GUIDELINES FOR TREATMENT OF BONE AND JOINT INFECTIONS IN ADULTS

Pelvic Osteomyelitis
Hematogenous
Vertebral Osteomyelitis Septic Arthritis Associated with Chronic
Osteomyelitis
Decubitus Ulcers

Osteomyelitis following
Diabetic Foot Ulcers with
Prosthetic Joint Infections Trauma and/or Orthopedic References
Osteomyelitis
Procedures

Antimicrobial Subcommittee Approval: 06/2016 Originated: 06/2016

P&T Approval: 07/2016 Last Revised: 03/2021
Revision History:
2/2021: Added fungi, mycobacteria, and Actinomyces comment
03/2021: Updated vancomycin dosing & hyperlinks
The 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 guidelines
should 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 from
time 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 to
confirm 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 Contents
Hematogenous Osteomyelitis
Clinical Setting Empiric Therapy Duration Comments
Usually associated with: Consider holding antibiotics until deep tissue cultures can be obtained in
 Patients under age 17 hemodynamically stable patients
years or over 50 years
(recommendations Preferred:
intended for adults only) Approximately 45% of S. aureus at UMHS are MRSA,
Vancomycin* IV (see nomogram)
so initial treatment to cover MRSA is warranted. De-
 IV drug use
escalate to a beta-lactam if methicillin-susceptible S.
 Other risk for bacteremia If known MSSA colonization or infection:
aureus (MSSA) is identified.
e.g., central line, dialysis, Cefazolin* 2 g IV q8h
sickle cell disease,
Infectious Diseases Consultation recommended.
urethral catheterization, Alternative for vancomycin allergy (not red mans syndrome**):
UTI Daptomycin* 6 mg/kg IV daily
Daptomycin requires prior approval.
Bacterial Etiology: If Sickle Cell disease:
Baseline CK followed by weekly CK should be
 S. aureus Vancomycin* IV (see nomogram) 4-6 weeks
measured in patients placed on daptomycin due to
 30% Gram negative bacilli + Ceftriaxone 2 g IV daily
increased risk of rhabdomyolysis.
(consider if fresh water
exposure, recent broad If IVDU or other Gram negative risk (see bacterial etiology):
Increased dose of daptomycin may be indicated
spectrum antibiotics in Vancomycin* IV (see nomogram)
with documented MRSA bacteremia.
the prior 90 days, recent + Piperacillin-tazobactam 4.5 g IV q6h
>2 days hospitalized in
Infections due to fungi, mycobacteria, or
prior 90 days, or Alternative for patient with mild penicillin allergy:
Actinomyces require longer durations of therapy –
hemodynamic instability) Vancomycin* IV (see nomogram)
consult appropriate national guidelines for
 Salmonella in sickle cell + Cefepime 2 g IV q8h
guidance.
disease
 Serratia and Alternative for patients with life-threatening penicillin allergy:
Pseudomonas spp. in Vancomycin* IV (see nomogram)
IVDU + Aztreonam 2 g IV q8h
* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patients
Target vancomycin AUC 400-600 mcg*hr/mL

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Vertebral Osteomyelitis
Clinical Setting Empiric Therapy Duration Comments
Evaluation for epidural infection is critical. See full Vertebral Osteomyelitis FGP Guideline
Consider holding antibiotics until deep
tissue cultures can be obtained in
Infectious Diseases consultation strongly recommended.
hemodynamically stable patients
Usually
hematogenous source Step down therapy to oral antibiotic usually indicated after 6 weeks of therapy.
Preferred:
Vancomycin* IV (see nomogram)
Persons at risk: Approximately 45% of S. aureus at UMHS are MRSA, so initial treatment to cover MRSA is
+ Ceftriaxone 2 g IV q12h
 Age >60 years warranted. De-escalate to a beta-lactam if methicillin-susceptible S. aureus (MSSA) is identified.
 IVDU If known MSSA colonization or infection:
Cefazolin may replace oxacillin, if no epidural extension of infection is present.
 Urinary tract Oxacillin 2 g IV q4h
infections
Linezolid requires prior approval.
Alternative for suspected or documented
Minimum 6
Bacterial Etiology: Pseudomonal infection (see bacterial
weeks Baseline CBCP and weekly CBCP are recommended with linezolid therapy due to risk of
 S. aureus etiology):
cytopenia, especially thrombocytopenia; alternative therapy should be considered in patients
 Occ. Coagulase Vancomycin* IV (see nomogram)
with thrombocytopenia.
negative + Cefepime* 2 g IV q8h
staphylococcus
Linezolid should be used with caution in patients on medications with serotonergic activity,
 Enteric Gram Alternative for severe penicillin allergy:
e.g., SSRI and MAOI. See SSRI & Linezolid Education.
negatives Vancomycin* IV (see nomogram)
 Pseudomonas + Aztreonam* 2 g IV q6h
Daptomycin may replace linezolid if no epidural extension of infection is present.
in IVDU or
water exposure Alternative for vancomycin allergy or
Empiric dosing takes into account epidural abscess with possible CNS extension.
intolerance (not red mans syndrome**):
Linezolid 600 mg PO/IV q12h
Infections due to fungi, mycobacteria, or Actinomyces require longer durations of therapy –
+ other antibiotic as indicated above
consult appropriate national guidelines for guidance.
* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patients
Target vancomycin AUC 400-600 mcg*hr/mL

