Bone and Joint Infections

Bone and Joint Infections

Osteomyelitis/Septic Arthritis

*Prophylaxis of open fracture - see local orthopaedic protocols and surgical prophylaxis guidelines

*Diabetic foot infections/ Prosthetic Joint Infection - please consult infection specialists (Clinical Microbiologist or Infectious Diseases).

General points

Send blood cultures, joint aspirate or bone for culture prior to commencing antimicrobial therapy if possible.
Review microbiology test results for history of infection or colonisation with MRSA.
The below recommendations do not relate to prosthetic joint infections.
Consider history of trauma or surgery to joint, risk of TB, infective endocarditis, sexual and travel history.

Empiric Antibiotic Therapy

First Line: Flucloxacillin 2g QDS IV

MRSA known or high risk: Add Vancomycin or Teicoplanin to the above agents while awaiting culture results. (Please see Vancomycin / Teicoplanin dosing schedule).

Penicillin allergy - NOT IgE mediated reaction/anaphylaxis :

Cefuroxime 1.5g TDS IV

MRSA known or high risk : Add Vancomycin or Teicoplanin to the above agents while awaiting culture results.

Penicillin allergy - Severe/ IgE-mediated reaction/anaphylaxis to penicillin:

Vancomycin or Teicoplanin

Comments

Adjust antimicrobial treatment when culture results available.
Total duration will depend on a number of factors including causative organism, success of source control procedures, and clinical response.
Monitor WCC, CRP, LFTs and renal function while on treatment .
Discuss cases with infection specialists (Clinical Microbiologist or ID).

Download / Print Section as PDF

Prophylaxis of Open Fracture

ANTIBIOTIC PROPHYLAXIS FOR OPEN FRACTURES

PHASE 1 : Within 1 hour of injury and continue until wound excision

Antibiotic Regimen should be administered as soon as possible after the injury:

Cefuroxime 1.5 g IV TDS plus Metronidazole 500 mg IV TDS until time of first debridement.
In case of IgE-mediated /severe penicillin allergy/anaphylaxis: Use Clindamycin 600mg-1.2 g QDS plus IV plus Gentamicin 3 mg/kg once daily IV. Patients with non-severe penicillin allergy (mild / rash only and no history of severe reaction / anaphylaxis / angioedema), a cephalosporin such as Cefuroxime is considered safe and is the agent of choice.
In the case of open fractures of the distal phalanx of the finger use Cefuroxime 1.5g TDS IV only – (in case of severe penicillin allergy/anaphylaxis use Clindamycin 600mg-1.2g QDS IV).
If history or high risk of MRSA colonisation / infection add Vancomycin 15mg/kg (max 2g) to the antibiotic regimens.
In the case of heavily contaminated wounds, e.g. farmyard injuries or injuries with vascular insufficiency or Gustilo Grade III fractures, add Gentamicin 3 mg/kg IV once daily to antibiotic regimen on initial presentation.At the time of first debridement and stabilisation, ensure prophylaxis of Cefuroxime 1.5 g IV and Metronidazole 500 mg IV is given; in addition give Gentamicin 3 mg/kg IV stat pre-operatively (unless Gentamicin has been given in the past 16 hours).
Antibiotics after wound excision should continue for 24 hours .

PHASE 2:

At the time of definitive skeletal stabilisation and definitive soft tissue coverage the patient should receive a single intravenous dose at induction of Vancomycin 15mg/kg (max 2g) (if it has been more than 12 hour since the last dose) plus Gentamicin 3 mg/ kg (if it has been more than 16 hours since the last dose).

Reference: Eccles S, et al. Standards for the management of open fractures. Oxford University Press; 2020.