1
|
Ekunseitan E, Sabatini CS, Swarup I. Surgical Debridement for Acute and Chronic Osteomyelitis in Children. JBJS Essent Surg Tech 2023; 13:e21.00039. [PMID: 38274285 PMCID: PMC10807896 DOI: 10.2106/jbjs.st.21.00039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
Background Osteomyelitis is an infection of the bone that commonly occurs in pediatric populations. First-line treatment most often involves a course of antibiotics. In recent studies, surgical debridement, in addition to antibiotics, has been shown to provide positive clinical and functional outcomes in children. Debridement is most often indicated in patients with an abscess or in those who do not respond to empiric antibiotic therapy; however, there are limited video resources describing this technique in pediatric patients. Description The key steps of the procedure, which are demonstrated in the present video article, are (1) preoperative planning, (2) positioning, (3) subperiosteal exposure and debridement, (4) cortical window creation, (5) irrigation, (6) adjunctive treatment, (7) drain placement, (8) wound closure, (9) dressing and immobilization, and (10) wound check and drain removal. Alternatives Nonoperative treatment is usually indicated for acute osteomyelitis in which patients present with little to no necrotic tissue or abscess formation. In these cases, a course of broad-spectrum antibiotics may be sufficient for a cure. Rationale This procedure allows for the removal of necrotic bone and soft tissue, thus facilitating the recovery process. It also allows for the retrieval of tissue samples that may be used to guide selection of the appropriate antibiotic therapy. Surgical debridement is a safe and reliable technique that has been associated with positive long-term outcomes. Expected Outcomes We expect that some patients will require repeat surgical debridement procedures to decrease pathogen burden and prevent future complications. However, we expect that the majority of patients who undergo surgical debridement for uncomplicated osteomyelitis will recover full functionality of the affected limb with no associated long-term sequelae10. Important Tips Understand preoperative imaging to identify areas of infection, localize critical structures and the physis, and plan surgical approaches.Use extensile approaches and preserve vascularity during the approach.Perform subperiosteal dissection and create a cortical window to debride areas of infection, but avoid excessive periosteal stripping.Close the dead space and wound in a layered manner. Acronyms and Abbreviations MRI = magnetic resonance imagingK-wire = Kirschner wireMRSA = methicillin-resistant Staphylococcus aureusPDS = polydiaxonone.
Collapse
Affiliation(s)
- Ernest Ekunseitan
- Division of Pediatric Orthopaedic Surgery, UCSF Benioff Children’s Hospital Oakland, Oakland, California
| | - Coleen S. Sabatini
- Division of Pediatric Orthopaedic Surgery, UCSF Benioff Children’s Hospital Oakland, Oakland, California
| | - Ishaan Swarup
- Division of Pediatric Orthopaedic Surgery, UCSF Benioff Children’s Hospital Oakland, Oakland, California
| |
Collapse
|
2
|
Lansell A, Vasili Y, Suchdev PS, Figueroa J, Kirpalani A. Impact of antibiotic pretreatment on cultures in children with osteomyelitis and septic arthritis: a retrospective review. BMC Pediatr 2021; 21:342. [PMID: 34389010 PMCID: PMC8361620 DOI: 10.1186/s12887-021-02806-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the management of pediatric osteomyelitis or septic arthritis, delay in treatment may affect outcome, while receipt of antibiotics prior to culture may affect culture results. We aimed to determine if pathogen identification decreased in cultures that were pretreated with antibiotics. METHODS We conducted a retrospective cohort study of 584 hospitalized children between 30 days and 18 years of age admitted to two tertiary children's hospitals. Logistic regression assessed the effect of antibiotic duration on blood, bone, joint aspirate, and "other" culture positivity. RESULTS Overall, 42% of blood cultures, 70% of bone cultures, 39% of joint cultures, and 70% of "other" cultures were positive. Compared with children who did not receive antibiotics prior to culture, there were no significant differences in odds of a positive culture in children whose cultures were pretreated with antibiotics for any of the culture types [OR (95% CI) 0.90 (0.56-1.44) for blood cultures, 0.77 (0.25-2.34) for bone cultures, 0.71 (0.39-1.28) for joint cultures, 1.18 (0.58-2.41) "for other" cultures; all p > 0.05]. Furthermore, the duration (hours) of antibiotics in the pretreated cultures was also not a significant predictor of culture positivity (OR ranged from 0.99-1.00 for all cultures, p > 0.05). CONCLUSIONS Culture positivity was not associated with antibiotic pretreatment in any of the samples, even for longer duration of antibiotics prior to culture, though the small sample size of subgroups is an important limitation. In pediatric patients hospitalized with osteomyelitis and/or septic arthritis, early initiation of antibiotics may not affect culture positivity.
