This handout is for acute osteomyelitis & septic arthritis. Your care team identified this based on: acute monoarthritis (warm, swollen, painful joint, restricted rom) + fever — septic arthritis until proven otherwise; stat arthrocentesis (margaretten jama 2007 pmid 17405973; idsa septic arthritis).
Other reasons your team may use this plan: refusal to bear weight / limp / atraumatic hip pain in a child — apply kocher predictors (fever > 38.5 °c, non-weight-bearing, esr > 40, wbc > 12,000) ± crp > 20 mg/l to distinguish septic hip vs transient synovitis (kocher 1999 pmid 10608376; caird 2006 pmid 16757758); pseudoparalysis / reluctance to move a limb in a neonate / young infant — septic arthritis or osteomyelitis until proven otherwise; often multifocal; gbs + s. aureus + gram-negative; stat imaging + aspiration (idsa/pids 2021); focal bone pain / point tenderness + fever ± overlying erythema — acute osteomyelitis (hematogenous in children long-bone metaphysis; vertebral / discitis in adults); mri for marrow oedema (idsa/pids 2021; berbari idsa 2015).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| vancomycin | Adult: 25-30 mg/kg IV load × 1 → 15-20 mg/kg q8-12 h targeting AUC24 400-600; Peds: 15 mg/kg IV q6 h (AUC-titrated) | IV | load then q6-12 h (AUC-titrated) | MRSA + most streptococcal cover; AUC-targeted not trough (IDSA 2020 vancomycin consensus PMID 32191793); narrow to a β-lactam once MSSA confirmed |
| ceftriaxone | Adult: 2 g IV q24h; Peds: 50-100 mg/kg/day IV | IV | q24h | Gram-negative + gonococcal + Salmonella cover; Kingella-active β-lactam in children < 4 yr (Kingella intrinsically vancomycin/clindamycin-resistant) (IDSA/PIDS 2021) |
| cefepime | Adult: 2 g IV q8h; Peds: 50 mg/kg/dose IV q8h | IV | q8h | Anti-pseudomonal cover for IVDU / plantar-puncture phenotype + healthcare-associated; renal adjust for CrCl < 60 (IDSA septic arthritis) |
Plan: BJI empiric (vancomycin + ceftriaxone/cefepime, age + host stratified) → culture-directed narrowing (MSSA → cefazolin/nafcillin; Kingella β-lactam; gonococcal ceftriaxone; Salmonella; Pseudomonas anti-pseudomonal; PJI rifampin combination) + source control (joint drainage / debridement / DAIR vs exchange) + IV-to-oral early switch (OVIVA Li NEJM 2019)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Orthopaedic + ID follow-up; CRP/ESR surveillance until normalised; functional rehabilitation (joint ROM, weight-bearing progression); relapse / chronic-osteomyelitis return precautions (recurrent pain, swelling, sinus drainage, fever); vertebral osteo — follow-up MRI only if clinical failure (not routine; Berbari IDSA 2015); PJI — chronic oral suppression audit in retention strategies + arthroplasty-team follow-up; address seeding source (endocarditis if S. aureus bacteraemia; line if CRBSI; diabetic-foot offloading + glycaemic control)
Guideline: IDSA Native Vertebral Osteomyelitis Guideline (Berbari CID 2015) + IDSA Septic Arthritis (native joint) standards + ACR acute monoarthritis approach + IDSA/PIDS Pediatric Acute Hematogenous Osteomyelitis Clinical Practice Guideline 2021 (Woods et al. — Kingella kingae age-shift, short-course IV-to-oral, MRI-first, CRP-guided duration) + IDSA Prosthetic Joint Infection Guideline (Osmon CID 2013 — DAIR vs 1-/2-stage exchange + rifampin combination for staphylococcal PJI with retained hardware) + ESCMID/EBJIS 2024 bone-and-joint-infection guidance + OVIVA (Li NEJM 2019 — oral vs IV antibiotic non-inferiority for complex BJI; failure 13.2 % oral vs 14.6 % IV) + Peltola pediatric short-course IV-to-oral RCTs + Margaretten JAMA 2007 (synovial-fluid rational clinical examination — synovial WBC LRs) + Kocher J Bone Joint Surg 1999 (paediatric septic-hip prediction rule) + Caird J Bone Joint Surg 2006 (CRP modification of Kocher) + Yagupsky Kingella kingae review + Zimmerli prosthetic-joint-infection review