The impact of evidence-based clinical practice guidelines applied by a multidisciplinary team for the care of children with osteomyelitis

Accelerated Severity of Illness Score Enhances Prediction of Complicated Acute Hematogenous Osteomyelitis in Children

BACKGROUND

Severity of illness determination for children with acute hematogenous osteomyelitis should be accomplished during the earliest stages of evaluation to guide treatment and establish prognosis. This study objectively defines an outcome of complicated osteomyelitis and explores an illness severity-based model with an improved ability to predict this outcome as soon and accurately as possible, comparing it to existing models.

METHODS

Children with Staphylococcus aureus acute hematogenous osteomyelitis (n = 438) were retrospectively studied to identify adverse events and predictors of severity. The outcome of complicated osteomyelitis was ultimately defined as the occurrence of any major or at least 3 minor adverse events, which occurred in 52 children. Twenty-four clinical and laboratory predictors were evaluated through univariate and stacked multivariable regression analyses of chronologically distinct groups of variables. Receiver operating characteristic curve analyses were conducted to compare models.

RESULTS

Accelerated Severity of Illness Score included: triage tachycardia [odds ratio: 10.2 (95% confidence interval: 3.48-32.3], triage tachypnea [6.0 (2.4-15.2)], C-reactive proteininitial ≥17.2 mg/dL [4.5 (1.8-11.8)], white blood cell count band percentageinitial >3.8% [4.6 (2.0-11.0)], hemoglobininitial ≤10.4 g/dL [6.0 (2.6-14.7)], methicillin-resistant S. aureus [3.0 (1.2-8.5)], septic arthritis [4.5 (1.8-12.3)] and platelet nadir [7.2 (2.7-20.4)]. The receiver operating characteristic curve of Accelerated Severity of Illness Score [area under the curve = 0.96 (0.941-0.980)] were superior to those of Modified Severity of Illness Score = 0.903 (0.859-0.947), Acute Score for Complications of Osteomyelitis Risk Evaluation = 0.878 (0.830-0.926) and Chronic Score for Complications of Osteomyelitis Risk Evaluation = 0.858 (0.811-0.904). Successive receiver operating characteristic curve analyses established an exponentially increasing risk of complicated osteomyelitis for children with mild (0/285 or 0%), moderate (4/63 or 6.3%), severe (15/50 or 30.0%) and hyper-severe (33/40 or 82.5%) acute hematogenous osteomyelitis (P<0.0001).

CONCLUSIONS

This study improves upon previous severity of illness models by identifying early predictors of a rigorously defined outcome of complicated osteomyelitis.

Early Reduction in C-Reactive Protein Following Treatment for Spinal Epidural Abscess: A Potential Treatment Guide

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

To assess the predictive value of early C-reactive protein (CRP) trends following diagnosis of spinal epidural abscess (SEA). Non-operative management with intravenous antibiotics has not demonstrated equivalent outcomes with regard to mortality and morbidity. Knowledge of specific patient and disease factors associated with worse outcomes may predict treatment failure.

METHODS

All patients treated for spontaneous SEA in a tertiary centre in New Zealand over a 10-year period were followed for at least 2 years. CRP at diagnosis and day 4-5 following treatment initiation was analyzed to determine predictors of CRP reduction of at least 50%. Proportional Cox hazards regression investigated mortality over 2 years.

RESULTS

94 patients met inclusion criteria and with CRP values available for analysis. Median age was 62 years (+/- 17.7) and 59 (63%) were treated operatively. Kaplan-Meier analysis estimate of 2-year survival was .81 (95% CI .72-.88). CRP reduction by 50% was seen in 34 patients. Patients who did not experience a 50% reduction were more likely to have thoracic infection (27 vs 8, P = .02) or multifocal sepsis (41 vs 13, P = .002). Failure to achieve a 50% reduction by day 4-5 was associated with worse post-treatment Karnofsky scores (70 vs 90, P = .03) and longer hospital stay (25 days vs 17.5 days, P = .04). Cox regression model showed mortality predicted by Charlson Comorbidity Index, thoracic location of infection, pre-treatment Karnofsky score, and failure to achieve a 50% CRP reduction by day 4-5.

CONCLUSIONS

Patients who fail to reduce CRP values by 50% at day 4-5 following treatment initiation are more likely to experience prolonged hospital stay, have poorer functional outcome and have greater mortality risk at 2 years. This group has severe illness regardless of treatment type. Failure to achieve a biochemical response to treatment should prompt reassessment.

Methods to Reduce Cost of Treatment in Childhood Bone and Joint Infection: A Systematic Review

BACKGROUND

Childhood bone and joint infection (BJI) is a potentially severe disease with consequences for growth and development. Critically unwell children may require prolonged hospitalization and multiple surgeries. Acknowledging rising healthcare costs and the financial impact of illness on caregivers, increased efforts are required to optimize treatment. This systematic review aims to characterize existing costs of hospital care and summarize strategies, which reduce treatment expense.