Collapse
Affiliation(s)
- Amanda Lansell
- Children's Healthcare of Atlanta, Atlanta, Georgia. .,Emory University Department of Pediatrics, Atlanta, Georgia. .,Rainbow Babies and Children's Hospital, Cleveland, OH, USA. .,Present Address: Department of Pediatrics, Rainbow Babies and Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Yasasvi Vasili
- Emory University Department of Pediatrics, Atlanta, Georgia
| | - Parminder S Suchdev
- Children's Healthcare of Atlanta, Atlanta, Georgia.,Emory University Department of Pediatrics, Atlanta, Georgia
| | - Janet Figueroa
- Emory University Department of Pediatrics, Atlanta, Georgia
| | - Anjali Kirpalani
- Children's Healthcare of Atlanta, Atlanta, Georgia.,Emory University Department of Pediatrics, Atlanta, Georgia
| |
Collapse
|
3
|
Similarities and Differences between Clavicular Bacterial Osteomyelitis and Nonbacterial Osteitis: Comparisons of 327 Reported Cases. J Immunol Res 2021; 2021:4634505. [PMID: 33575360 PMCID: PMC7857900 DOI: 10.1155/2021/4634505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 01/03/2021] [Accepted: 01/09/2021] [Indexed: 12/19/2022] Open
Abstract
Background Currently, both clavicular bacterial osteomyelitis (BO) and nonbacterial osteitis (NBO) remain not well understood owing to their much lower incidences. This study is aimed at summarizing similarities and differences between clavicular BO and NBO based on comparisons of literature-reported cases. Methods We searched the PubMed and Embase databases to identify English published literature between January 1st, 1980, and December 31st, 2018. Inclusion criteria were studies evaluating clinical features, diagnosis, and treatment of clavicular BO and NBO, with eligible data for synthesis analysis. Results Altogether, 129 studies with 327 patients were included. Compared with BO, clavicular NBO favored females (P < 0.001) and age below 20 years (P < 0.001) and mostly presented in a chronic phase (disease term exceeding 2 months) (P < 0.001). Although local pain and swelling were the top two symptoms for both disorders, fever, erythema, and a sinus tract were more frequently found in BO patients (P < 0.01). Although they both favored the medial side, lesions in the clavicular lateral side mostly occurred in BO patients (P = 0.002). However, no significant differences were identified regarding the serological levels of white blood cell count (P = 0.06), erythrocyte sedimentation rate (P = 0.27), or C-reactive protein (P = 0.33) between BO and NBO patients before therapy. Overall, the BO patients achieved a statistically higher cure rate than that of the NBO patients (P = 0.018). Conclusions Females, age below 20 years, and a long duration of clavicular pain and swelling may imply NBO. While the occurrence of a sinus tract and lesions in the lateral side may be clues of BO, inflammatory biomarkers revealed limited values for differential diagnosis. BO patients could achieve a better efficacy than the NBO patients based on current evidence.
Collapse
|
4
|
Hu WR, Yao ZL, Yu B, Jiang N. Clinical characteristics and treatment of clavicular osteomyelitis: a systematic review with pooled analysis of 294 reported cases. J Shoulder Elbow Surg 2019; 28:1411-1421. [PMID: 30826202 DOI: 10.1016/j.jse.2018.11.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/07/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is usually difficult to diagnose clavicular osteomyelitis (OM), and treatment is delayed because of its rarity. This study aimed to summarize clinical characteristics and treatment of this disease. METHODS We searched the PubMed and Embase databases to identify English studies that reported on clavicular OM from January 1980 through December 2016. Effective data were pooled for analysis. RESULTS In total, 111 studies comprising 294 cases (bacterial OM, 146; nonbacterial OM, 148) were included, with a sex ratio of 1.89:1 indicating female predilection. Overall, the median age at diagnosis was 16 years. The acute to chronic phase ratio was 0.30, with a median symptom duration of 4 months. The most frequently reported symptom was pain (192 cases), followed by swelling (151 cases) and fever (52 cases). Altogether, 86.94% cases of single-site involvement were reported, with the medial side being the most common site (69.95%). The erythrocyte sedimentation rate achieved the highest positive rate (74.44%) before treatment. The total positive rate of culture for bacterial OM was 81.82%, with Staphylococcus aureus being the most frequently detected pathogen (44.70%). The average cure rate was 83.52%, with no significant difference between surgical (89.70%) and nonsurgical (79.63%) cases (P = .079). CONCLUSIONS Clavicular OM, predominant in female patients and young people, usually occurred at a chronic stage. Pain was the most frequent symptom, with the medial side being the most involved site. The erythrocyte sedimentation rate may be a helpful indicator for diagnosis. Regardless of surgery or nonsurgery, most patients achieved a favorable prognosis.
