Specific Organisms and Therapeutic Regimens
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:
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Methicillin-susceptible Staphylococcus aureus
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Methicillin-resistant S aureus (MRSA)
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Streptococcus species
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Neisseria gonorrhoeae
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Pasteurella multocida
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Mycobacterium marinum
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Sporothrix schenckii
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Coccidioides species
Methicillin-susceptible Staphylococcus aureus
Treatment regimens for methicillin-susceptible S aureus include the following [1, 2, 3, 4] :
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Penicillin G 4 million units IV q4h or
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Nafcillin 2 g IV q4h or
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Oxacillin 2 g IV q4h or
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Cefazolin 2 g IV q8h or
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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] :
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Vancomycin 15-20 mg/kg q8-12h or
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Daptomycin 4-6 mg/kg IV q24h
Potential combination regimens with vancomycin or daptomycin, when indicated:
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Doxycycline 100 mg PO q12h or
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Trimethoprim/sulfamethoxazole (160 mg/800 mg) 1 DS tablet PO BID or
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Clindamycin 300-600 mg PO/IV TID or
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Linezolid 600 mg PO/IV q12h or
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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] :
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Penicillin G 4 million units IV q4h or
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Clindamycin 300-600 mg PO/IV TID or
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Ceftriaxone 1 g IV q24h or
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Amoxicillin/clavulanate 875 mg/125 mg PO BID or
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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] :
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Ceftriaxone 1 g IM/IV q24h (preferred) or
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Gentamicin 240 mg IM plus azithromycin 2 g PO as single doses or
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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] :
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Amoxicillin/clavulanate 875 mg/125 mg PO BID or
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Ampicillin/sulbactam 1-2 g IV q6h or
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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] :
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Clarithromycin 500 mg PO BID plus rifampin 600 mg PO daily or
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Clarithromycin 500 mg PO BID plus ethambutol 15 mg/kg PO daily or
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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]
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Minocycline 100 mg PO BID or
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Doxycycline 100 mg PO BID or
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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] :
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Itraconazole 200 mg PO BID or
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Amphotericin B liposomal 3-5 mg/kg/day IV daily until resolution, then continue with itraconazole 200 mg PO BID or
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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] :
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Itraconazole 200 mg PO BID or
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Fluconazole 400-800 mg PO daily or
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Amphotericin B phospholipid complex 3-5 mg/kg IV daily until improving, then continue with itraconazole 200 mg PO BID
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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.