Thursday, January 7, 2016

MRSA Bone & Joint Infections

Osteomyelitis
  • Surgical debridement and drainage of associated softtissue abscesses is the mainstay of therapy and should be performed whenever feasible
  • For choice of antibiotics, refer the table below
  • optimal duration of therapy for MRSA osteomyelitis is unknown.
  • A minimum 8-week course is recommended
  • Some experts suggest an additional 1-3 months (and possibly longer for chronic infection or if debridement is not performed) of oral rifampin-based combination therapy with TMP-SMX, doxycycline/minocycline, clindamycin, or a fluoroquinolone, chosen on the basis of susceptibilities
Septic Arthritis
  • Drainage or debridement of the joint space should always be performed
  • refer to antibiotic choices for osteomyelitis
  • A 3-4-week course of therapy is suggested
Pediatric
  • For children with acute hematogenous MRSA osteomyelitis and septic arthritis, IV vancomycin is recommended
  • If the patient is stable without ongoing bacteremia or intravascular infection, clindamycin 10–13 mg/kg/dose IV every 6–8 h (to administer 40 mg/kg/day) can be used as empirical therapy if the clindamycin resistance rate is low with transition to oral therapy if the strain is susceptible
  • The exact duration of therapy should be individualized, but typically a minimum 3–4-week course is recommended for septic arthritis and a 4–6-week course is recommended for osteomyelitis.
Antibiotic Considerations
  • Despite concerns about poor bone penetration and relative inefficacy in animal models, vancomycin remains the primary treatment of MRSA osteomyelitis
  • Failure rates of up to 35%–46% have been reported
  • These unsatisfactory responses to vancomycin have led some experts to recommend the addition of rifampin because of its excellent penetration into bone and biofilm
  • For patients with concurrent bacteremia, rifampin should be added to the treatment regimen after clearance of bacteremia.
  • Clindamycin achieves good bone concentrations and is highly effective for treatment of non–critically ill children with MRSA osteomyelitis




References:
  1. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clinical Infectious Diseases 2011;1–38
  2. National Antibiotic Guideline 2014

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