Collapse
Affiliation(s)
- Wei-Ran Hu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zi-Long Yao
- Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bin Yu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Nan Jiang
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| |
Collapse
|
5
|
John SK, Payyanur Thotan S, Kumar V, Prabhu S. Neonatal osteomyelitis of the first rib causing lung abscess. BMJ Case Rep 2016; 2016:bcr-2016-216933. [PMID: 27879302 DOI: 10.1136/bcr-2016-216933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Rib osteomyelitis (OM) is a rare disease that occurs in ∼1% or less of all haematogenous OM. Acute OM of the rib has rarely been reported and its treatment is difficult. Prompt recognition and aggressive treatment will reduce mortality and morbidity in a new born.
Collapse
Affiliation(s)
- Sijo K John
- Department of Paediatric Surgery, Manipal University, Manipal, Karnataka, India
| | | | - Vijay Kumar
- Department of Paediatric Surgery, Manipal University, Manipal, Karnataka, India
| | - Santosh Prabhu
- Department of Paediatric Surgery, Manipal University, Manipal, Karnataka, India
| |
Collapse
|
6
|
Abstract
BACKGROUND Osteomyelitis is a common problem among the pediatric population. The humerus is the most commonly affected bone in the upper limb; however, there are relatively few series in the literature. This article retrospectively reviews a large number of cases of pediatric humeral osteomyelitis. We aim to further define the disease and its clinical course to aid in improved treatment. METHODS A 10-year retrospective review was performed of clinical records of pediatric humeral osteomyelitis at the 2 children's orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007 at Starship Children's Hospital, and 1998 and 2008 at Middlemore's Kidz First Hospital. RESULTS Forty-nine patients were identified. Sixty-one percent were male with an average age of 4.2 years. Maori and Pacific Islanders were overrepresented. Seventy-eight percent were not using the limb, 70% complained of pain. Only 55% were febrile. White cell count, erythrocyte sedimentation rate, and C-reactive protein raised in 73%, 74%, and 79% of cases, respectively. X-ray, bone scintigraphy, and particularly magnetic resonance imaging were useful in radiologic diagnosis. Blood and tissue cultures revealed Staphylococcus aureus as the most common organism; there were 2 cases of community-acquired methicillin-resistant S. aureus. The distal humerus was more commonly affected. Fifty-three percent required surgery. Antibiotic therapy averaged 2.7 weeks intravenous and 2.6 weeks of oral therapy. There were 7 cases with adjacent septic arthritis, which had higher inflammatory markers. Major complications included 2 multiorgan failure and 1 growth disturbance. CONCLUSIONS Humeral osteomyelitis can be diagnosed with an appropriate history, clinical examination, and investigations. One should be aware of concurrent septic arthritis and be prepared to treat this urgently. Those children with septic arthritis were not using the limb and had higher inflammatory markers. Treatment with intravenous and oral antibiotics and surgical debridement/washout if indicated can lead to good clinical outcomes with minimal complications. LEVEL OF EVIDENCE Level IV-retrospective case series.
