Osteomyelitis and Diabetic Foot Infections (L24)

_________ osteomyelitis is often monomicrobial (ex: vertebral osteomyelitis in adults)

hematogenous (blood)

hematogenous osteomyelitis is often ______microbial (ex: vertebral osteomyelitis in adults)

mono

osteomyelitis due to contagious infections focus (ex: posttraumatic/associated with broken bones) or osteomyelitis associated with vascular insufficiency (ex: diabetic foot infections) is ______microbial

poly

osteomyelitis due to __________________________ (ex: posttraumatic/associated with broken bones) or osteomyelitis associated with _________________ (ex: diabetic foot infections) is polymicrobial

contagious infection focus, vascular insufficiency

bone infection is more likely to be initiated when these risk factors are present: very large amounts of _________, ________, or foreign bodies

bacteria, trauma

acute osteomyelitis is when there is NO bone ________ yet

necrosis

_________ osteomyelitis is when there is NO bone necrosis yet

acute

chronic osteomyelitis is when there IS bone ________ (often >___ months after the infection began)

necrosis, 3

_________ osteomyelitis is when there IS bone necrosis (often >3 months after the infection began)

chronic

the most common cause/pathogen of osteomyelitis is ____________

Staph aureus (MRSA rates are high)

the most common cause/pathogen of osteomyelitis is Staph aureus; and the rates of _________ are very high

MRSA

osteomyelitis presents as an _________ onset

gradual (over several days)

appropriate diagnosis of osteomyelitis is critical since treatment is prolonged (>_________)

6 weeks

osteomyelitis presents as a gradual onset (over several days) with symptoms like pain, tenderness, warmth, _________ and _________

erythema, swelling

the gold standard for diagnosing osteomyelitis is _____________

bone biopsy (not always practical tho)

the gold standard for diagnosing osteomyelitis is bone biopsy, but if that is not practical we also use ___________ findings, local signs of ___________, or _____________ test (useful for exclusion)

radiologic (MRI), inflammation, probe-to-bone

the need for surgery in pts with osteomyelitis in patients with ____________ infections (_____ months)

chronic, >3

selecting antibiotic therapy for osteomyelitis treatment is based according to ___________ and ____________ whenever possible (for stable pts we should wait for these results before beginning any treatment)

culture, susceptibility

selecting antibiotic therapy for osteomyelitis treatment is based according to culture and susceptibility

for __________ patients, we should wait for the bone biopsy culture/susceptibility results before starting treatment

stable

selecting antibiotic therapy for osteomyelitis treatment is based according to culture and susceptibility

for __________ patients, we do NOT need to wait for the bone biopsy culture/susceptibility results before starting treatment

hemodynamically unstable (ex: abnormal BP)

when treating osteomyelitis, we need to consider how much drug is getting into the bone

PO is generally considered _____________ vs. IV therapy

non-inferior (basically the same; but we should still give beta-lactams IV)

when treating osteomyelitis, we need to consider how much drug is getting into the bone

______________ (abx class) have poor bone absorption and should be avoided

aminoglycosides (ex: gentamicin)

when treating osteomyelitis, we need to consider how much drug is getting into the bone

_____________ is not a first line agent (despite good bone penetration) due to risk for anemia and thrombocytopenia seen with long term use

Linezolid (use vanco or dapto instead)

when treating osteomyelitis, we need to consider how much drug is getting into the bone

Linezolid is not a first line agent (despite good bone penetration) due to risk for _________ and ___________ seen with long term use (use vanco or dapto instead)

anemia, thrombocytopenia

when treating osteomyelitis, we need to consider how much drug is getting into the bone

PO is generally considered non-inferior to IV therapy

but… specifics for _________________ were not disclosed and therefore this class should still be given IV

beta-lactams

empiric antibiotic therapy for osteomyelitis is typically NOT required for osteomyelitis, since we should wait for _____________________ whenever possible

culture, susceptibilities (only empirically treat in unstable pts)

empiric antibiotic therapy for osteomyelitis is typically NOT required for osteomyelitis, since we should wait for cultures/susceptibilities whenever possible

however, if the patient is hemodynamically unstable, we should consider initial/empiric therapy that covers ________, __________, and gram-_________ bacilli

