Document Control: Antibiotic Guidelines For Bone and Joint Infections (Including Hot Joint Pathway)

Antibiotic Guidelines for Bone and Joint Infections
Document Control
Title
(Including Hot Joint Pathway)
Author Author’s job title
Consultant Microbiologist
Antibiotic Pharmacist
Consultant Orthopaedic Surgeon
Consultant Vascular Surgeon
Podiatrist
Consultant Rheumatologist
Rheumatology Registrar
Directorate Department
Diagnostic Pathology
Date
Version Status Comment / Changes / Approval
Issued
0.1 Mar Draft First draft for consultation
2011
0.2 Apr Draft Addition of audit criteria. Change to fluclox dosing in
2011 arteriopaths. Change to penicillin allergy regime for bites.
1.0 May Final Approved by the Lead Clinician for Drug and
2011 Therapeutics Group on 12th May 2011.
1.1 May Revision Minor amendments by Corporate Affairs to update to
2011 latest template. Rebuilt hyperlinks to appendices.
1.2 Jan Revision Bone and joint infections guidance split from skin and
2017 soft tissue guidance, references updated, diagnostic
information updated, new structure for layout of clinical
information. Submitted for review by AWG and clinical
specialists.
1.3 Jan Revision Feedback from Miss Baldwick: Changed name of septic
2017 arthritis in a prosthetic joint to infection in a prosthetic
joint, addition of criteria for “overtly septic” in appendices
3 and 4. Typographical errors corrected. Removal of
MRSA treatment audit criteria. Addition of discitis
guidance.
2.0 Feb Final Review of all supplementary guidance, review of relevant
2017 NICE guidance, and review of discitis guidance.
Approved by DTC 18th May.
2.1 Feb Revision Review of references, approval process updated.
2020 Reviewed by orthopaedic surgeon. Submitted to IPDG
with minor amendments re: diabetic foot pathway and
approved ….
2.2 Oct Revision Septic arthritis guidance amalgamated with Hot Joint
2020 Guideline, submitted for review.
3.0 Nov Revision Following submission to CRC 19.11.20 Flow chart for
2020 septic joint (page 21) amended to “admit or manage as
outpatient as clinically indicated” and “do not wait for
results of investigations if septic joint suspected”.
Agreed that only one guideline required with appropriate
links and searches on Microguide. Radiology information
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updated.
Main Contact
Consultant Microbiologist Tel: Direct Dial –
North Devon District Hospital Tel: Internal –
Raleigh Park Email:
Barnstaple, EX31 4JB
Lead Director
Director of Medicine
Superseded Documents
Antibiotic Guidelines for Bone & Joint Infections v1.5 30042020
Issue Date Review Date Review Cycle
Dec 2020 Nov 2023 Three years
Consulted with the following stakeholders:
 Antibiotic Working Group
 Infection Prevention and Decontamination Group
 Consultant Diabetologists
 Consultant Vascular Surgeons
 Consultant Orthopaedic Surgeons
 Consultant Rheumatologists
Approval and Review Process
 Antibiotic Working Group
 Clinical Audit and Guideline Group
Local Archive Reference
G:\ANTIBIOTICSTEWARDSHIP
Local Path
G:\ANTIBIOTIC STEWARDSHIP\Stewardship\Antibiotic policies\Published policies
Filename
Antibiotic Guidelines for Bone & Joint Infections with Hot Joint Pathway v1.7 19112020
Policy categories for Trust’s internal Tags for Trust’s internal website (Bob)
website (Bob) Bursitis, osteomyelitis, septic arthritis,
Pharmacy, microbiology, orthopaedics, prosthetic joint infection, hot joint pathway,
rheumatology, vascular surgery, diabetes podiatry
and endocrinology, tissue viability.
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CONTENTS
Document Control ............................................................................................................... 1
1. Purpose ........................................................................................................................ 3
2. Responsibilities ........................................................................................................... 4
Role of Antibiotic Working Group (AWG) ....................................................................... 4
3. Contacts ....................................................................................................................... 4
4. Management of Bone and Joint infections ................................................................ 4
5. Monitoring Compliance with and the Effectiveness of the Guideline ...................... 5
Suggested audit criteria ................................................................................................. 5
Process for Implementation and Monitoring Compliance and Effectiveness................... 5
6. Equality Impact Assessment....................................................................................... 5
7. References ................................................................................................................... 6
8. Associated Documentation ....................................................................................... 13
9. Appendix 1: Emergency department antibiotic Management of Open Fractures.. 13
10. Appendix 2: Surgical Prophylaxis at induction for Open Fracture surgery ........... 16
11. Appendix 3: Hot Joint (Septic Arthritis) in a Native Joint ....................................... 17
12. Appendix 4: Hot Joint (Infection) in a Prosthetic Joint ........................................... 22
13. Appendix 5: Acute Osteomyelitis ............................................................................. 23
14. Appendix 6: Osteomyelitis in the Diabetic Foot ...................................................... 26
15. Appendix 7: Discitis and vertebral osteomyelitis .................................................... 28
16. Appendix 8: Infected Bursitis.................................................................................... 30
1. Purpose
1.1. This document sets out Northern Devon Healthcare NHS Trust’s
best practice guidelines for appropriate microbiological investigation
and antimicrobial prescribing in adult patients with bone and joint
infections.
1.2. This guideline applies to all adults and must be adhered to. Special
considerations exist for pregnant and breastfeeding patients; liaise
with specialist clinicians as appropriate in these cases. See separate
guidance for paediatric patients.
1.3. Non-compliance with this guideline may be for valid clinical reasons
only. The reason(s) for non-compliance must be documented clearly
in the patient’s notes.
1.4. This guideline is primarily aimed at all prescribing teams but other
staff (e.g. nursing staff, pharmacists) may need to familiarise
themselves with some aspects of the guideline.
1.5. Implementation of this guideline will ensure that:
 Bone and joint infections are managed according to current evidence

and standards of practice in the wider healthcare community.
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 A standard of care is specified to facilitate a consistent approach

between surgery, tissue viability, endocrinology, microbiology and
pharmacy in terms of patient management, specimen processing and
drug availability.
2. Responsibilities
2.1. Responsibility for education and training on antibiotic use in NDHT lies
with the Lead Consultant Microbiologist for Antibiotic Stewardship. It
will be provided through formal study days and informal training on the
ward.
2.2. The author will be responsible for ensuring the guidelines are reviewed
and revisions approved by the Clinical Audit and Guidelines Group in
accordance with the Document Control Report.
2.3. All versions of these guidelines will be archived in electronic format by

the author within the Antibiotic Stewardship policy archive.
2.4. Any revisions to the final document will be recorded on the Document
Control Report.
2.5. To obtain a copy of the archived guidelines, contact should be made

with the author.
2.6. Monitoring of implementation, effectiveness and compliance with these

guidelines will be the responsibility of the Lead Clinician for Antibiotic
Stewardship. Where non-compliance is found, the reasons for this
must have been documented in the patient’s medical notes.
Role of Antibiotic Working Group (AWG)

2.7. The AWG is responsible for:
 Leading antibiotic guideline development and review within

Northern Devon Healthcare Trust
 Involving all relevant stakeholders in guideline development and
review
3. Contacts
3.1. Contact numbers:
 Microbiologist Bleep 193. Via switchboard out of hours.

