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Hi Doctam and friends ,
For Osteomyelitis ,adequate treatment needs bone biopsy to guide treatment.
My questions are 1. does that mean that we don't give empiric antibiotics and wait until culture results come back and treat with Abx based on culture results only.
2. Since the treatment entails 4-6 wks of abx therapy ,On CCS can we send the patient home with just IV access and continue him on the IV say ex Oxacilllin for MSSA ..or should he stay in the hospital till then.
Please help! Thankyou.
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Your no. 2 is a great question - since patient location is one of the criteria the CCS tests. Never thought about it.
I guess I will go with what happens in real life. Not sure pt will remain in hospital for 4-6 wks just to get abx ($$$$$). They will probably go home and have a home health nurse administer the abx at home or they will go daily to get IV drug in an out-patient clinic... just assuming though, not in residency yet so not sure what happens in real life
In CCS, if you dont discontinue anything and send the patient home, the software assumes pt is still on the order. So personally what i would do will be to send the patient home without dc the IV abx (then follow ESR).
For question 1, You give emperic abx for osteomeylitis to cover for Staph which is most common cause of osteo. However because you will be treating for so long (weeks) you dont want to treat with the wrong abx so you adjust if say for example cause of osteo is a gram -ve organism. If culture reveals osteo then give your oxa and nafcillin till the end
Hope this helps
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What I meant in the last sentence was - If culture reveals staph as the cause of the osteo then give your oxa and nafcillin till the end
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Thank you Ozone for the detailed reply.
Kaplan notes does mention that Empiric treatment should be discouraged. But also says oxacillin and ciprofloxacin or oxacillin and 3 rd gen cephalosporin are adequate empiric treatment before knowing bone biopsy results. Hence want more clarification on that!
Yes ,I was wondering if we could send pt home with an intact iva and leave the Abx order for 4-6 wks..and if we need to take any precautions like change catheter during that period.
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1 .. you start empiric abx and then switch abx based on culture results.. oxacillin and cipro are adequate empiric choices
2.. if you do send the patient home, make sure to change IV Abx to PO Abx alternatives.. also discontinue the IV access .. bc at home, there is no way to monitor the IV abx treatment .. PO can be managed by the patient itself because of clear cut directions.
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I've personally had osteomyelitis .. so when I had it, empiric oxacillin and cipro were started and then switched to a more suiting abx when my culture results came back.. when i was discharged from the hospital, i was put on PO abx for 3 weeks.
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@Doctam , Thank you so much for detailed reply .
Since I have not seen a real Osteomyelitis case, this seems hard. Since according to MTB page 6 and even Kaplan notes ,the only oral medication available for OM are quinolones as they concentrate in the bone without being given IV.
However Pencillins like Ox/Nafcillin have to be administered IV and continued that way if the sensitivity results are positive only for them .
If among the sensitivity results if the bug is sensitive to Ciprofloxacin ..then we can make the switch and give Oral ciprofloxacin conveniently .
So bit confused on that ..thanks again for taking time out and helping us!
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If the bug causing osteomyelitis is gram-negative fluoroquinolones are excellent agents even as PO because they have high bone penetration (as you already stated above) meaning we can send home on PO cipro
So what if the osteomyelitis is due to Staphylococcus aureus? What PO agent can be used at home? I just checked uptodate and it says-
"Oral regimens for MSSA may also be effective [42-44]. In one study of 50 patients with osteomyelitis treated with antibiotics following debridement, oral therapy with rifampin-cotrimoxazole demonstrated comparable efficacy to intravenous cloxacillin therapy"
Really? rifampin-cotrimoxazole? Never knew rifampin-cotrimoxazole was even effective against Staph
I'm even more confused lol