MRSA, Streptococci, negative (Vanco+Cefepime)

empiric antibiotic therapy for osteomyelitis is typically NOT required for osteomyelitis, since we should wait for cultures/susceptibilities whenever possible

however, if the patient is hemodynamically unstable, we should consider initial/empiric therapy that covers MRSA, Streptococci, and gram-negative bacilli

we would recommend ____________ + ____________ (unless pt has anaphylactic PCN allergy, then we would recommend ___________ or ___________ instead)

Vancomycin + Cefepime (or Cipro or Aztreonam in anaphylactic allergy)

Directed antibiotic therapy for Staphylococcus

if the pathogen is MSSA, our first IV choice is ___________ or ___________ OR _____________

Nafcillin, Oxacillin, Cefazolin (consider Vanco if pt has PCN allergy)

Directed antibiotic therapy for Staphylococcus

if the pathogen is MSSA, our first oral choice is ___________ + _______________

Levofloxacin + Rifampin (same as oral for MRSA)

Directed antibiotic therapy for Staphylococcus

if the pathogen is MSSA, our first IV choice is Nafcillin or Oxacillin OR Cefazolin

if the patient has a PCN allergy we could consider ___________

Vancomycin

Directed antibiotic therapy for Staphylococcus

if the pathogen is __________, our first oral choice is Levofloxacin + Rifampin

MRSA or MSSA (same for oral)

Directed antibiotic therapy for Staphylococcus

if the pathogen is _______, our first IV choice is Nafcillin or Oxacillin OR Cefazolin

MSSA (for MRSA IV option is Vanco or Dapto)

Directed antibiotic therapy for Staphylococcus

if the pathogen is MRSA, our first IV choice is ___________ or ___________

Vancomycin or Daptomycin

Directed antibiotic therapy for Staphylococcus

if the pathogen is MRSA, our first oral choice is ___________ + _______________

Levofloxacin + Rifampin (same as oral for MSSA)

we should consider adjunctive Rifampin for staphylococcal osteomyelitis when ____________ are involved or ________ therapy is required

prosthetic, oral

Directed antibiotic therapy for Streptococcus

for PCN-sensitive Strep, our first IV choice is _________ or ____________

Ceftriaxone or Penicillin G

Directed antibiotic therapy for Streptococcus

for PCN-sensitive Strep, out first oral choice is ______________

Amoxicillin

Directed antibiotic therapy for Streptococcus

for PCN-resistant Strep, our first IV choice is _________ or ____________ (optimal therapy is not well defined, base this on susceptibilities)

Ceftriaxone or Vancomycin

Directed antibiotic therapy for Streptococcus

for PCN-resistant Strep, our first oral choice is ______________

Levofloxacin

Directed antibiotic therapy for Streptococcus

for _____________ Strep, out first IV choice is Ceftriaxone or Penicillin G, and our first oral option is Amoxicillin

Penicillin-sensitive

Directed antibiotic therapy for Streptococcus

for _____________ Strep, out first IV choice is Ceftriaxone or Vancomycin, and our first oral option is Levofloxacin

Penicillin-resistant

Directed antibiotic therapy for Gram-Negatives

for enterobacterales pathogens, the first choice IV therapy is _________ or __________

Cefepime or Ertapenem

Directed antibiotic therapy for Gram-Negatives

for enterobacterales pathogens, the first choice oral therapy is ____________

Ciprofloxacin (good for pts with PCN allergy) (same oral tx for PSAE and Salmonella)

Directed antibiotic therapy for Gram-Negatives

for Pseudomonas aeruginosa pathogens, the first choice oral therapy is ____________

Ciprofloxacin (good for pts with PCN allergy) (same oral tx for enterobacterales and Salmonella)

