High-dose oral dicloxacillin treatment of acute staphylococcal osteomyelitis in children

What Is the Appropriate Dose, Route, and Duration of Antibiotic Therapy for Pediatric Acute Hematogenous Osteomyelitis (AHO)? I Wish I Knew

Treatment of pediatric AHO requires antibiotic/surgical management. Considerable clinical experience exists, but with current knowledge of antibiotic pharmacokinetics and pharmacodynamics, recommendations for dosages for old or new antibiotics should be based on current standards for drug development whenever possible.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

The History of Antibiotic Treatment of Osteomyelitis

Antibiotic treatment of osteomyelitis has evolved substantially over the past 80 years. Traditional teachings (eg, that antimicrobials must be given parenterally, selected based upon ratios of achieved bone vs serum drug levels, and continued for 4–6 weeks) are supported by limited data. New studies are challenging this dogma, however. In this review, we seek to contextualize the discussion by providing a narrative, chronologic review of osteomyelitis treatment spanning the pre-antibiotic era through the present day and by describing the quality of evidence supporting each component of traditional osteomyelitis therapy.

Systematic review of duration and choice of systemic antibiotic therapy for acute haematogenous bacterial osteomyelitis in children

AIM

Historically, children with acute osteomyelitis received 4-6 weeks of parenteral antibiotics; however, evidence to guide optimal duration of therapy is limited. This study aims to summarise the available evidence on the duration and choice of antimicrobial therapy for acute haematogenous osteomyelitis in children.

METHODS

We systematically reviewed the literature on children with acute osteomyelitis to determine if shorter durations of antibiotic treatment compared with protracted treatment gave different cure rates. We also analysed studies for choice of antibiotics to determine differences in success rates. Randomised controlled trials, cohort studies, case-control studies and case series were eligible for inclusion.

RESULTS

We identified six randomised controlled trials, three of which addressed duration of antibiotic use and three choice of antibiotic for acute osteomyelitis in children. We found 28 observational studies, 20 of which focused on duration and 22 of which allowed analysis of choice of antibiotic. A range of therapy durations and types of antibiotics were assessed. Only one small study looked at treatment of neonates.

CONCLUSIONS

The quality of evidence on antibiotic treatment for acute osteomyelitis is limited, allowing only weak (GRADE 2B) recommendations. Our review suggests that early transition from intravenous to oral therapy, after 3-4 days in patients responding well, followed by oral therapy to a total of 3 weeks may be as effective as longer courses for uncomplicated acute osteomyelitis. This recommendation does not apply to neonates.

Sequential antibiotic therapy: Effective cost management and patient care

The escalating costs associated with antimicrobial chemotherapy have become of increasing concern to physicians, pharmacists and patients alike. A number of strategies have been developed to address this problem. This article focuses specifically on sequential antibiotic therapy (sat), which is the strategy of converting patients from intravenous to oral medication regardless of whether the same or a different class of drug is used. Advantages of sat include economic benefits, patient benefits and benefits to the health care provider. Potential disadvantages are cost to the consumer and the risk of therapeutic failure. A critical review of the published literature shows that evidence from randomized controlled trials supports the role of sat. However, it is also clear that further studies are necessary to determine the optimal time for intravenous to oral changeover and to identify the variables that may interfere with the use of oral drugs. Procedures necessary for the implementation of a sat program in the hospital setting are also discussed.

Acute bacterial osteoarticular infections: eight-year analysis of C-reactive protein for oral step-down therapy

BACKGROUND

One of the most important decisions in the treatment of osteoarticular infections is the time at which parenteral therapy can be changed to oral therapy. C-reactive protein (CRP) is an acute inflammatory indicator with a half-life of 19 hours and thus can be helpful in assessing the adequacy of therapy for bacterial infections. At our institution, a combination of CRP and clinical findings is used to determine the transition to oral therapy.

METHODS

A search of 8 years of electronic records identified children with osteoarticular infections. Only children with culture-positive acute bacterial arthritis (ABA) or acute bacterial osteomyelitis (ABO) were studied further. A primary chart review of demographic and clinical data was conducted, and a secondary chart review of complicated outcomes was performed.

