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GUIDELINES FOR TREATMENT OF BONE AND JOINT INFECTIONS IN ADULTSHematogenousOsteomyelitisDiabetic Foot Ulcers withOsteomyelitisVertebral OsteomyelitisSeptic ArthritisPelvic OsteomyelitisAssociated with ChronicDecubitus UlcersProsthetic Joint InfectionsOsteomyelitis followingTrauma and/or OrthopedicProceduresReferencesAntimicrobial Subcommittee Approval:P&T Approval:06/201607/2016Originated:Last Revised:06/201603/2021Revision History:2/2021: Added fungi, mycobacteria, and Actinomyces comment03/2021: Updated vancomycin dosing & hyperlinksThe recommendations in this guide are meant to serve as treatment guidelines for use at Michigan Medicine facilities. If you are an individual experiencing a medical emergency, call 911 immediately. These guidelinesshould not replace a provider’s professional medical advice based on clinical judgment, or be used in lieu of an Infectious Diseases consultation when necessary. As a result of ongoing research, practice guidelines may fromtime to time change. The authors of these guidelines have made all attempts to ensure the accuracy based on current information, however, due to ongoing research, users of these guidelines are strongly encouraged toconfirm the information contained within them through an independent source.If obtained from a source other than https://www.med.umich.edu/asp, please visit the webpage for the most up-to-date document.

Table of ContentsHematogenous OsteomyelitisClinical SettingUsually associated with: Patients under age 17years or over 50 years(recommendationsintended for adults only) IV drug use Other risk for bacteremiae.g., central line, dialysis,sickle cell disease,urethral catheterization,UTIEmpiric TherapyDurationCommentsConsider holding antibiotics until deep tissue cultures can be obtained inhemodynamically stable patientsPreferred:Vancomycin* IV (see nomogram)Approximately 45% of S. aureus at UMHS are MRSA,so initial treatment to cover MRSA is warranted. Deescalate to a beta-lactam if methicillin-susceptible S.aureus (MSSA) is identified.If known MSSA colonization or infection:Cefazolin* 2 g IV q8hAlternative for vancomycin allergy (not red mans syndrome**):Daptomycin* 6 mg/kg IV dailyBacterial Etiology:If Sickle Cell disease:Vancomycin* IV (see nomogram)4-6 weeks S. aureus Ceftriaxone 2 g IV daily 30% Gram negative bacilli(consider if fresh waterIf IVDU or other Gram negative risk (see bacterial etiology):exposure, recent broadVancomycin* IV (see nomogram)spectrum antibiotics in Piperacillin-tazobactam 4.5 g IV q6hthe prior 90 days, recent 2 days hospitalized inAlternative for patient with mild penicillin allergy:prior 90 days, orVancomycin* IV (see nomogram)hemodynamic instability) Cefepime 2 g IV q8h Salmonella in sickle celldiseaseAlternative for patients with life-threatening penicillin allergy: Serratia andVancomycin* IV (see nomogram)Pseudomonas spp. in Aztreonam 2 g IV q8hIVDU* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patientsTarget vancomycin AUC 400-600 mcg*hr/mLPage 2 of 8Infectious Diseases Consultation recommended.Daptomycin requires prior approval.Baseline CK followed by weekly CK should bemeasured in patients placed on daptomycin due toincreased risk of rhabdomyolysis.Increased dose of daptomycin may be indicatedwith documented MRSA bacteremia.Infections due to fungi, mycobacteria, orActinomyces require longer durations of therapy –consult appropriate national guidelines forguidance.

Table of ContentsVertebral OsteomyelitisClinical SettingEmpiric TherapyDurationConsider holding antibiotics until deeptissue cultures can be obtained inhemodynamically stable patientsUsuallyhematogenous sourcePersons at risk: Age 60 years IVDU Urinary tractinfectionsBacterial Etiology: S. aureus Occ. Coagulasenegativestaphylococcus Enteric Gramnegatives Pseudomonasin IVDU orwater exposureInfectious Diseases consultation strongly recommended.Step down therapy to oral antibiotic usually indicated after 6 weeks of therapy.Preferred:Vancomycin* IV (see nomogram) Ceftriaxone 2 g IV q12hApproximately 45% of S. aureus at UMHS are MRSA, so initial treatment to cover MRSA iswarranted. De-escalate to a beta-lactam if methicillin-susceptible S. aureus (MSSA) is identified.If known MSSA colonization or infection:Oxacillin 2 g IV q4hAlternative for suspected or documentedPseudomonal infection (see bacterialetiology):Vancomycin* IV (see nomogram) Cefepime* 2 g IV q8hAlternative for severe penicillin allergy:Vancomycin* IV (see nomogram) Aztreonam* 2 g IV q6hAlternative for vancomycin allergy orintolerance (not red mans syndrome**):Linezolid 600 mg PO/IV q12h other antibiotic as indicated aboveCommentsEvaluation for epidural infection is critical. See full Vertebral Osteomyelitis FGP GuidelineCefazolin may replace oxacillin, if no epidural extension of infection is present.Linezolid requires prior approval.Minimum 6weeksBaseline CBCP and weekly CBCP are recommended with linezolid therapy due to risk ofcytopenia, especially thrombocytopenia; alternative therapy should be considered in patientswith thrombocytopenia.Linezolid should be used with caution in patients on medications with serotonergic activity,e.g., SSRI and MAOI. See SSRI & Linezolid Education.Daptomycin may replace linezolid if no epidural extension of infection is present.Empiric dosing takes into account epidural abscess with possible CNS extension.Infections due to fungi, mycobacteria, or Actinomyces require longer durations of therapy –consult appropriate national guidelines for guidance.* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patientsTarget vancomycin AUC 400-600 mcg*hr/mLPage 3 of 8

