Antibiotic Guideline: Empirical Treatment of Bone and Joint Infection in Adults Document type: Prescribing guideline Version: 5.0 Author (name and designation) Samim Patel, Antimicrobial Lead Pharmacist Dr Celia Chu, Consultant Microbiologist Dr Pradeep Subudhi, Consultant Microbiologist Validated by Antimicrobial Stewardship Committee Date validated 14 th June 2017 Ratified by Date ratified 13 th July 2017 Name of responsible committee/individual: Name of Executive Lead: Master Document Controller: Drugs and Therapeutics Committee Antimicrobial Stewardship Committee N/A Date uploaded to intranet: 5/9/17 Suzanne Schneider Keywords Osteomyelitis, vertebral osteomyelitis, discitis, sickle cell disease, septic arthritis, native joint infection, prosthetic joint infection, septic bursitis Review date: July 2019 Version Control Version Type of Change Date 5.0 Minor June 2017 Revisions from previous issues Teicoplanin for bone/joint infection now requires 5 loading doses and dose rounded to the nearest 100mg in line with the Trust Teicoplanin Factsheet
Content Page Purpose 2 Content 3-6 Monitoring 7 References 7 Appendices: 8 Appendix 1 Equality Impact Assessment Purpose: To provide staff with clear guidance in order to ensure consistent, evidence based approach to the empirical treatment of the most common types of bone and joint infections in immunocompetent adults. The following antibiotic regimens are recommended for the empirical treatment of common bone and joint infections in immunocompetent adult patients where the causative organisms are unknown. Treatment should be adjusted in light of clinical response and/or microbiological culture and sensitivity results. Appropriate samples must be taken for culture and sensitivity testing. Blood cultures must be taken in serious systemic infection. Antibiotic recommendations assume normal renal and hepatic function. Dose adjustments may be needed for patients with renal or hepatic impairment. Guidance for antimicrobial dosing in renal impairment is available on the intranet and in the individual fact sheets for gentamicin, vancomycin and teicoplanin. Contact ward pharmacist or the medicines information service (extension 5478) for further advice. When treating a patient with an MRSA positive result from any site, then antibiotics with activity against MRSA must be prescribed together with an MRSA decolonisation regime. If a patient is not responding to the empirical treatment recommendations (and in the absence of culture and sensitivity results) then further advice must be sought from the Consultant Microbiologist. In line with the Trust Antimicrobial Stewardship Policy and in order to minimise the risk of antibiotic resistance and healthcare acquired infection, ensure that all IV antibiotics are reviewed on a daily basis and switched to a suitable oral alternative (with a stop or review date). Empirical Treatment of Bone & Joint Infection in Adults Page 2 of 8
Content: Empirical Treatment of Bone & Joint Infection in Adults Page 3 of 8
Infection 1 st line Penicillin allergy MRSA (history of colonisation or infection) Osteomyelitis (Acute) For treatment of osteomyelitis associated with Diabetic Foot Infection, refer to separate guidance on the intranet Vertebral osteomyelitis/ discitis/ sickle cell disease To aid diagnosis ensure bone biopsies or deep tissue specimens and blood cultures are collected prior to initiation of antibiotic therapy Flucloxacillin 2g IV QDS Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to nearest 100mg dose). Tazocin 4.5g IV TDS Discuss with Microbiologist Tazocin 4.5g IV TDS plus Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to nearest 100mg dose). Usual treatment duration (IV and oral) Usually 4-6 weeks. Oral treatment to commence after a minimum of 2 weeks IV and after discussion with microbiologist Minimum 6-8 weeks. May require several months of treatment. Osteomyelitis (chronic) Surgical intervention is mainstay of treatment. To aid diagnosis, ensure bone biopsies or deep tissue specimens collected. Discuss with microbiologist prior to commencing treatment. Antibiotic choice should be tailored according to culture and sensitivity results and patient response. Long duration of therapy (usually a minimum of 12 weeks) required. Empirical Treatment of Bone & Joint Infection in Adults Page 4 of 8
