eMedicine Specialties > Emergency Medicine > Infectious Diseases
Osteomyelitis: Treatment & Medication
Updated: Nov 4, 2008
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Treatment
Emergency Department Care
Osteomyelitis rarely requires emergent stabilization or resuscitation. The primary challenge for ED physicians is considering the appropriate diagnosis in the face of subtle signs or symptoms.
Treatment for osteomyelitis involves the following:
- Initiation of intravenous antibiotics that penetrate bone and joint cavities
- Referral of the patient to an orthopedist or general surgeon
- Possible medical infectious disease consultation
Select the appropriate antibiotics using direct culture results in samples from the infected site, whenever possible. Empiric therapy is often initiated on the basis of the patient's age and the clinical presentation. Further surgical management may involve removal of the nidus of infection, implantation of antibiotic beads or pumps, hyperbaric oxygen therapy, or other modalities.
Diagnosis requires 2 of the 4 following criteria:
- Purulent material on aspiration of affected bone
- Positive findings of bone tissue or blood culture
- Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema
- Positive radiological imaging study
Consultations
Order an orthopedics, general surgery, or infectious disease consultation, as needed.
Medication
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.
The following 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 MRSA is considered likely. Linezolid is also used in these circumstances. In addition to these above-mentioned antibacterials, ciprofloxacin and rifampin may be an appropriate combination therapy for adult patients. If there is evidence of infection with gram-negative bacilli, 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 are nafcillin and ciprofloxacin. Alternatives include vancomycin and a third-generation cephalosporin with antipseudomonal activity.
Antibiotics
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.
Adult
1-2 g IV/IM q4h; reduce dose 35-50% in severe renal or hepatic impairment; change to PO as clinically indicated
Pediatric
100-200 mg/kg/d IV/IM divided q6h; maximum 12 g/d; change to PO as clinically indicated
Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
To optimize therapy, determine causative organisms and susceptibility; treatment should last more than 10 d to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); perform cultures after treatment to confirm that infection is eradicated
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.
Adult
2 g IV qd
Pediatric
75 mg/kg/d IV qd
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in women who are breastfeeding and in patients with an allergy to penicillin
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.
Adult
2 g IV/IM q8h; not to exceed 12 g/d
Pediatric
20 mg/kg/d IV/IM divided q8h depending on severity of infection; not to exceed 6 g/d
Probenecid prolongs effect; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive results for glucose at urine-dip testing
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; superinfections, promotion of nonsusceptible organisms, and pancytopenia may occur with prolonged use or repeated therapy; complications are usually reversible
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.
Adult
200-400 mg IV q12h
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; if used, administer antacids no sooner than 2-4 h before or after administration; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, periodically evaluate organ system (eg, renal, hepatic, hematopoietic) functions; adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
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.
Adult
2 g IV q8h
Pediatric
150 mg/kg/d IV divided q8h; not to exceed 6 g/d
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid use; probenecid may increase ceftazidime levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
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.
Adult
600-1200 mg/d IV/IM divided q6-8h, depending on the degree of infection
Pediatric
20-40 mg/kg/d IV/IM divided tid/qid
Severe infections: May increase dose to 16-20 mg/kg/d IV/IM divided tid/qid
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis, ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
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.
Adult
500 mg to 2 g/d IV divided tid/qid 7-10 d
Pediatric
40 mg/kg/d IV divided tid/qid 7-10 d
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
Linezolid (Zyvox)
Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against staphylococci.
Adult
400-600 mg PO/IV q12h
Pediatric
Preterm neonate <7 days: 10 mg/kg PO/IV q12h
Term neonates to 12 years: 10 mg/kg PO/IV q8h
>12 years: Administer as in adults
May cause hypertension when used concomitantly with adrenergic agents including pseudoephedrine, sympathomimetic agents, vasopressor or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents including tricyclic antidepressants, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake; may cause myelosuppression or pseudomembranous colitis inhibitors
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Has mild MAO inhibitor properties and has potential to have same interactions as other MAO inhibitors; caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism, and patients who are at increased risk for bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, or who may require >2 wk of therapy (monitor platelet counts); unnecessary use may lead to development of resistance to drug; may cause peripheral or optic neuropathy
More on Osteomyelitis |
| Overview: Osteomyelitis |
| Differential Diagnoses & Workup: Osteomyelitis |
 Treatment & Medication: Osteomyelitis |
| Follow-up: Osteomyelitis |
| Multimedia: Osteomyelitis |
| References |
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Further Reading
Keywords
osteomyelitis, bone infection, central osteitis, hematogenous osteomyelitis, direct inoculation osteomyelitis, chronic osteomyelitis, osteomyelitis secondary to peripheral vascular disease, contiguous inoculation osteomyelitis, vertebral osteomyelitis, spinal-cord compression, spinal osteomyelitis, Staphylococcus aureus, Enterobacter species, Haemophilus influenzae, Streptococcus species, Pseudomonas species, Salmonellae species, diabetes mellitus, sickle cell disease, acquired immune deficiency syndrome, AIDS, IV drug abuse, alcoholism, chronic steroid use, immunosuppression, chronic joint disease, MRSA, methicillin-resistant Staphylococcus aureus, community-associated methicillin-resistant Staphylococcus aureus, Kingella kingae
