Bone and joint antibiotics
Diabetic foot infection
Associated organisms include Staphylococcus, Streptococcus, Enterococcus, Enterobacteriaceae, Proteus, Bacteroides, and Pseudomonas, and Klebsiella
Superficial Mild Infections
- Clindamycin 450mg PO q8hrs daily x 14 days OR
- TMP/SMX 2DS tabs PO q12hrs daily x 14 days OR
- Doxycycline 100mg PO q12hrs daily x 14 days
Prior antibiotic treatment or moderate infections
- Amoxicillin/Clavulanate 875/125mg PO q12hrs + TMP/SMX 2DS tabs PO q12hrs daily x 14 days OR
- Clindamycin 450mg PO q8hrs + Ciprofloxacin 750mg PO q12hrs x 14 days
Inpatient Treatment
- Vancomycin 15-20mg/kg IV q12hrs plus
- Ampicillin/Sulbactam 3g IV q6hrs OR
- Piperacillin/Tazobactam 4.5g IV q8hrs OR
- Ticarcillin/Clavulanate 3.1g IV q8hrs OR
- Imipenem 500mg IV q6hrs OR
- Metronidazole 500mg IV q8hrs PLUS
- Cefepime 2g IV q12hrs OR
- Ciprofloxacin 400mg IV q12hrs OR
- Aztreonam 2g IV q8hrs
Diskitis or Osteomyelitis
- Treatment targets S. aureus, Streptococcus, Pseudomonas, E. coli
Inpatient Therapy
- Vancomycin 15-20 mg/kg IV BID PLUS any of the following:
- Ceftriaxone 2g IV daily
- Cefepime 2g IV three times daily
- Ceftazidime 2g IV three times daily
- Ciprofloxacin 400mg IV three times daily
Use cefepime or ciprofloxacin if targeting Pseudomonas spp
Felon
Definitive treatment is drainage but antibiotic coverage for S. aureus and Strep with caution to identify Herpetic whitlow
- Cephalexin 500mg PO q6hrs daily x 7 days
- TMP/SMX 2 DS tablets PO q12hrs x 7 days
- Clindamycin 450mg PO q8hrs x 7 days
- Dicloxacillin 250mg PO q6hrs daily x 7 days
Infectious Tenosynovitis
Treatment should cover S. aureus, Streptococcus, and MRSA
- Vancomycin 25-30 mg/kg IV loading dose then 15-20mg/kg IV q12hrs PLUS
- Levofloxacin 750 mg IV once daily (avoid in pediatrics) OR
- Ceftriaxone 1g IV daily
- If suspicious of Gonococcal infection then use Ceftriaxone 1g IV once daily AND Chlamydia coverage with
- Azithromycin 1g PO once OR
- Doxycycline 100mg PO twice daily
Animal Bites
- Ampicillin/Sulbactam 3g (50mg/kg) IV four times daily
Pediatrics
- Ceftriaxone 100mg/kg IV once daily AND Metronidazole 7.5mg/kg IV four times daily OR
- Clindamycin 10mg/kg IV four times daily AND TMP/SMX 5mg/kg IV BID
- Ampicillin/Sulbactam 50 mg/kg IV four times daily
Treatment should include usual therapy listed above in addition to:
- Clarithromycin 500mg PO twice daily PLUS
- Ethambutol 15 mg/kg PO once daily OR
- Rifampin 600 mg PO once daily AND consult infectious disease
Open fracture
Prophylactic Antibiotics for Open fractures
Initiate as soon as possible; increased infection rate when delayed[1]
Grade I & II Fractures Options
- Cefazolin 2 g IV (immediately and q8 hours x 3 total doses) (Ancef)[2]
- Cephalosporin allergy: Clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)[2]
Grade III Fracture Options
- Ceftriaxone 2 g IV (immediately x 1 total dose) PLUS Vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]
- Cephalosporin allergy: Aztreonam 2 g IV (immediately and q8 hours x 3) PLUS Vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]
Special Considerations
- Concern for clostridium (soil contamination, farm injuries, possible bowel contamination): additionally add penicillin[3][2]
- Fresh water wounds: fluoroquinolones OR 3rd/4th generation cephalosporin
- Saltwater wounds (vibrio): doxycycline + ceftazidime OR fluoroquinolone
Pediatric
Grade I & II
- Cefazolin 25mg/kg IV (max 2g) immediately then q8hrs x 3 doses
- Cephalosporin allergy: Clindamycin 10mg/kg IV (max 900mg) immediately then q8hrs x 3 doses
Grade III
- Ceftriaxone 50mg/kg IV (max 2g) x 1 + Vancomycin 15mg/kg IV (max 1g) then q12hrs x 2 doses
- Cephalosporin allergy: Aztreonam 30mg/kg IV (max 2g) then q8hrs x 3 + Vancomycin
Osteomyelitis