METHODS

A systematic review of the literature was performed from January 1, 1980, to January 31, 2024. Data were extracted on hospitalization costs for pediatric BJI by decade and global region. Results have been converted to cost per day in US dollars with purchase parity for 2023. Studies reporting innovations in clinical care to reduce length of stay (LOS) and simplify treatment were identified. Studies trialing shorter antibiotic treatment were only included if they specifically reported changes in LOS.

RESULTS

Twenty-three studies met inclusion criteria; of these, a daily hospitalization cost could be derived from 7 publications. Overall hospitalization cost and inpatient charges rose steeply from the 1990s to the 2020s. By contrast, average LOS seems to have decreased. Cost per day was higher in the United States than in Europe and higher for cases with confirmed methicillin-resistant Staphylococcus aureus. Sixteen studies report innovations to optimize care. For studies where reduced LOS was achieved, early magnetic resonance imaging with immediate transfer to theater when necessary and discharge on oral antibiotics were consistent features.

CONCLUSION

Rising costs of hospital care and economic consequences for families can be mitigated by simplifying treatment for childhood BJI. Hospitals that adopt protocols for early advanced imaging and oral antibiotic switch may provide satisfactory clinical outcomes at lower cost.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

CRP Predicts the Need to Escalate Care After Initial Debridement for Musculoskeletal Infection

BACKGROUND

Musculoskeletal infections (MSKIs) are a major cause of morbidity in the pediatric population and account for nearly 1 in every 10 consultations with a pediatric orthopaedic provider at a tertiary care center. To prevent or deescalate the risk of adverse medical and musculoskeletal outcomes, timely medical intervention in the form of antibiotics and potential surgical debridement is required. While there have been numerous studies indicating the value of laboratory testing during the initial workup of a child with MSKI, few studies to date have examined the utility of longitudinal assessment of laboratory measures in the acute setting to monitor the efficacy of antibiotic therapy and/or surgical intervention. The purpose of this investigation was to retrospectively determine whether measuring changes in the inflammatory response could indicate the need for escalated care. Specifically, this study examined the hypothesis that serial measurements of C-reactive protein (CRP), immediately preoperatively and 2 days after surgical debridement, could predict the need for medical (change in antibiotics) or surgical (additional debridement) escalation.

METHODS

Retrospective review of pediatric patients undergoing operative debridement for the treatment of MSKI between September 2009 and December 2015 from whom laboratory data (CRP) was obtained preoperatively and at postoperative day (POD) 2. Patient demographics, the need for escalated care, and patient outcomes were evaluated.

RESULTS

Across 135 pediatric patients, preoperative CRP values >90 mg/L and a positive change in CRP at POD2 effectively predicted the need for escalation of care after initial surgical debridement (Area under the Receiver Operator Curve: 0.883). For each 10-unit increase in preoperative CRP or postoperative change in CRP, there was a 21% or 22% increased risk of needing escalated care, respectively. Stratification by preoperative CRP >90 mg/L and change in CRP postoperatively likewise correlated with increased rates of disseminated disease, percent tissue culture positivity, length of stay, and rate of adverse outcomes.

CONCLUSIONS

This study demonstrates the utility of serial CRP to assess the need for escalated care in patients being treated for MSKI. As serial CRP measurements become standard of practice in the acute setting, future prospective studies are needed to optimize the timing of CRP reassessment during inpatient hospitalization to prognosticate patient outcomes, weighing both improvements of patient care and clinical burden.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Osteoarticular Infections: Younger Children With Septic Arthritis and Low Inflammatory Patterns Have a Better Prognosis in a European Cohort

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.

Acute musculoskeletal infection in children: assessment and management

Musculoskeletal infection in children is challenging to treat, and includes septic arthritis, deep tissue infection, osteomyelitis, discitis and pyomyositis. Delays to diagnosis and management, and under-treatment can be life-threatening and result in chronic disability. The British Orthopaedic Association Standards for Trauma include critical steps in the timely diagnosis and management of acute musculoskeletal infection in children, the principles of acute clinical care and the service delivery requirements to appropriately manage this cohort of patients. Orthopaedic and paediatric services are likely to encounter cases of acute musculoskeletal infection in children and thus an awareness and thorough understanding of the British Orthopaedic Association Standards for Trauma guidelines is essential. This article reviews these guidelines and associated published evidence for the management of children with acute musculoskeletal infection.