RESULTS

Of 194 total patients, complicated outcomes occurred in 40, of which 35 were prolonged therapy. Only 1 microbiologic failure occurred, presumably due to a retained intra-articular fragment of infected bone. CRP was highest initially among patients with simultaneous ABO + ABA and among those with complicated outcomes, and was lower at the transition to oral therapy in the complicated outcome group (1.5 vs 2.1 mg/dL; P = .012).

CONCLUSIONS

The combination of clinical findings and CRP is a useful tool to transition children with osteoarticular infections to oral therapy. Complicated outcomes were associated with higher early CRP at diagnosis and lower CRP at the end of parenteral therapy, suggesting that clinicians were more conservative with prolonged initial parenteral therapy in this group.

A multidisciplinary hospital-based antimicrobial use program: Impact on hospital pharmacy expenditures and drug use

The authors' hospital embarked on a three-component, multidisciplinary, hospital-based antimicrobial use program to cut costs and reduce inappropriate antimicrobial use. Initially, antimicrobial use patterns and costs were monitored for 12 months. For the next two years, an antimicrobial use program was implemented consisting of three strategies: automatic therapeutic interchanges; antimicrobial restriction policies; and parenteral to oral conversion. The program resulted in a reduction in the antimicrobial portion of the total pharmacy drug budget from 41.6% to 28.2%. Simultaneously, the average cost per dose per patient day dropped from $11.88 in 1991 to $10.16 in 1994. Overall, mean monthly acquisition cost savings rose from $6,810 in 1992 to $27,590 in 1994. This study demonstrates that a multidisciplinary antimicrobial use program in a Canadian hospital can effect dramatic cost savings and serve as a quality assurance activity of physician antimicrobial prescribing behaviour.

Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children

OBJECTIVES

Early transition from intravenous to oral antimicrobial therapy for acute osteomyelitis in children has been suggested as a safe and effective alternative to traditional prolonged intravenous therapy via central venous catheter, but no studies have directly compared these 2 treatment modalities. We sought to compare the effectiveness of early transition from intravenous to oral antimicrobial therapy versus prolonged intravenous antimicrobial therapy for the treatment of children with acute osteomyelitis.

METHODS

We conducted a retrospective cohort study of children aged 2 months to 17 years diagnosed with acute osteomyelitis between 2000 and 2005 at 29 freestanding children's hospitals in the United States to confirm the extent of variation in the use of early transition to oral therapy. We used propensity scores to adjust for potential differences between children treated with prolonged intravenous therapy and logistic regression to model the association of outcome (treatment failure rates within 6 months of diagnosis) and difference in the mode of therapy within hospitals and across hospitals.

RESULTS

Of the 1969 children who met inclusion criteria, 1021 received prolonged intravenous therapy and 948 received oral therapy. The use of prolonged intravenous therapy varied significantly across hospitals (10%-95%). The treatment failure rate was 5% (54 of 1021) in the prolonged intravenous therapy group and 4% (38 of 948) in the oral therapy group. There was no significant association between treatment failure and the mode of antimicrobial therapy. Thirty-five (3.4%) children in the prolonged intravenous therapy group were readmitted for a catheter-associated complication.

CONCLUSIONS

Treatment of acute osteomyelitis with early transition to oral therapy is not associated with a higher risk of treatment failures and avoids the risks of prolonged intravenous therapy through central venous catheters.

Acute haematogenous osteomyelitis in children: is there any evidence for how long we should treat?

PURPOSE OF REVIEW

Despite diagnostic and therapeutic advances, acute haematogenous osteomyelitis in children continues to cause significant morbidity and disease burden. The molecular epidemiology of causal organisms has wide geographic variation, but regardless of cause children often require several weeks of inpatient parenteral antibiotic therapy. This review focuses on antibiotic treatment and length of antibiotic therapy.

RECENT FINDINGS

Currently there is no international and little local consensus regarding the route or duration for antibiotic treatment of acute haematogenous osteomyelitis in children. Although there are encouraging data from review papers and case series, no randomized controlled trial has been conducted to show good evidence for shorter courses of parenteral antibiotic treatment. Prospective studies show effective treatment for a wide variety of antibiotic agents, but there are few comparative studies. Overall treatment for 4-6 weeks is considered standard therapy, but the laboratory or clinical parameters that would determine the decision to switch to oral therapy remain undefined.