 Antibiotic Pharmacist Bleep 029 (Mon-Fri only)
4. Management of Bone and Joint infections

See table of contents for appendices
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5. Monitoring Compliance with and the Effectiveness

of the Guideline
Suggested audit criteria
5.1. The following could be used:
 Percentage of patients with septic arthritis or osteomyelitis with

deep tissue samples taken
Process for Implementation and Monitoring Compliance and

Effectiveness
5.2. Incidents involving bone and joint infection should be reported
according to the Trust’s Incident Reporting Policy. Critical incident
reports relating to bone and joint infection will be collated by the
Antibiotic Pharmacist. Results will be reported on an annual basis to
the Infection Prevention and Decontamination Group.
6. Equality Impact Assessment

6.1. The author must include the Equality Impact Assessment Table and
identify whether the policy has a positive or negative impact on any of
the groups listed. The Author must make comment on how the policy
makes this impact.
Table 1: Equality impact Assessment
Group Positive Negative No Impact Comment

Impact Impact
Age X Separate guidance
for paediatrics
Disability X
Gender X
Gender Reassignment X
Human Rights (rights X
to privacy, dignity,
liberty and non-
degrading treatment)
Marriage and civil X
partnership
Pregnancy X Some treatment
advice may harm
the unborn foetus,
discuss on a case-
by-case basis with
Obstetricians and
Pharmacy for
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advice.
Maternity and X Some treatments
Breastfeeding may be excreted in
breast milk.
Discuss on a case-
by-case basis with
Paediatricians and
Pharmacy for
advice.
Race (ethnic origin) X
Religion (or belief) X
7. References
NICE Guideline NG37: Fractures (complex): assessment and management. Feb
2016.
Describes procedures for pre-hospital and in-hospital management of open

fractures.
In the emergency department, administer prophylactic intravenous

antibiotics immediately to people with open fractures if not already given
Study showing greatest benefit of early antibiotics probably had high

fraction of contaminated wounds. Used mainly cefazolin, but also
clindamycin and vancomycin. Other studies used cefuroxime, penicillin
plus gentamicin, clindamycin. All studies included debridement and
fixation as part of protocol.
NICE guideline NG38 Fracture (non-complex) Feb 2016
Guidelines do not discuss antibiotic prophylaxis
Johns Hopkins Antimicrobial Guidelines via

https://www.hopkinsguides.com/hopkins/index/Johns_Hopkins_ABX_Guide/Al
l_Topics/A
Diagnostic criteria and microbiological sampling advice for bone and joint
infections
Acute Osteomyelitis
 The distinction between acute (AOM) and chronic osteomyelitis (COM)
is not well-defined:
 "Acute" includes the first presentation of osteomyelitis, acute symptoms
(< 2 weeks), and absence of necrotic bone or sequestrum.
 AOM: most common in children (usually S. aureus) or in adults age> 50,
IV drug use, hemodialysis, diabetes, sickle cell disease, other risk
factors for bacteremia.
 Typical sites:
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 Vertebra (adults > adolescents > children)

 Long bones (children > adults)
 Axial joints (sternoclavicular, sacroiliac especially in IV drug users).
 Usually monomicrobial since hematogenous process common; whereas
contiguous-focus infections are more likely to be polymicrobial.
 MRSA may cause hematogenous osteomyelitis and pathologic fracture
after soft tissue infection.
 Acute symptoms/signs: two typical scenarios but both usually include
localized pain and diminished function or evidence of inflammation:
 Abruptly ill patient with signs of infection and focal bone pain:
fever/chills/night sweats, localizing pain/tenderness or
swelling/erythema.
 Afebrile patient or low-grade fever with gradual onset and
progression of symptoms and/or localizing signs.
 Vertebral osteomyelitis: new or worsening back or neck pain plus
localized tenderness and/or fever.[1]◦
 Suspect diagnosis also if risk factor (IDU), new or worsening back
or neck pain with bloodstream infection or infective endocarditis, or
if a recent episode of S. aureus bloodstream infection.
 Also, diagnosis even in the absence of back pain if fever and new
neurologic symptoms.
 May be complicated by discitis, epidural abscess, para-vertebral or
iliopsoas abscess.
 Neonatal osteomyelitis is typically associated with septic arthritis.
 Exam:
 Tenderness, soft tissue swelling or erythema of at end of long
bones (metaphyseal infection).
 Exposure of bone on visual inspection or by probing may be
diagnostic for osteomyelitis arising from a contiguous focus--this is
seen with COM >> AOM (and lack of probing to bone argues
against OM).
 Vertebral osteomyelitis: point tenderness along the spine, may also
have neurologic deficits
 Laboratory: elevated ESR, CRP expected; leukocytosis and elevated
platelet count are common. These are all non-specific.
 Radiology: periosteal elevation, focal osteopenia, cortical thinning or
scalloping on plain film or CT; marrow edema on MRI; tracer uptake on
radionuclide scans. Changes in plain films often take weeks to develop.
 Microbiology: isolation of the pathogen from the bone lesion (aspiration
or bone biopsy) or blood culture in the setting of suggestive clinical
scenario/radiologic imaging.
DIAGNOSIS
 Suspicion based on history, physical exam and supportive laboratory
findings.
 Imaging is important for diagnosis, staging and follow-up. ◦Plain films
may be sufficient if typical findings are present, but are insensitive at all
for early osteomyelitis (usually need 10-14d minimum to see changes).
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 MRI, CT and radionuclide scans are more sensitive in early or