Directed antibiotic therapy for Gram-Negatives

for Salmonella spp. pathogens, the first choice oral therapy is ____________

Ciprofloxacin (good for pts with PCN allergy) (same oral tx for enterobacterales or PSAE)

Directed antibiotic therapy for Gram-Negatives

for Pseudomonas aeruginosa pathogens, the first choice IV therapy is ____________ or ____________

Cefepime or Meropenem

Directed antibiotic therapy for Gram-Negatives

for Salmonella spp. pathogens, the first choice IV therapy is ____________

Ceftriaxone

Special considerations for treatment of Vertebral osteomyelitis

this is typically cause by _____________ spread

hematogenous (blood)

Special considerations for treatment of Vertebral osteomyelitis that is typically cause by hematogenous spread

patients usually present with acutely worsening ____________ focused to one location with other general signs of infection (_______, increased_________)

back pain, fever, WBC

Special considerations for treatment of Vertebral osteomyelitis that is typically cause by hematogenous spread

this means it is _____microbial and most commonly cause by which pathogen(s)

mono, Staph aureus

Special considerations for treatment of Posttraumatic osteomyelitis

this refers to infections following ________ _______

open fractures (bone sticking through skin)

Special considerations for treatment of Posttraumatic osteomyelitis that is typically caused by infections following open fractures

that means it is _____microbial and often caused by which pathogen(s)

poly, Staphylococcus and gram-negative bacilli

Special considerations for treatment of ____________ osteomyelitis, which is polymicrobial and often caused by Staphylococcus or gram-negative bacilli

posttraumatic (open fracture)

Special considerations for treatment of ____________ osteomyelitis, which is monomicrobial and often caused by Staph aureus

vertebral

Special considerations for treatment of Posttraumatic osteomyelitis that is typically caused by infections following open fractures

recommend ____________, ___________, and ___________ within 6 hours of the open trauma to reduce the osteomyelitis risk

irrigation, debridement, prophylaxis

Special considerations for treatment of Posttraumatic osteomyelitis that is typically caused by infections following open fractures

recommend irrigation, debridement, and prophylaxis within ___________ of the open trauma to reduce the osteomyelitis risk

6 hours

Special considerations for treatment of Posttraumatic osteomyelitis that is typically caused by infections following open fractures

recommend irrigation, debridement, and prophylaxis within 6 hours of the open trauma to reduce the osteomyelitis risk

the prophylactic treatment is given for _________, and differs slightly based on the grade of the injury

72 hours

Special considerations for treatment of Posttraumatic osteomyelitis that is typically caused by infections following open fractures

recommend irrigation, debridement, and prophylaxis within 6 hours of the open trauma to reduce the osteomyelitis risk

the prophylactic treatment is given for 72 hours

for Grade I or II fractures we should give _________

Vancomycin

Special considerations for treatment of Posttraumatic osteomyelitis that is typically caused by infections following open fractures

recommend irrigation, debridement, and prophylaxis within 6 hours of the open trauma to reduce the osteomyelitis risk

the prophylactic treatment is given for 72 hours

for Grade IIII fractures we should give _________

Vancomycin + Cefepime

osteomyelitis treatment duration is recommends __________ therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

prolonged (>6 weeks)

osteomyelitis treatment duration is recommends prolonged (minimum ___________) therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

6 weeks

osteomyelitis treatment duration is recommends prolonged (>6 weeks) therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

we should start counting the days of therapy after _______________

last debridement (once you know it has all been cleared and there is no more infected tissue)

osteomyelitis treatment duration is recommends prolonged (>6 weeks) therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

treatment with 6 weeks of therapy is recommended in most patients

consider IV to PO switch when possible for non-__________ antibiotics

beta-lactam

osteomyelitis treatment duration is recommends prolonged therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

treatment with 6 weeks of therapy is recommended in most patients

exception: >___ weeks for patients with vertebral osteomyelitis AND high risk for recurrence (paravertebral abscess or MRSA infection)