SUMMARY

Evidence-based data about the route and duration of intravenous antibiotic treatment for acute haematogenous osteomyelitis in children are still limited to observational and retrospective studies. A randomized controlled trial will provide much needed data.

Success of short-course parenteral antibiotic therapy for acute osteomyelitis of childhood

The outcome of acute osteomyelitis treated with sequential therapy consisting of a short course of parenteral antibiotics, followed by oral antibiotics, was studied. To be considered acute osteomyelitis, related symptoms must have been present for less than 2 weeks before diagnosis. Short-course parenteral antibiotics (therapy for 7 days or less) and then oral antibiotics were used to treat 29 patients (median age, 6.3 years). Pathogens were identified from blood cultures and bone aspirates. Staphylococcus aureus was isolated in 59%. Median duration of parenteral antibiotics and oral antibiotics was 4 days (range, 0-7 days) and 28 days (range, 14-42 days), respectively. Median duration of combined (parenteral and oral) therapy was 32 days (range, 20-49 days). No failures or complications were noted at the 6-month follow-up, which was available for 27 patients. Short-course parenteral antibiotic therapy followed by oral therapy appears to be effective for treatment of acute, uncomplicated osteomyelitis.

Complications of central venous catheters used for the treatment of acute hematogenous osteomyelitis

OBJECTIVE

To determine the complications and risk factors for complications associated with using central venous catheters (CVCs) for the treatment of acute hematogenous osteomyelitis (AHO).

METHODS

We conducted a retrospective cohort study of all patients admitted to the Children's Hospital of Philadelphia between January 1, 2000, and December 31, 2003, with a diagnosis of AHO.

RESULTS

Eighty patients with AHO met inclusion criteria. The median age was 5 years, and 66% of the patients were male. The most commonly affected bones were the femur (25%), tibia (20%), and pelvis (16%). Staphylococcus aureus was the most common organism identified from cultures of bone (67%) and blood (30%). Seventy-five patients (94%) received >2 weeks of intravenous (IV) antibiotic therapy via a CVC and 5 (6%) received <2 weeks of IV antibiotic therapy before conversion to oral therapy for a median of 25 days. None of the patients who switched to oral therapy within 2 weeks was rehospitalized or returned to the emergency department. Of the 75 patients who received >2 weeks of IV therapy, 41% had > or =1 CVC-associated complication. Seventeen patients (23%) had a CVC malfunction or displacement, 8 (11%) had a catheter-associated bloodstream infection, 8 (11%) had fever with negative blood culture results, and 4 (5%) had a local skin infection at the site of catheter insertion. Older age was protective against the development of a CVC-associated complication, whereas the lowest median household income was associated with development of a CVC-associated complication.

CONCLUSIONS

Interventions to reduce CVC-associated complications should be developed and evaluated, particularly for young children and those from families with low household incomes. Clinical trials are needed to evaluate the safety and efficacy of oral antibiotic therapy after a short course of IV therapy as an alternative to prolonged IV therapy.

Osteomyelitis in children

Osteomyelitis is one of the more common invasive bacterial infections in children leading to hospitalization and prolonged antibiotic administration. Over the past decade, increasing microbial virulence, diminishing antibiotic susceptibility, and advances in diagnostic molecular microbiology and imaging techniques have led to changes in the clinical management of children with suspected osteomyelitis, which are reviewed in this article.

Musculoskeletal infections in children

Serious musculoskeletal infections in children include osteomyelitis, septic arthritis, pyomyositis, and necrotizing fasciitis. The epidemiology, pathophysiology, and microbiology of each of these infections are reviewed. Specific diagnostic studies and management strategies are discussed. Prompt recognition and treatment is emphasized to prevent potential long-term sequelae.

Acute hematogenous osteomyelitis in children: recognition and management

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.

Antibiotic treatment of osteomyelitis: what have we learned from 30 years of clinical trials?

