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Osteomyelitis in Emergency Medicine Medication

  • Author: Randall W King, MD, FACEP; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
Updated: Jun 15, 2016

Medication Summary

The primary treatment for osteomyelitis is parenteral antibiotics that penetrate bone and joint cavities. Treatment is required for at least 4-6 weeks. After intravenous antibiotics are initiated on an inpatient basis, therapy may be continued with intravenous or oral antibiotics, depending on the type and location of the infection, on an outpatient basis.

Below are recommendations for the initiation of empiric antibiotic treatment based on the age of the patient and mechanism of infection.

With hematogenous osteomyelitis (newborn to adult), the infectious agents include S aureus, Enterobacteriaceae organisms, group A and B Streptococcus species, and H influenzae. Primary treatment is a combination of penicillinase-resistant synthetic penicillin and a third-generation cephalosporin. Alternate therapy is vancomycin or clindamycin and a third-generation cephalosporin, particularly if methicillin-resistant S aureus (MRSA) is considered likely. Linezolid is also used in these circumstances.[18, 19] In addition to these above-mentioned antibacterials, ciprofloxacin and rifampin may be an appropriate combination therapy for adult patients. If evidence of infection with gram-negative bacilli is observed, include a third-generation cephalosporin.

In patients with sickle cell anemia and osteomyelitis, the primary bacterial causes are S aureus and Salmonellae species. Thus, the primary choice for treatment is a fluoroquinolone antibiotic (not in children). A third-generation cephalosporin (eg, ceftriaxone) is an alternative choice.

When a nail puncture occurs through an athletic shoe, the infecting agents may include S aureus and Pseudomonas aeruginosa. The primary antibiotics in this scenario include ceftazidime or cefepime. Ciprofloxacin is an alternative treatment.

For patients with osteomyelitis due to trauma, the infecting agents include S aureus, coliform bacilli, and Pseudomonas aeruginosa. Primary antibiotics include nafcillin and ciprofloxacin. Alternatives include vancomycin and a third-generation cephalosporin with antipseudomonal activity.

In patients in whom tuberculosis is of concern as the etiology of a musculoskeletal infection, the choice of antibiotic is generally the same as for pulmonary infection.

Vertebral osteomyelitis

According to 2015 guidelines on vertebral osteomyelitis issued by the IDSA, unless patients are septic or have neurologic compromise, empiric antimicrobial therapy should be withheld until the microbiologic diagnosis is confirmed.[10, 11]

Most patients with S aureus bloodstream infection within the preceding 3 months and compatible spine MRI changes may be treated empirically without disc space aspiration.

Treatment usually includes intravenous antibiotics for 6 weeks based on the results of culture and in vitro susceptibility testing.



Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Nafcillin (Nafcil, Unipen)


Initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections. Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants. Because of thrombophlebitis, particularly in elderly patients, administer parenterally for only the short term (1-2 d). Change to PO route as clinically indicated. Note: Administer in combination with a third-generation cephalosporin to treat osteomyelitis. Do not admix with aminoglycosides for IV administration.

Ceftriaxone (Rocephin)


Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms; arrests bacterial growth by binding to one or more penicillin-binding proteins. Note: Administer with a penicillinase-resistant synthetic penicillin, when treating osteomyelitis.

Cefazolin (Ancef)


First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth; primarily active against skin flora, including S aureus; typically used alone for skin and skin-structure coverage.

Ciprofloxacin (Cipro)


Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Continue treatment for at least 2 d (typical treatment, 7-14 d) after signs and symptoms disappear.

Ceftazidime (Fortaz, Ceptaz)


Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms; arrests bacterial growth by binding to one or more penicillin-binding proteins.

Clindamycin (Cleocin)


Lincosamide for the treatment of serious skin and soft-tissue staphylococcal infections; also effective against aerobic and anaerobic streptococci (except enterococci); inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, arresting RNA-dependent protein synthesis.

Vancomycin (Vancocin)


Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who can not receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.

To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients with renal impairment.

Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.

Linezolid (Zyvox)


Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against staphylococci.

The FDA warns against the concurrent use of linezolid with serotonergic psychiatric drugs, unless indicated for life-threatening or urgent conditions. Linezolid may increase serotonin CNS levels as a result of MAO-A inhibition, increasing the risk of serotonin syndrome.


Antibiotic, Miscellaneous



For use in combination with at least one other antituberculous drug. Inhibits DNA-dependent bacterial RNA polymerase but not mammalian RNA polymerase. Cross-resistance may occur.

Treat for 6-9 months or until 6 months have elapsed from conversion to sputum culture negativity.

Contributor Information and Disclosures

Randall W King, MD, FACEP Assistant Clinical Professor of Emergency Medicine, University of Toledo College of Medicine; Director, Emergency Medicine Residency Program, Department of Emergency Medicine, Chief Medical Information Officer, Chief of Staff Elect, Mercy St Vincent Medical Center

Randall W King, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, American Medical Association, Ohio State Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


David Johnson, MD Assistant Clinical Professor, Department of Surgery, University of Toledo College of Medicine; Chairman, Department of Emergency Services, St Vincent's Mercy Medical Center, Toledo

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Dana A Stearns, MD Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Associate Director, Undergraduate Clerkship in Surgery, Massachusetts General Hospital/Harvard Medical School; Assistant Professor of Surgery, Harvard Medical School

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

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Osteomyelitis of the elbow. Photography by David Effron MD, FACEP.
Osteomyelitis of index finger metacarpal head secondary to clenched fist injury. Photography by David Effron MD, FACEP.
Osteomyelitis of index finger metacarpal head secondary to clenched fist injury. Photography by David Effron MD, FACEP.
Osteomyelitis of the great toe. Photography by David Effron MD, FACEP.
Osteomyelitis of T10 secondary to streptococcal disease. Photography by David Effron MD, FACEP.
Osteomyelitis of diabetic foot. Photography by David Effron MD, FACEP.
Osteomyelitis. Radiography of diabetic foot showing osteomyelitis with gas. Photography by David Effron MD, FACEP.
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