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Is there clinical evidence of infection?

• No, (prophylaxis is required)
• Yes, (established infection is present)

• If the wound is contaminated with soil or faeces (such as with farm injuries) or has been in contact with fresh or salt water then infectious diseases should be contacted immediately for targeted treatment.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

If there is serious tissue damage or clinical evidence of infection give:

AND If the wound is heavily contaminated with material embedded in bone or deep soft tissues (eg agriculture injuries, injuries involving sewage) ADD

Code for cefepime is: 3opf

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Regardless of injury severity, the total duration of prophylaxis should be no more than 72 hours, even if soft tissue coverage is not achievable
• Prophylaxis for nonsevere injuries comparable to Gustilo–Anderson type I or II (open fractures resulting from indirect injury or direct, low-energy injury) can be discontinued at definitive wound closure
• If there is likely to be a delay in accessing cefepime, give an immediate dose of cefazolin (as above), because the benefit of prophylaxis is greatest when it is given immediately after injury. Switch to cefepime as soon as it is available

References:

See section on open fractures - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has immediate severe penicillin hypersensitivity give:

Code for ciprofloxacin and clindamycin iv is: 3opf

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Regardless of injury severity, the total duration of prophylaxis should be no more than 72 hours, even if soft tissue coverage is not achievable
• Prophylaxis for nonsevere injuries comparable to Gustilo–Anderson type I or II (open fractures resulting from indirect injury or direct, low-energy injury) can be discontinued at definitive wound closure
• For patients who have adequate oral absorption and can tolerate oral therapy, step down to clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 8-hourly. If the wound has been immersed in water ADD on ciprofloxacin 750 mg (child: 20 mg/kg up to 750 mg) orally, 12-hourly

References:

See the section on open fractures - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If treating established infection with no penicillin allergy give:

OR if the wound has been immersed in water, replace piperacillin+tazobactam with:

AND with either of the above regimens, if the patient has sepsis or septic shock, or is at increased risk of MRSA ADD

Code for piperacillin or cefepime is: 7opc

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2opc

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Patients with severe tissue damage or evidence of infection all need presumptive treatment for 7 days total. Patients with established bone infection usually require a longer duration of IV antibiotic therapy followed by oral continuation therapy

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See the section on open fractures - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If treating established infection with delayed penicillin hypersensitivity give:

AND with the above regimen, if the patient has sepsis or septic shock, or is at increased risk of MRSA ADD

Code for cefepime is: 7opc

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2opc

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Patients with severe tissue damage or evidence of infection all need presumptive treatment for 7 days total. Patients with established bone infection usually require a longer duration of IV antibiotic therapy followed by oral continuation therapy

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See the section on open fractures - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has immediate severe penicillin hypersensitivity give:

Code for ciprofloxacin and clindamycin iv is: 7opf

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Please contact infectious diseases in patients who have sepsis or septic shock, or are at increased risk of MRSA infection
• Patients with severe tissue damage or evidence of infection all need presumptive treatment for 7 days total. Patients with established bone infection usually require a longer duration of IV antibiotic therapy followed by oral continuation therapy

References:

See the section on open fractures - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? See below for details on penicillin allergy severity

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is the patient an adult or a child?

• Adult
• Child < 12 years

• For treatment of osteomyelitis in a neonate please contact infectious diseases

Is the patient an adult or a child?

• Adult
• Child < 12 years

• For treatment of osteomyelitis in a neonate please contact infectious diseases

Is the patient an adult or a child?

• Adult
• Child < 12 years

• For treatment of osteomyelitis in a neonate please contact infectious diseases

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Where is the osteomyelitis located?

• Leg or foot ulcer
• Vertebral bone
• Long bone

Is the patient showing signs of sepsis?

• Yes, (treat as diabetic foot)
• No

Signs of Sepsis:

• See the management of severe sepsis section in the Australian Therapeutic Guidelines for more information on identifying a septic patient

Where is the osteomyelitis located?

• Leg or foot ulcer (treat as diabetic foot)
• Vertebral bone
• Long bone

Where is the osteomyelitis located?

