Patients with vertebral osteomyelitis associated with spinal epidural abscess or neurological compromise who have not had a recent spinal procedure
Urgent empirical antibiotic therapy is required for patients with vertebral osteomyelitis associated with spinal epidural abscess or neurological compromise. For adults who have not had a recent spinal procedure, as a 3-drug regimen, use initially:
flucloxacillin 2 g intravenously, 6-hourly. For patients with suspected meningitis or who are critically ill, use a 4-hourly dosing interval. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment. See advice on intravenous to oral switch and duration of therapy flucloxacillin flucloxacillin flucloxacillin
PLUS
ceftriaxone 2 g intravenously, daily. For patients with suspected meningitis or who are critically ill, use a 12-hourly dosing interval. See advice on intravenous to oral switch and duration of therapy ceftriaxone ceftriaxone ceftriaxone
PLUS
vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults. Loading doses are recommended for critically ill adults. See advice on intravenous to oral switch and duration of therapy. vancomycin vancomycin vancomycin
Prioritise administration of flucloxacillin and ceftriaxone, because vancomycin requires slow infusion.
For adults who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use initially:
ceftriaxone 2 g intravenously, daily. For patients with suspected meningitis or who are critically ill, use a 12-hourly dosing interval. See advice on intravenous to oral switch and duration of therapyceftriaxoneceftriaxoneceftriaxone
PLUS
vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults. Loading doses are recommended for critically ill adults. See advice on intravenous to oral switch and duration of therapyvancomycinvancomycinvancomycin.
For adults who have had a severe immediate1 hypersensitivity reaction to a penicillin, ceftriaxone plus vancomycin (at the dosages above) can be considered if a beta-lactam–based regimen is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).
For adults who have had a severe immediate1 hypersensitivity reaction to a penicillin in whom ceftriaxone plus vancomycin is not used, or for adults who have had a severe delayed2 hypersensitivity reaction to a penicillin, use initially:
vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults. Loading doses are recommended for critically ill adults. See advice on intravenous to oral switch and duration of therapyvancomycinvancomycinvancomycin
PLUS EITHER
1ciprofloxacin 400 mg intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. See advice on intravenous to oral switch and duration of therapy ciprofloxacin ciprofloxacin ciprofloxacin
OR
1ciprofloxacin 750 mg orally, 12-hourly. For dosage adjustment in adults with kidney impairment, see ciprofloxacin oral dosage adjustment. See advice on duration of therapy ciprofloxacin ciprofloxacin ciprofloxacin.