Empirical therapy for bite and clenched-fist injury infections associated with systemic features or deeper tissues
For empirical therapy of bite or clenched-fist injury infection associated with systemic features or involving deeper tissues (such as bones, joints, or tendons), use:
2+0.2 g formulation
adult, or child 40 kg or more: 2+0.2 g 8-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment
OR
1+0.2 g formulation
adult, or child 40 kg or more: 1+0.2 g 6-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment
child 1 month to younger than 3 months and less than 4 kg: 25+5 mg/kg 12-hourly
child 1 month to younger than 3 months and 4 kg or more: 25+5 mg/kg 8-hourly
child 3 months or older and less than 40 kg: 25+5 mg/kg up to 1+0.2 g 8-hourly. If the bone is infected, use a dose of 25+5 mg/kg up to 1+0.2 g 6-hourly.
Amoxicillin+clavulanate is preferred to piperacillin+tazobactam because it has a narrower spectrum of activity; however, if amoxicillin+clavulanate is not available, a reasonable alternative is:
piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see piperacillin+tazobactam dosage adjustment. For duration of therapy, see below. piperacillin + tazobactam piperacillin+tazobactam piperacillin+tazobactam
For patients at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin to the above regimens. Use:
vancomycin intravenously; see Intermittent vancomycin dosing in noncritically ill adults or Intermittent vancomycin dosing for young infants and children for initial dosing. vancomycin vancomycin vancomycin
In some regions, based on local susceptibility data, clindamycin or lincomycin is a suitable alternative to vancomycin (see dosage below).
For patients with hypersensitivity to penicillins, use oral ciprofloxacin plus clindamycin as for localised infection because these drugs have excellent oral bioavailability; for duration of therapy, see below. If oral therapy is not possible, use:
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 12-hourly1. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. For duration of therapy, see below ciprofloxacin ciprofloxacin ciprofloxacin
PLUS
clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly2. For duration of therapy, see below. clindamycin clindamycin clindamycin
For patients with hypersensitivity to penicillins who are at increased risk of MRSA infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), use:
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 12-hourly1. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. For duration of therapy, see below ciprofloxacin ciprofloxacin ciprofloxacin
PLUS
vancomycin intravenously; see Intermittent vancomycin dosing in noncritically ill adults or Intermittent vancomycin dosing for young infants and children for initial dosing vancomycin vancomycin vancomycin
PLUS
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. metronidazole metronidazole metronidazole
Modify therapy based on the results of Gram stain, culture and susceptibility testing. Once the patient is stable (eg systemic features are resolved, source control is achieved and oral therapy is tolerated), switch to oral therapy if not used initially. Use the regimens for localised infection if the pathogen is unknown.
For bite or clenched-fist injury infections associated with systemic features, total treatment duration is usually 14 days (intravenous + oral). For bite or clenched-fist injury infections involving the deeper tissues, a longer duration of therapy is needed. For the suggested duration of intravenous and oral therapy, see How to choose the duration of therapy for osteomyelitis in adults and children for infection involving bone, and Suggested duration of antibiotic therapy for native joint septic arthritis for infection involving a joint.