• Leg or foot ulcer (treat as diabetic foot)
• Vertebral bone
• Long bone

Does the patient have signs of compromise after neurological examination? (see below)

• Yes, neurological compromise present
• No

• Select yes if the patient has either signs of neurological compromise, or spinal, paraspinal or epidural spinal abscess

Does the patient have signs of compromise after neurological examination? (see below)

• Yes, neurological compromise present
• No

• Select yes if the patient has either signs of neurological compromise, or spinal, paraspinal or epidural spinal abscess

Does the patient have signs of compromise after neurological examination? (see below)

• Yes, neurological compromise present
• No

• Select yes if the patient has either signs of neurological compromise, or spinal, paraspinal or epidural spinal abscess

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

For osteomyelitis treatment in a child with non-severe or no penicillin hypersensitivity, at risk of MRSA give:

Code for vancomycin is: 2ost

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for cefotaxime or ceftriaxone is: 5ost

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• K. kingae infections can be comcomitant with upper respiratory diseases or stomatitis, since disrupted respiratory or buccal mucosa is likely to facilitate bacterial invasion and hematogenous dissemination. K. kingae should be considered in children younger than 4 years who fail to improve rapidly with antistaphylococcal therapy
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• Children usually require a shorter duration of therapy than adults because their bones have an excellent blood supply. Intravenous therapy should generally be continued until blood culture results are negative, the child is afebrile and has clinically improved, and C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) is decreasing
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy. In children, bone biopsy is not required if there is a good response to empirical antibiotic therapy, even if blood culture results are negative

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For osteomyelitis treatment in a child with no penicillin hypersensitivity, not at risk of MRSA give:

Code for cefotaxime or ceftriaxone is: 5ost

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• K. kingae infections can be comcomitant with upper respiratory diseases or stomatitis, since disrupted respiratory or buccal mucosa is likely to facilitate bacterial invasion and hematogenous dissemination. K. kingae should be considered in children younger than 4 years who fail to improve rapidly with antistaphylococcal therapy
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• Children usually require a shorter duration of therapy than adults because their bones have an excellent blood supply. Intravenous therapy should generally be continued until blood culture results are negative, the child is afebrile and has clinically improved, and C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) is decreasing
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy. In children, bone biopsy is not required if there is a good response to empirical antibiotic therapy, even if blood culture results are negative

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For osteomyelitis treatment in a child with non-severe penicillin hypersensitivity, not at risk of MRSA give:

Code for cefotaxime or ceftriaxone is: 5ost

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• K. kingae infections can be comcomitant with upper respiratory diseases or stomatitis, since disrupted respiratory or buccal mucosa is likely to facilitate bacterial invasion and hematogenous dissemination. K. kingae should be considered in children younger than 4 years who fail to improve rapidly with antistaphylococcal therapy
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• Children usually require a shorter duration of therapy than adults because their bones have an excellent blood supply. Intravenous therapy should generally be continued until blood culture results are negative, the child is afebrile and has clinically improved, and C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) is decreasing
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy. In children, bone biopsy is not required if there is a good response to empirical antibiotic therapy, even if blood culture results are negative

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For osteomyelitis treatment in a child with severe penicillin hypersensitivity:

Code for vancomycin is: 2ost

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• K. kingae infections can be comcomitant with upper respiratory diseases or stomatitis, since disrupted respiratory or buccal mucosa is likely to facilitate bacterial invasion and hematogenous dissemination. K. kingae should be considered in children younger than 4 years who fail to improve rapidly with antistaphylococcal therapy
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• Children usually require a shorter duration of therapy than adults because their bones have an excellent blood supply. Intravenous therapy should generally be continued until blood culture results are negative, the child is afebrile and has clinically improved, and C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) is decreasing
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy. In children, bone biopsy is not required if there is a good response to empirical antibiotic therapy, even if blood culture results are negative

Vancomycin Dosing in Paediatrics

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known
4. Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
5. Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
6. If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Adult long bone osteomyelitis with no MRSA or penicillin allergy should be treated with:

• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient tolerates penicillin use as a single agent:

Code for IV Amoxicillin+Clavulanate is: 5ost

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This regimen will not cover MRSA. Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection. Contact infectious diseases if MRSA infection is suspected
• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Adult long bone osteomyelitis with no MRSA and non-severe penicillin hypersensitivity should be treated with:

• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Adult long bone osteomyelitis with MRSA or severe penicillin hypersensitivity treat with:

Code for vancomycin is: 2ost

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Adult vertebral osteomyelitis with no MRSA or penicillin allergy and normal neurological examination should be treated with:

Withhold antibiotic therapy until a microbiological diagnosis is made in all adults who have a normal neurological examination.