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Septic Arthritis
Clinical Setting Empiric Therapy Duration Comments
Approximately 45% of S. aureus at UMHS are MRSA, so
initial treatment to cover MRSA is warranted. De-
Usually associated with:
escalate to a beta-lactam if methicillin-susceptible S.
 Age >80 years Consider holding antibiotics until deep tissue cultures
aureus (MSSA) is identified.
 Diabetes mellitus can be obtained in hemodynamically stable patients
 Rheumatoid arthritis
Consult Orthopedic surgery for joint drainage.
 Prosthetic joint Preferred:
 Recent joint surgery Vancomycin* IV (see nomogram) 2-4 weeks
ID consultation recommended.
 Skin infection
 IV drug abuse If known MSSA colonization or infection: For S. aureus:
Linezolid and daptomycin require prior approval.
 Alcoholism Cefazolin* 2 g IV q8h minimum 4 weeks
 Prior intra-articular steroid injection Baseline CBCP and weekly CBCP are recommended
Alternative for vancomycin allergy (not red mans**):
with linezolid therapy due to risk of cytopenia,
Bacterial Etiology: Linezolid 600 mg PO/IV q12h For N. gonorrhea:
especially thrombocytopenia; alternative therapy
 S. aureus OR After 24-48h of
should be considered in patients with
Daptomycin* 6 mg/kg IV daily ceftriaxone with
 Streptococcal species, including S. thrombocytopenia.
substantial clinical
pneumoniae
If risk for gonorrhea: improvement,
 Gram negative bacilli associated with Linezolid should be used with caution in patients on
Vancomycin* IV (see nomogram) transition to oral
trauma, intravenous drug users, older medications with serotonergic activity, e.g., SSRI and
+ Ceftriaxone 1 g IV daily stepdown therapy
adults, and in association with MAOI. See SSRI & Linezolid Education.
+ Azithromycin 1 g PO in a single dose to complete total
underlying immunosuppression.
of at least 7 days
 N. gonorrhea in oligoarthritis, Baseline CK followed by weekly CK should be measured
If risk for Gram negative bacilli (see bacterial
(particularly young, sexually active), in patients placed on Daptomycin due to increased risk
associated tenosynovitis, vesicular etiology):
of rhabdomyolysis.
pustules, late complement deficiency, Vancomycin* IV (see nomogram)
negative synovial fluid culture and Gram + Piperacillin-tazobactam* 4.5 g IV q6h
Infections due to fungi, mycobacteria, or Actinomyces
stain
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 patients
Target vancomycin AUC 400-600 mcg*hr/mL

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Pelvic Osteomyelitis Associated with Chronic Decubitus Ulcers
Clinical Setting Empiric Therapy Duration Comments

Consider holding antibiotics until deep tissue cultures can be obtained in

hemodynamically stable patients Infectious Disease consultation recommended.