Collapse
|
7
|
Bueno Barriocanal M, Ruiz Jiménez M, Ramos Amador JT, Soto Insuga V, Bueno Sánchez A, Lorente Jareño ML. [Acute osteomyelitis: epidemiology, clinical manifestations, diagnosis and treatment]. An Pediatr (Barc) 2012; 78:367-73. [PMID: 23219025 DOI: 10.1016/j.anpedi.2012.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/26/2012] [Accepted: 09/27/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS The present study focuses on the epidemiology, clinical and laboratory data, and management of osteomyelitis in a pediatric third level hospital. METHODOLOGY All cases of children under 15 years-old admitted with osteomyelitis between 2000 and 2011 were retrospectively reviewed until July 2006, then prospectively from then until 2011. RESULTS A total of 50 patients were identified (52% males) with median age at diagnosis of 2 years. Principal onset manifestations were pain (94%), functional impairment (90%) and fever (72%). The femur (32%), fibula (28%) and calcaneus (22%) were most affected bones. Leucocytosis > 12.000/μl was found in 56%, elevated ESR > 20 mm/h in 26%, and elevated CRP > 20 mg/L in 64%. Blood culture was positive in 20%, with group A streptococcus being the most frequently isolated bacteria (11%). All diagnoses were confirmed by a (99)Tc scintigraphy bone scan. Antibiotic therapy was initially intravenously (mean time of administration: 10 days ± 3 SD), followed by oral medication (mean time of administration: 18 days ± 6 SD). Surgery was necessary in 3 patients. Evolution of all cases was excellent, despite 3 exceptions that resolved over time. CONCLUSIONS The current short-term intravenous therapy led to shorter hospitalizations. There were no statistically significant differences between time from clinical onset or in CRP levels at discharge compared to long-term therapies prior to 2006.
Collapse
|
8
|
Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. ACTA ACUST UNITED AC 2012; 94:584-95. [PMID: 22529075 DOI: 10.1302/0301-620x.94b5.28523] [Citation(s) in RCA: 184] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations. Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment.
Collapse
Affiliation(s)
- J Dartnell
- Maidstone and Tunbridge Wells NHS Trust, Pembury, UK
| | | | | |
Collapse
|
9
|
Gilbert C, Babyn P. MR imaging of the neonatal musculoskeletal system. Magn Reson Imaging Clin N Am 2011; 19:841-58; ix. [PMID: 22082741 DOI: 10.1016/j.mric.2011.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Experience in magnetic resonance (MR) imaging of the neonatal musculoskeletal system is rapidly increasing. The exquisite ability of MR to image the soft tissues, especially cartilage, without radiation is its key strength. Although it is not practical or sensible to undertake MR imaging in conditions in which radiography and ultrasound provide adequate information, MR is proving to be a useful adjunct and problem-solving tool in many neonatal musculoskeletal conditions.
Collapse
|
10
|
Abstract
Long bone osteomyelitis presents a variety of challenges to the physician. The severity of the disease is staged depending upon the infection's particular features, including its etiology, pathogenesis, extent of bone involvement, duration, and host factors particular to the individual patient (infant, child, adult, or immunocompromised). Long bone osteomyelitis may be either hematogenous or caused by a contiguous spread of infection. A single pathogenic organism is almost always recovered from the bone in hematogenous osteomyelitis; Staphylococcus aureus is the most common organism isolated. A variety of multidrug-resistant organisms of bacteria continue to be a source of concern in arresting infection. The primary weapons to treat these infections are culture-specific antibiotics, aggressive debridement, muscle flaps, and bone grafts. This article offers a basic review of the classification, etiology, epidemiology, pathogenesis, and treatment of long bone osteomyelitis.
Collapse
|
11
|
Howard-Jones AR, Isaacs D. Systematic review of systemic antibiotic treatment for children with chronic and sub-acute pyogenic osteomyelitis. J Paediatr Child Health 2010; 46:736-41. [PMID: 20825612 DOI: 10.1111/j.1440-1754.2010.01831.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is a lack of consensus on the most appropriate antibiotics to treat children with chronic or sub-acute pyogenic bacterial osteomyelitis and on the optimal duration of antibiotic therapy. AIM To review the published evidence on the duration of antibiotic therapy and outcomes in children with chronic and sub-acute pyogenic bacterial osteomyelitis. METHODS Systematic review of the literature. RESULTS We found no randomised controlled trials comparing different antibiotic regimens or comparing duration of antibiotic treatment for chronic or sub-acute osteomyelitis in children. We found 14 observational case series published between 1973 and 2008. Most children with chronic osteomyelitis received 4-6 weeks of parenteral antibiotics followed by oral antibiotics to a total duration of 3-6 months. Small observational studies suggest that a shorter duration of parenteral and oral antibiotics may be equally effective. CONCLUSION There is no high level evidence on the optimal duration of parenteral and oral antibiotics for children with chronic or sub-acute osteomyelitis. A large randomised controlled trial is needed comparing short course parenteral and oral antibiotics with longer antibiotic duration.
