Duration of antimicrobial therapy for acute suppurative osteoarticular infections

Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics

This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the 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 ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA 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 approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). 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.

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.

Prediction of Adverse Outcomes in Pediatric Acute Hematogenous Osteomyelitis

BACKGROUND

Clinicians cannot reliably predict complications of acute hematogenous osteomyelitis (AHO).

METHODS

Consecutive cases of AHO from 2 pediatric centers in the United States were analyzed retrospectively to develop clinical tools from data obtained within 96 hours of hospitalization to predict acute and chronic complications of AHO. Two novel composite prediction scores derived from multivariable logistic regression modeling were compared with a previously published severity of illness (SOI) score, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) using area under the receiver operating characteristic curve analyses.

RESULTS

The causative organisms were identified in 73% of 261 cases. Bacteremia (45%), abscesses (38%), and associated suppurative arthritis (23%) were relatively common. Acute or chronic complications occurred in 24% and 11% of patients, respectively. Multivariable logistic regression identified bone abscess (odds ratio [OR], 2.3 [95% confidence interval {CI}, 1.0-5.2]), fever > 48 hours (OR, 2.7 [95% CI, 1.2-6.0]), suppurative arthritis (OR, 3.2 [95% CI, 1.3-7.5]), disseminated disease (OR, 4.6 [95% CI, 1.5-14.3]), and delayed source control (OR, 5.1 [95% CI, 1.4-19.0]) as strong predictors of acute complications. In a separate model, CRP ≥ 100 mg/L at 2-4 days after antibiotics (OR, 2.7 [95% CI, 1.0-7.3]), disseminated disease (OR, 3.3 [95% CI, 1.1-10.0]), and requirement for bone debridement (OR, 6.7 [95% CI, 2.1-21.0]) strongly predicted chronic morbidity. These variables were combined to create weighted composite prediction scores for acute (A-SCORE) and chronic (C-SCORE) osteomyelitis, which were superior to SOI, CRP, and ESR and had negative predictive values > 90%.

CONCLUSIONS

Two novel composite clinical scores were superior to existing tools to predict complications of pediatric AHO.

A Comparison of the Epidemiology, Clinical Features, and Treatment of Acute Osteomyelitis in Hospitalized Children in Latvia and Norway

Background and objectives: Paediatric acute osteomyelitis (AO) may result in major life-threatening and limb-threatening complications if not recognized and treated early. The management of AO may depend on local microbial prevalence and virulence factors. This study compares the approach to paediatric AO in hospitals in two countries—Latvia and Norway. Materials and Methods: The study includes patients with AO hospitalized in the paediatric department in the Norwegian hospital Sørlandet Sykehus Kristiansand (SSK), in the period between the 1st of January 2012 and the 31st of December 2019. The results from SSK are compared to the results of a published study of AO in patients hospitalized at the Children’s Clinical University Hospital (CCUH) in Riga, Latvia. Results: The most isolated pathogen from cultures in both hospitals was S. aureus (methicillin-sensitive). The lower extremity was the most affected body part (75% in CCUH, 95% in SSK), the main clinical symptom was pain (CCUH 92%, SSK 96.6%). Deep culture aspiration was most often taken intraoperatively in CCUH (76.6%) and percutaneously in SSK (44.8%). Oxacillin was the most applied antibiotic in CCUH (89.4%), and Cloxacillin in SSK (84.6%). Combined treatment with anti-Staphylococcal penicillins and Clindamycin was administered in 25.5% and 33.8% of CCUH and SSK patients, respectively. The median duration of the intravenous antibacterial treatment in CCUH and SSK was 15 and 10 days, respectively, and a switch to oral therapy was mainly made at discharge in both hospitals. The median total duration of antibiotic treatment was 25 days in CCUH and 35 days in SSK. 75% of CCUH and 10.3% of SSK patients were treated surgically. Complications were seen in 47% of patients in CCUH and in 38% in SSK. Conclusions: The transition to oral antibacterial treatment in both hospitals was delayed, which suggests a lack of criteria for discontinuation of intravenous therapy and could potentially contribute to longer hospitalization, higher cost of treatment and risk of complications. The use of more invasive techniques for deep culturing and significantly more common surgical interventions could possibly be linked to a higher complication rate in AO patients treated at the Latvian hospital.

