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By Dr.

Mohd Viquasuddin Saim


An infection of bone most commonly
caused by pyogenic bacteria and
1. Hematogenous osteomyelitis
2. Osteomyelitis secondary to contiguous
focus of infection
3. Chronic osteomyelitis

Microbiology of hematogenous
Majority of cases occur in children
95% of cases of hematogenous
osteomyelitis are caused by a single
Staph.aures accounts for 50% of cases.
Other common pathogens are group A
streptococci in children, group B
streptococci and E.coli in neonates.
Microbiology of hematogenous
In adults, hematogenous osteomyelitis
occurs most commonly in vertebrae.
The organisms are staph.aureus,
pseudomonas, serratia and candida.
The most common risk factor is iv drug
Hemoglobionopathy patients have
osteomyelitis of long bones caused by
salmonella and staph.aureus.
Microbiology of hematogenous
Immunocompromised persons may
develop osteomyelitis due to atypical
mycobacteria, bartonella and fungi.

Microbiology of contiguous
focus osteomyelitis
Staph.aureus accounts for >50% cases.
However, these infections are mostly
polymicrobial and involve anaerobes
and gram negative bacteria.
Staph.aureus most common cause of
post operative osteomyelitis.
Coagulase negative staph are common
pathogens after implantation of
orthopaedic appliances.
Microbiology of contiguous
focus osteomyelitis
Mycoplasma can cause sternal
osteomyelitis after cardiac surgery.
Pseudomonas can cause osteomyelitis
after puncture wounds of foot.
Pasteurella.multocida osteomyelitis
follows cat bite.
Principles of Antibiotic therapy
in osteomyelitis
Antibiotics should be administered only
after appropriate specimens have been
obtained for culture.
use of bactericidal antibiotics is
Antibiotics should be given in high dose
Principles of Antibiotic therapy
in osteomyelitis
Guidelines for empirical therapy:
It should be chosen based on findings
on gram staining of a specimen from a
bone or abscess.
Or it can be chosen to cover the most
likely pathogens.(staph.aureus)
Empirical antibiotic therapy should also
include against anaerobes in the setting
of decubitis ulcer and diabetic foot.