| Risk Factor | Likely Organism | Initial Empiric Antibiotic Therapy' |
| Elderly, hematogenous spread | MRSA, MSSA, gram neg | Vancomycin 1g IV q12h + (Piperacillin/Tazobactam 3.375g IV q6h OR Imipenem 500mg IV q6h) |
| Sickle Cell Disease | Salmonella, gram-negative bacteria | Ceftriaxone 50mg/kg IV once daily OR Cefotaxime 50mg/kg IV three times daily, PLUS
|
| DM or vascular insufficiency | Polymicrobial: Staph, strep, coliforms, anaerobes | Vancomycin 1g IV q12h + (Piperacillin/Tazobactam 3.375g IV q6h OR Imipenem 500mg IV q6h) |
| IV drug user | MRSA, MSSA, pseudomonas | Vancomycin 1g IV q12h |
| Newborn | MRSA, MSSA, GBS, Gram Negative | Vancomycin 15mg/kg load, then reduce dose, AND Ceftazidime 30mg/kg IV q12 h |
| Children | MRSA, MSSA | Vancomycin 10mg/kg q6 h AND Ceftazidime 50mg/kg q8hr |
| Postoperative (ortho) | MRSA, MSSA | Vancomycin 1g IV q12h |
| Human bite | Strep, anaerobes, HACEK organism | Piperacillin/Tazobactam 3.375gm OR Imipenem 500mg IV q6h |
| Animal bites | Pasteurella, Eikenella, HACEK organism | Piperacillin/Tazobactam 3.375gm OR Imipenem 500mg IV q6h |
| Foot puncture wound | Pseudomonas | Anti-pseudomonal, staph coverage |
- Dicloxacillin <40kg: 50-100mg/kg/day PO divided q6h; >40kg: 250-500mg PO q6h
Septic Arthritis
For adults treatment should be divided into Gonococcal and Non-Gonococcal
Gonococcal
- Ceftriaxone 1g IV once daily
- Cefixime 400 mg PO BID is an option for outpatient therapy after initial 3 days of Ceftriaxone
Non-Gonococcal
- Treatment should cover S. aureus, Streptococcus, Pseudomonas, Enterococcus, B. burgdorferi
- Vancomycin 15-20 mg/kg IV BID PLUS any of the following:
- Ceftriaxone 2g IV once daily
- Cefepime 2g IV three times daily
- Ceftazidime 2g IV three times daily
- Ciprofloxacin 400mg IV three times daily
Pediatrics
Neonates (<3 months)
- Nafcillin 50mg/kg IV q6hrs + Cefotaxime 50mg/kg IV q8hrs
Children (>3 months)
- Ceftriaxone 50-75mg/kg IV daily (max 2g) OR
- Cefazolin 25mg/kg IV q8hrs (max 2g/dose)
- If MRSA suspected: Vancomycin 15mg/kg IV q6hrs OR Clindamycin 10-13mg/kg IV q8hrs (max 900mg/dose)
Sickle Cell
Coverage for Salmonella and Staphylococcus spp
- Vancomycin 20mg/kg IV twice daily PLUS
- Ciprofloxacin 400mg IV three times daily OR
- Imipenem/Cilastatin 1g IV three times daily
Septic Bursitis
Cover Staphylococcus aureus (80-90%) and Streptococcus
Outpatient Options
- Clindamycin 300 mg PO three times daily x 14 days OR
- TMP/SMX 2 DS tabs PO two times daily x 14 days OR
- Dicloxacillin 500mg PO q6hr x10 days
Treatment followup with primary physician is important since the regimen may need extension to 3 weeks.
Inpatient Options
- Vancomycin 25-30 mg/kg IV loading then 15-20 mg/kg IV OR
- Clindamycin 600 mg IV three times daily
- Linezolid 600 mg IV BID
- Clindamycin 10mg/kg IV three times daily
- Linezolid 10mg/kg Q8hrs
See Also
Antibiotics by diagnosis
- Bone and joint antibiotics
- Cardiovascular antibiotics
- ENT antibiotics
- Eye antibiotics
- GI antibiotics
- GU antibiotics
- Neuro antibiotics
- OB/GYN antibiotics
- Pulmonary antibiotics
- Skin and soft tissue antibiotics
- Bioterrorism antibiotics
- Environmental exposure antibiotics
- Immunocompromised antibiotics
- Post exposure prophylaxis antibiotics
- Pediatric antibiotics
- Sepsis antibiotics
- Arthropod and parasitic antibiotics
For antibiotics by organism see Microbiology (Main)
References
- ↑ Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
- ↑ 2.0 2.1 2.2 2.3 2.4 Garner MR, et al. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. Journal of the American Academy of Orthopaedic Surgeons. April 15, 2020. 28(8):309-315
- ↑ HoffWS, Bonadies JA, Cachecho R, Dorlac WC: East practice management guidelines work group: Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011;70:751-754.