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TABLE 120-2. Selection of antibiotics for treatment of acute  osteomyelitis

Suggested Regimen^a

 Organism

Primary

Alternatives^b

Staphylococcus aureus

 Penicillin-resistant, methicillin-sensitive (MSSA)

Nafcillin or oxacillin, 2 g IV q4h

Cefazolin, 1 g IV q8h; ceftriaxone, 1 g IV q24h; clindamycin, 900 mg IV q8h^c

 Penicillin-sensitive

Penicillin, 3-4 million U IV q4h

Cefazolin, ceftriaxone, clindamycin (as above)

 Methicillin-resistant (MRSA)

Vancomycin, 15 mg/kg IV q12h; rifampin, 300 mg PO q12h (see text)

Clindamycin^c (as above); linezolid, 600 mg IV or PO q12h^d; daptomycin, 4-6 mg/kg IV q24h^d

Streptococci (including S. milleri, β-hemolytic streptococci)

Penicillin (as above)

Cefazolin, ceftriaxone, clindamycin (as above)

Gram-negative aerobic bacilli

 Escherichia coli, other "sensitive" species

Ampicillin, 2 g IV q4h; cefazolin, 1 g IV q8h

Ceftriaxone, 1 g IV q24h; parenteral or oral fluoroquinolone (e.g., ciprofloxacin, 400 mg IV or 750 mg PO q12h)^e

Pseudomonas aeruginosa

Extended-spectrum β-lactam agent (e.g., piperacillin, 3-4 g IV q4-6h; or ceftazidime, 2 g IV q12h) plus tobramycin, 5-7 mg/kg q24h^f

May substitute parenteral or oral fluoroquinolone for β-lactam agents (if patient is allergic) or for tobramycin (in relation to nephrotoxicity)

Enterobacter spp., other "resistant" species

Extended-spectrum β-lactam agent IV or fluoroquinolone IV or PO^e (as above)

Mixed infections possibly involving anaerobic bacteria

Ampicillin/sulbactam, 1.5-3 g IV q6h; piperacillin/tazobactam, 3.375 g IV q6h

Carbapenem antibiotic or a combination of a fluoroquinolone plus clindamycin (as above) or metronidazole, 500 mg PO tid

^aDuration of treatment is discussed in the text.

^bCephalosporins may be used for the treatment of patients allergic to penicillin whose reaction did not consist of anaphylaxis or urticaria (immediate-type hypersensitivity).

^cBecause of the possibility of inducible resistance, clindamycin must be used with caution for the treatment of strains resistant to erythromycin. Consult clinical microbiology laboratory.

^dExperience is limited; there are anecdotal reports of efficacy.

^eOral fluoroquinolones must not be coadministered with divalent cations (calcium, magnesium, iron, aluminum), which block the drugs' absorption.

^fTobramycin levels and renal function must be monitored closely to minimize the risks of nephro- and ototoxicity.