Preferred: Surgical debridement of overlying ulcer with deep tissue or

Vancomycin* IV (see nomogram) bone biopsy is an important component of management.
+ Piperacillin-tazobactam* 4.5 g IV q6h
Acute osteomyelitis Tailor therapy based on culture data.
associated with contiguous Alternative for patients with penicillin allergy:
spread from pressure ulcer Mild allergy (rash) Treatment should be modified to cover previously isolated
6-8 weeks of
Vancomycin* IV (see nomogram) pathogens with recurrent or relapse of the same site.
therapy
Bacterial Etiology: + Cefepime* 2 g IV q8h
depending
Mixed infections due to + Metronidazole 500 mg PO/IV q8h Daptomycin requires prior approval.
on response
Staphylococcus sp.,
Streptococcus sp. and Anaphylaxis: Baseline CK followed by weekly CK should be followed in
enteric organisms Vancomycin* IV (see nomogram) patients placed on daptomycin due to increased risk of
+ Aztreonam* 2 g IV q8h rhabdomyolysis.
+ Metronidazole 500 mg PO/IV q8h
Infections due to fungi, mycobacteria, or Actinomyces
Alternatives for vancomycin intolerance (not red mans**) or allergy: require longer durations of therapy – consult appropriate
Daptomycin* 6 mg/kg IV daily national guidelines for guidance.
+ other antibiotic as indicated above.

* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patients
Target vancomycin AUC 400-600 mcg*hr/mL

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Clinical Setting
Acute osteomyelitis with recent ulcer
 Staphylococcus spp (esp S.
aureus)
 Streptococcus spp
 Corynebacterium and other skin
flora
Risk for Gram negative bacillus
infection:
 Chronic ulcer with osteomyelitis
 Osteomyelitis with fresh water
exposure
 recent broad spectrum
antibiotics in the prior 90 days
 recent >2 days hospitalized in
prior 90 days hemodynamic
instability
Bacterial etiology
 Staphylococcus spp (esp S.
aureus)
 Streptococcus spp
 Enterobacteraciae
 Obligate anaerobes
 Rarely Pseudomonas
* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patients
Target vancomycin AUC 400-600 mcg*hr/mL
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Diabetic Foot Ulcers with Osteomyelitis
Empiric Therapy Duration Comments
Consider holding antibiotics until deep tissue
cultures can be obtained in hemodynamically
stable patients
Infectious Disease consultation recommended.
Preferred:
Vancomycin* IV (see nomogram) Surgical debridement of overlying ulcer with deep tissue or bone
biopsy is an important component of management.
Alternatives for Vancomycin intolerance (not
red mans**) or allergy: Tailor therapy based on culture data.
Daptomycin* 6 mg/kg IV daily
OR Treatment should be modified to cover previously isolated
Linezolid 600 mg PO/IV q12h pathogens with recurrent or relapse of the same site.
Preferred if risk for Gram negative:
Linezolid and daptomycin require prior approval.
Vancomycin* IV (see nomogram)
+ Piperacillin-tazobactam* 4.5 g IV q6h
6-8 weeks of Baseline CBCP and weekly CBCP are recommended with linezolid
therapy depending therapy due to risk of cytopenia, especially thrombocytopenia;
Alternative for patients with penicillin allergy
on response alternative therapy should be considered in patients with
Mild allergy (rash)
thrombocytopenia.
Vancomycin* IV (see nomogram)
+ Cefepime* 2 g IV q8h
Linezolid should be used with caution in patients on medications
+ Metronidazole 500 mg PO/IV q8h
with serotonergic activity, e.g., SSRI and MAOI. See SSRI & Linezolid
Education.
Anaphylaxis
Vancomycin* IV (see nomogram)
Baseline CK followed by weekly CK should be followed in patients
+ Aztreonam* 2 g IV q8h
placed on daptomycin due to increased risk of rhabdomyolysis.
+ Metronidazole 500 mg PO/IV q8h
Infections due to fungi, mycobacteria, or Actinomyces require longer
Alternatives for Vancomycin intolerance (not
durations of therapy – consult appropriate national guidelines for
red mans**) or allergy
Daptomycin* 6mg/kg IV daily
guidance.
OR
Linezolid 600mg PO/IV q12h
+ other antibiotic as indicated above.
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Prosthetic Joint infections
Clinical Setting Empiric Therapy Duration Comments