Only treat empirically with the treatment below if microbiological diagnosis cannot be made.

• Contact infectious diseases if the patient has suspected gram negative infection
• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Adult vertebra osteomyelitis with no MRSA and non-severe penicillin hypersensitivity should be treated with:

Withhold antibiotic therapy until a microbiological diagnosis is made in all adults who have a normal neurological examination.

Only treat empirically with the treatment below if microbiological diagnosis cannot be made.

• Contact infectious diseases if the patient has suspected gram negative infection
• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For adult vertebral osteomyelitis with severe penicillin hypersensitivity and no MRSA risk factors treat with:

Withhold antibiotic therapy until a microbiological diagnosis is made in all adults who have a normal neurological examination.

Only treat empirically with the treatment below if microbiological diagnosis cannot be made.

Code for vancomycin is: 2ost

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Contact infectious diseases if the patient has suspected gram negative infection
• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples before antibiotic therapy is started. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If a patient with vertebral osteomyelitis has MRSA risk factors then treatment is complex. Contact infectious diseases for advice

For adult vertebral osteomyelitis with neurological compromise and no penicillin allergy treat with:

Code for vancomycin is: 2ost

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for ceftriaxone is: 4ost

This code is valid for FOUR days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past four days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If there is only a single line it is best to give the other antibiotics before starting vancomycin as vancomycin has a lengthy infusion time
• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples as soon as possible. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For adult vertebral osteomyelitis with neurological compromise and non-severe penicillin hypersensitivity treat with:

Code for vancomycin is: 2ost

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for ceftriaxone is: 4ost

This code is valid for FOUR days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past four days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If there is only a single line it is best to give the ceftriaxone before starting vancomycin as vancomycin has a lengthy infusion time
• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples as soon as possible. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For adult vertebral osteomyelitis with neurological compromise and severe penicillin hypersensitivity treat with:

Code for vancomycin is: 2ost

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for ciprofloxacin IV is: 4ost

This code is valid for FOUR days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past four days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If there is only a single line it is best to give the ciprofloxacin before starting vancomycin as vancomycin has a lengthy infusion time
• This regimen is for both acute and chronic osteomyelitis until a microbiological diagnosis is made. Obtain diagnostic samples as soon as possible. Once a microbiological diagnosis is made, modify therapy accordingly
• If the patient is septic please treat as per sepsis treatment pathway
• For adults or children with osteomyelitis associated with prosthetic material, seek expert advice
• Prolonged antibiotic therapy is required to cure osteomyelitis. Recommended duration of therapy for vertebral osteomyelitis is usually a total of 6 weeks of antibiotic therapy (IV PO). Though this can vary depending on the patient’s age, whether the infection is acute or chronic, the pathogen, presence of collections and the patient’s clinical response. Intravenous antibiotic therapy is almost always required initially, but oral antibiotic therapy is usually preferred to complete the treatment course
• To cure chronic osteomyelitis, surgical debridement of necrotic bone and sequestra is essential
• Collect blood samples for culture because more than 50% of patients with vertebral or acute long-bone osteomyelitis have bacteraemia. To increase blood culture yield, adults should have two sets of samples (ie four bottles) collected. If blood culture results are positive, bone biopsy is generally unnecessary. However, if no organism, or an organism of questionable significance (eg a commensal organism such as a coagulase-negative staphylococcus), is identified, it is critical to collect suitable samples of bone or pus for culture and histopathology. These samples should be collected by radiologically guided percutaneous or open biopsy

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on osteomyelitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Please note this section is for empiric treatment of septic arthritis before results of culture.
Take diagnostic samples before starting antibiotic therapy

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is the septic arthritis associated with a diabetic foot or leg ulcer or vascular insufficiency?

• Yes (treat as diabetic foot)
• No

Is the septic arthritis associated with a diabetic foot or leg ulcer or vascular insufficiency?

• Yes (treat as diabetic foot)
• No

Is the patient at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection?