Chronic Osteomyelitis Caused by Haemophilus parainfluenzae: A Case Report

CASE

A 14-year-old boy presented with a pathologic fracture of the distal aspect of the tibia and a remote history of a dog bite near the injury site. Imaging studies, biopsy, and presentation corroborated the diagnosis of chronic osteomyelitis. Multiple diagnostic methods were negative until an open biopsy identified Haemophilus parainfluenzae, a fastidious oropharyngeal bacterium, with polymerase chain reaction analysis. The patient underwent extensive debridement, placement of external fixation, and a year-long antibiotic therapy regimen. He subsequently required a tibial-fibular osteotomy at a second site with placement of an intramedullary nail for correction of a leg-length discrepancy.

CONCLUSION

This case report illustrates the complex management of chronic osteomyelitis in pediatric patients, its sequelae, and the importance of considering treatment of atypical pathogens.

Two weeks versus four weeks of antibiotic therapy after surgical drainage for native joint bacterial arthritis: a prospective, randomised, non-inferiority trial

Objective

The optimal duration of postsurgical antibiotic therapy for adult native joint bacterial arthritis remains unknown.

Methods

We conducted a prospective, unblinded, randomised, non-inferiority study comparing either 2 or 4 weeks of antibiotic therapy after surgical drainage of native joint bacterial arthritis in adults. Excluded were implant-related infections, episodes without surgical lavage and episodes with a follow-up of less than 2 months.

Results

We enrolled 154 cases: 77 in the 4-week arm and 77 in the 2-week arm. Median length of intravenous antibiotic treatment was 1 and 2 days, respectively. The median number of surgical lavages was 1 in both arms. Recurrence of infection was noted in three patients (2%): 1 in the 2-week arm (99% cure rate) and 2 in the 4-week arm (97% cure rate). There was no difference in the number of adverse events or sequelae between the study arms. Of the overall 154 arthritis cases, 99 concerned the hand and wrist, for which an additional subgroup analysis was performed. In this per-protocol subanalysis, we noted three recurrences: one in the 2-week arm (97 % cure); two in the 4-week arm (96 % cure) and witnessed sequelae in 50% in the 2-week arm versus 55% in the 4-week arm, of which five (13%) and six (13%) needed further interventions.

Conclusions

After initial surgical lavage for septic arthritis, 2 weeks of targeted antibiotic therapy is not inferior to 4 weeks regarding cure rate, adverse events or sequelae and leads to a significantly shorter hospital stay, at least for hand and wrist arthritis.

Trial registration number

NCT03615781.

Bacteriological aspects of chronic osteoarticular infections in adults: the influence of the osteosynthesis material

Background

The aim of this study is to establish the bacterial epidemiology of chronic osteoarticular infections in adults, to study the susceptibility of the isolated strains to antibiotics and to demonstrate the influence of osteosynthesis material thereon.

Patients and methods

This is a retrospective study of 78 months, from January 2006 to June 2012, providing bacteriological samples from patients with osteitis and osteoarthritis in the Mohammed V military teaching hospital of Rabat. Isolation and identification of bacteria were made by bacteriological classical techniques. The antimicrobial susceptibility testing of the isolates was performed by disk diffusion agar method, as recommended by the Committee of the susceptibility of the French Society for Microbiology (CA-SFM).

Results

We collected 234 cases, 53% (n = 124) of patients without osteosynthesis material (group A) and 47% (n = 110) patients with osteosynthesis material (group B).We isolated 371 bacteria which 51.49 (n = 191) in group A and 48.51% (n = 180) in group B. Gram-positive cocci were the most frequent (n = 234), followed by the Gram-negative bacilli (n = 114) and the Gram-positive bacilli (n = 19). Our study shows that the rate of resistance to antibiotics in strains obtained from patients with osteosynthesis material is higher compared to those obtained from patients without osteosynthesis material.

Conclusions

Chronic OA infection in adults is difficult to diagnose and treat. Its good management must be multidisciplinary.

