SSTIS &

OSTEOMYELITIS
Brian Wenger, PharmD
PGY1 Pharmacy Resident
 OBJECTIVES

• Recognize key clinical features, diagnostic criteria, and non-

pharmacologic management of SSTIs and osteomyelitis
• Develop an appropriate pharmacotherapy plan for patients with
SSTIs
• Develop an appropriate pharmacotherapy plan for patients with
osteomyelitis
 CASE 
• 52 YOF presents to the emergency department with a puncture wound on her left calf. She complains of dull pain, redness,
and swelling at the site. Symptoms have worsened over the last week after she had an accident at her job site where she
sustained the injury. Symptoms have not improved with over-the-counter remedies. Patient also reports subjective fevers at
home.
• Past medical history: HTN, HLD, Afib
• NKDA
• Pertinent labs/vital:
• Temp 100.9 Admitting diagnoses:
• HR 89 bpm Purulent LLE cellulitis
• BP 138/86 mm Hg Rule-out osteomyelitis
• WBC 17.6K
• SCr 0.7

• Physical findings:
• Malodorous purulent drainage noted
• Large red/tender diameter around wound
 SSTI BACKGROUND
• Account for more than 14 million physician office visits each year in the US in
addition to ED and hospital visits
• Greatest incidence among patients aged 18-44
• Result from microbial invasion of the skin & supporting structures 
• Classified as uncomplicated/simple or complicated
• Simple: usually monomicrobial and localized
• Complicated: monomicrobial or polymicrobial with potential systemic manifestations

• Clinical presentation: erythema, warmth, pain, edema

• Systemic signs implicated in advanced or necrotizing SSTIs
• Purulence, odorous drainage seen in some cases
 SSTI RISK FACTORS

Comorbidities

• Immunocompromising conditions, debility, _______, dialysis, hepatic disease,

obesity, peripheral neuropathy, ____/_____

Trauma

• IVDU, surgery, sports participation

Exposure

• Military, long-term care facility, water exposure, children, health care worker,
prolonged hospitalization
 SSTI CAUSATIVE ORGANISMS

Abscess/purulent cellulitis  _______, Streptococcus spp., anaerobes

Cellulitis (non-purulent) Beta-hemolytic streptococci
Gangrene ________, polymicrobial 
Animal or human bites Anaerobes
 NON-PURULENT SSTI
Culture if:
immunocompromised or
trauma

Typical localized Systemic infection:

cases: cover Strep Add MRSA
consider adding
spp. coverage if…
____ coverage

Can treat with PO MRSA colonization

Should be
if no SIRS, AMS, Penetrating (or alternate MRSA SIRS criteria met
hospitalized for IV
or hemodynamic trauma/IVDU source)
therapy if…
instability

*Consider broad-spectrum coverage (vancomycin +

Concern for Patient has poor anti-pseudomonal beta lactam) in immunocompromised
deep/necrotizing adherence/has
infection patients
failed PO therapy
 PURULENT SSTI

Obtain culture from

drainage (if possible)

Mainstay of treatment is Consider antibiotics if

_______ ______

MRSA coverage: failed

initial treatment or
immunocompromised
 SSTI ANTIBIOTIC DOSING & SELECTION
Amoxicillin (500mg PO TID)
Severe:
• Limited spectrum (________?), inexpensive
• Not as common in clinical practice *Broad empiric coverage
(eg
Cephalosporins vancomycin +
___________)
• Cefazolin (1-2g IV q8h)/cephalexin (500mg PO QID): narrow, best
____ coverage, PO common “stepdown” therapy *C&S to narrow therapy
• Ceftriaxone (1-2g IV daily): broader spectrum, often started
empirically in ED *If necrotizing: add
__________

Clindamycin (PO: 300mg QID, IV: 450mg QID)

• Adds _______/_____ coverage but loses _____ _________

• More likely to cause C. difficile diarrhea
• Good option for patients with beta-lactam allergies
 WHAT ELSE TO KNOW?

• Duration: ___ days

• Unless?

