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Previous Volume 337:428-429 August 7, 1997 Number 6 Next

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To the Editor: Several comments are in order for the U.S. audience of the excellent review of osteomyelitis by Lew and Waldvogel (April 3 issue),¹ especially regarding Table 2. Many infectious-disease specialists prescribe both penicillin and nafcillin every four hours, rather than every six hours as suggested in the article. These beta-lactams have a short half-life, and consideration should certainly be given to using the higher dose (i.e., a shorter interval between doses). Clindamycin can be given effectively every eight hours because of its prolonged half-life. No clinical advantage has ever been proved for the administration of 600 mg every six hours as opposed to every eight hours. A dosing regimen involving six-hour intervals is more toxic, more expensive, and certainly much more difficult to give on an outpatient basis. Ciprofloxacin, at doses of 750 mg every 8 to 12 hours, should also be considered as an acceptable therapy for serratia or pseudomonas. (It was only listed as the treatment of choice for enteric gram-negative rods in Table 2.) Amoxicillin–clavulanate is not available in the United States as an intravenous preparation; cloxacillin is not available at all, although dicloxacillin is. Numerous other drugs can be substituted for intravenous amoxicillin–clavulanate, including ampicillin–sulbactam, ticarcillin–clavulanate, piperacillin–tazobactam, and a third-generation cephalosporin plus metronidazole. Other potential options in the United States for the treatment of methicillin-resistant Staphylococcus aureus in cases in which intravenous vancomycin cannot be used include agents such as trimethoprim–sulfamethoxazole, clindamycin, minocycline, and a quinolone with or without rifampin.

Aaron E. Glatt, M.D.
Catholic Medical Center of Brooklyn and Queens
Jamaica, NY 11432

References

1. Lew DP, Waldvogel FA. Osteomyelitis. N Engl J Med 1997;336:999-1007. [Free Full Text]

Although oral beta-lactam agents have limited bioavailability, as the authors pointed out, they have been used quite successfully in the treatment of osteomyelitis and septic arthritis, when given in appropriate doses.¹ Although the quinolones have revolutionized the approach to treating severe infections in the outpatient setting, other oral agents such as clindamycin, trimethoprim–sulfamethoxazole, metronidazole, doxycycline, and minocycline also offer excellent bioavailability, favorable dosing schedules, good tissue penetration, long-term tolerability, and low cost. . . .

Kevin W. Shea, M.D.
Carolinas Hospital System
Florence, SC 29501

References

1. Black J, Hunt TL, Godley PJ, Matthew E. Oral antimicrobial therapy for adults with osteomyelitis or septic arthritis. J Infect Dis 1987;155:968-972. [Erratum, J Infect Dis 1987;156:541.] [Medline]

To the Editor: Dr. Glatt makes some valuable comments on treatment recommendations. Table 2 of our article was not exhaustive, and obviously other antibiotics may be prescribed as he suggests. Parenteral penicillins may indeed be prescribed every four to six hours, although in some cases such as the antipseudomonas penicillins the interval between doses can be extended successfully to eight hours.¹ Clindamycin may be prescribed every six to eight hours (which is more convenient for oral administration) as indicated by the severity of symptoms and infecting microorganisms. In our opinion the glycopeptides are often the only available therapeutic agents for methicillin-resistant Staphylococcus aureus. The other alternatives proposed (trimethoprim–sulfamethoxazole and minocycline) may be used for minor infections with methicillin-resistant S. aureus. Unfortunately, a large proportion of methicillin-resistant S. aureus are resistant to quinolones.

Dr. Shea raises the issue of the role of oral antibiotics in the treatment of osteomyelitis. Although oral treatment of acute osteomyelitis in children has been an accepted approach for many years, the approach to the treatment of acute or chronic osteomyelitis in adults has traditionally been intravenous. In our opinion, for beta-lactam antibiotics intravenous therapy remains the standard for osteomyelitis in adults. Among other agents, clindamycin may be a reasonable alternative for sequential intravenous–oral therapy because of its excellent bone penetration and good bioavailability.

Several good-quality comparative trials have shown the equivalence of oral quinolones and parenteral therapy. We have performed a cumulative analysis of published comparative trials of quinolones to treat osteomyelitis.² With oral ciprofloxacin, success rates of 92 percent for Enterobacteriaceae (even higher if serratia are excluded), 72 percent for Pseudomonas aeruginosa, and 75 percent for S. aureus were found.² On treatment with quinolones osteomyelitis due to P. aeruginosa or S. aureus was associated with a fourfold increase in the failure rate, as compared with the failure rate in osteomyelitis due to other pathogens.² Thus, in the case of osteomyelitis due to Enterobacteriaceae the success rate is so good that no further trials appear to be necessary. This is not the case for S. aureus and P. aeruginosa.

Figure 2B of our article was printed upside down. Therefore, the T₁-weighted image appears on the right and the image after the intravenous injection of gadolinium on the left.

Daniel P. Lew, M.D.
Francis Waldvogel, M.D.
Geneva University Hospital
CH-1211 Geneva 14, Switzerland

References

1. Quintiliani R, Nightingale CH, Sullivan MC. Use of pharmacodynamic concepts in developing a cost-effective dosing method for piperacillin. Clin Ther 1993;15:Suppl A:44-49.
2. Lew DP, Waldvogel FA. Quinolones and osteomyelitis: state-of-the-art. Drugs 1995;49:Suppl 2:100-101.

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