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Antibiotic therapy for treatment of osteomyelitis or prosthetic joint infection in adults

時々遭遇、人工関節感染

 

白熱議論になる人工関節感染

バンコマイシンのトラフを、over20にするしないの綱引きもよくあります。

そのくらい、悩みが深い疾患ですよね。 

治療シーズ何かありますか?

 

ちなみに、Up To Date では以下の感じ。

 

In general, management of prosthetic joint infection (PJI) consists of surgery and antimicrobial therapy. The approach depends on a number of factors including the timing and microbiology of infection, condition of the joint and implant, and individual patient circumstances.

 


Surgical approaches for management of PJI include debridement and retention of prosthesis, resection arthroplasty with reimplantation, permanent resection arthroplasty, or amputation. 

 

Patients presenting >30 days after prosthesis implantation require prosthesis removal for definitive management. Options for replacement arthroplasty include one-stage or two-stage procedures.

 

-The two-stage exchange is the most definitive curative approach for management of PJI. Stage one consists of prosthesis resection, debridement of soft tissue and bone, and placement of a joint spacer, followed by systemic antibiotic therapy for four to six weeks; stage two consists of new prosthesis implantation and additional antibiotic therapy in some circumstances.

 

Patients presenting within 30 days of prosthesis implantation or <3 weeks of symptom onset (in the setting of a well-fixed prosthesis and in the absence of a sinus tract) may be candidates for debridement and retention of prosthesis. 

 

Patients who do not meet criteria for reimplantation may warrant permanent resection arthroplasty. Amputation should be the last option considered; it may be appropriate for patients who do not meet criteria for the above approaches. 

 


Antibiotic regimens for treatment of PJI are outlined in the table. Antibiotic therapy should be tailored to culture and susceptibility data when available.

 

For treatment of PJI due to methicillin-resistant Staphylococcus aureus, we suggest vancomycin (Grade 2C); daptomycin is an acceptable alternative agent. 

 

For patients with S. aureus PJI and residual hardware following surgery (eg, patients who undergo debridement with retention or patients who undergo one-stage exchange), we suggest adjunctive use of rifampin (in combination with at least one other anti-staphylococcal agent) (Grade 2C). Use of rifampin must be weighed against the likelihood of toxicity and drug interactions.

 

The duration of antimicrobial therapy for treatment of PJI must be tailored to surgical management. Following completion of definitive antibiotic therapy, antibiotic suppression with an oral regimen may be warranted for individuals with retained hardware and/or necrotic bone not amenable to complete debridement. 

 

