Osteomylitis Treatment _Streptococcus spp._ PCN RESISTANT 1st Choice

base on susceptibilities: _CeftriaXone_ or _Vancomycin_

25 - Osteomyelitis & Diabetic Foot Flashcards by Karlo Sison

What is the Gold Standard in diagnosing

OSTEOMYELITIS

BONE BIOPSY
w/ Bacterial growth & Histologic Findings
Of
inflammation & necrosis

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Diabetic Foot Infection Treatment

1st line Therapy

Moderate
MSSA + Streptococcus
Enterobacteriaceae + anaerobes

Amoxicillin / Clavulanate

Ampicillin / Sulbactam

Piperacillin / Tazobactam

*2-3 Weeks**
until infection has cleared*

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Diabetic Foot Infection Treatment

Moderate
MSSA + Streptococcus
Enterobacteriaceae + anaerobes
+
MRSA Risk Factor
H/O MRSA infxn OR High MRSA Prevelence

MODERATE + MRSA Risk Factor

*AMPICILLIN/SULBACTAM_ + _VANCOMYCIN**
*2-3 Weeks**

Moderate Treatment:
Amoxicillin / Clavulanate

Ampicillin / Sulbactam

Piperacillin / Tazobactam

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Diabetic Foot Infection Treatment

Moderate
MSSA + Streptococcus
Enterobacteriaceae + anaerobes
+
P. Aeruginosa Risk Factor
MACERATED would OR High Prevelence

MODERATE + P.Aeruginosa Risk Factor (MACERATED)

*PIP TAZO**
*2-3 Weeks**

Moderate Treatment:
Amoxicillin / Clavulanate

Ampicillin / Sulbactam

Piperacillin / Tazobactam

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*Hematogenous** Osteomyelitis
*Vertebral**

is _____microbial?

MONOmicrobial

Hematogenous = MONOmicrobial
VERTEBRAL

Hema - Mono

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Osteomylitis Treatment
Gram Negatives

*Enterobacteriaceae**
*E. Coli / K. Pneumoniae / Enterobacter / Citrobacter**

PCN ALLERGY or PO Therapy

Alternate for PCN allergy or PO therapy:
CIPROFLOXACIN

Normal:
CefePIME or Ertapenem

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Osteomyelitis:

Which bacteria are considered

Enterobacteriaceae?

E. Coli

Kleb. Pneumoniae

Enterobacter

Citrobacter

Treat with:
CefePIME or Ertapenem

Alternate for PCN allergy:
Ciprofloxacin

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Osteomylitis Treatment
Gram Negatives

*Enterobacteriaceae**
*E. Coli / K. Pneumoniae / Enterobacter / Citrobacter**

1st Choice

CefePIME

Ertapenem

Alternate for PCN allergy:
Ciprofloxacin

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Diabetic Foot Infection Treatment

1st line Therapy

SEVERE
IV ONLY
VERY BROAD:
MRSA / Streptococcus / Enterobaceteriae
Anaerobes / P.aeruginosa

SEVERE = VCM ALL 3

Vancomycin

Cefepime

Metronidazole

Moerate or Severe = 2-3 Weeks
until infection has cleared

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Diagnosis of Osteomyelitis

Local Signs of Inflammation
VV
Probe-to-Bone Test = useful for EXCLUSION

Positive Result
VVV
Radiologic Imaging** or **BONE BIOPSY
bone biopsy = gold standard

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Osteomylitis Treatment

*Streptococcus spp.**
*PCN RESISTANT**

1st Choice

base on susceptibilities:

CeftriaXone

Vancomycin

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Osteomyelitis Treatment

MSSA
Staphlococcus

ALTERNATE CHOICE

PCN Allergy:
VANCOMYCIN

Alt:
BACTRIM DS** + **RIFAMPIN

N-O-C
Nafcillin** or **Oxacillin
or
CefaZolin

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Osteomylitis Treatment

When to add RIFAMPIN?
to regular treatment of:

MSSA
or
MRSA** + **Coagulase NEG Staphylococci

RIFAMPIN in COMBO
has synergistic activity against BIOFILMS
for
PROSTHETIC JOINTS
or
Alternative PO THERAPY

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Osteomylitis Treatment

MSSA
Staphlococcus

1st Choice

N-O-C

Nafcillin** or **Oxacillin

CefaZolin

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Osteomylitis Treatment
Gram Negatives

*Salmonella Spp**
SICKLE CELL*

ALTERNATE

Alternate:
CEFTRIAXONE

normal:

CIPROFLOXACIN
Salmonella = typically with SICKLE CELL

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Osteomylitis Treatment
Gram Negatives

Salmonella Spp

1st Choice

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CIPROFLOXACIN

Salmonella = typically with SICKLE CELL

Alternate:
CeftriaXone

Osteomylitis Treatment

DURATION

Special Considerations?