OBJECTIVES AND DESIGN

To determine the most appropriate approach to antibiotic therapy for osteomyelitis, the medical literature for articles published from 1968 to 2000 was reviewed.

RESULTS

Ninety-three clinical trials in children and adults were identified using almost every antibiotic class. Most studies were non-comparative and the comparative trials involved relatively few patients. Publications generally did not provide clinically important information regarding infection staging or classification, surgical treatment provided, or the presence of orthopedic hardware. The median duration of follow-up after treatment was only 12 months. The clinical outcome was better for acute than chronic osteomyelitis in eight of the 12 studies allowing comparison. In the comparative trials, few statistically significant differences were observed between the tested treatments. In one small trial, the combination of nafcillin plus rifampin was more effective than nafcillin alone. In pediatric osteomyelitis, oral therapy with cloxacillin was more effective than tetracycline in one study, and oral clindamycin was as effective as parenteral anti-staphylococcal penicillins in another. In several investigations oral fluoroquinolones were as effective as standard parenteral treatments.

CONCLUSIONS

Although the optimal duration of antibiotic therapy remains undefined, most investigators treated patients for about six weeks. Despite three decades of research, the available literature on the treatment of osteomyelitis is inadequate to determine the best agent(s), route, or duration of antibiotic therapy.

Fosfomycin for the initial treatment of acute haematogenous osteomyelitis

BACKGROUND AND AIMS

At our institution there has been a dichotomous antimicrobial treatment behaviour for acute haematogenous osteomyelitis (AHOM) since 1984. The surgical department favoured fosfomycin as initial choice and the medical department beta lactams. We aimed to compare the performance of both strategies.

METHODS

Data from patients discharged with the diagnosis of AHOM between January 1984 and January 1998 were gathered from the charts by means of a questionnaire. Patients receiving fosfomycin treatment (FT) were compared with those receiving fosfomycin plus other antimicrobials (FT+) and those receiving no fosfomycin treatment (NFT).

RESULTS

A total of 103 patients aged 0.1-15.5 years (mean 6.5, median 6.9) with AHOM received no surgical treatment initially. In 23 (22.3%) FT was instilled initially, in 47 (45.6%) FT+, and in 33 (32.0%) NFT. The pathogen was established in 30%, 36%, and 42% of FT, FT+, and NFT patients, respectively, Staphylococcus aureus being the predominant isolate. Mean C reactive protein levels and erythrocyte sedimentation rates normalised in all treatment groups after two and four weeks, respectively. The mean duration of intravenous antimicrobial treatment in FT patients was 2.5 weeks, in FT+ patients 3.1 weeks, and in NFT patients 3.8 weeks (p < 0.05), whereas the mean duration of intravenous plus oral treatment was comparable (7.1 v 6.8 v 6.5 weeks).

CONCLUSIONS

The leucocyte penetrating fosfomycin performed similarly to extracellular beta lactams in the treatment of AHOM. Intravenous treatment for longer than 2.5 weeks offered no advantage.

Shorter courses of parenteral antibiotic therapy do not appear to influence response rates for children with acute hematogenous osteomyelitis: a systematic review

BACKGROUND

Acute hematogenous osteomyelitis (AHO) occurs primarily in children and is believed to evolve from bacteremia followed by localization of infection to the metaphysis of bones. Currently, there is no consensus on the route and duration of antimicrobial therapy to treat AHO.

METHODS

We conducted a systematic review of a short versus long course of treatment for AHO due primarily to Staphylococcus aureus in children aged 3 months to 16 years. We searched Medline, Embase and the Cochrane trials registry for controlled trials. Clinical cure rate at 6 months was the primary outcome variable, and groups receiving less than 7 days of intravenous therapy were compared with groups receiving one week or longer of intravenous antimicrobials.

RESULTS

12 eligible prospective studies, one of which was randomized, were identified. The overall cure rate at 6 months for the short course of intravenous therapy was 95.2% (95% CI = 90.4 - 97.7) compared to 98.8% (95% CI = 93.6, 99.8) for the longer course of therapy. There was no significant difference in the duration of oral therapy between the two groups.

