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Nielsen AB, Holm M, Lindhard MS, Glenthøj JP, Borch L, Hartling U, Schmidt LS, Rytter MJH, Rasmussen AH, Damkjær M, Lemvik G, Petersen JJH, Søndergaard MJ, Thaarup J, Kristensen K, Jensen LH, Hansen LH, Lawaetz MC, Gottliebsen M, Horsager TH, Zaharov T, Hoffmann TU, Nygaard T, Justesen US, Stensballe LG, Vissing NH, Blanche P, Schmiegelow K, Nygaard U. Oral versus intravenous empirical antibiotics in children and adolescents with uncomplicated bone and joint infections: a nationwide, randomised, controlled, non-inferiority trial in Denmark. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:625-635. [PMID: 39025092 DOI: 10.1016/s2352-4642(24)00133-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Bone and joint infections (BJIs) are treated with intravenous antibiotics, which are burdensome and costly. No randomised controlled studies have compared if initial oral antibiotics are as effective as intravenous therapy. We aimed to investigate the efficacy and safety of initial oral antibiotics compared with initial intravenous antibiotics followed by oral antibiotics in children and adolescents with uncomplicated BJIs. METHODS From Sept 15, 2020, to June 30, 2023, this nationwide, randomised, non-inferiority trial included patients aged 3 months to 17 years with BJIs who presented to one of the 18 paediatric hospital departments in Denmark. Exclusion criteria were severe infection (ie, septic shock, the need for acute surgery, or substantial soft tissue involvement), prosthetic material, comorbidity, previous BJIs, or antibiotic therapy for longer than 24 h before inclusion. Patients were randomly assigned (1:1), stratified by C-reactive protein concentration (<35 mg/L vs ≥35 mg/L), to initially receive either high-dose oral antibiotics or intravenous ceftriaxone (100 mg/kg per day in one dose). High-dose oral antibiotics were coformulated amoxicillin (100 mg/kg per day) and clavulanic acid (12·5 mg/kg per day) in three doses for patients younger than 5 years or dicloxacillin (200 mg/kg per day) in four doses for patients aged 5 years or older. After a minimum of 3 days, and upon clinical improvement and decrease in C-reactive protein, patients in both groups received oral antibiotics in standard doses. The primary outcome was sequelae after 6 months in patients with BJIs, defined as any atypical mobility or function of the affected bone or joint, assessed blindly, in all randomised patients who were not terminated early due to an alternative diagnosis (ie, not BJI) and who attended the primary outcome assessment. A risk difference in sequelae after 6 months of less than 5% implied non-inferiority of the oral treatment. Safety outcomes were serious complications, the need for surgery after initiation of antibiotics, and treatment-related adverse events in the as-randomised population. This trial was registered with ClinicalTrials.gov, NCT04563325. FINDINGS 248 children and adolescents with suspected BJIs were randomly assigned to initial oral antibiotics (n=123) or initial intravenous antibiotics (n=125). After exclusion of patients without BJIs (n=54) or consent withdrawal (n=2), 101 patients randomised to oral treatment and 91 patients randomised to intravenous treatment were included. Ten patients did not attend the primary outcome evaluation. Sequelae after 6 months occurred in none of 98 patients with BJIs in the oral group and none of 84 patients with BJIs in the intravenous group (risk difference 0, one-sided 97·5% CI 0·0 to 3·8, pnon-inferiority=0·012). Surgery after randomisation was done in 12 (9·8%) of 123 patients in the oral group compared with seven (5·6%) of 125 patients in the intravenous group (risk difference 4·2%, 95% CI -2·7 to 11·5). We observed no serious complications. Rates of adverse events were similar across both treatment groups. INTERPRETATION In children and adolescents with uncomplicated BJIs, initial oral antibiotic treatment was non-inferior to initial intravenous antibiotics followed by oral therapy. The results are promising for oral treatment of uncomplicated BJIs, precluding the need for intravenous catheters and aligning with the principles of antimicrobial stewardship. FUNDING Innovation Fund Denmark and Rigshospitalets Forskningsfond.