Bone and Joint Infections in Children: Acute Hematogenous Osteomyelitis

Acute hematogenous osteomyelitis (AHO) is one of the commonest bone infection in childhood. Staphylococcus aureus is the commonest organism causing AHO. With use of advanced diagnostic methods, fastidious Kingella kingae is increasingly becoming an important organism in etiology of osteoarticular infections in children under the age of 3 y. The diagnosis of AHO is primarily clinical. The main clinical symptom and sign in AHO is pain and tenderness over the affected bone especially in the metaphyseal region. However, in a neonate the clinical presentation may be subtle and misleading. Laboratory and radiological investigations supplement the clinical findings. The acute phase reactants such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are frequently elevated. Ultrasonography and MRI are key imaging modalities for early detection of AHO. Determination of infecting organism in AHO is the key to the correct antibiotic choice, treatment duration and overall management and therefore, organism isolation using blood cultures and site aspiration should be attempted. Several effective antibiotics regimes are available for managing AHO in children. The choice of antibiotic and its duration and mode of delivery requires individualization depending upon severity of infection, causative organism, regional sensitivity patterns, time elapsed between onset of symptoms and child's presentation and the clinical and laboratory response to the treatment. If pus has been evidenced in the soft tissues or bone region, surgical decompression of abscess is mandatory.

Osteoarticular Infections in Children

For a child with a suspected bone or joint infection, knowledge of the workup and initial therapy is important to provide quality care. Fever and pain are hallmarks of a pediatric osteoarticular infection, although occasionally the signs and symptoms can be more subtle. The use of C-reactive protein to diagnose and validate effective management of treatment has become standard. Multiple reports confirm the success of much shorter intravenous (IV) courses than traditionally taught. The ideal IV and oral antibiotic duration, as well as defining the markers indicating need for surgical intervention, are questions yet to be answered.

Subperiosteal abscess in a child. Trueta's osteomyelitis hypothesis undermined?

Subperiosteal abscess formation is almost exclusively seen secondary to underlying hematogenous infected osteomyelitis or secondary as a result of a contagious focus. We present an unusual case of a 9-year-old girl with progressive ankle pain due to an isolated subperiosteal abscess of the distal fibula without concomitant osteomyelitis. The subperiosteal abscess was most likely caused by hematogenous spread to the periosteal region of the distal fibula located above the highly vascularized metaphysis. Remarkably, there were no signs of osteomyelitis on either MRI or during surgical inspection. She was successfully treated with debridement and antibiotic therapy. We hypothesize that subperiosteal abscess formation near the metaphysis originates in the periosteal region and not from outward extension from the sinusoidal veins in the intrametaphyseal area to the cortex and subperiosteal region.

Kingella kingae sequence type-complex 14 arthritis in a 16-month-old child in Greece

We describe the first case of Kingella kingae arthritis in a 16-month-old girl in Greece, which has been diagnosed by novel molecular techniques. A joint aspiration of her knee was performed before the initiation of antibiotics, as well as on the 5th and 14th day of empiric antimicrobial therapy. The synovial fluid white blood cell count decreased from 65,000 to 1500 cells/mm, but the percentage of neutrophils remained 90% in all 3 specimens. Molecular analysis of the synovial fluid specimens by real-time polymerase chain reaction and multilocus sequence typing enabled us to reveal the presence of K. kingae belonging to the international sequence type-complex 14, which persisted up to the fifth day of antibiotic 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.

[Intravenous antibiotic therapy for acute hematogenous osteomyelitis in children: short versus long course]

The aim of this study was to evaluate the results of two antibiotic therapy protocols for osteomyelitis with different durations of intravenous treatment. This was a prospective randomized study of children treated for acute hematogenous osteomyelitis. Patients in group 1 (G1) received 7 days of intravenous antibiotics, whereas patients in group 2 (G2) received 14 days. Treatment was deemed effective if there were no signs of chronic osteomyelitis at the last follow-up. Fifty-three patients were included in the study (G1=27, G2=26). After a mean follow-up of 11.5 months, none of the patients in either group showed signs of chronic osteomyelitis. In conclusion, a shortened treatment of 7 days of intravenous antibiotic therapy is as effective as a longer treatment.

Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature

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.