ambiguous cases.
 CT is most helpful in the setting of a prosthesis or other hardware.
 MRI (with contrast) has best capacity to diagnosis early changes
consistent with AOM as well as to assess soft tissue changes,
discitis and presence of epidural abscess.
 Bone scan imaging may detect as early 3d, but is less sensitive in
children and may be falsely negative even with bone infections of
longer duration.
 Nuclear medicine imaging usually only performed if
contraindication to MRI imaging.
 MRI w/ contrast is preferred for suspected vertebral osteomyelitis
to exclude paravertebral or epidural abscess, cord impingement,
discitis.
 Endocarditis associated up to 30-50% of vertebral OM cases. If
bacteremic, obtain echocardiographic imaging.
 If a patient with suspected vertebral osteomyelitis cannot get spine
MRI, options include a bone scan, CT scan, or PET-CT
 Imperative to establish the microbial etiology (ideally before antibiotic
initiation), if feasible.
 Obtain blood cultures x 2.
 Bone biopsy: include cultures for standard C&S in all, fungal and
AFB if clinical history, epidemiological factors, host risk factors, or
radiologic clues suggest one of these organisms
TREATMENT - General considerations
 Orthopedic surgeon, other surgeon or interventional radiologist to assist
with obtaining culture from involved bone and/or drain collections.
 Surgery indications: failure to respond to antibiotics, requirement for
debridement of bone, drainage of soft tissue abscess, joint infection,
epidural abscess/ neurologic progression and spinal instability, or
persistently positive blood cultures.
 Empiric antibiotic therapy should be directed against S. aureus as most
common if treatment thought to be needed prior to microbiological data.
 The transition from IV to oral therapy should be guided by pathogen,
presence or absence of bacteremia, improvement in ESR and CRP,
availability of bioavailable oral agent, and clinical response.
 ◦Guidelines for non-vertebral osteomyelitis suggest at least 6
weeks of total therapy.
 Trial in children with AOM suggests IV course may be as short as
2-4d and total course of 20d
 Recent OVIVA randomized pragmatic clinical trial in the United
Kingdom randomized patients with bone and joint infections to
receive oral or IV therapy 7 days after surgery or initiation of
antibiotics. Most patients in this trial received antibiotic therapy
beyond 6 weeks (78 days in IV group and 71 days in PO group).
Relapse happened in 14.6% of patients in the IV group and 13.2%
of patients in the PO group, no difference. Early discontinuation of
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therapy happened more frequently in the IV group than the PO

group.
 Hematogenous AOM
 Usually, need to cover MRSA, but in areas with little such resistance or
negative MRSA screen, empiric MSSA coverage may be sufficient.
 Use susceptibility information to help guide choices (parenteral or oral).
 MSSA:
 Nafcillin or oxacillin 2g IV q4h (may be placed on an infusion pump
for OPAT)
 Cefazolin 2g IV q6-8h
 ◦Ceftriaxone 2g IV q24h
 ◦Clindamycin 600mg PO q6h (particularly in children)
 ◦Rifampin 600mg PO daily may be considered in addition to the
agents above if hardware is in place but should not be given as
monotherapy.
 MRSA:
 Vancomycin 15mg/kg IV q12h. Target goal trough 12-18 mg/L.
 Linezolid 600 mg PO q12h (toxicities may limit use beyond 2
weeks)
 Daptomycin 6-8mg/kg/d IV
 Rifampin 600mg PO daily may be considered in addition to the
agents above if hardware is in place but should not be given as
monotherapy.[4]
 Streptococcal or enterococcal species: ◦Penicillin G 2-4 MU IV q4-6h
 Ampicillin 2g IV q6h (+/- ceftriaxone 2g IV q12H for Streptococcus
agalactiae, other higher PCN MIC strep or enterococcal species)
 Gram negatives:
 Ampicillin/sulbactam 3g IV q6h
 Piperacillin/tazobactam 3.375 g IV q4-6h
 Ciprofloxacin 750mg PO q12h (oral is as efficacious as IV, and
quinolones have higher efficacy in susceptible organisms due to
high bone penetration)
 Levofloxacin 500-750 mg PO once-daily(oral is as efficacious as
IV, and quinolones have higher efficacy in susceptible organisms
due to high bone penetration)
 Moxifloxacin 400mg PO once daily(oral is as efficacious as IV, and
quinolones have higher efficacy in susceptible organisms due to
high bone penetration)
 Ceftriaxone 2g IV q24h
 Cefotaxime 2g IV q6-8h
 Ceftazidime 2g IV q8h
 Cefepime 2g IV q12h or Q8H
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 Duration: frequent recommendation is 2-6 wks parenteral therapy with

potential transition to oral therapy to complete 4-6 wks, 6 wks often used
on average. ◦Timing of transition not well established and many change
when there is sufficient clinical improvement which can mean in a matter
of days.
 In OVIVA study, the transition to orals happened at 1 week.
 Duration in children can be shortened to 3-4 week total with early
transition to oral.
 One large study suggests that high-risk patients should receive at least
8 weeks of antibiotic therapy.
 High risk: MRSA, undrained para-vertebral/psoas collections and
ESRD.
 Contiguous focus or inoculation osteomyelitis
 Leg/foot ulcer: orthopedic consult, consider a vascular evaluation if signs
of insufficiency present.
 Often bone involvement in these scenarios represent COM than
AOM.
 Decubitus ulcer: plastic surgery consult, again these often are COM
problems.
 Osteomyelitis under chronic ulcer is often polymicrobial. If vascular
insufficiency present, include anaerobic coverage.
 The general recommendation is 6-8 weeks of abx (commonly 2 wks of
initial IV therapy or until clinical improvement/stability) following surgical
debridement.
 Use regimens under hematogenous osteomyelitis when guided by
culture data. Empiric regimens are given below. Add vancomycin when
MRSA risk factors present. Empiric regimens:
 Clindamycin 600mg PO q6h or 900mg PO q8h + ciprofloxacin
750mg PO q12h or levofloxacin 750mg PO once daily.
 Ampicillin/sulbactam 3g (2g/1g respectively) IV q6h
 Piperacillin/tazobactam 3.375g IV q4-6h
 Ertapenem 1g IV q24h
 Imipenem 500mg IV q6h
 Meropenem 1g IV q8h
 Ceftriaxone 2g IV q24h or cefotaxime 2g IV q6-8h or ceftazidime
2g IV q8h or cefepime 2g IV q8h + metronidazole 500mg PO q8h
 Human or animal bite: ampicillin/sulbactam 3g (2g/1g respectively) IV
q6h
 Oral regimens (to follow parenteral therapy)
 The erratic oral bioavailability of penicillins and cephalosporins plus
lower vascular penetration of bone makes these agents often less
desirable. However, streptococci are usually highly susceptible.
Use pathogen sensitivities to guide therapy.
 Staph (MSSA, MRSA) or anaerobes: clindamycin 300-450mg PO
q6h
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 Staph (MSSA, MRSA): ◦Minocycline 100 mg PO once-daily