CONCLUSIONS

Given the potential increased morbidity and cost associated with longer courses of intravenous therapy, this finding should be confirmed through a randomized controlled equivalence trial

Antimicrobial treatment of chronic osteomyelitis

Chronic osteomyelitis has been a difficult problem for patients and the treating physicians. Appropriate antibiotic therapy is necessary to arrest osteomyelitis along with adequate surgical therapy. Factors involved in choosing the appropriate antibiotic(s) include infection type, infecting organism, sensitivity results, host factors, and antibiotic characteristics. Initially, antibiotics are chosen on the basis of the organisms that are suspected to be causing the infection. Once the infecting organism(s) is isolated and sensitivities are established, the initial antibiotic(s) may be modified. In selecting specific antibiotics for the treatment of osteomyelitis, the type of infection, current hospital sensitivity resistance patterns, and the risk of adverse reactions must be strongly appraised. Antibiotic classes used in the treatment of osteomyelitis include penicillins, beta-lactamase inhibitors, cephalosporins, other beta-lactams (aztreonam and imipenem), vancomycin, clindamycin, rifampin, aminoglycosides, fluoroquinolones, trimethoprim-sulfamethoxazole, metronidazole, and new investigational agents including teicoplanin, quinupristin/dalfopristin, and oxazolidinones. Traditional treatments have used operative procedures followed by 4 to 6 weeks of parenteral antibiotics. Adjunctive therapy for treating chronic osteomyelitis may be achieved by using beads, spacers, or coated implants to deliver local antibiotic therapy and/or by using hyperbaric oxygen therapy (once per day for 90-120 minutes at two to three atmospheres at 100% oxygen).

Relationship between plasma and bone concentrations of cefuroxime and flucloxacillin. Three different parenteral administrations compared in 30 arthroplasties

(i) The objective was to determine the range of bone levels of cefuroxime and flucloxacillin achieved after one intravenous (IV) administration of different dosages of cefuroxime and flucloxacillin. (ii) Six groups of five patients participated in the study. The first three groups (A-C) received respectively 1500 mg, 1000 mg, and 500 mg cefuroxime intravenously and the second three groups (D-F) received 2000 mg, 1500 mg, and 1000 mg flucloxacillin intravenously. (iii) Parenteral administration of cefuroxime and flucloxacillin resulted in measurable bone concentrations in all patients. (iv) Large inter-individual variation in bone concentration was observed. (v) The bone concentrations of IV cefuroxime were higher (1500 mg, p = 0.0057; 1000 mg, p = 0.0260) than those of flucloxacillin. The bone concentrations of cefuroxime and flucloxacillin were dose dependent.

Plasma and bone concentrations of cefuroxime and flucloxacillin. Oral versus parenteral administration in 20 arthroplasties

Our objective was to determine and to compare the range of bone levels of cefuroxime and flucloxacillin achieved after oral and intravenous administration in 20 arthroplasty patients, allocated to 4 groups: 1 x 500 mg or 7 x 500 mg oral cefuroxime was followed by 2000 mg Flucloxacillin i.v.; 1 x 500 mg and 7 x 500 mg oral flucloxacillin was followed by 1500 mg cefuroxime i.v. Bone samples of hip and knee were obtained. Oral administration did not result in a measurable bone concentration of any of the antibiotics. Intravenous administration resulted in measurable bone concentrations of both cefuroxime and flucloxacillin, with large inter-individual variations. The bone concentrations of intravenous cefuroxime were higher than those of flucloxacillin, despite the lower dose. Oral pretreatment had no effect on the bone concentrations after intravenous administration. No accumulation of the drugs in bone was observed.

Serious bacterial infections in children. When can outpatient treatment be used?

Several studies now support outpatient treatment of many serious bacterial infections in children, such as periorbital or buccal cellulitis, urinary tract infection, pneumonia, and abscess. However, an appropriate agent, that is, a third-generation cephalosporin with a long half-life, must be available and its effectiveness properly researched. In addition, children must be free of other illnesses and able to ingest fluids and maintain hydration, and their parents must be willing and able to cooperate with an outpatient treatment regimen. Family physicians can maintain the close patient and family contact needed to facilitate this form of therapy.