Antibiotic treatment for acute haematogenous osteomyelitis of childhood: moving towards shorter courses and oral administration

Acute haematogenous osteomyelitis (AHOM) of childhood usually affects the long bones of the lower limbs. Although almost any agent may cause AHOM, Staphylococcus aureus is the most common bacterium, followed by Streptococcus pneumoniae and, in some countries, Salmonella spp. and Kingella kingae. Magnetic resonance imaging (MRI) has improved the diagnostic accuracy of traditional radiography and scintigraphy. Except for the pre-treatment diagnostic sample from bone before the institution of antibiotic therapy, no other surgery is usually required. Traditionally, non-neonatal AHOM has been treated with a 1-3-month course of antibiotics, including an intravenous (i.v.) phase for the first weeks, but recent prospective randomised studies challenge this approach. For most uncomplicated cases, a course of 20 days including an i.v. period of 2-4 days suffices, provided large enough doses of a well-absorbed agent (clindamycin or a first-generation cephalosporin, local resistance permitting) are used, administration is four times daily and most symptoms and signs subside within a few days. Serum C-reactive protein (CRP) is a good guide in monitoring the course of illness, and the antimicrobial can usually be discontinued if CRP has decreased to <20 mg/L. Newer and costly agents, such as linezolid, should be reserved for cases due to resistant S. aureus strains. AHOM in neonates and immunocompromised patients probably requires a different approach. Because sequelae may develop slowly, follow-up for at least 1 year post hospitalisation is recommended.

Short- versus long-term antimicrobial treatment for acute hematogenous osteomyelitis of childhood: prospective, randomized trial on 131 culture-positive cases

BACKGROUND

Considerable uncertainty exists on the optimal duration of antimicrobials for acute hematogenous osteomyelitis (AHOM) in children. Often they are administered for 1 to 2 months, the first 1 to 2 weeks intravenously, and decompressive surgery is usually added. No prospective, randomized, sufficiently powered comparative trial has been available.

METHODS

Children aged 3 months to 15 years with culture-positive AHOM were randomly assigned to receive clindamycin or a first-generation cephalosporin for 20 or 30 days, including an intravenous phase for the first 2 to 4 days. Surgery was kept at minimum. Illness was monitored with preset criteria. Antimicrobial was discontinued once most signs had subsided and serum C-reactive protein decreased ≤20 mg/L. The primary end point was full recovery without need for further antimicrobial therapy because of an osteoarticular indication during the 12 months after the primary therapy.

RESULTS

Of the 131 cases, 18% also involved the adjacent joint. Staphylococcus aureus caused 89% of cases, and all strains were methicillin susceptible. The median duration of treatment was 20 days for 67 children, and 30 days for 64 children. Most children underwent only the diagnostic percutaneous aspiration or drilling, and 24% had no surgery. Except for 1 mild sequela in both treatment groups, all patients recovered entirely.

CONCLUSIONS

Most cases of childhood AHOM can be treated for 20 days, including a short period intravenously, with large doses of a well-absorbed antimicrobial such as clindamycin or a first-generation cephalosporin, provided the clinical response is good and C-reactive protein normalizes within 7 to 10 days. Extensive surgery is rarely needed.

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.

[French nationwide survey about management of acute osteomyelitis in children]

PURPOSE

The outcome of acute osteomyelitis in children has been modified by the use of potent antibiotics. However, treatment management remains unclear. The aim of this study was to investigate the current management of acute osteomyelitis in children in France.

PATIENTS AND METHODS

A questionnaire regarding the choice and the duration of antibiotics was sent to French pediatricians and pediatric orthopedists.

RESULTS

Ninety-four centers answered the questionnaire: 72 pediatricians and 22 pediatric orthopedists. The response rate was 51% and the median number of children hospitalized per year for osteomyelitis was 4 in each center. The radiologic procedures most often used for diagnosis were X-rays (99%) and bone scintigraphy (82%). Two intravenous antibiotics schemes were used by 80% of centers: either an association of 3rd-generation cephalosporin plus fosfomycin or an association of penicillin M and aminoglycoside, followed by oral penicillin M or pristinamycin. Intravenous therapy lasted 7 to 14 days in 72% of the centers. The total duration of antibiotic therapy was 6 weeks for 55% of centers. In 83% of cases, immobilization was prescribed. The decision for treatment withdrawal was based on clinical, biological or empirical findings for 59, 75 and 60% of departments, respectively.

CONCLUSION

In spite of controversies and lack of consensus, regarding both the diagnostic procedures and treatment management, 2 main antibiotic therapy schemes emerged from our survey. However, the treatment duration appeared more variable. Reaching a consensus for acute-osteomyelitis care in children remains a critical issue.