• Yes
• No

• Risk factors for MRSA infection include;
  • residence in an area with a high prevalence of MRSA (e.g. Regions north of metropolitan Perth in Western Australia, especially the Kimberly and Pilbara; Northern Territory and remote communities in northern Queensland;)
  • known or suspected to be colonised with methicillin-resistant Staphylococcus aureus (MRSA)
  • previous colonisation or infection with MRSA, particularly if recent or associated with the current episode of care
  • frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA, particularly if associated with antibiotic exposure or recent surgery
  • residence in an aged-care facility with a high prevalence of MRSA, particularly if the patient has had multiple courses of antibiotics
  • an intravascular catheter-related infection in a unit with a significant incidence of MRSA infection

Is the patient at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection?

• Yes
• No

• Risk factors for MRSA infection include;
  • residence in an area with a high prevalence of MRSA (e.g. Regions north of metropolitan Perth in Western Australia, especially the Kimberly and Pilbara; Northern Territory and remote communities in northern Queensland;)
  • known or suspected to be colonised with methicillin-resistant Staphylococcus aureus (MRSA)
  • previous colonisation or infection with MRSA, particularly if recent or associated with the current episode of care
  • frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA, particularly if associated with antibiotic exposure or recent surgery
  • residence in an aged-care facility with a high prevalence of MRSA, particularly if the patient has had multiple courses of antibiotics
  • an intravascular catheter-related infection in a unit with a significant incidence of MRSA infection

For empirical therapy in a patient with no penicillin allergy and no MRSA risk factors, while awaiting the results of cultures and susceptibility use:

• The durations of therapy suggested in this table should be modified according to clinical response.
• These treatment durations do not apply to gonococcal arthritis, which should be treated for a total of 7 days
• If the patient is clinically improving, an earlier switch to oral therapy may be possible, as long as there is an appropriate oral antimicrobial available that is as effective as intravenous therapy (eg ciprofloxacin, clindamycin). Conversely, some patients need a longer duration of intravenous therapy than recommended in this table. Seek expert advice

• Take diagnostic samples before starting antibiotic therapy to exclude alternative or coexisting diagnoses (such as an acute crystal arthropathy) and enable antibiotic therapy to be directed. Appropriate diagnostic samples include blood for culture, and a joint aspirate for Gram stain, culture and microscopy
• Joint aspiration should be performed by experienced clinicians, using an aseptic technique. When performing diagnostic aspiration, aspirating the bulk of the effusion can offer therapeutic benefits. Aspiration should be as complete as possible without compromising patient comfort or causing damage to the joint
• Acute rheumatic fever may present as an acute monoarthritis and should be excluded, particularly in Aboriginal and Torres Strait Islander people living in rural or remote settings, and other populations who may be at high risk (eg Aboriginal and Torres Strait Islander people living in urban settings, Maori and Pacific Islander people
• If the patient has a postoperative infection of a prosthetic shoulder joint please contact infectious diseases for advice before starting treatment. Management is complex
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection

References:

See section on Septic Arthritis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For empirical therapy in a patient with non-severe penicillin hypersensitivity and no MRSA risk factors, while awaiting the results of cultures and susceptibility use:

• The durations of therapy suggested in this table should be modified according to clinical response.
• These treatment durations do not apply to gonococcal arthritis, which should be treated for a total of 7 days
• If the patient is clinically improving, an earlier switch to oral therapy may be possible, as long as there is an appropriate oral antimicrobial available that is as effective as intravenous therapy (eg ciprofloxacin, clindamycin). Conversely, some patients need a longer duration of intravenous therapy than recommended in this table. Seek expert advice

• Take diagnostic samples before starting antibiotic therapy to exclude alternative or coexisting diagnoses (such as an acute crystal arthropathy) and enable antibiotic therapy to be directed. Appropriate diagnostic samples include blood for culture, and a joint aspirate for Gram stain, culture and microscopy
• Joint aspiration should be performed by experienced clinicians, using an aseptic technique. When performing diagnostic aspiration, aspirating the bulk of the effusion can offer therapeutic benefits. Aspiration should be as complete as possible without compromising patient comfort or causing damage to the joint
• Acute rheumatic fever may present as an acute monoarthritis and should be excluded, particularly in Aboriginal and Torres Strait Islander people living in rural or remote settings, and other populations who may be at high risk (eg Aboriginal and Torres Strait Islander people living in urban settings, Maori and Pacific Islander people
• If the patient has a postoperative infection of a prosthetic shoulder joint please contact infectious diseases for advice before starting treatment. Management is complex
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection