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Affiliation(s)
- Allan Bybeck Nielsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark
| | - Mette Holm
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Morten S Lindhard
- Department of Pediatrics and Adolescent Medicine, Regional Hospital Randers, Randers, Denmark
| | - Jonathan P Glenthøj
- Department of Paediatrics and Adolescent Medicine, Hillerød University Hospital, Hillerød, Denmark
| | - Luise Borch
- Department of Paediatrics and Adolescent Medicine, Gødstrup Hospital, Gødstrup, Denmark; NIDO Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Ulla Hartling
- Department of Paediatrics and Adolescent Medicine, Hans Christian Andersen Children's Hospital, Odense, Denmark
| | - Lisbeth S Schmidt
- Department of Paediatrics and Adolescent Medicine, Herlev University Hospital, Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maren J H Rytter
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Annett H Rasmussen
- Department of Paediatrics and Adolescent Medicine, Hans Christian Andersen Children's Hospital, Odense, Denmark
| | - Mads Damkjær
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Grethe Lemvik
- Department of Paediatrics and Adolescent Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Jens J H Petersen
- Department of Paediatrics and Adolescent Medicine, Esbjerg Central Hospital, Esbjerg, Denmark
| | - Mia J Søndergaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Thaarup
- Department of Paediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Kim Kristensen
- Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Nykobing Falster, Denmark
| | - Lise H Jensen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lotte H Hansen
- Department of Paediatrics and Adolescent Medicine, Aabenraa Hospital, Aabenraa, Denmark
| | - Marie C Lawaetz
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Gottliebsen
- Department of Paediatric Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Tanja H Horsager
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Paediatrics and Adolescent Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Tatjana Zaharov
- Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Nykobing Falster, Denmark
| | - Thomas U Hoffmann
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark
| | - Tobias Nygaard
- Department of Paediatric Orthopaedic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ulrik S Justesen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Lone G Stensballe
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nadja H Vissing
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Paul Blanche
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Agúndez Reigosa B, Cabrera López IM, Sánchez Marcos E, Galán-Olleros M, Sánchez Olivier M, Calleja Gero L, Jiménez García R. Hospital at Home Program for the Treatment of Pediatric Osteoarticular Infections. Hosp Pediatr 2024; 14:75-83. [PMID: 38186289 DOI: 10.1542/hpeds.2023-007265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVES Hospital at home (HAH) replaces acute inpatient hospital care for selected patients by providing care in their homes. We sought to describe the characteristics, management, and complications of patients with osteoarticular infections (OAIs) treated in an HAH program and its economic impact. METHODS We conducted a retrospective observational study evaluating an HAH program in a pediatric hospital in Spain, describing the characteristics of patients with confirmed OAIs requiring intravenous antibiotic therapy admitted to this program between January 2019 and December 2022. The program operates as a virtual ward with possible daily visits by physicians and nurses and 24/7 telephone contact. RESULTS A total of 88 patients (median age, 4.1 years; interquartile range [IQR], 1.7-10.6) with OIAs were admitted to the HAH program. Osteomyelitis (57%) and septic arthritis (29%) were the most frequent infections. Cefuroxime (42%) and cefazolin (39%) were the most frequently prescribed antibiotics. Caregiver self-administration was performed in 99%, allowing multiple daily doses of antimicrobial therapy, 80% by peripheral line. Thirteen patients (15%) had drug-related adverse events, only 3 requiring drug modification. Two patients (2%) were readmitted during HAH, and 1 was readmitted within 30 days of HAH discharge. The median HAH stay was 7 days (IQR, 4-8.75). For osteomyelitis, hospital days lowered from 8.5 days (IQR, 4.5-12) to 4 days (IQR, 3-7) after HAH implementation (P = .005) with 68% per-patient estimated cost savings. CONCLUSIONS HAH treatment of OAIs is effective and cost-efficient. Patient support by medical and nursing staff, adequate family training, and regular communication are essential to ensure safe home admission.