Principles of Antibiotic therapy
in osteomyelitis
Specific therapy:
Its ultimately based on in-vitro susceptibility
testing of organisms isolated from bone or
The decision to give outpatient parenteral
antimicrobial therapy is suitable for
medically stable and motivated patients.
Parenteral therapy should be given for 5-10
days and then oral antibiotics should be
For Staph aureus
Penicillin resistant, methicillin sensitive :
Nafcillin / Oxacillin 2gm IV q4h
Penicillin sensitive : Penicillin 3-4 million U
IV q4h
Methicillin resistant : Vancomycin 15mg/kg
IV Q12h + Rifampicin 300mg PO q12h
Penicillin allergic patients : Clindamycin
900mg IV q8h / Cefazolin 1g IV q8h.
Streptococci : d.o.c Penicillin.
Alternatives: cefazolin, clindamycin.
Gram negative bacilli : E.coli : d.o.c :
Ampicillin 2g IV q4h , alternative :
Ceftriaxone Pseudomonas : d.o.c :
Piperacillin 3-4g IV / Ceftazidime 2g IV
plus Tobramycin 5-7mg/kg
Mixed infections : Ampicillin+sulbactam,
Piperacillin+tazobactamalternative :
Carbapenem+ Clindamycin.
Septic arthritis
Every bacterial pathogen is capable of
causing septic arthritis
In infants : group B Streptococci, gram
negative bacilli and staph aureus.
Adolescents and young adults :
neisseria gonorrhea is most common
Staph aureus most common non
gonoccocal cause
Septic arthritis
Infections after surgical procedures and
penetrating injuries are caused by staph
Human bites near joints and extension
of decubitus ulcers cause septic arthritis
due to anaerobes
Bites and scratches from cats introduce
pasteurella into joints.
Septic arthritis
Prompt administration of systemic
antibiotics and drainage of involved joint
is needed.
Emperical antibiotics should be started
once samples of blood and synovial fluid
have been obtained for culture.
Emperical antibiotics are given based on
bacteria visualised on smears
Septic arthritis
Initial therapy should consist of iv
adminsitration of bactericidal agents
Direct administration of antibiotics into
joints is not necessary
D.o.c: iv cefotaxime or ceftriaxone if
smears show no organisms
Is smears show gram positive cocci :
oxacillin or naficillin is used
If MRSA : Vancomycin
Septic arthritis
Definitive therapy is based on identity and
antibiotic susceptibilty of bacteria isolated
in culture
For staph : oxacillin/ naficillin or
For pneumococcal and strepto :2 weeks of
For H. Influenzae : cefotaxime
Enteric gram negative infections :
ceftriaxone or fluroquinolone for 3-4 weeks
Gonococcal arthritis
Initial treatment iv ceftriaxone 1gm
Once local and systemic signs resolve 7
day course of ciprofloaxcin can be given
Infections in prosthetic joints
High dose parenteral antibiotics for 4-6
weeks because bone is involved.
A high cure rate with retention of
prosthesis has been reported with the
combination of oral rifampicin and
ciprofloxacin for 3-6 months
Role of antibiotics in gas
Previously the antibiotic of choice has
been PenicillinG , 20 MILLION UNITS
per day.
But due to increasing resistance to this
drug, antibiotics inhibiting toxin
synthesis appear to be favourable.
Clindamycin treatment enhanced
survival than penicillin treatment
Dose of clindamycin : 600mg every 6h.
Anti TB drugs
First line essential drugs
1. Rifampicin : most important and most
2. Isoniazid : 2
best anti TB drug
3. ethambutol : least potent amongst
first line drugs
4. Pyrazinamide : important in short
course therapy
Anti TB drugs
First line supplemental drugs
1. streptomycin : available for iv/ im
administration only
2. rifabutin : recommended in HIV
positive individuals in place of rifampicin
Anti TB drugs
Second line drugs
1. Quinolones : Levofloxacin and
2. Capreomycin
3. Amikacin
4. Ethionamide
5. Para-aminosalicylic acid
6. Cycloserine
Newer anti TB drugs
LINEZOLID : can be used in drug
resistant TB cases
Can be used iv or orally
Anti TB drug regimens
Category I includes : spinal disease with
neurological complications.
The treatment in Category I consists of an
intensive phase of isoniazid (H), rifampicin (R),
Pyraziamide (Z) and ethambutol (E)
administered under a direct supervision thrice
weekly on alternate days for 2 months (24
dosages), followed by a continuation phase of
H and R thrice weekly on alternate days for 4
months (18 weeks, 54dosages).
The first dose of each week given directly
supervised and the patient self-administering
next two doses of the week, at home.

Anti TB drug regimens
Category III: includes sputum negative
musculo-skeletal TB
Category III treatment is similar to that of
Category I, but is executed without an
inclusion of ethambutol.

Anti TB drug regimens
Category II :
Relapsed and treatment failure (smear-positive)
Treatment after substantial interruption.
These patients are at risk of developing multidrug
resistant tuberculosis (MDR-TB)
In category II intensive phase consists streptomycin
(S), H, R, Z and E for 2 months followed by 1 month
of H, R, Z and E (total 36 dosages), is administered
in the same supervised manner as Category I and is
followed by an appropriately supervised continuation
phase consisting of 5 months (22 weeks, 66
dosages) of H, R and E.

Side effects of anti TB drugs
Rifampicin : GI upset, hepatitis, rash, flu
like syndrome and red orange urine.
Isoniazid : hepatitis, peripheral neuropathy
and seizures.
Pyrazinamide : hepatitis, hyperuricemia
and arthralgia
Ethambutol : optic neuritis
Streptomycin, amikacin and capreomycin :
ototoxicity and nephrotoxicity
Side effects of other antibiotics
Beta lactams : allergies in 1-4 %
patients, diarrhea, non allergic skin
Vancomycin : red man syndrome,
nephrotoxicity and ototoxicity
Aminoglycosides : nephrotoxicity
(reversible) ,ototoxicity (irreversible)
Clindamycin : diarrhea due to colitis
Fluoroquinolones : tendon ruptures
Side effects of other antibiotics
Metronidazole : metallic taste
Linezolid : thrombocytopenia and
peripheral neuropathy.
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