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    SUBJECTIVE/OBJECTIVE                                        ASSESSMENT                                                                PLAN
                                                                                                                                           GOALS &
  OBJECTIVE EVIDENCE                                           THERAPY; THERAPY OPTIONS                            TREATMENT;         PARAMETERS (TOXIC          EDUCATION
                                                                                                                  FURTHER TESTS         & THERAPEUTIC)
SEPTIC ARTHRITIS              Microbiology:           Yes, to prevent complications of infection, and to stop   *Note: See syllabus   Goals:
(INFECTIOUS                   Need to consider pt     transmission of infection to others.                      pg.259 for dosing.    Preserve joint f(x)
ARTHRITIS) – bacterial        characteristics (age,                                                                                   Prevent spread of
infection of the joint. May   underlying dz)          Treatment Options:                                                              infection
also be due to viral,         Infant <1month old:    Empiric
mycobacterial, and fungal     Variable (S. aureas,     Parenteral therapy                                                            Monitor:
pathogens.                    Grp B strep, GNR’s)      Must cover S. aureus                                                          •S/Sx of infection
                              Children <5yo:          Based on pt subgroup and gram-stain results                                   Joint fluid (WBC,
Usually monoarticular        S. aureus, H. flu           Penicillinase-resistant -lactam (Nafcillin)                               culture)
(90%)                         Children >5yo and          Cephalosporin (Cefazolin)                                                  Joint inflammation
Subacute or chronic          adults:                     Vancomycin                                                                 Temperature
presentation suggests         S. aureus                   Change therapy if suspect other organism (i.e.                             ESR, WBC
mycobacterial or fungal       Adults <30you,         GNRs)
infection                     sexually active:              √ Antipseudomonal agents (IVDU) (Ceftazadime,                             •SE of meds
Most common joints           N. gonnorrhoae          Aminoglycoside, Piperacillin/tazobactam, Cefepime,                              Nafcillin: D,
involved:                     IVDU:                  Fluoroquinolone)                                                                neutropenia,
√ knee                        P. aeruginosa                 √ Gonococcal arthritis: Cetriaxone                                        hypersensitivity rxns
√ hip                                                 Definitive
√ shoulder                    Pathogenesis:            Based on culture and susceptibility results                                   Cephalosporins: D,
√ sternoclavicular            Hematogenously             S. aureus: Nafcillin or cefazolin or vancomycin                            hypersensitivity rxns
√ sacroiliac                  acquired (most              MRSA: Vancomycin
Typical complaints:          common)                     N. gonorrhoae: Ceftriaxone                                                 Vancomycin: red neck
 Fever                       Contiguous site of         P. aeruginosa: Ceftazadime + Aminoglycoside or                             syndrome (hypotsn,
 Localized joint pain,       infection (bone or      Fluoroquinolones                                                                flushing),
swelling, tenderness          soft tissue)            Duration of Therapy                                                            nephrotoxicity,
 Limited joint motion        Direct inoculation      Usually 2-3 weeks                                                             ototoxicity
Joint effusion present on    (surgery, injection,     2 weeks: H. influenzae, Streptococci
exam (>90%)                   trauma)                  3 weeks: S. aureus, GNRs                                                      Aminoglycoside:
Lab tests:                                            May change to oral therapy if good response and pt                            nephrotoxicity,
 Elevated ESR                Diagnosis:              compliant                                                                       ototoxicity
 Elevated WBC (50%)          Aspiration of                 Cephalexin, Dicloxacillin, Clindamycin,
 Positive blood cultures     synovial fluid:         TMP/SMX, Quinolones                                                             Piperacillin/tazobactam:
(50%)                          turbid (cloudy)                                                                                       hypersensitivity rxns,
                               high WBC                                                                                              D, platelet dysf(x),
                              (>50,000/mm3) w/                                                                                        HypoK+
                              predominance                                                                                            Fluoroquinolone: rash,
                               organisms seen                                                                                        photosensitivity,
                              gram stain                                                                                              cartilate toxicity, QTc
                                                                                                                                      prolongation, CNS
                               culture and
                                                                                                                                      irritation, N/V/D,
                                                                                                                                      abdominal pain
                              Blood cultures
                              Lab tests (maybe                                                                                       Ceftriaxone: D,
                              non-specific): WBC,                                                                                     hypersensitivity rxns,
                              ESR                                                                                                     biliary sludging
                                                                                                                                              Dicloxacillin: N/D,
                                                                                                                                              adominal pain

                                                                                                                                              Clindamycin: N/D/V,
                                                                                                                                              hypersensitivity rxns,

                                                                                                                                              TMP/SMX: N/D/V,
                                                                                                                                              cholestatic hepatitis,
                                                                                                                                              HA, confusion,
                                                                                                                                              hypersensitivity rash