Duration of antimicrobial therapy for acute suppurative osteoarticular infections

From 1974 to 1983, inclusive, 274 children with acute suppurative osteoarticular infections were treated with antibiotic regimens that were shorter than usually recommended. The median duration of antibiotic treatment for acute suppurative arthritis caused by staphylococci, streptococci, Haemophilus influenzae type b, gram-negative cocci, or other gram-negative bacteria was 23, 16, 16, 15, and 22 days, respectively. For acute osteomyelitis caused by staphylococci, streptococci, H influenzae, or other gram-negative bacteria the median duration of antibiotic therapy was 24, 23, 17, and 22.5 days, respectively. Osteoarthritis usually had to be treated for about a month. 180 patients received large dosages of oral antimicrobials after clinical stabilisation with intravenous treatment, the median duration of intravenous therapy being about a week (range up to 7 weeks). 99% of patients underwent needle aspiration for diagnostic reasons. 36%, 71%, and 63% of the patients with acute suppurative arthritis, osteomyelitis, and osteoarthritis, respectively, underwent incision and drainage. Recurrence occurred in 4 patients with acute osteomyelitis (3.8% of cases). There was no recurrence of arthritis.

Plasma concentration following oral administration of di- and flucloxacillin in infants and children

The bioavailability of commercial liquid preparations of di- and flucloxacillin was compared in infants and children. The plasma concentrations following a dose of 12.5 mg/kg were equal within the two age groups. Infants 0-1 months old, however, demonstrated a better absorption than older children.

The course, costs and complications of oral versus intravenous penicillin therapy of erysipelas

Oral versus intravenous antibiotic therapy of severe erysipelas was compared in a controlled trial of 60 patients. No clinical benefit of intravenous therapy was found, as evaluated by fever duration, hospital stay and sick leave. Untoward reactions were comparable between the groups. No difference in recurrence was found. The difference in administration time and drug cost was considerable. It is therefore suggested that erysipelas without complications should be treated orally.

Oral therapy for orthopedic infections in children and adults

Literature and clinical experience in the treatment of both adult and pediatric osteomyelitis by oral antibiotics is reviewed. Antibiotics achieving adequate penetration into joint fluid and bone are listed. Particular discussion is given to penicillins, cephalosporins, and non-β-lactam antibiotics. Techniques for monitoring therapeutic effectiveness and patient compliance are noted.

Cost-effective antibiotic prescribing

Antibiotics are often misused, resulting in a high frequency of adverse effects, emergence of drug-resistant organisms, and excessive costs. The high cost of antibiotics is currently receiving the greatest attention. Considerable cost savings can be achieved by appropriate prescribing of antibiotics for patients receiving these drugs prophylactically as well as for those with established infections. This article cites specific examples of how cost-effective antibiotic prescribing practices can realize substantial cost savings without any diminished quality in patient care.

Long-term follow-up of ambulatory management of osteomyelitis

Over four years, 50 patients with osteomyelitis (32 classified as acute and 18 as subacute or chronic disease) were treated with oral antibiotics in an ambulatory setting. The profile of clinical and laboratory parameters, including etiologic agents, was similar to previous series. Forty-eight patients initially received parenteral drugs, mean duration 14 days (range 0-36). Oral agents administered at home included cephalosporins, clindamycin, dicloxacillin, penicillin VK, amoxicillin, and sulfa-trimethoprim. Mean duration of total therapy was 53.2 days (range 16-365). In follow-up, ranging from 12 to 60 months (mean 35), relapses occurred in one patient with acute and one with chronic disease. Both responded to oral treatment. No residual infection has resulted, although clinical and radiographic sequelae remain in six more patients initially termed subacute or chronic. Long-term follow-up of patients receiving high-dose oral antibiotic therapy for osteomyelitis due to sensitive organisms confirms the safety and efficacy of this mode of treatment and the feasibility of ambulatory management. The outcome after oral therapy is equivalent to that following parenteral therapy. Patients with subacute or chronic disease have a significantly poorer prognosis despite a milder initial illness and longer course of therapy.