Bone and joint antibiotics

Diabetic foot infection

Associated organisms include Staphylococcus, Streptococcus, Enterococcus, Enterobacteriaceae, Proteus, Bacteroides, and Pseudomonas, and Klebsiella

Superficial Mild Infections
  • Clindamycin 450mg PO q8hrs daily x 14 days OR
  • TMP/SMX 2DS tabs PO q12hrs daily x 14 days OR
  • Doxycycline 100mg PO q12hrs daily x 14 days

Prior antibiotic treatment or moderate infections

Inpatient Treatment


Diskitis or Osteomyelitis

Inpatient Therapy

Use cefepime or ciprofloxacin if targeting Pseudomonas spp

Felon

Definitive treatment is drainage but antibiotic coverage for S. aureus and Strep with caution to identify Herpetic whitlow

Infectious Tenosynovitis

Treatment should cover S. aureus, Streptococcus, and MRSA

Animal Bites

Ampicillin/Sulbactam 3g (50mg/kg) IV four times daily

Pediatrics

Treatment should include usual therapy listed above in addition to:

AND consult infectious disease

Open fracture

Prophylactic Antibiotics for Open fractures[1]

Initiate as soon as possible; increased infection rate when delayed for >3 hours from injury (NNT 12.5)[2]

Grade I & II Fractures Options

Grade III Fracture Options
  • Treatment as above for Grade I/II
  • PLUS aminoglycoside: e.g. Gentamicin 300 mg (1-1.7mg/kg) IV
    • Once daily dosing has been shown to be safe and effective

Special Considerations

Osteomyelitis
Risk Factor Likely Organism Initial Empiric Antibiotic Therapy'
Elderly, hematogenous spread MRSA, MSSA, gram neg Vancomycin 1gm + (Piperacillin/Tazobactam 3.375 grams OR imipenem 500mg)
Sickle Cell Disease Salmonella, gram-negative bacteria Ceftriaxone 50mg/kg IV once daily OR Cefotaxime 50mg/kg IV three times daily, PLUS
  • Vancomycin 15mg/kg IV four times daily OR
  • Clindamycin 10mg/kg IV PO four times daily OR
  • Nafcillin 50 mg/kg IV four times daily to cover K. Kingae (common in daycare population)
DM or vascular insufficiency Polymicrobial: Staph, strep, coliforms, anaerobes Vancomycin 1gm + (Piperacillin/Tazobactam 3.375 grams OR imipenem 500mg)
IV drug user MRSA, MSSA, pseudomonas Vancomycin 1gm 
Newborn MRSA, MSSA, GBS, Gram Negative Vancomycin 15mg/kg load, then reduce dose, AND ceftazidime 30mg/kg IV q12 h
Children MRSA, MSSA Vancomycin 10mg/kg q6 h AND ceftazidime 50mg/kg q8hr
Postoperative (ortho) MRSA, MSSA Vancomycin 1gm
Human bite Strep, anaerobes, HACEK organism Piperacillin/Tazobactam 3.375gm OR imipenem 500mg
Animal bites Pasteurella, Eikenella, HACEK organism Piperacillin/Tazobactam 3.375gm OR imipenem 500mg
Foot puncture wound Pseudomonas Anti-pseudomonal, staph coverage

Septic Arthritis

For adults treatment should be divided into Gonococcal and Non-Gonococcal

Gonococcal

Non-Gonococcal

Pediatrics

Sickle Cell

Coverage for Salmonella and Staphylococcus spp

  • Vancomycin 20mg/kg IV twice daily PLUS
    • Ciprofloxacin 400mg IV three times daily OR
    • Imipenem/cilastatin 1g IV three times daily

Septic Bursitis

Cover Staphylococcus aureus (80-90%) and Streptococcus

Outpatient Options
  • Clindamycin 300 mg PO three times daily x 14 days OR
  • TMP/SMX 2 DS tabs PO two times daily x 14 days OR
  • Dicloxacillin 500mg PO q6hr x10 days

Treatment followup with primary physician is important since the regimen may need extension to 3 weeks.

Inpatient Options
  • Vancomycin 25-30 mg/kg IV loading then 15-20 mg/kg IV OR
  • Clindamycin 600 mg (10/mg/kg) IV three times daily
  • Linezolid 600 mg IV BID (10mg/kg Q8hrs for pediatrics)

See Also

Antibiotics by diagnosis

For antibiotics by organism see Microbiology (Main)

References
  1. Open Fractures, Prophylactic Antibiotic Use in — Update. https://www.east.org/education/practice-management-guidelines/open-fractures-prophylactic-antibiotic-use-in-update
  2. Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
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