Osteomyelitis, staphylococcal

Duration - Duration of therapy varies with the type and severity of infection as well as the overall condition of the patient therefore, determine duration by the clinical and bacteriological response of the patient. In severe staphylococcal infections, continue nafcillin therapy for at least 14 days. Continue therapy for at least 48 hours after the patient has become afebrile and asymptomatic and cultures are negative. The treatment of endocarditis and osteomyelitis may require a longer duration of therapy. 

Streptococci and staphylococci Serious respiratory tract infections serious skin and soft tissue infections septicemia (parenteral only) acute staphylococcal hematogenous osteomyelitis (parenteral only). 

Oral anti-staphylococcal penicillins or cotrimox-azole are effective against most skin pathogens. Five days of therapy (or 3 days after local signs are resolved) is usually sufficient. For arthritis 2 or 3 weeks of therapy are required. In chronic osteomyelitis, resection of dead tissue should be followed by at least six weeks to 3 months of antibiotics until the ESR returns to normal. Oral quinolones are useful for gram-negative osteomyelitis while clindamycin is effective in gram-positive and anaerobic infections. 

For parenteral therapy, nafciUin and oxacillin offer comparable efficacy and antimicrobial spectra of activity. Although both drugs undergo hepatic metabolism, only nafcillin requires dose adjustment in patients with combined hepatic and renal insufficiency. Other pharmacokinetic data for nafcillin and oxacillin appear in Table 45.1. Indications for nafcillin or oxacillin include severe staphylococcal infections like cellulitis, empyema, endocarditis, osteomyelitis, pneumonia, septic arthritis, and toxic shock syndrome. 

Rifampin is a first-line antitubercular drug used in the treatment of all forms of pulmonary and extrapul-monary tuberculosis. Rifampin is an alternative to isoniazid in the treatment of latent tuberculosis infection. Rifampin also may be combined with an antileprosy agent for the treatment of leprosy and to protect those in close contact with patients having H. influenza type b and N. meningitidis infection rifampin is also used in methicillin-resistant staphylococcal infections, such as osteomyelitis and prosthetic valve endocarditis. 

Rifampin combined with a second agent is used to eradicate staphylococcal carriage. Rifampin combination therapy is also indicated for treatment of serious staphylococcal infections such as osteomyelitis and prosthetic valve endocarditis. 

Rifampin is used in a variety of other clinical situations. An oral dosage of 600 mg twice daily for 2 days can eliminate meningococcal carriage. Rifampin, 20 mg/kg/d for 4 days, is used as prophylaxis in contacts of children with Haemophilus influenzae type b disease. Rifampin combined with a second agent is used to eradicate staphylococcal carriage. Rifampin combination therapy is also indicated for treatment of serious staphylococcal infections such as osteomyelitis and prosthetic valve endocarditis. Rifampin has been recommended also for use in combination with ceftriaxone or vancomycin in treatment of meningitis caused by highly penicillin-resistant strains of pneumococci. 

Uses. Sodium fusidate is a valuable drug for treating severe staphylococcal infections, including osteomyelitis and is available as i.v. and oral preparations. In an ointment or gel, sodium fusidate is used topically for staphylococcal skin infection and as a cream is applied to eradicate the staphylococcal nasal carrier state. Another gel preparation is used for topical application to the eye this contains such a high fusidic acid concentration that it possesses useful activity against most bacteria that cause conjunctivitis, not only staphylococci. 

The glycopcptide antibiotic vancomycin has been efta -tive in the treatment of clindamycin-induced pseudoiiKm branous colitis and in the control of the experimentally in duced bacterial condition in animals. Clindamycin shotiU be reserved for staphylococcal tissue infections, such asetf lulitis and osteomyelitis, in penicillin-allergic patients aid for severe anaerobic infections ouLside the central nemw.. system. Ordinarily, it should not be used to treat upper ie p ratory tract infections caused by bacteria sen.sitivc to oiiia safer antibiotics or in prophylaxis. 

Guglielmo BJ, Luber AD, Paletta D, Jacobs RA. Ceftriaxone therapy for staphylococcal osteomyelitis A review. Clin Infect Dis 2000 30 205-207. 

Peltola H, Unkila-Kallio L, Kallio MJT. Simplified treatment of acute staphylococcal osteomyelitis of childhood. Pediatrics 1997 99 846-850. 

The recommended dose is 10,000 to 20,000 units given intramuscularly every 6 hours and accompanied by careful studies of the renal function i " . In this way bacitracin is absorbed readily from the site of injection although pain and some injury may be observed there. It has been used in the treatment of staphylococcal bacteremias, osteomyelitis, bacterial endocarditis, and in the control of urinary tract infections either alone or in combination with other drugs . Local injection into circumscribed areas, such as furuncles and abscesses, has also been successful. Orally, bacitracin has been used either alone or in combination with other antibiotics as an intestinal antiseptic i, for example in the pre-operative sterilization of the bowel. Because of the poor absorption from the gastro-intestinal tract, no special precautions are necessary. 

Rifampin also is indicated for the prophylaxis of meningococcal disease and Haemophilus influenzae meningitis. To prevent meningococcal disease, adults may be treated with 600 mg twice daily for 2 days or 600 mg once daily for 4 days children should receive 10-15 mg/kg, to a maximum cf600 mg. Combined with a f-lactam antibiotic or vancomycin, rifampin is used in selected cases of staphylococcal endocarditis or osteomyelitis. Rifampin may be used to eradicate nasal staphylococci in patients with chronic furunculosis. 

Sulfonamides - The synergistic combination of sulfamethoxazole with trimethoprim has emerged as a first choice drug in the treatment of sal-monenosis , chronic pyelonephritis , non-specific and chronic urinary tract infections , and upper respiratory tract infections, especially chronic bronchitis . Favorable results were also achieved in the treatment of purulent angina, bacterial skin infections , staphylococcal osteomyelitis , and endocarditis due to E. coli as well as a variety... 

D.L. Hamblin, Hyperbaric oxygenation, its effect on experimental staphylococcal osteomyelitis in... 

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