Duration of therapy: 6 weeks, likely to require IV therapy at least initially
Patients with osteomyelitis require protracted treatment with agents that have good bone penetration and are at particular risk of drug-related adverse events due to the required duration of treatment.
Bone biopsy is the gold standard sampling procedure.
See guidance on diabetic foot infections.
In patients where osteomyelitis is suspected clinically or based on imaging, but who are not systemically unwell it is reasonable to delay empirical antimicrobials until bone/tissue sampling has taken place and culture results are available.
If the patient deteriorates with features of sepsis while culture results are outstanding, treat as 'suspected osteomyelitis with sepsis' (see below).
| Infection |
|
Suspected osteomyelitis with sepsis |
| Antibiotic Therapy (before prescribing, carefully read the Notes / Comments section below) |
|
Flucloxacillin IV 2g 6 hourly and Gentamicin* IV (dosing info here) If true penicillin / beta-lactam allergy or known MRSA: Vancomycin IV (dosing info here) and Gentamicin IV (dosing info here) |
| Notes / Comments |
|
Gentamicin must not be administered to patients with myasthenia gravis as it can precipitate a myasthenic crisis. Review gentamicin at 72 hours as per 'IV Gentamicin Review after 72 hours of Treatment' algorithm (N.B. links within the document are only active if accessing via NHS network). *Patients with acute or chronic impairment of renal function and an eGFR <20ml/min and those with decompensated alcoholic liver disease are at increased risk of adverse events with gentamicin. IV temocillin (adjusted to renal function) is a beta-lactam antimicrobial with a comparable breadth of gram negative cover which can replace gentamicin in these patient populations, provided they do not have a history of penicillin allergy. |
| Guideline reviewed | September 2023 |
| Page updated | February 2024 |