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Affiliation(s)
| | | | | | | | - Monica Sánchez Olivier
- Hospital at Home Program, Department of Pediatrics
- Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Lourdes Calleja Gero
- Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Raquel Jiménez García
- Hospital at Home Program, Department of Pediatrics
- Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Suárez-Bustamante Huélamo M, Alonso-Cadenas JA, Cortés BG, Goikoetxea IG, Hernández-Bou S, de la Torre Espí M. Staphylococcus aureus Bacteremia in the Pediatric Emergency Department and Predictors of Poor Outcome. Pediatr Infect Dis J 2023; 42:954-959. [PMID: 37523577 DOI: 10.1097/inf.0000000000004053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND Staphylococcus aureus has become the leading cause of bacteremia among previously healthy children older than 5 years. METHODS We aimed to describe the infants presenting to pediatric emergency departments and diagnosed with S. aureus bacteremia (SAB) and identify predictors (clinical and laboratory variables) of poor outcome (complications, sequelae or death). We performed an observational study and subanalysis of a multicenter prospective registry, including every patient under the age of 18 years with a positive blood culture obtained at any of the 22 participating Spanish pediatric emergency departments between 2011 and 2016. We considered chronic diseases, immunosuppressive treatment and the presence of mechanical devices as risk factors for SAB. RESULTS Of the 229 patients with SAB, 176 (76.9%) were previously healthy, 192 (83.8%) had a normal pediatric assessment triangle and 158 (69.0%) had an associated focal infection (mainly osteoarticular infection, skin and soft tissue infection and pneumonia). Fifty-three patients (23.1%) had 1 or more risk factors for SAB. Thirty-one (13.5%) presented a poor outcome, including 4 deaths (1.7%). A poor outcome was more common in patients with SAB risk factors [odds ratio (OR): 7.0; 95% CI: 3.2-15.4], abnormal PAT (OR: 5.9; 95% CI: 2.6-13.3), elevated procalcitonin (OR: 1.2; 95% CI: 1.05-1.3) and C-reactive protein, the latter being the only independent predictor of poor outcome (OR: 1.01; 95% CI: 1.01-1.02). CONCLUSIONS Overall, children with SAB are previously healthy, appear well, and have an associated focal infection. One of 7 had a poor outcome, with C-reactive protein being the only predictor identified.
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Affiliation(s)
| | | | - Borja Gómez Cortés
- Pediatric Emergency Department, Hospital Cruces (Barakaldo), Vizcaya, Spain
| | | | - Susanna Hernández-Bou
- Pediatric Emergency Department, Hospital Sant Joan de Déu de Barcelona (Esplugues de Llobregat), Barcelona, Spain
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Gouveia C, Subtil A, Aguiar P, Canhão H, Norte S, Arcangelo J, Varandas L, Tavares D. Osteoarticular Infections: Younger Children With Septic Arthritis and Low Inflammatory Patterns Have a Better Prognosis in a European Cohort. Pediatr Infect Dis J 2023; 42:969-974. [PMID: 37625093 DOI: 10.1097/inf.0000000000004074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
BACKGROUND Osteoarticular infections (OAI) are associated with complications and sequelae in children, whose prediction are of great importance in improving outcomes. We aimed to design risk prediction models to identify early complications and sequelae in children with OAI. METHODS This observational study included children (>3 months-17 years old) with acute OAI admitted to a tertiary-care pediatric hospital between 2008 and 2018. Clinical treatment, complications and sequelae were recorded. We developed a multivariable logistic predictive model for an acute complicated course (ACC) and another for sequelae. RESULTS A total of 240 children were identified, 17.5% with ACC and 6.0% and 3.6% with sequelae at 6 and 12 months of follow-up, respectively. In the multivariable logistic predictive model for ACC, predictors were fever at admission [adjusted odds ratio (aOR): 2.98; 95% confidence interval (CI): 1.10-8.12], C-reactive protein ≥100 mg/L (aOR: 2.37; 95% CI: 1.05-5.35), osteomyelitis (aOR: 4.39; 95% CI: 2.04-9.46) and Staphylococcus aureus infection (aOR: 3.50; 95% CI: 1.39-8.77), with an area under the ROC curve of 0.831 (95% CI: 0.767-0.895). For sequelae at 6 months, predictors were age ≥4 years (aOR: 4.08; 95% CI: 1.00-16.53), C-reactive protein ≥110 mg/L (aOR: 4.59; 95% CI: 1.25-16.90), disseminated disease (aOR: 9.21; 95% CI: 1.82-46.73) and bone abscess (OR: 5.46; 95% CI: 1.23-24.21), with an area under the ROC curve of 0.887 (95% CI: 0.815-0.959). CONCLUSIONS In our model we could identify patients at low risk for complications and sequelae, probably requiring a less aggressive approach.