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.

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.

Bone and joint infections in children

Bone and joint infections are a significant cause of morbidity in infants and young children. Although many principles regarding pathogenesis, diagnosis, and treatment of infection have remained constant over the years, other aspects of this important pediatric diagnosis are continuing to evolve. This article reviews current information regarding pathogenesis, epidemiology, and microbiology of pediatric bone and joint infections and the clinical presentation, diagnosis, and treatment of these infections.

Infections ostéo-articulaires de l’enfant

PURPOSE OF THE STUDY

The purpose of this study was to evaluate a diagnostic and management protocol for osteoarticular infection in children which was developed at the Rouen University Hospital in 1993. We studied the technical aspects of the protocol allowing improved certain diagnosis and bacteriological documentation as well as the reduction in intravenous treatments and hospital stay.

MATERIAL AND METHODS

Two successive series were compared. The first constituted from May 1984 to February 1992 was a retrospective series of 106 children with osteoarticular infections. The second series was prospective an included 104 children with osteoarticular infection treated after institution of the protocol (January 1995 to December 1998). All children were treated in the same unit. Files were reviewed at a minimum follow-up of 18 months following the end of treatment. We analyzed: clinical, biological, and radiological data at admission; elements of the bacteriological study and their contribution to identification of the causal agent; duration of intravenous antibiotic therapy; total duration of antibiotic therapy, and hospital stay; complications and sequelae.

RESULTS

After institution of the protocol, we observed significant progress: certain diagnosis of acute osteomyelitis improved from 67% to 85% after institution of a more comprehensive diagnostic program; bacteriological identification improved from 37.5% to 72.2% for acute osteomyelitis and from 41.6% to 59.5% for septic arthritis, with a growing number of recognized cases of Kingella kingae infections causing acute osteomyelitis (n=2) or septic arthritis (n=4) due to technical progress in sampling and culturing. Mean duration of intravenous antibiotic therapy (15 days versus 9.95 days), mean duration of total antibiotic therapy (47.3 versus 33.8 d) as well as length of hospital stay (17.5 d versus 12.5 d) were significantly improved. The shorter antibiotic therapy did not led to any supplementary morbidity.

CONCLUSIONS

A systematic bacteriological diagnostic protocol has enabled an improvement in treatment and hospitalization. The protocol has been further updated and simplified in light of these findings and observations of insufficiencies, taking into account recent data in the literature and epidemiological features of osteoarticular infection in children.

Short course intravenous benzylpenicillin treatment of adults with meningococcal disease

BACKGROUND

Short-course treatment of meningococcal disease (including meningitis) with 4-5 days of an i.v. beta-lactam is of proven efficacy. Since April 1998, all adult patients with meningococcal disease admitted to Auckland Hospital were prospectively treated with 3 days of i.v. benzylpenicillin.

AIMS

To assess the clinical features, laboratory findings, disease complications and outcome of patients with meningococcal disease prospectively treated with 3 days of i.v. benzylpenicillin.

METHODS

A retrospective chart review of all adult patients with meningococcal disease admitted to Auckland Hospital from April 1998 to December 2002 was conducted.

RESULTS

Ninety patients with definite (n = 72) or -probable (n = 16) meningococcal disease were admitted during the study period. Two were excluded on the basis of treatment duration. The remaining 88 patients received a mean +/- standard deviation duration of treatment of 3.1 +/- 0.5 days (excluding those who died while receiving treatment). Six patients (7%) died, four of whom while on treatment. There were no relapses.

CONCLUSION

Three days of i.v. benzylpenicillin for the treatment of adults with meningococcal disease is effective.