8 (longer tx if patient has vertebral osteomyelitis AND paravertebral abscess or MRSA)

osteomyelitis treatment duration is recommends prolonged therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

treatment with 6 weeks of therapy is recommended in most patients

exception: >8 weeks for patients with ______________ AND high risk for recurrence (paravertebral abscess or MRSA infection)

vertebral osteomyelitis

osteomyelitis treatment duration is recommends prolonged therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

treatment with 6 weeks of therapy is recommended in most patients

exception: >8 weeks for patients with vertebral osteomyelitis AND high risk for _____________

recurrence (paravertebral abscess or MRSA)

osteomyelitis treatment duration is recommends prolonged therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

treatment with 6 weeks of therapy is recommended in most patients

exception: >8 weeks for patients with vertebral osteomyelitis AND high risk for recurrence (______________ or _______ infection)

paravertebral abscess, MRSA

osteomyelitis treatment duration is recommends prolonged therapy d/t bacterial biofilms, persistence and unreliable antibiotic bone penetration

treatment with 6 weeks of therapy is recommended in most patients

exception: >8 weeks for patients with vertebral abscess AND high risk for recurrence

pts are considered high risk for recurrence if they have _______ risk factor for recurrence

>1 (paravertebral abscess or MRSA)

Patient PC has been diagnosed with osteomyelitis of her clavicle. The bone biopsy culture revealed Klebsiella pneumoniae. Which of the following treatment regimens do you recommend for her right now? The patient requires IV antibiotics.

a. Cefazolin x6 weeks

b. Cefazolin x12 weeks

c. Cefepime x6 weeks

d. Cefepime x12 weeks

c (12 weeks is too long) (Klebsiella is an enterobacterales bacteria; Cefazolin IV would be for MSSA)

diabetic foot infections are soft skin and tissue infections below the ankle, with or without ___________ involvement

bone

diabetic foot infections are soft skin and tissue infections below the ankle, with or without bone involvement

patients with peripheral ___________, peripheral _________ disease, and impaired _________ are at high risk

neuropathy, artery, immunity

diabetic foot infections are soft skin and tissue infections below the ankle, with or without bone involvement

____________ is the most common pathogen

Staphylococci

diabetic foot infections are soft skin and tissue infections below the ankle, with or without bone involvement

not all diabetic foot ulcers are infected; infection is likely if there is ___________ and __________

inflammation and purulence

empiric treatment for diabetic foot infections is based on _______________ (1-4)

classification

empiric treatment for diabetic foot infections is based on classification

Mild infections (class 2) should receive _________ antibiotics

oral

empiric treatment for diabetic foot infections is based on classification

Mild infections (class 2) should receive oral antibiotics

patients with no risk factors should get __________, or ___________, or _____________

Cephalexin, Amox/Clav, Clindamycin

empiric treatment for diabetic foot infections is based on classification

Mild infections (class 2) should receive oral antibiotics

patients with MRSA risk factors (prior MRSA infection or recent hospitalization, recent abx use, or residence in long-term care facility) should get _____________ or __________

Linezolid or Bactrim

empiric treatment for diabetic foot infections is based on classification

Mild infections (class 2) should receive oral antibiotics, and Moderate (class 3) should receive oral or IV

patients with MRSA risk factors should receive alternative antibiotics

risk factors include history of _______, recent ___________ or __________ use, or residence in a long-term care facility

MRSA, hospitalization, antibiotic

empiric treatment for diabetic foot infections is based on classification

Mild infections (class 2) should receive oral antibiotics

patients with ________ risk factors should get Vancomycin or Bactrim

MRSA

empiric treatment for diabetic foot infections is based on classification

Mild infections (class 2) should receive oral antibiotics

patients with Pseudomonas aeruginosa risk factors (tropical climate or previous PSAE isolated in wound) should receive ___________ AND ___________

Cephalexin and Ciprofloxacin

empiric treatment for diabetic foot infections is based on classification

Mild infections (class 2) should receive oral antibiotics

patients with _____________ risk factors should receive Cephalexin AND Ciprofloxacin