References:

See section on Septic Arthritis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For empirical therapy in a patient with either severe penicillin allergy and/or a patient with MRSA risk factors, while awaiting the results of cultures and susceptibility use:

Code for vancomycin is: 2cac

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Take diagnostic samples before starting antibiotic therapy to exclude alternative or coexisting diagnoses (such as an acute crystal arthropathy) and enable antibiotic therapy to be directed. Appropriate diagnostic samples include blood for culture, and a joint aspirate for Gram stain, culture and microscopy
• Joint aspiration should be performed by experienced clinicians, using an aseptic technique. When performing diagnostic aspiration, aspirating the bulk of the effusion can offer therapeutic benefits. Aspiration should be as complete as possible without compromising patient comfort or causing damage to the joint
• Acute rheumatic fever may present as an acute monoarthritis and should be excluded, particularly in Aboriginal and Torres Strait Islander people living in rural or remote settings, and other populations who may be at high risk (eg Aboriginal and Torres Strait Islander people living in urban settings, Maori and Pacific Islander people
• If the patient has a postoperative infection of a prosthetic shoulder joint please contact infectious diseases for advice before starting treatment. Management is complex
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on Septic Arthritis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have any systemic symptoms?

• Yes
• No

Does the patient have any systemic symptoms?

• Yes
• No

Does the patient have any systemic symptoms?

• Yes
• No

Does the patient have any systemic symptoms?

• Yes
• No

Is methicillin-resistant Staphylococcus aureus (MRSA) infection suspected or is the patient at increased risk of MRSA?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is methicillin-resistant Staphylococcus aureus (MRSA) infection suspected or is the patient at increased risk of MRSA?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is methicillin-resistant Staphylococcus aureus (MRSA) infection suspected or is the patient at increased risk of MRSA?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is methicillin-resistant Staphylococcus aureus (MRSA) infection suspected or is the patient at increased risk of MRSA?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is methicillin-resistant Staphylococcus aureus (MRSA) infection suspected or is the patient at increased risk of MRSA?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is methicillin-resistant Staphylococcus aureus (MRSA) infection suspected or is the patient at increased risk of MRSA?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is methicillin-resistant Staphylococcus aureus (MRSA) infection suspected or is the patient at increased risk of MRSA?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is methicillin-resistant Staphylococcus aureus (MRSA) infection suspected or is the patient at increased risk of MRSA?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

For a patient who is displaying systemic symptoms of infection, and at risk of MRSA infection give:

Code for vancomycin is: 2bur

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Bursitis is most commonly noninfective. Septic bursitis is usually caused by Staphylococcus aureus and often follows local trauma. The usual sites of infection are the prepatellar and olecranon bursae. When there are signs of infection, confirm the diagnosis by microscopic examination and culture of a bursal aspirate. If the joint is involved, see septic arthritis
• If clinical improvement is delayed, repeated aspiration, catheter drainage or surgical excision may be required. When the patient is clinically improving (usually 3 to 7 days), switch to oral therapy as for septic bursitis without systemic symptoms and continue until the resolution of symptoms (usually 2 weeks)

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on post septic bursitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For a patient with no penicillin allergy, who is displaying systemic symptoms of infection, not at risk of MRSA infection give:

• Bursitis is most commonly noninfective. Septic bursitis is usually caused by Staphylococcus aureus and often follows local trauma. The usual sites of infection are the prepatellar and olecranon bursae. When there are signs of infection, confirm the diagnosis by microscopic examination and culture of a bursal aspirate. If the joint is involved, see septic arthritis
• If clinical improvement is delayed, repeated aspiration, catheter drainage or surgical excision may be required. When the patient is clinically improving (usually 3 to 7 days), switch to oral therapy as for septic bursitis without systemic symptoms and continue until the resolution of symptoms (usually 2 weeks)

References:

See section on post septic bursitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For a patient who is not displaying systemic symptoms of infection, at risk of MRSA infection give:

• Bursitis is most commonly noninfective. Septic bursitis is usually caused by Staphylococcus aureus and often follows local trauma. The usual sites of infection are the prepatellar and olecranon bursae. When there are signs of infection, confirm the diagnosis by microscopic examination and culture of a bursal aspirate. If the joint is involved, see septic arthritis
• Continue treatment until infection has clinically resolved (usually 2 weeks). If infection is not improving after 48 hours of oral therapy, start intravenous therapy as for septic bursitis with systemic symptoms, and consider repeated aspiration or catheter drainage