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minimum of

*>** 6 Weeks
consider IV –> PO switch for NON-B-lactam ABs*

EXCEPTION:
> 8 Weeks
VERTEBRAL OSTEOMYELITIS
+
PARAvertebral ABSCESS** OR **MRSA Infection

Diabetic Foot Infection Treatment

1st line Therapy

MILD
Oral –> target MSSA & Streptococcus

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Cephalexin

Augmetin

Clindamycin

*1-2 Weeks**
until the infection has cleared*

Diabetic Foot Infection Treatment

1st line Therapy

MILD
+
MRSA Risk Factor
H/O MRSA Infxn OR High Local MRSA prevelence

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MRSA Risk Factor:
CEPHALEXIN** + **BACTRIM (sulfa+trimeth)
Mild = 1-2 Weeks
until the infection has cleared

Normal Mild Treatment:
Cephalexin** OR **Augmentin** OR **Clindamycin

Diabetic Foot Infection Treatment

1st line Therapy

MILD
+
P. Aeruginosa Risk Factor
MECERATED WOUND OR High Local P.Aeruginosa Prevelence

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P. Aeruginosa Risk Factor = Macerated Wound
CEPHELEXIN** + **CIPROFLOXACIN
Mild = 1-2 Weeks
until the infection has cleared

Normal Mild Treatment:
Cephalexin** OR **Augmentin** OR **Clindamycin

Osteomylitis Treatment
Gram Negatives

P. Aeruginosa

PCN ALLERGY

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Alternate for PCN allergy:
CIPROFLOXACIN

Normal:
CefePIME or MEROpenem

Osteomylitis Treatment
Gram Negatives

P. Aeruginosa

1st Choice

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CefePIME

MEROpenem

Alternate for PCN allergy:
Ciprofloxacin

Osteomylitis Treatment

*MRSA**
*Coagulase Negative Staphylococcus**

ALTERNATE Choice

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DAPTOMYCIN
or
Bactrim DS** + **RIFAMPIN

Normal:
VANCOMYCIN

Osteomylitis Treatment

*MRSA**
*Coagulase Negative Staphylococcus**

1st Choice

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VANCOMYCIN

**Osteomylitis Treatment** **_Streptococcus spp._** **1st Choice**

**_CeftriaXone_** **_Penicillin G_** PCN Allergy: **Vancomycin**

**Osteomylitis Treatment** * *_Streptococcus spp._** * pcn sensitive* **PCN Allergy**

PCN Allergy: **_VANCOMYCIN_** Normal: **_CeftriaXone_** or **_Penicillin G_**

**_Osteomyelitis Risk Factors_**

**_Bactremia_** expecially with **hardware** **_Compound Fracture_** **_Recent Surgery_** **_Chronic/Poorly Healing Wounds_** decibitus ulcers / diabetic foot infection

Osteomyelitis due to **_Contiguous Infection_** and **_Diabetic Foot infections_** (Broken Bones/Post traumatic) ## Footnote **is \_\_\_\_\_microbial?**

**_POLYmicrobial_** * *POLY** * *Continguous Infection** **Diabetic Foot / Broken Bones / Post-Traumatic**

**Most Common Bacteria** **_Osteomyelitis_**

**_STAPH. AUREUS_** MRSA is increasing ## Footnote **Streptococcus** **Gram -NEG- Bacilli** **P. Aeruginosa** **Anaerobes**

**WHEN to treat EMPIRICALLY** + **What Abx?** for **Osteomyelitis?**

*_typically NOT treating empirically_* --\> want **cultures first** only if: **_HEMODYNAMICALLY UNSTABLE_** cover for: **MRSA** / **Streptococci** / **Gram-NEG- bacilli** **_VANCOMYCIN**_ + _**CEFEPIME_** PCN ALLERGY: *instead of cefepime* --\> **cipro** or **aztreonam**

Special Considerations for: **_Vertebral Osteomyelitis_** ## Footnote **RISK FACTORS FOR BACTEREMIA**

**Vertebral Osteomyelitis** typically caused by **hematogenous spread** Increased risk for bacteremia: * *_IVDA_** * *_HEMODIALYSIS_** * *_Immunocompromised Host_**

Special Considerations for **_Posttraumatic Osteomyelitis_** ## Footnote **Recommendations**

**1/4** of **compound fractures** --\> **Osteomyelitis** **_Within 6 HOURS of open Trauma_** **IRRIGATION** + **DEBRIDEMENT** + **_PROPHYLAXIS_** **Vancomycin** + **Cefepime** for **1-3 days post trauma** *avoid FQ's due to reduced fracture healing*

**_Diabetic Foot Infections_** **RISK FACTORS**

Patients with these are at **HIGH RISK:** *inspect feet DAILY* **_Peripheral Neuropathy_** **_PAD_** = **Peripheral Arterial Disease** **_Immune Impairment_**

25 - Osteomyelitis & Diabetic Foot Flashcards

(33 cards)