Pseudomonas aeruginosa (PSAE)

empiric treatment for diabetic foot infections is based on classification

Mild infections (class 2) should receive oral antibiotics, and Moderate (class 3) should receive oral or IV

patients with Pseudomonas aeruginosa risk factors should receive alternative antibiotics

risk factors include _________ climate or previous isolation of PSAE in _______

tropical, wound

empiric treatment for diabetic foot infections is based on classification

Moderate (class 3) should receive _________ antibiotics

oral or IV

empiric treatment for diabetic foot infections is based on classification

Moderate (class 3) should receive oral or IV antibiotics

patients with no risk factors should receive ________ or __________ or _________

Amox/Clav, Ampicillin/Sulbactam, Ertapenem

empiric treatment for diabetic foot infections is based on classification

Moderate (class 3) should receive oral or IV antibiotics

patients with MRSA risk factors (prior MRSA infection or recent hospitalization, recent abx use, or residence in long-term care facility) should receive _____________ AND __________

Ampicillin/Sulbactam and Vancomycin

empiric treatment for diabetic foot infections is based on classification

Moderate (class 3) should receive oral or IV antibiotics

patients with ________ risk factors should receive Ampicillin/Sulbactam AND Vancomycin

MRSA

empiric treatment for diabetic foot infections is based on classification

Moderate (class 3) should receive oral or IV antibiotics

patients with Pseudomonas aeruginosa risk factors (tropical climate or previous PSAE isolated in wound) should receive __________________

Piperacillin/Tazobactam

empiric treatment for diabetic foot infections is based on classification

Moderate (class 3) should receive oral or IV antibiotics

patients with __________ risk factors should receive Piperacillin/Tazobactam

Pseudomonas aeruginosa (PSAE)

empiric treatment for diabetic foot infections is based on classification

Severe (class 4) should receive _____ antibiotics

IV

empiric treatment for diabetic foot infections is based on classification

Severe (class 4) should receive IV antibiotics to cover MRSA, Streptococcus, Enterobacterales, Anaerobes, and PSAE

we should treat any patient in this class with __________+__________+__________ OR __________+__________

Vanco+Cefepime+Metronidazole or Vanco+Meropenem

targeted treatment for diabetic foot infections is based on an appropriately conducted _______ _________

wound culture

targeted treatment for diabetic foot infections is based on an appropriately conducted wound culture

a good culture is ______ _______ specimen/aspirate from the abscess or ________ ________ _______

soft tissue, deep tissue scraping

targeted treatment for diabetic foot infections is based on an appropriately conducted wound culture

a ______ culture is soft tissue specimen/aspirate from the abscess or deep tissue scraping

good

targeted treatment for diabetic foot infections is based on an appropriately conducted wound culture

a bad culture is a __________ swab of the wound

superficial

targeted treatment for diabetic foot infections is based on an appropriately conducted wound culture

a ________ culture is a superficial swab of the wound

bad

targeted treatment for diabetic foot infections is based on an appropriately conducted wound culture

we should reassess patients being treated ________ if they are hospitalized and every _________ if they are being treated outpatient

daily, 2-7 days

targeted treatment for diabetic foot infections is based on an appropriately conducted wound culture

we should reassess patients being treated daily if they are hospitalized and every 2-7 days if they are being treated outpatient

if the patient is worsening: reassess their need for _________ and possibly broaden their therapy if the infection is not _________ (even if initial therapy was thought to be appropriate)

surgery, healing

targeted treatment for diabetic foot infections is based on an appropriately conducted wound culture

we should reassess patients being treated daily if they are hospitalized and every 2-7 days if they are being treated outpatient

if patient is improving: switch from __________ to _________ in 5-7 days if possible and consider streamlining treatment to target the identified organisms

IV to PO

duration of treatment for diabetic foot infections is based on the individual

we should administer antibiotics until the infection has cleared

about __________ for most infections

about __________ for extensive infection or ones that are resolving more slowly

1-2 weeks, 3-4 weeks