Treatment of chronic osteomyelitis in children resistant to previous therapy

Patients admitted to the authors' institution with tibial osteomyelitis between 1978 and 1998 were reviewed. The purpose of this study was to determine the incidence, etiology, treatment, and outcome in chronic pediatric tibial osteomyelitis. The authors describe their treatment of chronic osteomyelitis in children resistant to previous therapeutic modalities. Thirty patients were identified with a mean age of 8.5 years at diagnosis. Mean age at admission was 9.6 years, indicating more than a 1-year duration of disease. Follow-up averaged 2.3 years. Patients underwent 97 procedures, averaging 3.2 procedures per patient. Hospital stay ranged from 2 weeks to 18 months, with an average stay of 4.7 months. Seventy-seven percent of patients were culture-positive, and 78% of positive cultures identified Staphylococcus aureus as the causative pathogen. Eighty percent of patients had a good outcome, 13% had a fair outcome, and there were no poor results. Patients with large tibial defects obtained good results with both tibiofibular synostosis and Ilizarov distraction osteogenesis. The authors describe the only reported group of pediatric patients successfully treated using Ilizarov bone transport for bony tibial defects due to osteomyelitis.

Skeletal scintigraphy in the multimodality assessment of young children with acute skeletal symptoms

The authors review the scintigraphic manifestations of acute osteomyelitis, septic arthritis, transient synovitis, Legg-Calvé-Perthes disease, fractures of toddlers, and some systemic conditions that cause skeletal symptoms during childhood. They offer suggestions regarding incorporation of skeletal scintigraphy into a multimodality approach for assessing children with skeletal symptoms.

Orthopedic pitfalls in the ED: osteomyelitis

Osteomyelitis can present to the emergency department as an acute, subacute, or chronic orthopedic concern. The presentation can range from subtle, as with acute hematogenous osteomyelitis in the pediatric patient population, to obvious, as with the diabetic patient who presents with a foot ulcer overlying exposed bone. Accurate early diagnosis and prompt treatment, whether with antibiotics, debridement, or both, are important in helping determine the ultimate outcome in this potential orthopedic pitfall. We review here the clinical presentation, diagnostic techniques, and management options for osteomyelitis that are applicable to the emergency practitioner.

Septic arthritis in patients followed-up in neonatal intensive care unit

BACKGROUND

Septic arthritis is an uncommon, but serious disorder in neonates. Most patients survive with permanent handicaps. Due to the rarity of this condition in neonates and paucity of signs and symptoms, the diagnosis of septic arthritis in newborns is more difficult than in older children.

METHODS

Septic arthritis or suppurative arthritis is an infection of the joint by a variety of microorganisms, including bacteria, viruses, mycobacteria and fungi. Purulent synovial fluid, positive culture and positive Gram stain were accepted as a gold standard for exact diagnosis. Fourteen neonates who were followed-up in a neonatal intensive care unit, with septic arthritis, were included in a study based on a review of medical reports and a long-term clinical and radiological follow-up. Clinical symptoms, bacteriology, risk factors and outcomes are discussed.

RESULTS

Staphylococcus aureus was the predominant causative organism. Risk factors for septic arthritis were prematurity (4/14), umbilical catheterization or venous catheterization (3/14), sepsis (3/14), perinatal asphyxia (2/14) and difficult birth (1/14). All cases of septic arthritis in neonates were improved without squealae except in two patients. One patient died and one patient had severe squealae. In these two patients, the duration of disease from clinical onset to initiation of therapy was long.

CONCLUSIONS

The most important prognostic factor in predicting a favorable outcome in neonatal septic arthritis is early diagnosis and therapy. When appropriate treatment is delayed, catastrophic sequelae are inevitable. Early diagnosis of the condition and rapid removal of pus are mandatory for the survival of the joint. Long-term follow-up may reveal effects of epiphyseal damage, early degenerative changes and limitation of the range of motion.

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

Duration of antibiotics in children with osteomyelitis and septic arthritis

OBJECTIVE

To evaluate the outcomes of children with acute osteomyelitis and septic arthritis at a hospital where short-duration antibiotic treatment (< or = 3.5 weeks) was considered routine.

METHODOLOGY

We carried out a retrospective chart review, with telephone interviews to follow up and determine long-term outcomes. Patients were selected to be at low risk for complications (illness < or = 14 days, no underlying disease, uncomplicated presentation).

RESULTS

Thirty-two children with osteomyelitis (OM), 34 with septic arthritis (SA) and five with OM and SA (OMSA) were included. Blood cultures were positive (mainly Staphylococcus aureus) in 15% of patients who had not had prior antibiotic treatment, and microbiological confirmation (positive blood culture, Gram stain or culture of surgical specimen) was obtained in 36%. The median duration of antibiotic treatment was 5.4, 4.4 and 5.0 weeks for OM, SA and OMSA, respectively. Only 22% of patients received antibiotics for 3.5 weeks or less. Overall, the recurrence rate was 1.4%. At follow-up, only two patients had mild occasional pain at the site of the original infection; all patients had normal function.