 Doxycycline 100g PO q12h
 Either +/- rifampin 600 mg PO once daily
 Staph (MSSA, MRSA) or GNB: ◦Trimethoprim/sulfamethoxazole
DS 2 tabs PO q8-12h (+/- rifampin 600 mg PO once daily for
staphylococci)[8]
 GNB: ◦Ciprofloxacin 750mg PO q12h
 Levofloxacin 750 mg PO once daily
 Anaerobes: metronidazole 500mg PO q8h
 Mixed infection: clindamycin + fluoroquinolone
 MRSA or VRE: linezolid 600 mg PO q12h
 Human or animal bite: amoxicillin/clavulanate 875-1000 mg PO
twice-daily
NICE CKS: Olecranon bursitis. Revised Sept 2016.
Diagnostics and management – needle aspiration, [uncomplicated] oral

antibiotics to cover Staph and Streps usually 1 week – 2 if immunosuppressed
NICE CKS: Pre-patellar bursitis. Revised Dec 2016.
Describes risk factors and management of pre-patellar bursitis (incorporated

into septic arthritis guidance)
NICE Guideline NG19: Diabetic foot problems: Prevention and management. Oct
2019.
If a diabetic foot infection is suspected and a wound is present, send a

soft tissue or bone sample from the base of the debrided wound for
microbiological examination. If this cannot be obtained, take a deep
swab because it may provide useful information on the choice of
antibiotic treatment
Start antibiotic treatment for suspected diabetic foot infection as soon

as possible. Take cultures and samples before, or as close as possible
to, the start of antibiotic treatment
Give oral antibiotics first line if the person can take oral medicines, and
the severity of their condition does not require intravenous antibiotics.
Review intravenous antibiotics by 48 hours and consider switching to
oral antibiotics if possible. Other antibiotics may be appropriate based
on microbiological results and specialist advice. Skin takes some time
to return to normal, and full resolution of symptoms after a course of
antibiotics is not expected. Review the need for continued antibiotics
regularly.
When choosing an antibiotic for people with a suspected diabetic foot

infection (see recommendations 1.6.8 and 1.6.9), take account of:
The severity of diabetic foot infection (mild, moderate or severe)
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The risk of developing complications

Previous microbiological results
Previous antibiotic use
Patient preferences
Diabetic foot infection is defined by the presence of at least 2 of the

following:
Local swelling or induration, erythema, local tenderness or pain, local

warmth, purulent discharge.
Mild diabetic foot infection
Local infection involving only the skin and subcutaneous tissue; if

erythema, must be 0.5 cm to less than 2 cm around the ulcer (exclude
other causes of inflammatory response, such as trauma, gout, acute
Charcot neuro-osteoarthropathy, fracture, thrombosis and venous
stasis).
Moderate diabetic foot infection
Local infection with erythema more than 2 cm around the ulcer or

involving structures deeper than skin and subcutaneous tissues (such
as abscess, osteomyelitis, septic arthritis or fasciitis), and no systemic
inflammatory response signs.
Severe diabetic foot infection
Local infection with signs of systemic inflammatory response (such as

temperature of more than 38°C or less than 36°C, increased heart rate
or increased respiratory rate).
When microbiological results are available:
•review the choice of antibiotic and
•change the antibiotic according to results, using a narrow-spectrum

antibiotic, if appropriate. [2019]
1.6.15 Reassess people with a suspected diabetic foot infection if

symptoms worsen rapidly or significantly at any time, do not start to
improve within 1 to 2 days, or the person becomes systemically very
unwell or has severe pain out of proportion to the infection. Take
account of:
•other possible diagnoses, such as pressure sores, gout or non-

infected ulcers
•any symptoms or signs suggesting a more serious illness or condition,

such as limb ischaemia, osteomyelitis, necrotising fasciitis or sepsis
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•previous antibiotic use.
Murillo O and Lora-Tamayo J (2016) Pyogenic Vertebral Osteomyleitis. CID

62 1270-71
Discuss recent evidence of management of VO (infection of vertebra

and spread to contiguous structures, including disc). Can treat
conservatively with 6 weeks abx if : no abscess, not MDR organisms.
Otherwise higher risk of failure. Need longer courses and review of
need for formal debridement. Combination options are preferred : cip/rif
is favoured for MSSA.
8. Associated Documentation
 Incident reporting policy
 Antibiotic guidelines for management of severe sepsis and septic shock
 Antibiotic prescribing policy
 Penicillin allergy policy
 Antibiotic guidelines for surgical prophylaxis
9. Appendix 1: Emergency department antibiotic

Management of Open Fractures
9.1. Name of guideline on app
Open Fractures – Pre-operative Management

9.2. Location on app
Infection
Secondary Care
Adult treatment
Bone and Joint
Open Fractures
Emergency department Management
9.3. Header
An open fracture is defined as a broken bone that is in communication

with the environment through broken skin. Requires urgent senior
orthopaedic review.
9.4. Diagnosis and things to watch out for
 Open fracture classifications [Gustilo]:
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 Type I: Open fracture with a skin wound less than 1cm long and
clean
 Type II: Open fracture with a laceration more than 1cm long
without extensive soft tissue damage, flaps or avulsions
 Type III: Either an open segmental fracture, an open fracture with
extensive soft tissue damage, or a traumatic amputation.
 Monitor the patient for complications such as compartment syndrome.
 Do not take wound swabs unless there is clearly infection and frank pus
present as culture results are rarely helpful from a fresh, contaminated
wound.
9.5. Always Remember To…
 Give the first dose of antibiotic in the Emergency department, and within
an hour of arrival.
 Check the Tetanus status and treat according to Trust protocol
9.6. Watch Out For (red flags)…
 Rapidly spreading skin and soft tissue changes may correspond to

developing infection or compartment syndrome and require urgent
senior assessment.
9.7. Treatment [closed]
 Type I and II Fractures:
 First Line
Flucloxacillin PO 1g QDS
Until surgery
 Penicillin allergy or known positive MRSA:
Patients under 60kg: Teicoplanin IV 400mg every 12 hours for 3

