Bone and Joint
Acute Osteomyelitis and Septic Arthritis
- Refer to Infectious Diseases and Orthopaedics. These services should also be involved in the management of chronic osteomyelitis.
- Unless the patient has sepsis and/or neurological deficits, diagnostic cultures must be taken before initiating antimicrobial treatment.
- For acute swelling of a single joint, see Hospital HealthPathways.
- For osteomyelitis associated with ulceration see Infected ulcers.
- Empiric treatment of vertebral osteomyelitis differs from non-vertebral osteomyelitis and septic arthritis – consult Infectious Diseases.
- Diseases notifiable in New Zealand include all forms of tuberculosis.
Pathogens
- Common: S. aureus, Streptococcus species
- Other: Enterobacteriaceae (mainly coliforms), Pseudomonas aeruginosa
Drug Treatment
- Duration: Variable. Usual total duration of treatment is approximately:
- 6 to 8 weeks for acute osteomyelitis.
- 4 to 6 weeks for septic arthritis of a native joint (significantly longer for a prosthetic joint).
- Consult with Infectious Diseases about the duration of IV therapy, follow-on oral antimicrobials (where appropriate), and total duration of treatment.
Empiric
Non-vertebral osteomyelitis and septic arthritis
- fe = 0.7, consider adjusting dose if CrCl reduced.
- Risk of hepatotoxicity is increased in females, patients > 55 years old, high doses, and courses longer than 14 days duration.
If risk factors for MRSA, add:
- Known recent MRSA-positive
- Household contact with known recent MRSA-positive
- Recent admission to any overseas healthcare facility
- Recent residence overseas
- fe = 0.9, adjust dose if CrCl reduced.
- Must be given diluted (1 g in at least 200 mL) and slowly (≤ 1000 mg/hour) to minimise infusion reactions.
Mild penicillin allergy
- fe = 0.9, consider adjusting dose if CrCl is reduced.
If risk factors for MRSA, add:
- Known recent MRSA-positive
- Household contact with known recent MRSA-positive
- Recent admission to any overseas healthcare facility
- Recent residence overseas
- fe = 0.9, adjust dose if CrCl reduced.
- Must be given diluted (1 g in at least 200 mL) and slowly (≤ 1000 mg/hour) to minimise infusion reactions.
Severe penicillin allergy
- fe = 0.9, adjust dose if CrCl reduced.
- Must be given diluted (1 g in at least 200 mL) and slowly (≤ 1000 mg/hour) to minimise infusion reactions.
Vertebral osteomyelitis
Consult Infectious Diseases/Clinical Microbiology.
Pathogens Known
S. aureus
Methicillin susceptible S. aureus (MSSA)
See empiric treatment.
Methicillin resistant S. aureus (MRSA)
- fe = 0.9, adjust dose if CrCl reduced.
- Must be given diluted (1 g in at least 200 mL) and slowly (≤ 1000 mg/hour) to minimise infusion reactions.
Streptococcus (Note: check susceptibility)
- fe = 0.8, consider adjusting dose if CrCl is reduced.
Mild penicillin allergy (Note: check susceptibility)
- fe = 0.9, consider adjusting dose if CrCl is reduced.
Severe penicillin allergy (Note: check susceptibility)
- fe = 0.9, adjust dose if CrCl reduced.
- Must be given diluted (1 g in at least 200 mL) and slowly (≤ 1000 mg/hour) to minimise infusion reactions.
Enterobacteriaceae (mainly coliforms)
Treat according to known or local susceptibilities.
Pseudomonas aeruginosa (suspect if penetrating foot injury through a shoe)
Consult Infectious Diseases/Clinical Microbiology.
Topic Code: 99210