• Systemic corticosteroids may be considered

• Blunts immune response
• May help with inflammatory pain
• Eg: prednisone 40mg daily x 7 days

• Recurrent cellulitis
• Treat predisposing risk factors
• Consider prophylactic antibiotics in patients who have__ to __ episodes per year despite adequate attempts to treat
 OUR PATIENT
• Patient was admitted to hospital for IV antibiotics and fluids
• Wound & blood cultures pending
• The team asks for recommendations – what do you say?
 OSTEOMYELITIS BACKGROUND
• Inflammatory bone changes caused by pathogenic bacteria
• Classified based on illness duration (acute/chronic) and mechanism of infection (Hematogenous/non-
hematogenous)
• Non-hematogenous: infection spreads from ____ _______to bone
• Hematogenous: infection spreads from ______ to bone

• Signs/symptoms can include both local and systemic

• Dull ______________ pain, swelling, warmth, erythema
• Fever, rigors, chills

• No clear diagnostic criteria

• Combination of clinical suspicion, inflammatory markers, and imaging
• MRI more accurate than CT or x-ray, but not always realistic
• Always consider HPI and PMH
 OSTEOMYELITIS RISK FACTORS

Hematogenous Non-hematogenous
Endocarditis Poorly healed SSTI
Indwelling catheter Orthopedic hardware
Orthopedic hardware Diabetes
____ PVD/PAD
Dialysis Neuropathy
Sickle cell disease
 OSTEOMYELITIS CAUSATIVE ORGANISMS

Non-hematogenous (poly or Hematogenous

Rare Organisms
monomicrobial) (monomicrobial)
• Staph spp. • Staph aureus • Beta hemolytic Strep
• Coagulase-negative • Aerobic GNR • Mycobacterium
Staph • IVDU: ____________, • Bartonella
• ____ and ____ Serratia • Candida
• Gram negative rods • Immunocompromised:
(GNR) molds
OSTEOMYELITIS MANAGEMENT

Debridement is • Surgeon may place

cornerstone of antibiotic spacer for
localized action
therapy

Antibiotics should • If not, ideal to have

be delayed until 2 weeks off
antibiotics before
bone culture any surgical
obtained intervention

Example empiric • What are

regimen:
vancomycin + our
_____________ bugs?
 OSTEOMYELITIS MANAGEMENT

Organism Primary regimen Alternative regimen

Anaerobes Clindamycin 600mg IV q6h Metronidazole 500mg IV q6h
GNRs Ceftriaxone 2g IV q24h Ciprofloxacin 400mg IV q8-12h

Pseudomonas Cefepime 2g IV q8-12h +/- Pip/tazo 3.375g IV q6h +/-

___________________ __________________

MSSA Nafcillin 1-2g IV q4h Cefazolin 1g q6h

MRSA Vancomycin (AUC dosing) Linezolid 600mg IV q12h
Streptococcus spp. Penicillin G 2-4 million units IV q4h Ceftriaxone 2g IV q24h
OSTEOMYELITIS ANTIBIOTIC DOSING &
SELECTION
Ceftriaxone

• Covers majority of GNRs well but prone to __________

• Maintains Streptococcus and Staphylococcus (non-MRSA) activity
• Ease of use, limited PCN allergy cross-reactivity, cost

Piperacillin/tazobactam or cefepime

• Add coverage for _____________

• More reliable activity against resistant GNRs
• Pip/tazo: risk of AKI noted when given with vancomycin

Ciprofloxacin

• Adequate ____ penetration

• Good coverage against GNRs and _____________ (limited)
• Toxicity risk with long course
 WHAT ELSE TO KNOW?

Treatment Duration varies based on surgical

success intervention
rate: ___ to
___ If orthopedic hardware present, need to
remove or treat with extended course
Long-term PO suppressive therapy can be
considered in certain cases
 OUR PATIENT

• Day 1: Started on empiric vancomycin upon admission

• General surgery consulted – plan on I&D

• Day 2: CT shows acute non-hematogenous osteomyelitis of the left femur

• Ceftriaxone added

• Day 3: Blood and bone/wound cultures finalize, growing MSSA

What are your recommendations?

 PATIENT SUMMARY

Surgical debridement Discharged with home

Vancomycin/ceftriaxone
performed – no residual health - 10 additional days
switched to cefazolin
infection of cefazolin
Questions?
 SSTIS &
OSTEOMYELITIS
Brian Wenger, PharmD
PGY1 Pharmacy Resident