a

Antibiotic therapy for treatment of osteomyelitis or prosthetic joint infection in adults
Infectious agent Antibiotic regimen Dosing
Empiric therapy Vancomycin PLUS a third- or fourth-generation cephalosporin (such as ceftriaxone, ceftazidime, or cefepime) As summarized below
Pathogen-specific therapy
Staphylococci, methicillin susceptible* Nafcillin 2 g IV every 4 hours
Oxacillin 2 g IV every 4 hours
Cefazolin 2 g IV every 8 hours
Ceftriaxone 2 g IV every 24 hours
Staphylococci, methicillin resistant* Regimen of choice:
VancomycinΔ 20 mg/kg loading dose, then 15 mg/kg/dose IV every 12 hours, not to exceed 2 g per dose initially
Alternative regimens:
Daptomycin§ 6 to 10 mg/kg IV once daily
Teicoplanin (where available)¥‡ 12 mg/kg IV every 12 hours for 3 to 5 doses, followed by 12 mg/kg once daily
Staphylococci, adjunctive agents* Rifampin 300 to 450 mg orally twice daily
Fusidic acid (where available)¥ 500 mg orally 3 times daily
Gram-negative organisms Ciprofloxacin†,**,¶¶ 750 mg orally twice daily or 400 mg IV every 12 hours; if treating Pseudomonas, increase IV dose to 400 mg IV every 8 hours
Levofloxacin**,¶¶ 750 mg orally or IV once daily
CeftriaxoneΔΔ 2 g IV every 24 hours
Ceftazidime** 2 g IV every 8 hours
Cefepime** 2 g IV every 8 to 12 hours
ErtapenemΔΔ 1 g IV every 24 hours
Meropenem** 1 g IV every 8 hours
Enterococci◊◊ Monotherapy regimens:
Ampicillin 12 g IV every 24 hours, either continuously or in 6 equally divided doses
Aqueous crystalline penicillin G 20 to 24 million units IV every 24 hours, either continuously or in 6 equally divided doses
VancomycinΔ 20 mg/kg loading dose, then 15 mg/kg IV every 12 hours, not to exceed 2 g per dose
Daptomycin§ 6 to 10 mg/kg IV once daily
Teicoplanin (where available)¥‡ 12 mg/kg IV every 12 hours for 3 to 5 doses, followed by 12 mg/kg once daily
Combination therapy regimen:
Ampicillin 12 g IV every 24 hours, given either continuously or in 6 equally divided doses
PLUS
Ceftriaxone 2 g IV every 12 to 24 hours
Streptococci, penicillin sensitive One of the following:
Aqueous crystalline penicillin G 20 to 24 million units IV every 24 hours, either continuously or in 6 equally divided doses
Ampicillin 12 g IV every 24 hours, either continuously or in 6 equally divided doses
Ceftriaxone 2 g IV every 24 hours
VancomycinΔ 20 mg/kg loading dose, then 15 mg/kg/dose IV every 12 hours, not to exceed 2 g per dose, initially
Cutibacterium (formerly Propionibacteriumacnes§§ One of the following:
Aqueous crystalline penicillin G 20 million units IV every 24 hours, either continuously or in 6 divided doses
Ceftriaxone 2 g IV every 24 hours

 

b

Treatment of Staphylococcus aureus prosthetic joint infection in adults with retained hardware following debridement and completion of intravenous therapy: Oral antibiotic continuation therapy *
Antibiotic regimen Dosing
Preferred regimens include:
One of the following:
Levofloxacin 500 to 750 mg daily
Ciprofloxacin 500 to 750 mg twice daily
PLUS
RifampinΔ 300 to 450 mg twice daily
Alternative regimens include:
One of the following agents:§
Trimethoprim-sulfamethoxazole 1 double-strength tablet twice daily
Doxycycline 100 mg twice daily
Minocycline 100 mg twice daily
Dicloxacillin 500 mg 3 or 4 times daily
Cefadroxil 500 mg twice daily
Cephalexin 500 mg 3 or 4 times daily
PLUS  
RifampinΔ 300 to 450 mg twice daily

 

c

Suppression of prosthetic joint infection in adults: Oral antibiotic regimens*
Infectious agent Antibiotic regimen Dosing
Staphylococci, methicillin susceptible One of the following:
Cefadroxil 500 to 1000 mg twice daily
Cephalexin 500 mg 3 or 4 times daily, or 1000 mg 2 or 3 times daily
Dicloxacillin 500 mg 3 or 4 times daily
Staphylococci, methicillin resistantΔ One of the following:
Trimethoprim-sulfamethoxazole 1 double-strength tablet twice daily
Doxycycline 100 mg twice daily
Minocycline 100 mg twice daily
Clindamycin 600 mg 3 times daily
Gram-negative organisms One of the following:
Trimethoprim-sulfamethoxazole 1 double-strength tablet twice daily
Ciprofloxacin 250 to 500 mg twice daily
Levofloxacin 500 mg once daily
Penicillin-sensitive streptococci and enterococci One of the following:
Amoxicillin 500 mg 2 to 3 times daily
Penicillin V K 500 mg 2 to 3 times daily
Cutibacterium (formerly Propionibacteriumacnes One of the following:
Amoxicillin 500 mg 2 to 3 times daily
Penicillin V K 500 mg 2 to 3 times daily