Infectious Tenosynovitis Organism-Specific Therapy

Refer to regional and institutional culture and sensitivity data to guide antimicrobial selection for individual patients. Organism-specific therapeutic regimens for infectious tenosynovitis are provided below, including those for the following pathogens:

• Methicillin-susceptible Staphylococcus aureus
• Methicillin-resistant S aureus (MRSA)
• Streptococcus species
• Neisseria gonorrhoeae
• Pasteurella multocida
• Mycobacterium marinum
• Sporothrix schenckii
• Coccidioides species

Methicillin-susceptible Staphylococcus aureus

Treatment regimens for methicillin-susceptible S aureus include the following ^{[1, 2, 3, 4]} :

• Penicillin G 4 million units IV q4h or
• Nafcillin 2 g IV q4h or
• Oxacillin 2 g IV q4h or
• Cefazolin 2 g IV q8h or
• Cephalexin 250-1000 mg PO q6h

Treatment courses should be individualized on the basis of initial staging, as well as clinical response to antibiotics, with or without irrigation, drainage, and debridement. Duration of therapy for uncomplicated infection is 7-14 days. For complicated infections, longer courses of 14-21 days are considered, depending on treatment response.

Methicillin-resistant Staphylococcus aureus

Treatment regimens for MRSA include the following ^{[5, 1, 6, 7, 8, 9, 10, 11]} : 

• Vancomycin 15-20 mg/kg q8-12h or
• Daptomycin 4-6 mg/kg IV q24h 

Potential combination regimens with vancomycin or daptomycin, when indicated:

• Doxycycline 100 mg PO q12h or
• Trimethoprim/sulfamethoxazole (160 mg/800 mg) 1 DS tablet PO BID or
• Clindamycin 300-600 mg PO/IV TID or
• Linezolid 600 mg PO/IV q12h or
• Ceftaroline 600 mg IV q12hr

Note that vancomycin is the first-line drug of choice for empiric MRSA coverage for hospitalized patients.

Treatment courses should be individualized on the basis of initial staging, as well as clinical response to antibiotics, with or without irrigation, drainage, and debridement. Duration of therapy for uncomplicated infection is 7-14 days. For complicated infections, longer courses of 14-21 days are considered, depending on treatment response.

Streptococcus species

Treatment regimens for Streptococcus species include the following ^[12] :

• Penicillin G 4 million units IV q4h or
• Clindamycin 300-600 mg PO/IV TID or
• Ceftriaxone 1 g IV q24h or
• Amoxicillin/clavulanate 875 mg/125 mg PO BID or
• Ampicillin/sulbactam 1-2 g IV q6h

Treatment courses should be individualized on the basis of initial staging, as well as clinical response to antibiotics, with or without irrigation, drainage, and debridement. Duration of therapy for uncomplicated infection is 7-14 days. For complicated infections, longer courses of 14-21 days are considered, depending on treatment response.

Neisseria gonorrhoeae

Treatment regimens for N gonorrhoeae include the following ^[13] :

• Ceftriaxone 1 g IM/IV q24h (preferred)  or
• Gentamicin 240 mg IM plus azithromycin 2 g PO as single doses or
• Cefixime 800 mg PO as a single dose 

Consult with an infectious disease specialist to assess antibiotic resistance to N gonorrhoeae. For more information, see current Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines.  

Pasteurella multocida

Treatment regimens for P multocida include the following ^[14] :

• Amoxicillin/clavulanate 875 mg/125 mg PO BID  or
• Ampicillin/sulbactam 1-2 g IV q6h  or
• Doxycycline 100 mg PO BID

Treatment courses should be individualized on the basis of initial staging, as well as clinical response to antibiotics, with or without irrigation, drainage, and debridement. Duration of therapy for uncomplicated infection is 7-14 days. For complicated infections, longer courses of 14-21 days are considered, depending on treatment response.

Mycobacterium marinum

Treatment regimens for M marinum include the following ^{[15, 16, 17]} :

• Clarithromycin 500 mg PO BID  plus   rifampin 600 mg PO daily  or
• Clarithromycin 500 mg PO BID  plus   ethambutol 15 mg/kg PO daily  or
• Clarithromycin 500 mg PO BID  plus  rifampin 10 mg/kg (max 600 mg) PO daily plus  ethambutol 14-21 mg/kg (max 1600 mg) PO daily ^[18]
• Minocycline 100 mg PO BID  or
• Doxycycline 100 mg PO BID  or
• Trimethoprim/sulfamethoxazole (160 mg/800 mg) 1 DS tablet PO BID

Treatment is continued for 4-6 weeks after symptoms resolve; duration of therapy is usually a minimum of 3 months.

For treatment of M tuberculosis infection, please refer to Tuberculosis Organism-Specific Therapy.

Sporothrix schenckii

Treatment regimens for S schenckii include the following ^{[19, 20]} :

• Itraconazole 200 mg PO BID  or
• Amphotericin B liposomal 3-5 mg/kg/day IV daily until resolution, then continue with itraconazole 200 mg PO BID   or
• Amphotericin B deoxycholate 0.7-1 mg/kg/day until resolution, then continue with itraconazole 200 mg PO BID

Duration of therapy is at least 12 months.

Note that due to the significant adverse effect profile of amphotericin B, regimens that contain this agent are used only in case of extensive disease and/or unresponsiveness to itraconazole.

Coccidioides species

Treatment regimens for Coccidioides species include the following ^{[21, 22, 23, 24]} :

• Itraconazole 200 mg PO BID  or
• Fluconazole 400-800 mg PO daily  or
• Amphotericin B phospholipid complex 3-5 mg/kg IV daily until improving, then continue with itraconazole 200 mg PO BID
• Duration of therapy: at least 6 to 12 months

Note: Consider higher doses of azoles based on clinical response. Reserve amphotericin for unresponsive disease due to its significant adverse effect profile.