Collapse
Affiliation(s)
- Annaleise R Howard-Jones
- Faculty of Medicine, University of Sydney, Sydney, and Children's Hospital at Westmead, Westmead, NSW 2145, Australia
| | | |
Collapse
|
12
|
Role of MRI in detecting early physeal changes due to acute osteoarticular infection around the knee joint: a pilot study. INTERNATIONAL ORTHOPAEDICS 2008; 33:1707-11. [PMID: 18670775 DOI: 10.1007/s00264-008-0625-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 05/28/2008] [Accepted: 05/29/2008] [Indexed: 10/21/2022]
Abstract
Physeal changes of any aetiology in children are usually diagnosed once the deformity is clinically evident. Between January 2006 and June 2007, 15 children who suffered from acute osteoarticular infection around the knee joint were studied. They were called up for follow-up six months after the onset of infection. All patients were evaluated by clinical and roentgenographic examination before undergoing magnetic resonance imaging (MRI) study of both knees "with the unaffected knee serving as control". Abnormal findings in the physis, metaphysis and/or epiphysis on MRI were observed in five children. This group of five children was compared with the other ten children for clinical presentation and course of disease. We believe that MRI is a useful tool in the evaluation of growth plate insult in the early period following acute osteoarticular infection, and we can diagnose and prevent the catastrophic complications of the same.
Collapse
|
13
|
Tanaka R, Hayashi T. Computed tomography findings of chronic osteomyelitis involving the mandible: correlation to histopathological findings. Dentomaxillofac Radiol 2008; 37:94-103. [DOI: 10.1259/dmfr/38320433] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
14
|
Yousef A, Pace A, Livesley P. Chronic haematogenous Pseudomonas aeruginosa osteomyelitis of the clavicle, a case report and review of the literature. Eur J Pediatr 2006; 165:424-6. [PMID: 16565829 DOI: 10.1007/s00431-006-0092-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Accepted: 01/18/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Almunir Yousef
- Orthopaedics and Trauma, Kings Mill Hospital, Sutton-in-Ashfield, NG17 4JL, UK
| | | | | |
Collapse
|
15
|
Abstract
Acute hematogenous osteomyelitis is most common in children and has the potential to cause life-long musculoskeletal deformities. Most cases are caused by Staphylococcus aureus. Haemophilus influenzae type b (Hib) is now rare in countries that routinely use the Hib vaccine. Although magnetic resonance imaging is the preferred modality in localized disease, scintigraphy is often preferred as the first line of investigation because it helps to clarify the location of infection and exclude the presence of multifocal disease. Where the presentation is typical, there is no underlying disease, there is a low prevalence of community-acquired methicillin-resistant S. aureus (CA-MRSA), and there is a good response to antibacterial therapy, a diagnostic bone aspirate or biopsy is not necessary. The first-line antibacterial choice in most circumstances is a beta-lactamase-resistant penicillin. If CA-MRSA is suspected, the first-line options include clindamycin, the addition of an aminoglycoside or, rarely, vancomycin. In most patients, the total duration of therapy can be substantially shorter than the traditional 6 weeks, and oral therapy can be commenced after a brief course of intravenous antibacterials. We recommend 3 days of intravenous therapy followed by 3 weeks of high-dose oral antibacterials, provided there is no underlying illness, the presentation is typical and acute, and there has been a good response to treatment initially. Any deviation from this requires more intensive confirmation of the diagnosis (with imaging and/or biopsy or aspiration), and prolongation of intravenous therapy and total duration of treatment. Close monitoring and follow-up for at least 2 years are advised to detect complications.