doses, then OD
Patients 60kg or more*: Teicoplanin IV 800mg every 12 hours for 3

doses, then OD
*Patients who weigh more than 130kg should have a dose calculated in
the range 6-12mg/kg/day and rounded to the nearest whole vial (vials
are 200mg and 400mg)
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Until surgery. Antibiotics are not generally required after this.
 Type III Fractures
 First line:
Flucloxacillin IV 2g QDS
Plus
Gentamicin IV as per trust guidelines
 Penicillin allergy or known positive MRSA:
Patients under 60kg: Teicoplanin IV 400mg every 12 hours for 3

doses, then OD
Patients 60kg or more*: Teicoplanin IV 800mg every 12 hours for 3

doses, then OD
*Patients who weigh more than 130kg should have a dose calculated in
the range 6-12mg/kg/day and rounded to the nearest whole vial (vials
are 200mg and 400mg)
Plus
Gentamicin IV as per trust guidelines
9.8. If No Better…
 Ensure an accurate wound history has been taken to ascertain if atypical

or unusual organisms may be responsible for infection symptoms.
 Senior orthopaedic review for source control required, then if required
contact microbiologist to discuss further antibiotic management.
 Medication review with Pharmacy and/or specialist clinical team, ensure
that any immune-suppressing drugs are being used appropriately
9.9. Other Relevant Guidelines
 Antibiotic Guidelines for Skin and Soft Tissue Infections

 Severe Sepsis and Septic Shock Guidelines, and Septic Shock
Algorithm
9.10. Organisms and Sensitivities
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9.11. Version Control
Antibiotic Guidelines for Bone & Joint Infections with Hot Joint Pathway v1.7
19112020
10. Appendix 2: Surgical Prophylaxis at induction for

Open Fracture surgery
Open Fractures – Pre-operative Management

Infection
Secondary Care
Adult treatment
Bone and Joint
Open Fractures
Surgical Prophylaxis at induction
10.3. To be given at induction
Teicoplanin IV injection
 400mg if less than 60kg
 800mg if 60kg or more
Do not give if less than 12 hours since previous teicoplanin dose
Plus
Gentamicin IV injection
 160mg at induction
Unless already on Gentamicin
 Do not give routine post-operative antibiotics

 Orthopaedic senior to discuss with Microbiology if post-operative
antibiotics felt necessary
 Wounds that are left open after surgical debridement do not require
ongoing antibiotics unless there is evidence of cellulitis.
10.5. Other Relevant Guidelines

Algorithm
10.6. Organisms and Sensitivities
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10.7. Version Control
19112020
11. Appendix 3: Hot Joint (Septic Arthritis) in a Native

Joint
Hot Joint (Septic Arthritis in a Native Joint)

Infection
Secondary Care
Adult treatment
Bone and Joint
Hot Joint (Septic Arthritis)
Native Joint
11.3. Header
Early involvement of orthopaedics in suspected cases is advised. Blood

cultures must be taken before antibiotics. A joint aspirate must be attempted
prior to antibiotics.
Please see separate guidance below for advice on managing suspected

prosthetic joint infections.
The following guidance is for acute hospital inpatients only. See flowchart in
BOB guideline for advice on when patients may be safely discharged home for
management in the community.
Patients with a short history of a hot, red, tender, swollen joint with a restricted
range of movement should be regarded as having septic arthritis till proven
otherwise. If clinical suspicion is high it is important to treat as septic arthritis
even in the absence of a fever or a raised white cell count or CRP.
Presentation
A wide range of presentations may be seen, including rationalisation of joint

pains as secondary to an injury.
 More common in children and elderly

 Often joint disease/problem or soft tissue injury prior – cut/graze/bite,
arthritis (esp. rheumatoid), procedure on joint (injection, surgical
manipulation)
 Painful, markedly swollen joint – either very acute onset or 1-2 weeks of
gradually worsening symptoms
Microbiology
Page 17 of 32
 General malaise, ~ 50% report fevers and rigors

 Marked decrease in range of movement in affected joint(s),
 More common in large joints, 20% cases may present with polyarticular
involvement.
Things to watch out for:
 Recent acute history or recurrent episodes of other “deep” infections e.g.

endocarditis, endophthalmitis, liver abscess
 Contact microbiology to discuss treatment and further specialist
investigations in these cases, after sending the usual samples
 Note any recent bone / joint procedures
 Recent skin-breaking injury prior to joint problem occurring – particularly
note:
 acquired in marine/soil environment
 human/animal bite
 area/country where acquired, if travel history
 Immunosuppression
 Patients’ immunosuppressing drugs should be managed in
conjunction with their parent specialty – especially if for solid
organ transplant
 Previous or recent tick bite (Lyme)
 No obvious factors and divulge history of risky sexual behaviour –
consider Gonococcal arthritis, esp. if skin lesions and presenting with
tenosynovitis
Samples
 Blood cultures prior to first dose of antibiotics
 Superficial wound swabs are not predictive of infecting organisms
 but if not possible to aspirate joint prior to first dose of antibiotics
(e.g. due to haemodynamically unstable patient) and deep wound
discharging pus, then a sample of this could be sent for MC&S
 Deep samples (joint aspirate, tissue from surgical debridement) are the
only way to diagnose less common infecting organisms, but must be
collected before the first dose of antibiotics is given
Imaging
 Plain X-ray should be performed to exclude other pathology, sometimes
shows chondrocalcinosis suggestive of calcium pyrophosphate
(pseudogout), but not helpful if looking solely for septic arthritis
 MRI with contrast may identify developing osteomyelitis, likely to require
surgical management
Differentials
 Gout / pseudogout
 Non-infective arthritis – rheumatoid, reactive
Microbiology
Page 18 of 32
 Traumatic injury / intra-articular haemorrhage (suspect if bloody

aspirate)
 Viral or Lyme arthritis
 Take blood cultures

 Aspiration of synovial fluid before antibiotics, unless patient is
haemodynamically unstable on presentation and there is no possibility of
obtaining an aspirate within an hour.
 If an aspirate is taken out of hours, contact the on call microbiology
technician via switchboard, as they may not be on site.
 Take sample in 2 bottles
 1st: 1 to 2mls in a sterile container to microbiology for microscopy,
white cell count and analysis for crystals (culture will be done on
this sample if blood culture bottle not provided)
 2nd: Remainder (1 to 3mls) in a paediatric blood culture bottle to
microbiology for culture
 NB. warfarin or DOAC use does not contraindicate needle
aspiration. Apply caution and discuss with a senior
orthopaedic or rheumatology doctor if the INR is above
therapeutic range or there is overlying cellulitis.
 Paediatric blood culture bottles are available from the
Emergency Department if they are not available in the clinical
area where your patient is.
11.6. Antibiotic treatment
Dose/frequency should be adjusted according to blood test results for renal

function, U+Es, FBC etc.
 First Line (MRSA negative):
Flucloxacillin 2g QDS IV
 Penicillin allergy or MRSA positive:
Vancomycin IV (dose according to Trust protocol)
Duration and oral switch – treatment is usually prolonged. At least 1

week IV, then 2 weeks oral antibiotics
Antibiotic treatment will be tailored according to culture results.
11.7. If no better…
 Many cases of septic arthritis require repeated aspirations and/or

washouts
Microbiology
Page 19 of 32
 Septic joints should be aspirated to dryness as often as required