OSTEOMYELITIS –                    Microbiology:            Yes, to prevent complications of infections such as         *Note: See syllabus   Goals:
inflammation of bone marrow        •Hematogenous            necrosis.                                                   pg.259 for dosing.    Complete eradication
and surrounding bone. Often         Usually one                                                                                              of infection
results in severe morbidity.       organism                 Treatment Options:                                                                Avoid the need for
                                    S. aureus              Empiric                                                                          future surgery
Acute:                             GNRs                    Initial therapy based on the following:
 Infection of recent onset        Contiguous                 √ Age                                                                          Monitor:
(several days to 1 week)            May be                    √ Site of Infection                                                            S/Sx of infection
Chronic                           polymicrobial               √ Underlying risk factors                                                      WBC, ESR
 Infection which is present        S. aureus                 √ History of prior onset of symptoms (trauma, surgery,                         Temperature
>1 month or relapse of              Streptococci, S.       etc.)                                                                             VS
previous infection                 epidermidis                 √ Findings (i.e. gram stain) at debridement surgery or                         Cultures of blood
Hematogenous (children             GNRs (E. coli, P.      bone aspiration                                                                   and/or bone aspirate
and elderly) – bacteria            aeruginosa, Proteus       Must cover S. aureus!! Also cover GNRs +/- anaerobes                            (before administration
spreads through bloodstream        spp., Klebsiella spp.)    Many possible regimens                                                          of antibiotics)
to bone (from a distant site)      Contiguous w/              √ Nafcillin or cefazolin or clindamycin or vancomycin                          Serum drug levels
 Onset: Abrupt                    Vascular                 (hematogenous, child)
 Systemic signs: Fever,           Insufficiency               √ Ampicillin/sulbactam or piperacillin/tazobactam                              SE of meds
chills                              Usually                   √ Cefotaxime or ceftriaxone + clindamycin or                                   Nafcillin: D,
 Local signs: Tenderness,         polymicrobial            metronidazole                                                                     neutropenia,
pain, swelling, ROM,                                          √ Nafcillin + aminoglycoside or quinolone +/-
                                    S. aureus                                                                                                hypersensitivity rxns
unable to bear weight               Streptococci, S.
 Labs: WBC, ESR                                             √ Clindamycin + fluoroquinolone                                                Cephalosporins: D,
                                                               √ May add coverage for Pseudomonas (IVDU):
 Sites: Long bones (femur,        Enterococci                                                                                                hypersensitivity rxns
                                                            ceftazadime, fluoroquinolone, aminoglycoside
tibia) in children; vertebrae in    GNRs (E. coli, P.
adults                                                      Definitive                                                                       Clindamyicn: N/D/V,
                                   aeruginosa, Proteus
Contiguous (adults) –                                       Use culture results to streamline antibiotic therapy                            hypersensitivity rxns,
                                   spp., Klebsiella spp.)
                                                             Staphylococcus spp:                                                             pseudomembranous
organism reaches bone from          Anaerobes
adjoining soft tissue infection                                √ Nafcillin (100-150 mg/kg/day divided Q4-6h) or                               colitis
                                   (Bacteroides spp.)
or due to direct inoculation                                      cefazolin (2g IV Q8h) or
(trauma, surgery)                                                 clindamycin (600-900mg IV Q8h) or                                           Vancomycin: red neck
                                   Risk Factors:
 Onset: May be acute or                                          vancomycin (MRSA or MRSE – 25-30mg/kg/day)                                  syndrome (hypotsn,
                                                               √ May consider ceftriaxone for home therapy (2g IV                             flushing),
chronic                             Bacteremia
                                                            Q24h) if MIC low                                                                  nephrotoxicity,
 Systemic signs: Rare, but        (IVDU, sickle cell
may have fever                                               Pseudomonas aeruginosa:                                                         ototoxicity
                                   anemia, catheters,
                                                               √ Often “double-cover”
 Local signs: Warmth,             dialysis lines, non-
                                                               √ Ceftazidime (2g IV Q8h) + Aminoglycoside                                     Ampicillin/sulbactam:
erythema, swelling,                penetrating trauma)
tenderness, pain                Contiguous               (5mg/kg/day)                                                                        D, platelet dysf(x)
 Labs: Rarely elevated          Surgery,                   √ Piperacillin (or Piperacillin/tazobactam) (200-
 Sites: femur, tibia, skull,   penetrating wounds,       300mg/kg/day pip divided Q6h) + Ciprofloxacin (400mg                                Piperacillin/tazobactam:
mandible (feet in contiguous    gunshot wounds,           IV Q8h)                                                                             hypersensitivity rxns,
osteomyelitis w/ vascular       cellulites, prostheses,    Anaerobes (B. fragilis):                                                          D, platelet dysf(x),
insufficiency)                  hip fractures,               √ Metronidazole (500mg IV/PO Q8h) or Clindamycin                                 HypoK+
Contiguous w/ Vascular         decubitus ulcers          *Note: consider importance of home care therapy in this
Insufficiency (adults) –        Contiguous w/            dz, therefore longer t1/2 drugs are often used (i.e.                                Metronidazole: N/V/D,
subdivision of contiguous       Vascular Injury           Ceftriaxone, Vancomycin)                                                            metallic taste,
osteomyelitis (organism          DM, peripheral          Role of Oral Therapy                                                               disulfiram rxn, rash,
reaches bone from adjoining     vascular dz,               Gram negative osteomyelitis (Enterobacter, Proteus,                               peripheral neuropathy,
soft tissue infection           peripheral                Pseudomonas) --> Ciprofloxacin 750mg PO BID                                         red urine, reversible
 Onset: Often chronic          neuropathy,                Gram positive osteomyelitis (S. aureus) -->                                       neutropenia
 Systemic signs: Often         cellulitesdeep           Ciprofloxacin + rifampin
absent                          ulcerosteomyelitis        When to switch to PO? Stable, improved, debridement,                              Aminoglycoside:
 Local signs: Pain,                                      compliant, 2 wks IV already                                                         nephrotoxicity,
swelling, erythema, draining                              Duration of Therapy                                                                ototoxicity
sinus tracts (boneskin),                                  Acute:
                                                                                                                                              Fluoroquinolone: rash,
ulcers, history of cellulites                                √ 4-6 weeks w/ high dose IV antibiotics
 Labs: Rarely elevated                                      √ Possible oral therapy
                                                                                                                                              cartilate toxicity, QTc
 Sites: Usually feet                                      Chronic: (not well defined)
                                                                                                                                              prolongation, CNS
                                                             √ 4-6 weeks high dose IV antibiotics +/- followed by 2
                                                                                                                                              irritation, N/V/D,
                                                          months PO
                                                                                                                                              abdominal pain
                                                             √ Chronic suppressive therapy
                                                          Non-Pharmacologic Therapy
                                                           Rarely need surgery for acute hematogenous
                                                           Tx is very difficult in setting of vascular insufficiency
                                                          or chronic bone destruction
                                                           Surgery is an integral part of tx to remove dead bone,
                                                          devitalized tissue and sinus tracts