CONCLUSIONS

Contrary to expectations and local protocols, most patients were treated with conventional long-duration therapy. Patients treated for short courses had good outcomes. The low rate of complications may make randomized controlled equivalence trials unfeasible. Increasing evidence of the efficacy and safety of short-duration treatment (3-3.5 weeks) for acute, uncomplicated OM or SA in children suggests that this could be accepted as the standard treatment. However, this should be evaluated prospectively using a register, with at least 12 months' of follow-up.

Review article: Paediatric bone and joint infection

Paediatric musculoskeletal infection remains an important cause of morbidity. Methicillin sensitive Staphylococcus aureus is still the most common organism although the incidence of methicillin resistant S. aureus in the community is rising. Osteomyelitis and septic arthritis due to Haemophilus influenzae is decreasing in incidence secondary to immunisation and in some units has been replaced by infections with the gram negative bacillus, Kingella kingae. Recent prospective studies indicate that uncomplicated osteomyelitis can be treated by three to four weeks of antibiotics. However, there is still a small group of children who will have overwhelming disseminated infection. These children require aggressive surgical and medical intervention. Two recent reports have identified an increased incidence of septic arthritis in children who have hemophilia and are HIV positive.

Diagnosis and treatment of osteomyelitis

The diagnosis and therapy of osteomyelitis remains difficult despite recent advances. Clinical decision making is also difficult because of considerable variations in the types of disease observed and the lack of large comparative trials studying the variety of approaches.

Agrobacterium yellow group: bacteremia and possible septic arthritis following peripheral blood stem cell transplantation

A 47-year-old male patient developed sepsis and monoarticular arthritis following autologous stem cell transplantation for recurrent Hodgkin's disease. Blood cultures were positive for Agrobacterium yellow group. The knee pain and swelling responded promptly to the institution of empirical broad-spectrum antibiotics. Recurrent bacteremia developed necessitating Hickman line removal for eventual resolution of the infection. Transplant physicians should be aware of this unusual pathogen and the potential for both persistent line-related sepsis and possible septic arthritis.

Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991

AIMS

To determine the clinical features of a large number of unselected UK hospital patients with confirmed septic arthritis and to determine those features associated with a poor outcome.

STUDY DESIGN

Retrospective, case-note survey.

SETTING

A single English Health District.

PATIENTS

All patients admitted to hospital in Nottingham during the period 1 January 1982 to 31 December 1991 with confirmed septic arthritis were included.

OUTCOME MEASURES

Death, osteomyelitis and recorded functional impairment.

RESULTS

The spectrum of causative organisms remains similar to that seen in previous studies with the Gram positive organisms Staphylococcus aureus and Streptococci responsible for 74% of cases, gonococcal infections though were less common. Culture of joint aspirates and or blood were positive in 82% of cases, with the Gram stain demonstrating the causative organism in 50% of cases. Pre-existing joint disease was evident in 35% of cases. The mortality remains high at 11.5% with a significant additional morbidity of 31.6%. Multivariate analysis suggests that important predictors of death are: confusion at presentation, age > or = 65 years, multiple joint sepsis or involvement of the elbow joint, and of morbidity are: age > or = 65 years, diabetes mellitus, open surgical drainage, and Gram positive infections other than S aureus.

CONCLUSIONS

Septic arthritis continues to be associated with a considerable degree of morbidity and mortality. These results confirm the importance of obtaining synovial fluid and blood for culture before starting antimicrobial treatment. The apparent poorer outcome found with surgical intervention is in line with some previous suggestions but should be interpreted with caution in light of the retrospective nature of this study.

Septic arthritis in children

Because of its seriousness, septic arthritis should be considered early in the differential diagnosis of any child presenting with joint inflammation. Physicians who care for children should be aware of the early signs and symptoms of septic arthritis and be aggressive about establishing the diagnosis so that treatment is not delayed. Early orthopedic consultation and a low threshold for performing arthrocentesis are prudent. Prolonged and appropriate antimicrobial therapy is warranted to achieve optimal results.