 This can be done either through a closed-needle approach or
arthroscopically according to preference.
 In suspected hip joint infection aspiration will require guidance by
ultrasound or image intensifier and will be done via the orthopaedic
team.
 Surgery to washout and or debride the joint is often necessary, this
would be directed by the orthopaedic team.
 Consider MRI to investigate for osteomyelitis, discuss with radiology
11.8. Organisms
 S. aureus is the most common infecting organism, but many organisms

may be involved
11.9. General Interest and other points
 About 10% of S.aureus is resistant to

macrolides/clindamycin/tetracyclines
 Resistance to clarithromycin on pathology system denotes resistance to
clindamycin also
11.10. Other relevant guidelines

Algorithm
11.11. Version control
19112020
11.12. Flowchart for BOB guideline (not app-compatible)
Microbiology
Page 20 of 32
Patient presents with acute hot swollen joint
Investigations:
X-ray
Bloods: CRP, FBC, U&E
Blood cultures. Lactate if septic.
Definite alternative diagnosis Clinical impression: SEPTIC ARTHRITIS (Or

diagnosis uncertain)
E.g. bursitis, cellulitis
Can the patient be discharged Joint aspiration

safely? Refer to Trauma and Orthopaedics bleep 265
Inform lab when sending synovial fluid samples
Do not aspirate through overlying cellulitis
Collect samples:
YES NO 1. Sterile sample pot 2. Paediatric blood

(at least 1ml) for culture bottle (1 to
microbiology + 3ml)
cytology
Home
Admit to ADMIT or manage as outpatient as clinically
With appropriate indicated
medicine
treatment, safety net
advice and GP follow-up if (Upper limb cellulitis Start antibiotics
required * Senior review dw T&O)
required if repeat Do not wait for results of investigations
presentation to ED if septic joint suspected
Microbiology
Page 21 of 32
12. Appendix 4: Hot Joint (Infection) in a Prosthetic

Joint
Septic Arthritis in a Prosthetic Joint

Infection
Secondary Care
Adult treatment
Bone and Joint
Septic Arthritis
Prosthetic Joint
12.3. Header
Senior orthopaedic surgeon must be involved at an early stage if suspected.

Antibiotics are not usually indicated without prior sample results and
discussion with microbiology. If acutely unwell, discuss with microbiology
 Prosthetic joint infection usually presents as a sub-acute problem

 A high index of suspicion should be maintained for any patient
complaining of recurrent pain in a prosthetic joint. Fever and
leucocytosis may be absent.
 Signs and symptoms may include:
 Pain in the affected joint(s)
 Discharge from wound site(s)
 Loosening of the prosthesis
 Raised inflammatory markers
 ‘Never right since the operation’
 Management of prosthetic joint infection always involves debridement of
infected tissue
 A joint revision is often required
 Management of these patients should be tailored to individual
circumstances
12.5. Always remember to…
 Aspiration of a prosthetic joint is normally only attempted by an

orthopaedic specialist
 Aspiration of synovial fluid before antibiotics (unless there is likely to be
significant delay). This is particularly important in these infections, as
there are a wide range of potentially pathogenic organisms, treatment is
prolonged, antibiotic resistance is unpredictable and response to
treatment often hard to assess.
Microbiology
Page 22 of 32
 Superficial wound swabs should be taken if the wound is discharging

frank pus: Isolation of S. aureus from a discharging wound is highly
suggestive of deeper infection
12.6. Antibiotic treatment
 In overtly septic patients, manage according to the septic arthritis in a

native joint guideline [link]
 Management of patients with infection in a prosthetic joint should be
tailored to individual circumstances
 Discuss antibiotic management of all cases with a Consultant
Microbiologist
 Consider re-sampling joint fluid, but likely to need debridement, or

revision.

Algorithm
19112020
13. Appendix 5: Acute Osteomyelitis

Acute Osteomyelitis
Infection
Secondary Care
Adult treatment
Bone and Joint
Osteomyelitis
Acute Osteomyelitis
13.3. Header
Microbiology
Page 23 of 32
Microbiological diagnosis is essential. Ensure blood cultures sent before

giving antibiotics. Senior orthopaedic review when suspected. Consider deep
samples where possible
 History of presenting complaint variable, but usually includes localised

pain, diminished function / evidence of inflammation:
 Sudden illness with signs of infection such as fevers/rigors/night
sweats and bone pain/erythema
 Usually under 2 weeks for acute presentations
 Absence of bony destruction on scans
 Afebrile or low grade fever, gradual onset / worsening of symptoms
 Endocarditis associated with vertebral osteomyelitis 30-50% of cases.
 On examination:
 Tenderness, soft tissue swelling or erythema at end of long boes
 Exposure of bone on probing affected area
 [Vertebral osteomyelitis]: point tenderness along the spine, ±
neurologic deficit
 Isolation of pathogen from bone biopsy or aspiration, or blood culture in
context of suggestive clinical/radiologic picture
 Blood cultures are mandatory, preferably taken prior to first dose of

antibiotics
 Seek senior orthopaedic opinion at an early stage
 Any expressed pus needs to be cultured, as do samples from effusion
taps.
 Explore whether bone cultures (or curettage where there are associated
ulcers) required – gold standard for diagnosis, with positive test in ~90%
of patients
 Specifically inform the laboratory if you suspect mycobacterial or fungal
infections, as these require different growth media
 Radiological imaging is necessary
 MRI with contrast is the imaging modality of choice for investigation
of acute osteomyelitis, allowing good visualisation of even subtle
abnormalities
 CT scan sometimes more helpful where prostheses in situ
 Request echo if bacteraemic to check for endocarditis
 X-ray and CT scan may be helpful in the diagnosis of chronic
osteomyelitis (look for patchy osteopenia and signs of bone
destruction) but use is limited in acute cases where early signs of
soft tissue swelling only become apparent after at least 2-3 days
 Superficial wound swabs are not predictive of infecting organisms in the
bone, but may be useful if concurrent discharging septic arthritis or
polymicrobial infection
Microbiology
Page 24 of 32
13.6. Antibiotic Treatment
 First line (MRSA negative)
Flucloxacillin IV 2g QDS
 Penicillin allergy or MRSA positive:
Vancomycin IV (dose according to Trust protocol)
Duration and oral switch: Generally 4-6 weeks total antibiotic treatment,
with at least 2 weeks IV antibiotics. For possible oral switch options,
discuss with Microbiology.
 Surgical debridement of sequestrum is often necessary