BONE AND JOINT                  Microbiology:
                                                          Yes, to prevent extension of infection.                       *Note: See syllabus   Goals:
INFECTIONS                      Staphylococcus spp.
                                (especially S.                                                                          pg.259 for dosing.    Eradication of
ASSOCIATED W/                                             Treatment Options:
                                epidermidis)                                                                                                  prosthetic joint
PROSTHETIC                                                Empiric
                                May also see:                                                                                                infection
MATERIAL – infection of                                    Must cover Staph spp.
foreign body                    Streptococci, GNRs,                                                                                           Reverse S/Sx
                                                             √ Nafcillin or cefazolin or clindamycin or vancomycin
                                                             √ Keep in mind tha >60% of S. epidermidis isolates are                           Monitor:
May be acute or indolent
process                         Risk Factors:
                                                          nafcillin-resistant                                                                 S/Sx of infection
                                                          Definitive                                                                         Joint function
  function of joint           Surgical site
                                                           Based on culture results and susceptibilities                                     Temperature
  ROM                         infection
                                                           Consider long-acting agents for home care
Localized symptoms in          Presence of                                                                                                  WBC, ESR
                                malignancy                administration                                                                      Blood and joint fluid
region of prosthetic joint:                               Non-Drug Treatment
   √ Pain                       History of prior                                                                                             cultures
                                joint arthroplasty         Standard is “two-stage” procedure: remove hardware
   √ Swelling
   √ Erythema
                                                          entirely if possiblejoint immobilization and high dose IV                          SE of meds
                                                          antibiotics x 6 weeksre-implant prosthesis                                         Nafcillin:
   √ Warmth                     Diagnosis:
                                Joint fluid aspirate:     Surgery is an integral part of therapy…must remove                                Cefazolin:
   √ Tenderness
                                  PMNs                  infected hardware for optimal eradication                                           Clindamycin:
 +/- Systemic signs (fever)
 +/-  WBC or ESR    Organisms seen       Duration of Treatment                                Vancomycin:
                     on gram stain and/or    4-6 weeks after removal of hardware
                     culture                 May consider life-long suppressive antibiotics if
                     Intra-operative       hardware cannot be removed
                     observations and
                     Need to evaluate
                     extent of dz

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