Patients with vertebral osteomyelitis who have not had a recent spinal procedure and are at increased risk of infection caused by MRSA or gram-negative organisms

Targeted therapy is required for patients with vertebral osteomyelitis who are at increased risk of infection caused by MRSA or a gram-negative organism (see Aetiology of osteomyelitis in adults). Vancomycin is added when the patient is at risk of MRSA infection, and ceftriaxone or ciprofloxacin is added when the patient is at increased risk of infection with gram-negative organisms.

For adults who have a normal neurological examination; do not have spinal epidural abscess, sepsis or septic shock; and have not had a recent spinal procedure, as a 2- or 3-drug regimen (depending on the patient’s risk), use:

flucloxacillin 2 g intravenously, 6-hourly. 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 if the patient is at increased risk of MRSA

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults. See advice on intravenous to oral switch and duration of therapy vancomycin vancomycin vancomycin

PLUS if the patient is at increased risk of gram-negative organisms

ceftriaxone 2 g intravenously, daily. See advice on intravenous to oral switch and duration of therapy. ceftriaxone ceftriaxone ceftriaxone