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Affiliation(s)
- Catarina Gouveia
- Faculdade de Ciências Médicas, Nova Medical School
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Ana Subtil
- NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
- CEMAT, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Pedro Aguiar
- NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
| | - Helena Canhão
- NOVA Medical School, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
- Orthopaedic Unit, Paediatric Department, Hospital de Dona Estefânia, CHULC - EPE, Lisbon, Portugal
| | - Susana Norte
- NOVA Medical School, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
- Orthopaedic Unit, Paediatric Department, Hospital de Dona Estefânia, CHULC - EPE, Lisbon, Portugal
| | - Joana Arcangelo
- NOVA Medical School, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
- Orthopaedic Unit, Paediatric Department, Hospital de Dona Estefânia, CHULC - EPE, Lisbon, Portugal
| | - Luís Varandas
- Faculdade de Ciências Médicas, Nova Medical School
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Delfin Tavares
- NOVA Medical School, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
- Orthopaedic Unit, Paediatric Department, Hospital de Dona Estefânia, CHULC - EPE, Lisbon, Portugal
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Mainard N, Canavese F. News in paediatric orthopaedic surgery: an overview of the latest advances in paediatric orthopaedics and traumatology (2020-2023). INTERNATIONAL ORTHOPAEDICS 2023; 47:2113-2123. [PMID: 37300564 PMCID: PMC10257171 DOI: 10.1007/s00264-023-05858-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE We propose to survey - even if arbitrarily - the publications in paediatric orthopaedics and traumatology that have had the greatest impact on the specialty during the period extending from the beginning of the COVID-19 pandemic in December 2020 and the end of all health restrictions in March 2023. METHODS Only studies with a high level of evidence or clinical relevance were selected. We briefly discussed the results and conclusions of these quality articles to situate them in relation to the existing literature and current practice. RESULTS Publications are presented by dividing traumatology and orthopaedics whose publications are further subdivided according to anatomical districts; articles concerning neuro-orthopaedics, tumours, and infections were presented separately while sports medicine is jointly presented with knee-related articles. CONCLUSIONS Despite the difficulties encountered during the global COVID-19 pandemic (2020-2023), orthopaedic and trauma specialists, including paediatric orthopaedic surgeons, have maintained a high level of scientific output, in terms of quantity and quality of production.
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Affiliation(s)
- Nicolas Mainard
- Department of Pediatric Orthopedics, Lille University Center, Jeanne de Flandre Hospital, Avenue Eugène-Avinée, 59037, Lille Cedex, France
| | - Federico Canavese
- Department of Pediatric Orthopedics, Lille University Center, Jeanne de Flandre Hospital, Avenue Eugène-Avinée, 59037, Lille Cedex, France.
- Faculty of Medicine, Nord-de-France Lille University, 59000, Lille, France.
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