic guide for soft tissue injury.

Gustilo 3 fractures

Mostly nosocomial and gram positive

As per Gustilo 1 and 2 fractures

PLUS

*Gentamicin 3-5mg/kg IV stat dose

PLUS

**Metronidazole 500mg IV q8h