Higher risk associated: Consider holding antibiotics until deep tissue cultures can be 4-6 weeks Infectious Diseases consultation strongly
 Prior arthroplasty obtained in hemodynamically stable patients recommended.
 RA Oral antimicrobial
 Periorperative infections Early (<3 mo) and Late (>24 mo) Onset suppression indicated Approximately 45% of S. aureus at UMHS are
 Prior joint infections Preferred: in some cases of MRSA, so initial treatment to cover MRSA is
 Prolonged surgery Vancomycin* IV (see nomogram) retained hardware warranted. De-escalate to a beta-lactam if
 High BMI + Piperacillin-tazobactam 4.5 g IV q6h methicillin-susceptible S. aureus (MSSA) is
 Postoperative bleeding identified.
 DM Alternative for Suspected or Documented Gram negative
 Advanced age Infection: Linezolid and daptomycin require prior approval.
Vancomycin* IV (see nomogram)
Bacterial Etiology: + Cefepime* 2 g IV q8h Baseline CBCP and weekly CBCP are
Early onset: <3 months after surgery recommended with linezolid therapy due to risk
Alternative for Severe Penicillin Allergy: of cytopenia, especially thrombocytopenia;
 S. aureus
Vancomycin* IV (see nomogram) alternative therapy should be considered in
 Aerobic Gram negative bacilli
+ Aztreonam* 2 g IV q8h patients with thrombocytopenia.
 Anaerobes
 Mixed infections
Alternative for Vancomycin Allergy or Intolerance (not red Linezolid should be used with caution in patients
Delayed onset: 3-24 months after
mans**): on medications with serotonergic activity, e.g.,
surgery
Daptomycin* 6 mg/kg IV daily SSRI and MAOI. See SSRI & Linezolid Education.
 Coagulase negative + other antibiotic as indicated above
staphylococcus Baseline CK followed by weekly CK should be
 Enterocococcus Delayed (3-24 mo) Onset followed in patients placed on daptomycin due to
 Propionibacterium Preferred: increased risk of rhabdomyolysis.
Late onset: >24 months after surgery Vancomycin* IV (see nomogram)
 S. aureus Infections due to fungi, mycobacteria, or
 Beta-hemolytic streptococci Alternatives for Vancomycin intolerance (not red mans**) or Actinomyces require longer durations of therapy –
 Aerobic Gram negative bacilli allergy: consult appropriate national guidelines for
Daptomycin* 6 mg/kg IV daily guidance.
OR
Linezolid 600 mg PO/IV q12h

*Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patients
Target vancomycin AUC 400-600 mcg*hr/mL

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Osteomyelitis following Trauma and/or Orthopedic Procedures
Clinical Setting Empiric Therapy Duration Comments

Associated with contaminated Consider holding antibiotics until deep tissue cultures 6 weeks Infectious Diseases consult strongly recommended.
open fractures or surgical can be obtained in hemodynamically stable patients
treatment of closed fractures Oral Approximately 45% of S. aureus at UMHS are MRSA, so initial treatment to
Preferred: suppression cover MRSA is warranted. De-escalate to a beta-lactam if methicillin-
Bacterial Etiology: Vancomycin* IV (see nomogram) indicated in susceptible S. aureus (MSSA) is identified.
Most common + Piperacillin-tazobactam* 4.5 g IV q6h some cases of
 S. aureus retained Linezolid and daptomycin require prior approval.
 Coagulase negative Alternative for Vancomycin Allergy or Intolerance hardware
staphylococcus (not red mans**): Linezolid should be used with caution in patients on medications with
 Enteric Gram negative Daptomycin* 6 mg/kg IV daily serotonergic activity, e.g., SSRI and MAOI. See SSRI & Linezolid Education.
bacilli OR
Less common Linezolid 600 mg IV q12h Baseline CBCP and weekly CBCP are recommended with linezolid therapy
 Enterococcus sp. + other antibiotic as indicated above. due to risk of cytopenia, especially thrombocytopenia; alternative therapy
 Acinetobacter should be considered in patients with thrombocytopenia.
 Pseudomonas sp. Alternative for Penicillin Allergy (non-anaphylaxis):
 Anaerobes Vancomycin* IV (see nomogram) Baseline CK followed by weekly CK should be followed in patients placed on
+ Cefepime* 2 g IV q8h daptomycin due to increased risk of rhabdomyolysis.

Alternative for Severe Penicillin Allergy: Infections due to fungi, mycobacteria, or Actinomyces require longer
Vancomycin* (see nomogram) durations of therapy – consult appropriate national guidelines for guidance.
+ Aztreonam * 2 g IV q8h
* Adjust dose based on renal function; vancomycin dose may require adjustment for select organisms or patients
Target vancomycin AUC 400-600 mcg*hr/mL
** For red mans syndrome vancomycin infusion should be slowed to >2 hr

References:
1. Lipsky BA, Berendt RA, Cornia PB, etal. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis
2012;54(12):132-173.
2. Berbari EF, Kanj SS, Kowalski TJ, etal. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults.
Clin Infect Dis 2015;61(6):e26-46.
3. Osmon Dr, Berbari EF, Berendt, etal. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis
2013;56(1);e1-25.
4. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic joint infections. N Engl J Med 2004;351:1645.

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