 Antibiotics may not resolve pain or neurological symptoms, as bony
changes on radiological imaging are slow to resolve
 Treatment is prolonged – weeks to months
 Monitor infection markers closely
 Discuss with Consultant Microbiologist if signs of infection persist
 S. aureus is the most common infecting organism, but many organisms

may be involved
 Acute osteomyelitis includes first presentation of osteomyelitis, acute
symptoms (under 2 weeks duration), and absence of necrotic bone or
sequestrum
 Typical sites of infection in adults include vertebra, long bones (less
common), axial joints e.g. sterno-clavicular and sacroiliac (most
prevalent in drug users)

Algorithm
19112020
Microbiology
Page 25 of 32
14. Appendix 6: Osteomyelitis in the Diabetic Foot

Acute Osteomyelitis
Infection
Secondary Care
Adult treatment
Bone and Joint
Osteomyelitis
Osteomyelitis in the Diabetic Foot
14.3. Header
Initially conservative (medical) management may be appropriate in some

cases, although debridement of sequestrum is often necessary. Ensure
prompt referral to vascular surgeons and diabetic foot services on diagnosis
(see general interest).
14.4. Diagnosis and things to watch out for [open]
 Suspect infection in any diabetic foot wound. Wounds need 2 or more

classic findings for diagnosis of infection:
 Inflammatory signs – rubor, warmth, swelling, local tenderness or
pain
 Purulent discharge
 Secondary signs of infection include:
 Non-purulent secretions
 Friable or discoloured tissue
 Undermining of wound margins
 Foul odour
 Risk factors:
 Neuropathy
 Peripheral artery disease
 Trauma
 Consider osteomyelitis if:
 Ulcer not healed after 6 weeks of therapy for diabetic foot ulcer
 If bone is visible or can be probed
 A swollen foot with history of foot ulceration
 A sausage toe
 Radiological evidence of bone destruction
14.5. Always remember to… [open]
 Ideally take deep swabs after debridement and before antibiotics

 At the minimum, take deep swabs after cleaning the wound.
Microbiology
Page 26 of 32
 Superficial swabs are unhelpful – DO NOT SEND.

 Prior antibiotics greatly reduce the utility of swabs
 Alert diabetes CNS and vascular team about patient admission
14.6. Antibiotic Treatment [closed]
 Empirical treatment as per diabetic foot ulcer guidelines [link], but review
with culture results
 There is little evidence to prefer parenteral treatment over oral options
 Generally, 6 weeks of antibiotics are recommended, but shorter
antibiotic courses may be considered if there has been adequate
debridement or amputation.
 Antibiotic therapy needs to be combined with enforced non-weight
bearing status, good glycaemic control and scrupulous wound care
14.7. If no better… [closed]
 Assess compliance with non-weight bearing status and wound care

regime
 Consult with tissue viability CNS and vascular surgeon teams regarding
further debridement and/or amputation, ongoing footcare by podiatry
team
 Assess blood supply to the affected tissues
 Consider collections
 In nearly all studies of diabetic foot osteomyelitis, the most common

pathogen is S. aureus. Next most frequent are other aerobic Gram-
positive cocci, followed by various aerobic Gram-negative bacilli.
see links for North Devon Diabetes Footcare Pathway
Community podiatry:
 01271 341509
 ndht.podiatry@nhs.net
NDDH foot clinic:
 ndht.diabeteshotfoot@nhs.net
Diabetes on call Foot Team:
 For anything to be referred within 24 hours (Mon-Fri) 01271 322424

 For anything out of hours via vascular on call via Musgrove Park Hospital 01823 33344
14.9. Other relevant guidelines [closed]
Microbiology
Page 27 of 32

Algorithm
19112020
15. Appendix 7: Discitis and vertebral osteomyelitis

Infection
Secondary Care
Adult treatment
Bone and Joint
Vertebral osteomyelitis including discitis
15.2. Header
 Vertebral osteomyelitis is defined as infection of the vertebra and

associated structures, including the disc, epidural space, and
paravertebral muscles.
 More usually haematogenous seeding of infection from elsewhere, but

can be directly inoculated from spinal surgery / neurosurgical procedure
/ steroid intra-articular injection
 Risk factors:
 IVDU
 Immunocompromised – diabetes, alcoholism, medication,
liver/kidney/cardiac disease, HIV/AIDS
 Previous TB or exposure to active TB in same household
 Symptoms:
 Back pain
 Fevers / rigors (variable)
 Weakness (up to half of initial presentations)
 Focal vertebral pain (may be a heralding symptom)
 Spinal/paraspinal tenderness to percussion
 Radicular pain or paresthesia along involved nerve roots.
 Symptoms with advancing spinal cord compression:
 Motor weakness
 Bowel or bladder dysfunction
 Sensory changes
 Paralysis (possibly depressed respiratory function if cervical cord
involved)
 Cauda equina syndrome.
Microbiology
Page 28 of 32
 Differential diagnosis: routine back pain, Guillain-Barré, spinal cord

tumor/infarction/hematoma, HIV-related vacuolar myelopathy, cervical
spondylosis, HTLV-1; symptoms may also be confused with Zoster sine
herpeticum, Borrelia burgdorferi neuritis [Lyme neuroborreliosis].
 Pain may locate to mimic MI, cholecystitis, sciatica or abdominal pain
 Request urgent senior orthopaedic review

 Onset of new neurological symptoms can happen quickly.
 Ensure neurological observations are scheduled at least every 2
hours, especially in the initial diagnostic period, even if the patient
is initially admitted without neurological deficit or signs of sepsis
 Send blood cultures before antibiotics. Culture based therapy is
highly desirable, and antibiotics before sampling may severely
compromise this.
 Treatment is prolonged and organisms may be unusual
 CT-guided aspiration of abscess, or biopsy for microbiological samples
may be possible in certain cases, discuss with radiology.
 Radiological imaging: Discuss with radiologist. MRI with contrast is the
gold standard.
 Withhold antibiotics if the patient is stable, without neurological

symptoms. Monitor regularly.
 In cases of severe sepsis: Make sure at least 2 sets of blood cultures

have been sent. Treat according to sepsis of unknown origin protocol.
 Treatment should be tailored to the culture and sensitivity results

obtained from samples. If organisms are sensitive, the preferred option
is
 Ciprofloxacin* 500mg BD PO plus rifampicin 300mg BD PO

 For 6 weeks, if no evidence of abscess formation
 Otherwise will need prolonged course +/- aspiration +/-
surgery
* Note safety alert for quinolones [details in BNF] – some patients may
require alternatives, seek microbiology advice
 Consider further debridement / washout

 Consider further sampling of infected tissue / pus from abscess for
atypical organisms
Microbiology
Page 29 of 32
 Location of infection more common: thoracic > lumbar > cervical.

