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Bone and Joint Infections

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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).


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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.