Treatment for Staphylococcus aureus Osteomyelitis

Initial Assessment and Surgical Management

The American College of Physicians recommends surgical debridement as the cornerstone of therapy for osteomyelitis, particularly for MRSA infections, and should include drainage of associated soft-tissue abscesses whenever feasible 1, 2
The Infectious Diseases Society of America considers factors that may favor primarily antibiotic treatment over surgical intervention, including patient is medically unstable for surgery, poor postoperative foot mechanics likely, infection confined to small forefoot lesion, and no adequately skilled surgeon available 3
Factors favoring surgical treatment include substantial bone necrosis or exposed joint, functionally nonsalvageable foot, pathogen resistant to available antibiotics, and limb has uncorrectable ischemia 3

The American College of Cardiology recommends first-line treatment with IV vancomycin (15-20 mg/kg/dose every 8-12 hours, not to exceed 2g per dose) for MRSA osteomyelitis 1, 2
The Infectious Diseases Society of America targets trough concentrations of 15-20 μg/mL for serious infections and monitors vancomycin levels, especially in patients who are morbidly obese, have renal dysfunction, or fluctuating volume of distribution 4
The American Academy of Orthopaedic Surgeons recommends addition of rifampin (600 mg daily or 300-450 mg twice daily) due to excellent penetration into bone and biofilm 1, 2

The American College of Physicians recommends first-line treatment with β-lactam antibiotic (in absence of allergy) for MSSA osteomyelitis 4
The Infectious Diseases Society of America considers adding rifampin (600 mg daily or 300-450 mg twice daily) for biofilm penetration 1, 2

The American College of Cardiology recommends a minimum 8-week course of antibiotics for MRSA osteomyelitis 1, 2
The Infectious Diseases Society of America suggests that if all infected bone is surgically removed, a shorter course (2-14 days) may be sufficient, depending on soft tissue status 3

The American College of Physicians recommends follow-up blood cultures 2-4 days after initial positive cultures to document clearance of bacteremia 4
The Infectious Diseases Society of America uses MRI with gadolinium as the imaging modality of choice for detection of early osteomyelitis and associated soft-tissue disease 1, 2

The American Academy of Orthopaedic Surgeons notes that vancomycin has shown failure rates of up to 35-46% in MRSA osteomyelitis, with concerns about poor bone penetration 1, 2
The Infectious Diseases Society of America recommends that rifampin should always be combined with another active agent to prevent emergence of resistance 1, 2

The American Academy of Pediatrics recommends IV vancomycin as first-line treatment for children with acute hematogenous MRSA osteomyelitis 1, 2
The Infectious Diseases Society of America suggests that if the patient is stable without ongoing bacteremia, clindamycin 10-13 mg/kg/dose IV every 6-8 hours can be used if local resistance rates are low (<10%) 1, 2