References:

See section on post septic bursitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For a patient with no penicillin allergy, who is not displaying systemic symptoms of infection, not at risk of MRSA infection give:

• Bursitis is most commonly noninfective. Septic bursitis is usually caused by Staphylococcus aureus and often follows local trauma. The usual sites of infection are the prepatellar and olecranon bursae. When there are signs of infection, confirm the diagnosis by microscopic examination and culture of a bursal aspirate. If the joint is involved, see septic arthritis
• Continue treatment until infection has clinically resolved (usually 2 weeks). If infection is not improving after 48 hours of oral therapy, start intravenous therapy as for septic bursitis with systemic symptoms, and consider repeated aspiration or catheter drainage

References:

See section on post septic bursitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For a patient with non-severe penicillin allergy, who is displaying systemic symptoms of infection, not at risk of MRSA infection give:

• Bursitis is most commonly noninfective. Septic bursitis is usually caused by Staphylococcus aureus and often follows local trauma. The usual sites of infection are the prepatellar and olecranon bursae. When there are signs of infection, confirm the diagnosis by microscopic examination and culture of a bursal aspirate. If the joint is involved, see septic arthritis
• If clinical improvement is delayed, repeated aspiration, catheter drainage or surgical excision may be required. When the patient is clinically improving (usually 3 to 7 days), switch to oral therapy as for septic bursitis without systemic symptoms and continue until the resolution of symptoms (usually 2 weeks)

References:

See section on post septic bursitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For a patient with no penicillin allergy, who is not displaying systemic symptoms of infection, not at risk of MRSA infection give:

• Bursitis is most commonly noninfective. Septic bursitis is usually caused by Staphylococcus aureus and often follows local trauma. The usual sites of infection are the prepatellar and olecranon bursae. When there are signs of infection, confirm the diagnosis by microscopic examination and culture of a bursal aspirate. If the joint is involved, see septic arthritis
• Continue treatment until infection has clinically resolved (usually 2 weeks). If infection is not improving after 48 hours of oral therapy, start intravenous therapy as for septic bursitis with systemic symptoms, and consider repeated aspiration or catheter drainage
• It is safe to use cefalexin in patients who had a delayed nonsevere reaction to a penicillin in the distant past. It is also safe to use cefalexin in patients who have had a delayed nonsevere reaction recently, unless the reaction involved amoxicillin or ampicillin, because cross-reactivity between these drugs is possible. For patients who have had a recent delayed nonsevere reaction to amoxicillin or ampicillin, use the treatment recommended for patients with immediate (nonsevere or severe) or delayed severe hypersensitivity

References:

See section on post septic bursitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For a patient with severe penicillin allergy, who is displaying systemic symptoms of infection, and at risk of MRSA infection give:

Code for vancomycin or IV clindamycin is: 2bur

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Bursitis is most commonly noninfective. Septic bursitis is usually caused by Staphylococcus aureus and often follows local trauma. The usual sites of infection are the prepatellar and olecranon bursae. When there are signs of infection, confirm the diagnosis by microscopic examination and culture of a bursal aspirate. If the joint is involved, see septic arthritis
• If clinical improvement is delayed, repeated aspiration, catheter drainage or surgical excision may be required. When the patient is clinically improving (usually 3 to 7 days), switch to oral therapy as for septic bursitis without systemic symptoms and continue until the resolution of symptoms (usually 2 weeks)

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on post septic bursitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For a patient with severe penicillin allergy, who is not displaying systemic symptoms of infection, not at risk of MRSA infection give:

Code for oral clindamycin is: 7bur

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Bursitis is most commonly noninfective. Septic bursitis is usually caused by Staphylococcus aureus and often follows local trauma. The usual sites of infection are the prepatellar and olecranon bursae. When there are signs of infection, confirm the diagnosis by microscopic examination and culture of a bursal aspirate. If the joint is involved, see septic arthritis
• Continue treatment until infection has clinically resolved (usually 2 weeks). If infection is not improving after 48 hours of oral therapy, start intravenous therapy as for septic bursitis with systemic symptoms, and consider repeated aspiration or catheter drainage

References:

See section on post septic bursitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.