Oral antibiotic regimens for completing treatment of vertebral osteomyelitis in adults*

Infectious agent	Antibiotic regimen^¶	Dosing
Staphylococci, methicillin susceptible	One of the following:
	Rifampin^Δ plus one of the following:	300 to 450 mg twice daily
	Levofloxacin	500 to 750 mg once daily
	Ciprofloxacin	500 to 750 mg twice daily
	Fusidic acid (where available)^◊	500 mg three times daily
	Clindamycin	300 to 450 mg three times daily
Staphylococci, methicillin resistant	One of the following:
	Rifampin^Δ plus one of the following:	300 to 450 mg twice daily
	Levofloxacin	500 to 750 mg once daily
	Ciprofloxacin	500 to 750 mg twice daily
	Fusidic acid (where available)^◊	500 mg three times daily
	Clindamycin	300 to 450 mg three times daily
	Linezolid	600 mg twice daily
Gram-negative organisms	One of the following:
	Ciprofloxacin^§	500 to 750 mg twice daily
	Levofloxacin^§	500 to 750 mg once daily
	Trimethoprim-sulfamethoxazole	1 double-strength tablet twice daily
Penicillin-sensitive streptococci	One of the following:
	Amoxicillin^¥	750 to 1000 mg three times daily
	Clindamycin	300 to 450 mg three times daily

The doses recommended above are intended for adults with normal renal function; the doses of some of these agents must be adjusted in patients with renal insufficiency. Refer to the Lexicomp drug-specific monographs for renal dose adjustments.

* Following at least two weeks of parenteral therapy, completion of treatment with oral therapy may be reasonable in some circumstances; refer to UpToDate for further discussion.
¶ The choice of antibiotic regimen should be based on susceptibility, as well as patient drug allergies, intolerances, and potential drug-drug interactions or contraindications to a specific agent.
Δ Rifampin should not be used alone; it must be combined with a second agent to reduce the likelihood of selection for drug resistance.
◊ Fusidic acid is not available in the United States. Fusidic acid should not be used alone; it must be combined with a second agent to reduce the likelihood of selection for drug resistance. When rifampicin is combined with fusidic acid, fusidic acid levels may be reduced.^[1]
§ Ciprofloxacin and levofloxacin have activity against Pseudomonas aeruginosa. For P. aeruginosa the higher dose range of fluoroquinolone should be used; ciprofloxacin 750 mg every 12 hours or levofloxacin 750 mg once daily.
¥ Oral amoxicillin therapy may be considered after an initial period of intravenous therapy for the management of penicillin-susceptible streptococci.

Reference:

Pushkin R, Iglesias-Ussel MD, Keedy K, et al. A randomized study evaluating oral fusidic acid (CEM-102) in combination with oral rifampin compared with standard-of-care antibiotics for treatment of prosthetic joint infections: a newly identified drug-drug interaction. Clin Infect Dis 2016; 63:1599.

Data from:

Société de Pathologie Infectieuse de Langue Français (SPILF). Primary infectious spondylitis and following intradiscal procedure, without prosthesis. Recommendations. Med Mal Infect 2007; 37:573.
Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis 2015; 61:e26.
Bernard L, Dinh A, Ghour I, et al Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet 2015; 385:875.
Li H-K, Rombach I, Zambellas R, Oral versus Intravenous Antibiotics for Bone and Joint Infection. NEJM 2019; 380:425.

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Oral antibiotic regimens for completing treatment of vertebral osteomyelitis in adults*