Collapse
Affiliation(s)
- Andrew C Steer
- Royal Children's Hospital, Melbourne, Victoria, Australia
| | | |
Collapse
|
16
|
Girschick HJ, Raab P, Surbaum S, Trusen A, Kirschner S, Schneider P, Papadopoulos T, Müller-Hermelink HK, Lipsky PE. Chronic non-bacterial osteomyelitis in children. Ann Rheum Dis 2005; 64:279-85. [PMID: 15647436 PMCID: PMC1755336 DOI: 10.1136/ard.2004.023838] [Citation(s) in RCA: 180] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chronic recurrent multifocal osteomyelitis (CRMO) in children is a chronic non-suppurative inflammation involving multiple sites. Some children affected by chronic non-bacterial osteomyelitis (CNO) do not have multiple lesions or a recurrent course. OBJECTIVE To characterise the long term outcome of children with the full spectrum of CNO. METHODS 30 children diagnosed with CNO were followed up for a mean of 5.6 years and their disease assessed using a clinical score, multiple imaging, and a diagnostic biopsy, including extensive microbial analysis. RESULTS 9 patients had unifocal non-relapsing disease, 3 unifocal lesions with relapses, 9 multifocal lesions without relapses, and 9 multifocal lesions with relapses (CRMO). Granulocytes were present significantly more often in CRMO than in unifocal and non-recurrent lesions. Pustulosis was more common in multifocal cases regardless of recurrence. Mean duration of treatment in 15 children with a single occurrence was 9.2 months. Naproxen treatment was generally effective. Naproxen treatment in 12 patients with relapses lasted 25 months. However, 7 of these were not effectively treated with naproxen alone. Five were treated with oral glucocorticoids for 27 days in addition to naproxen, which induced remission in four, lasting for at least 1.5 years. Longitudinal growth of affected bones was not altered, except for the development of hyperostosis. CONCLUSION CNO is a spectrum of inflammatory conditions, with CRMO being the most severe. Most children with CNO have a favourable outcome of the disease. Oral glucocorticoids may be necessary in severe recurrent cases.
Collapse
Affiliation(s)
- H J Girschick
- Section of Paediatric Rheumatology, Children's Hospital, University of Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
Osteomyelitis in long bones remains challenging and expensive to treat, despite advances in antibiotics and new operative techniques. Plain radiographs still provide the best screening for acute and chronic osteomyelitis. Other imaging techniques may be used to determine diagnosis and aid in treatment decisions. The decision to use oral or parenteral antibiotics should be based on results regarding microorganism sensitivity, patient compliance, infectious disease consultation, and the surgeon's experience. A suppressive antibiotic regimen should be directed by the results of cultures. Standard operative treatment is not feasible for all patients because of the functional impairment caused by the disease, the reconstructive operations, and the metabolic consequences of an aggressive therapy regimen. Operative treatment includes debridement, obliteration of dead space, restoration of blood supply, adequate soft-tissue coverage, stabilization, and reconstruction.
Collapse
Affiliation(s)
- Luca Lazzarini
- Infectious Disease Unit, Department of Internal Medicine, San Bortolo Hospital, Viale Rodolfi 47, 36100 Vicenza, Italy
| | | | | |
Collapse
|
18
|
Melhus A, Ryan AF. Expression of molecular markers for bone formation increases during experimental acute otitis media. Microb Pathog 2001; 30:111-20. [PMID: 11273736 DOI: 10.1006/mpat.2000.0414] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Bony tissues are integral parts of the function of the middle ear and the protection of adjacent vital structures. To explore the reaction of middle ear bone to acute otitis media, rats were challenged with Streptococcus pneumoniae and Haemophilus influenzae. Local changes were monitored for up to 1 month. After reverse transcription, competitive polymerase chain reaction was used to determine the expression levels of two molecular markers of bone formation, osteocalcin and procollagen I, and the two cytokines interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha, in the bone. Middle ear bone responded rapidly to bacterial challenge, and the reaction depended upon the causative agent. On day 1, IL-6 and TNF-alpha transcripts were detected in the bone from all middle ears. After a short period of decreased expression of osteocalcin, during which the otitis diagnosis could not be made clinically, the levels of bone formation markers increased dramatically. The maximum levels of these markers were reached on days 6 and 14 for animals challenged with H. influenzae and pneumococci, respectively. Infections induced by pneumococci had a longer duration, and after the initial phase the production of osteocalcin and procollagen transcript were significantly higher in the pneumococcus-infected animals. The results indicate that even in an uncomplicated infection, the bone of the bulla reacts to an acute otitis media with a short period of inhibited osteoblast activity followed by a longer period of new bone formation.
Collapse
Affiliation(s)
- A Melhus
- Department of Surgery/Otolaryngology, University of California at San Diego School of Medicine and Veterans Affairs Medical Center, La Jolla, California, USA.
| | | |
Collapse
|