ED/INPATIENT SUSPECTED MUSCULOSKELETAL (MSK) GUIDELINE Includes acute hematogenous osteomyelitis, septic arthritis, and deep (pelvic, hip) pyomyositis in patients ages 6 mo–18 yr

Aim: To decrease variation in management of patients with musculoskeletal .

Patients referred into CONCERN FOR MUSCULOSKELETAL INFECTION? system with definite diagnosis of MSK infection DO: should be directed to • Make patient NPO • If isolated joint swelling, if it is felt that an initial joint Minneapolis campus • Obtain labs including CBC with diff, CRP, ESR, blood tap may be warranted, discuss with ortho. cx, BMP (for creatinine). Consider Lyme, strep testing. • Manage (NSAIDS are ok to use) • Obtain imaging: Plain films, possibly US (if hip). MRI • Administer IV fluids if needed recommended even for septic joints, radiology + ortho • Call ortho early — must call prior to obtaining to discuss contrast need. diagnostic MRI DON’T: Give unless instructed by Ortho, or ill-appearing

Low Likelihood of Medium/High (or unsedated MRI feasible) musculoskeletal infection (or sedated MRI needed)

MRI or admit to • Consult Ortho, including decision about transfer to Minneapolis short stay, • Explore MRI availability depending on MRI and bed availability • Transfer to Minneapolis campus if MRI available • Ortho to speak with radiologist re: MRI strategy EXCLUSION GUIDELINES • Ortho to coordinate OR options if indicated Patients excluded from this MSK infection? Yes guideline: • ≥14 days of symptoms No • Critically ill • Admit to inpatient • Immunodeficiency • To OR with Ortho if indicated • Sickle Cell disease Off guideline • Start antibiotics (discuss with ortho first) • Trauma – After bone/joint fluid cultured • Post operative infection – If significantly ill-appearing • Skull/vertebral, hand/foot – If no OR planned in >12 hours infection • Concern for or unusual organism

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. M0865 | Reviewer: Hester | Rev 2/21 | Exp 2/24 | Page 1 INPATIENT MUSCULOSKELETAL (MSK) INFECTION GUIDELINE Includes acute hematogenous osteomyelitis, septic arthritis, and deep (pelvic, hip) pyomyositis in patients ages 6 mo–18 yr

Aim: To decrease variation in management of patients with musculoskeletal infections.

See page 1 (ED/Inpatient guideline) for details on exclusions and initial workup

Admit to hospitalist service with Ortho and ID consults

• Initiate empiric therapy once instructed by Ortho • Assess for risk of DVT

Daily care: Antibiotic Special Scenarios ® • Monitor fever curve Cefazolin (Ancef ) 40 mg/kg/dose (max 2000 mg/dose) • Add Vancomycin 15 mg/kg IV Q6 if • Labs: CRP every other day at 0500 clinically deteriorating • Determine need for NPO status (generally IV Q8H found in Ortho daily notes or updates) • Add Clindamycin 10 mg/kg IV Q8 if • Ortho to make decision about by 0830 known MRSA carrier, history of MRSA daily (via labs, fever trend, exam, imaging) in the family, recently or Adjust antibiotics based on frequently hospitalized and communicate to primary team. Will also bone and blood culture results indicate recommendations in daily note. • Confer with ID for antibiotic selection • Multidisciplinary bedside rounds if feasible on patients at risk for non-staph/strep • DVT prophylaxis as indicated pathogens (e.g. sickle cell disease - • PT when appropriate Negative cultures Positive cultures Salmonella; underimmunized for age See page 3 See page 4 - H. flu; risk of )

D/C criteria (and consider for oral therapy): D/C planning: • Completed minimum 72 hr IV antibiotics • ID follow-up within 1 week • Significant decline in CRP • Ortho follow-up per ortho team • Afebrile x 48 hr • DME (crutches, wheelchair if indicated) • Most recent blood cultures negative x 48H • Physical therapy at discretion of orthopedist • Regaining use of involved extremity • Child life oral med teaching (start 48 hr prior • Demonstrates oral intake including meds to anticipated discharge) • No further surgery planned • No barrier to outpatient care

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. M0865 | Reviewer: Hester | Rev 2/21 | Exp 2/24 | Page 2 INPATIENT MUSCULOSKELETAL (MSK) INFECTION GUIDELINE Antibiotics at 72 hours if: No organism identified on any culture; on Cefazolin monotherapy (See Note 1)

Aim: To decrease variation in management of patients with musculoskeletal infections.

Yes Responding? No

Continue Cefazolin 40 mg/kg/dose For non-responders on appropriate antibiotics: (max 2000 mg/dose) IV Q8 • Consult with ID, Ortho • Assess source control • Consider re-imaging Responding and candidate for PO? No • Consider alternate/additional diagnoses (See Note 2)

Yes

Cephalexin 50 mg/kg/dose (max 1250 mg/dose) PO TID

NOTE 1. NOTE 2. Patients with negative cultures Consider transition to oral antibiotics if: who respond to Cefazolin AND • Completed minimum 72 hr IV antibiotics Vancomycin are excluded from • Significant decline in CRP this guideline. • Most recent blood cultures negative x 48H • Afebrile x 48 hr • Regaining use of involved extremity • Demonstrates oral intake including meds • No further surgery planned • No barrier to outpatient care

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. M0865 | Reviewer: Hester | Rev 2/21 | Exp 2/24 | Page 3 INPATIENT MUSCULOSKELETAL (MSK) INFECTION GUIDELINE Antibiotics at 48 hours (organism identified on culture)

Aim: To decrease variation in management of patients with musculoskeletal infections.

MSSA, Group A Strep, Kingella MRSA sensitive to Clindamycin MRSA resistant to Clindamycin

• Continue Cefazolin • Discontinue Cefazolin • Continue Vancomycin • Discontinue Vancomycin • Change Vancomycin to Clindamycin • Discontinue Cefazolin (if applicable) 10 mg/kg/dose IV Q8 (max 600 mg/dose) (See Note 1) Responding and Responding and candidate for PO? No candidate for PO? No Responding and (See Note 2) (See Note 2) candidate for PO? No (See Note 2) Yes Yes Yes Consider switch to: Cephalexin • Daptomycin IV 50 mg/kg/dose Clindamycin • Linezolid PO (max 1250 mg/dose) PO TID 10 mg/kg/dose PO TID • Bactrim PO (max 600 mg/dose)

For non-responders on appropriate antibiotics: • Consult with ID, Ortho NOTE 1. NOTE 2. • Assess source control Only change from Consider transition to oral antibiotics if: • Consider re-imaging Vanco if most • Completed minimum 72 hr IV antibiotics recent blood • Significant decline in CRP • Consider alternate/additional diagnoses cultures negative • Most recent blood cultures negative x 48H x 48 hours and good • Afebrile x 48 hr source control. • Regaining use of involved extremity • Demonstrates oral intake including meds • No further surgery planned • No barrier to outpatient care

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. M0865 | Reviewer: Hester | Rev 2/21 | Exp 2/24 | Page 4