Table of ContentsSeptic ArthritisClinical SettingUsually associated with: Age 80 years Diabetes mellitus Rheumatoid arthritis Prosthetic joint Recent joint surgery Skin infection IV drug abuse Alcoholism Prior intra-articular steroid injectionBacterial Etiology: S. aureus Streptococcal species, including S.pneumoniae Gram negative bacilli associated withtrauma, intravenous drug users, olderadults, and in association withunderlying immunosuppression. N. gonorrhea in oligoarthritis,(particularly young, sexually active),associated tenosynovitis, vesicularpustules, late complement deficiency,negative synovial fluid culture and GramstainEmpiric TherapyDurationConsider holding antibiotics until deep tissue culturescan be obtained in hemodynamically stable patientsCommentsApproximately 45% of S. aureus at UMHS are MRSA, soinitial treatment to cover MRSA is warranted. Deescalate to a beta-lactam if methicillin-susceptible S.aureus (MSSA) is identified.Consult Orthopedic surgery for joint drainage.Preferred:Vancomycin* IV (see nomogram)2-4 weeksIf known MSSA colonization or infection:Cefazolin* 2 g IV q8hFor S. aureus:minimum 4 weeksAlternative for vancomycin allergy (not red mans**):Linezolid 600 mg PO/IV q12hORDaptomycin* 6 mg/kg IV dailyIf risk for gonorrhea:Vancomycin* IV (see nomogram) Ceftriaxone 1 g IV daily Azithromycin 1 g PO in a single doseFor N. gonorrhea:After 24-48h ofceftriaxone withsubstantial clinicalimprovement,transition to oralstepdown therapyto complete totalof at least 7 daysIf risk for Gram negative bacilli (see bacterialetiology):Vancomycin* IV (see nomogram) Piperacillin-tazobactam* 4.5 g IV q6h* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patientsTarget vancomycin AUC 400-600 mcg*hr/mLPage 4 of 8ID consultation recommended.Linezolid and daptomycin require prior approval.Baseline CBCP and weekly CBCP are recommendedwith linezolid therapy due to risk of cytopenia,especially thrombocytopenia; alternative therapyshould be considered in patients withthrombocytopenia.Linezolid should be used with caution in patients onmedications with serotonergic activity, e.g., SSRI andMAOI. See SSRI & Linezolid Education.Baseline CK followed by weekly CK should be measuredin patients placed on Daptomycin due to increased riskof rhabdomyolysis.Infections due to fungi, mycobacteria, or Actinomycesrequire longer durations of therapy – consultappropriate national guidelines for guidance.

Table of ContentsPelvic Osteomyelitis Associated with Chronic Decubitus UlcersClinical SettingEmpiric TherapyDurationConsider holding antibiotics until deep tissue cultures can be obtained inhemodynamically stable patientsInfectious Disease consultation recommended.Preferred:Vancomycin* IV (see nomogram) Piperacillin-tazobactam* 4.5 g IV q6hAcute osteomyelitisassociated with contiguousspread from pressure ulcerBacterial Etiology:Mixed infections due toStaphylococcus sp.,Streptococcus sp. andenteric organismsCommentsSurgical debridement of overlying ulcer with deep tissue orbone biopsy is an important component of management.Tailor therapy based on culture data.Alternative for patients with penicillin allergy:Mild allergy (rash)Vancomycin* IV (see nomogram) Cefepime* 2 g IV q8h Metronidazole 500 mg PO/IV q8h6-8 weeks oftherapydependingon responseAnaphylaxis:Vancomycin* IV (see nomogram) Aztreonam* 2 g IV q8h Metronidazole 500 mg PO/IV q8hTreatment should be modified to cover previously isolatedpathogens with recurrent or relapse of the same site.Daptomycin requires prior approval.Baseline CK followed by weekly CK should be followed inpatients placed on daptomycin due to increased risk ofrhabdomyolysis.Alternatives for vancomycin intolerance (not red mans**) or allergy:Daptomycin* 6 mg/kg IV daily other antibiotic as indicated above.* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patientsTarget vancomycin AUC 400-600 mcg*hr/mLPage 5 of 8Infections due to fungi, mycobacteria, or Actinomycesrequire longer durations of therapy – consult appropriatenational guidelines for guidance.