Infection 1 st line Penicillin allergy MRSA (history of colonisation or infection) To aid diagnosis ensure synovial fluid / joint aspirates and blood cultures are collected prior to initiation of antibiotic therapy Usual treatment duration (IV and oral) Synovial fluid / Joint aspirates: Once collected, promptly transport to Microbiology lab and inform the Duty Biomedical Scientist Septic Arthritis: Native Joint Infection Septic Arthritis: Prosthetic Joint Infection Flucloxacillin 2g IV QDS Tazocin 4.5g IV TDS plus Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to Discuss with Microbiologist Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to Tazocin 4.5g IV TDS plus Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to Usually 4-6 weeks. Oral treatment to commence after a minimum of 2 weeks IV Usually 4-6 weeks. Oral treatment may be possible after a minimum of 2 weeks IV depending upon C&S results. Liaise with microbiologist before switching from IV to oral. Septic Bursitis Flucloxacillin 2g IV QDS Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to Teicoplanin IV 12mg/kg every 12 hours for 5 doses then 12mg/kg daily (round to 2 weeks (initially IV with switch to oral agents based on clinical response and culture results) Empirical Treatment of Bone & Joint Infection in Adults Page 5 of 8
Infection 1 st line Penicillin allergy MRSA (history of colonisation or infection) Diabetic Foot Infection Refer to separate guideline for empirical treatment of Diabetic Foot Infection on the Intranet Usual treatment duration (IV and oral) Empirical Treatment of Bone & Joint Infection in Adults Page 6 of 8
Monitoring The Trust Antimicrobial Stewardship Committee is responsible for the monitoring and review of this document. Adherence to the Trust antimicrobial prescribing guidelines is subject to regular (quarterly) audit with feedback of results to the divisions via the Trust Antimicrobial Stewardship and Infection Prevention and Control Committee. References: 1. Gould F.K et al on behalf of the MRSA Working Party of the British Society for Antimicrobial Chemotherapy. Guidelines (2008) for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the United Kingdom. Journal of Antimicrobial Chemotherapy (2009). 63: 849 861. 2. Spellberg B, Lipsky B.A. Systemic Antibiotic Therapy for Chronic Osteomyelitis in Adults. Clinical Infectious Diseases 2012; 54(3):393-407. 3. Mruk AlisonL et al. Antimicrobial Options in the Treatment of Adult Staphylococcal Bone and Joint Infections in an Era of Drug Shortages. Pharmacology Update 2012; 35(5):401-407. 4. Lew P Daniel, Waldvogel Francis A. Osteomyelitis. Lancet 2004; 364:369-79. 5. Burke A. Cunha. Osteomyelitis in Elderly Patients. Clinical Infectious Diseases 2002; 35:287-93. 6. Osmon Douglas R, Berbari Elie F. Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases 2013:56(1):e1-25. 7. Clerc Olivier, Prod hom et al. Adult native septic arthritis: a review of 10 years of experience and lessons for empirical antibiotic therapy. Journal of Antimicrobial Chemotherapy 2011; 66:1168-1173. 8. Coakley G, Mathews C et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for the management of the hot swollen joint in adults. Rheumatology 2006; 45:1039-1041. 9. Mathews C.J, Weston V.C et al. Bacterial Septic Arthritis in Adults. Lancet 2010;375:846-55. 10. Moran E, Byren I and Atkins B.L. The diagnosis and management of prosthetic joint infections. Journal of Antimicrobial Chemotherapy 2010;65(3).iii 45-54 11. John Hopkins Antibiotic Guide. Accessed April 2014. [www.hopkinsguides.com]. 12. Gilbert D.N. The Sanford Guide to Antimicrobial Therapy 2013. 43 rd Edition. 13. Finch R.F and Greenwood D. Antibiotic and Chemotherapy: Anti-infective agents and their use in therapy. Churchill Livingstone. 8 th Edition 2003. 14. BNF online. Last accessed via Medicines Complete on 12 th June 2017. Empirical Treatment of Bone & Joint Infection in Adults Page 7 of 8
APPENDIX 1: - EQUALITY IMPACT ASSESSMENT TOOL To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender (including gender reassignment) Culture Religion or belief Sexual orientation Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? Yes/ N/A 5. If so, can the impact be avoided? N/A 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A Comments Empirical Treatment of Bone & Joint Infection in Adults Page 8 of 8