 Epidural abscesses may extend many levels up and down the spinal
cord.
 Iliopsoas abscess with lumbar involvement may be produced when
infection extends into paravertebral tissue or into muscle.
 Abrupt loss of motor function: may be due to cord ischemia, from
infectious vasculitis or thrombosis of a spinal artery rather than
compression.
 The likelihood of neurological recovery is low if surgery is delayed by
more than 24-36 hours following onset of paralysis.
 Paralysis for more than 2-3 days may therefore be an indication for
conservative (i.e. non-surgical) management. Discuss on a case-by-
case basis with the multidisciplinary team, and involve the patient and
their family.
 The likelihood of positive blood cultures is 60-70% in general, and is
greatest with infections caused by S. aureus.
 More common in males, age over 50.

Algorithm
19112020
16. Appendix 8: Infected Bursitis

Infection
Secondary Care
Adult treatment
Bone and Joint
Infected Bursitis
16.2. Header
It may be difficult to clinically differentiate between septic and non-septic

bursitis. Features that may indicate septic bursitis include:
 Increased tenderness or painful, red, hot swelling of the bursa which is

progressively worsening.
Microbiology
Page 30 of 32
 Local cellulitis.
 Abrasion or laceration over the bursa.
 Fever.
 Immunocompromised state.
 Seeking medical help soon after the onset of swelling.
Consider other diagnoses if:

 There is generalized joint swelling.
 The range of movement is restricted or the joint is held in flexion.
 Differentials include: rheumatoid arthritis, gout/pseudogout, tennis
elbow, local bone/soft tissue tumours
 Aspirate bursal fluid using an aseptic technique and treat empirically

until culture results are known.
 If gout or rheumatoid arthritis also present, ensure these are managed
appropriately alongside infection
First line
Flucloxacillin 1g QDS PO for 7 days
Second line
Clarithromycin 500mg BD PO for 7 days
Note intravenous antibiotics are rarely indicated
 Adjust antibiotic treatment according to sensitivities.

 If swelling, tenderness, and erythema recur, consider
repeated aspiration. The period between aspirations should be guided
by clinical response.
 Bursal warmth is almost always present in septic bursitis, but it is also

present in half of people with non-septic bursitis.
 Clinically significant fever (eg; 38 degrees Celsius) is present in about
40% of patients with septic bursitis.
 Tenderness is usually present regardless of whether the bursitis is
septic.
 Peri-bursal cellulitis is present in more than 60% of people with septic
bursitis and more than 25% of people with non-septic bursitis.
Microbiology
Page 31 of 32

Algorithm
19112020
Microbiology
Page 32 of 32

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Antibiotic Guidelines for Bone and Joint Infections

1.5. Implementation of this guideline will ensure that:

 Bone and joint infections are managed according to current evidence

 A standard of care is specified to facilitate a consistent approach

2.3. All versions of these guidelines will be archived in electronic format by

2.5. To obtain a copy of the archived guidelines, contact should be made

2.6. Monitoring of implementation, effectiveness and compliance with these

Role of Antibiotic Working Group (AWG)

 Leading antibiotic guideline development and review within

 Microbiologist Bleep 193. Via switchboard out of hours.

4. Management of Bone and Joint infections

5. Monitoring Compliance with and the Effectiveness

 Percentage of patients with septic arthritis or osteomyelitis with

Process for Implementation and Monitoring Compliance and

6. Equality Impact Assessment

Group Positive Negative No Impact Comment

Describes procedures for pre-hospital and in-hospital management of open

In the emergency department, administer prophylactic intravenous

Study showing greatest benefit of early antibiotics probably had high

NICE guideline NG38 Fracture (non-complex) Feb 2016

Guidelines do not discuss antibiotic prophylaxis

Johns Hopkins Antimicrobial Guidelines via

 Vertebra (adults > adolescents > children)

 MRI, CT and radionuclide scans are more sensitive in early or

therapy happened more frequently in the IV group than the PO

 Duration: frequent recommendation is 2-6 wks parenteral therapy with

 Staph (MSSA, MRSA): ◦Minocycline 100 mg PO once-daily

NICE CKS: Olecranon bursitis. Revised Sept 2016.

Diagnostics and management – needle aspiration, [uncomplicated] oral

NICE CKS: Pre-patellar bursitis. Revised Dec 2016.

Describes risk factors and management of pre-patellar bursitis (incorporated

If a diabetic foot infection is suspected and a wound is present, send a

Start antibiotic treatment for suspected diabetic foot infection as soon

When choosing an antibiotic for people with a suspected diabetic foot

The severity of diabetic foot infection (mild, moderate or severe)

The risk of developing complications

Diabetic foot infection is defined by the presence of at least 2 of the

Local swelling or induration, erythema, local tenderness or pain, local

Mild diabetic foot infection

Local infection involving only the skin and subcutaneous tissue; if

Moderate diabetic foot infection

Local infection with erythema more than 2 cm around the ulcer or

Severe diabetic foot infection

Local infection with signs of systemic inflammatory response (such as

When microbiological results are available:

•review the choice of antibiotic and

•change the antibiotic according to results, using a narrow-spectrum

1.6.15 Reassess people with a suspected diabetic foot infection if

•other possible diagnoses, such as pressure sores, gout or non-

•any symptoms or signs suggesting a more serious illness or condition,

•previous antibiotic use.

Murillo O and Lora-Tamayo J (2016) Pyogenic Vertebral Osteomyleitis. CID

Discuss recent evidence of management of VO (infection of vertebra

9. Appendix 1: Emergency department antibiotic

Open Fractures – Pre-operative Management

An open fracture is defined as a broken bone that is in communication

9.4. Diagnosis and things to watch out for