Bone and Joint Infections

Cloxacillin 2g (child 50mg/kg) IV QID

Alternative:

Cefazolin 2g (child 50mg/kg) IV TID

OR

Clindamycin 600mg (child 15mg/kg) IV TID

OR

Vancomycin IV, dose according to Vancomycin dosing section

Change to oral antibiotics when appropriate (see comments). If susceptibility results are not available use:

Cloxacillin 1g (child 25mg/kg) PO QID

Take blood cultures prior to antibiotics.

Acute osteomyelitis is potentially curable with antibiotics alone. In adults who respond to treatment rapidly an early IV to PO switch can be considered if susceptibilities are known, and antibiotics with good oral bioavailability are used (e.g. clindamycin, co-trimoxazole, ciprofloxacin). Adults with an associated Staphylococcus aureus bacteraemia should receive at least 4 weeks IV therapy (see Staphylococcus bacteraemia in Sepsis and Directed Therapy for Blood Stream Infections).

Duration:

Adults: Treat for a total of 6 weeks, with a minimum of 2-4 weeks IV.

Children:

Uncomplicated: Treat for at least 3 weeks, with a minimum of 3 days IV.

Complicated (non-long bone, associated abscess, delayed presentation, slow clinical improvement): Treat as per adult.

Unless septic do not give antibiotics until after bone has been debrided and culture results are available. Use directed treatment wherever possible.

Cloxacillin 2g (child 50mg/kg) IV QID.

Alternative:

Cefazolin 2g (child 50mg/kg) IV TID

OR

Clindamycin 600mg (child 15mg/kg) IV TID

OR

Vancomycin IV dose according to Vancomycin dosing section

Followed by:

Cloxacillin 1g (child 25mg/kg) PO QID

Send tissue and deep sinus tract swab for cultures. Send blood cultures if systemically unwell. Change antibiotics according to culture results.

Aggressive debridement of necrotic bone is important to achieve cure.

Patients on long-term antibiotic therapy should have CBC, and liver and renal function monitored regularly.

Duration:

Adults: Change to oral antibiotics after 2 weeks IV. Treat for a total of 3 months. Longer therapy may be required if inflammatory markers (ESR, CRP) do not normalize.

Children: Change to oral antibiotics when well. Treat for a minimum of 6 weeks.

Unless septic do not give antibiotics (except surgical prophylaxis) until after bone has been debrided and sent for culture. Commence empiric treatment after debridement, or after blood cultures if septic.

Cloxacillin 2g (child 50mg/kg) IV QID

Alternative:

Cefazolin 2g (child 50mg/kg) IV TID

OR

Clindamycin 600mg (child 15mg/kg) IV TID

OR

Vancomycin IV, dose according to Vancomycin dosing section

In the case of Staphylococcus aureus infection with retention of hardware, after thorough debridement and a course of IV antibiotics consider the use of biofilm active agents:

Rifampicin 300mg PO BID

PLUS

Ciprofloxacin 500mg PO BID

Do not use either of these agents alone, and ensure there are no symptoms of TB before commencing rifampicin.

Send tissue and deep sinus tract swab for cultures. Send blood cultures if systemically unwell.

Where hardware is no longer required for bone stability, it should be removed and necrotic bone and tissue thoroughly debrided.

Where hardware must be retained for fracture nonunion, continue antibiotics until fracture union is achieved, then remove hardware.

Cure of infection with retention of hardware is more likely to be achieved if infection has occurred within 3 weeks of hardware insertion.

Duration:

With removal of hardware: Treat for 2-6 weeks IV, then change to oral antibiotics. Continue antibiotics for 6 weeks after removal of hardware.

Without removal of hardware: If hardware cannot be removed continue antibiotics for 12 weeks and consider ongoing long-term suppression after this.

See Open Fracture prophylaxis in Antibiotic Prophylaxis.

Cloxacillin 2g (child 50mg/kg) IV QID

Alternative:

Cefazolin 2g (child 50mg/kg) IV TID

OR

Clindamycin 600mg (child 15mg/kg) IV TID

OR

Vancomycin IV, dose according to Vancomycin dosing section

Send blood cultures prior to commencement of antibiotics. Unless patient is septic send synovial fluid for culture prior to commencement of antibiotics.

Exclude acute rheumatic fever in young patients.

Consider Gonococcal arthritis in patient with risk factors. Send urine and synovial fluid for gonococcal PCR, and send urethral, vaginal, or rectal swabs for PCR and culture.

Send synovial fluid for TB PCR if consistent clinical picture.

Surgical options for treatment of PJI include one and two-stage exchange arthroplasty, debridement and retention of prosthesis (DAIR), excision arthroplasty and implant retention without curative intent. Two-stage arthroplasty has the highest cure rates (85-95%).

Seek review by Infectious Diseases if available.

Antimicrobial 

Comments and Duration of Therapy