Institutional performance and validation of severity of illness score for children with acute hematogenous osteomyelitis

A scoring system has recently been published that uses parameters within the first 4-5 days of hospitalization to determine the severity of illness (SOI) in children with acute hematogenous osteomyelitis (AHO). To our knowledge, no additional studies to date have examined the validity of the SOI score outside of the institution of origin. This study evaluates the performance of the SOI score in a retrospective cohort of cases at our institution. Patients admitted to our institution over the past 5 years with AHO who met inclusion and exclusion criteria were analyzed. Parameters including C reactive protein over the first 96 h of hospitalization, febrile days on antibiotics, ICU admission, and presence of disseminated disease were used to calculate the SOI score for each patient. Pearson and Spearman correlations were used when appropriate. SOI score comparison between groups was achieved with the Kruskal-Wallis and Wilcoxon two-sample tests. Seventy-four patients were analyzed. Significantly higher SOI scores were noted for patients with bacteremia, ICU admission, fever for two or more days on presentation, multiple surgeries, and any complication. Markers of disease severity that significantly correlated with SOI score were total length of stay, LOS, duration of antibiotic course, number of surgical procedures, and case mix index. The SOI score functioned well as higher scores were associated with sicker patients. The SOI score is helpful for determining which patients will require longer hospitalizations and more intense treatment in a setting other than the institution of origin.

Identifying Patient-Centered Outcomes for Caregivers and Children With Musculoskeletal Infections

Background

Musculoskeletal infections (MSKI), including osteomyelitis and septic arthritis, are among the most common invasive infections in children and have the potential to cause significant morbidity. Guidelines have been developed to optimize care based on clinician-developed endpoints. Patient-centered outcomes have not been defined for children with MSKI. This study identified outcomes most important to caregivers and patients with MSKI.

Methods

This was a single-center prospective qualitative study of children 6 months to 18 years of age hospitalized with MSKI from November 2019 to September 2021. Using design-research methods, patients and caregivers participated in interviews and/or completed journals to describe their experiences during acute infection and recovery from MSKI.

Results

A total of 51 patient/caregivers were approached to participate in the study, 35 of whom declined to participate, resulting in 8 interviews conducted and 14 journals collected from 16 patient/caregivers. From these, a journey map was created highlighting points of stress during the onset of symptoms, through hospitalization, and returning home with new challenges. In addition, patient-centered outcomes were identified. For caregivers, these included managing mental health, managing responsibilities, and receiving support. Both caregivers and patients shared the importance of understanding of treatment plans and responsibilities. For patients, improving mental and physical health was important.

Conclusions

Management of children with MSKI is complex and requires a multidisciplinary team approach. Validation of the outcomes identified and development of a measurement tool are needed. Addressing the patient-centered outcomes we identified in this study can greatly improve the holistic care of children with MSKI.

Early Transition to Oral Antimicrobial Therapy Among Children With Staphylococcus aureus Bacteremia and Acute Hematogenous Osteomyelitis

BACKGROUND

Staphylococcus aureus bacteremia (SAB) is a frequent complication of acute hematogenous osteomyelitis (AHO) in children, but data on the optimal duration of parenteral antibiotics prior to transition to oral antibiotics remains sparse. We examined clinical outcomes associated with early transition to oral antimicrobial therapy among children admitted to our institution with AHO and SAB, and evaluated the utility of a severity of illness score (SIS) to guide treatment decisions in this setting.

METHODS

Children with AHO and SAB admitted to our institution between January 1, 2009, and December 31, 2018, were retrospectively reviewed and stratified according to a previously validated SIS into mild (0-3), moderate (4-7) and severe (8-10) cohorts. Groups were assessed for differences in treatment (eg, parenteral and oral antibiotic durations, surgeries) and clinical response (eg, bacteremia duration, acute kidney injury, length of stay and treatment failure).

RESULTS

Among 246 children identified with AHO and SAB, median parenteral antibiotic duration differed significantly between mild (n = 80), moderate (n = 98) and severe (n = 68) cohorts (3.6 vs. 6.5 vs. 14.3 days; P ≤ 0.001). SIS cohorts also differed with regard to number of surgeries (0.4 vs. 1.0 vs. 2.1; P ≤ 0.001), duration of bacteremia (1.0 vs. 2.0 vs. 4.0 days; P ≤ 0.001), acute kidney injury (0.0% vs. 3.0% vs. 20.5%; P ≤ 0.001), hospital length of stay (4.8 vs. 7.4 vs. 16.4 days; P ≤ 0.001) and total duration of antibiotics (34.5 vs. 44.7 vs. 60.7 days; P ≤ 0.001). Early transition to oral antimicrobial therapy among mild or moderate SIS cohorts was not associated with treatment failure despite SAB.

CONCLUSIONS

SAB is associated with a wide range of illness among children with AHO, and classification of severity may be useful for guiding treatment decisions. Early transition to oral antimicrobial therapy appears safe in children with mild or moderate AHO despite the presence of SAB.

Clinical Scores Predict Acute and Chronic Complications in Pediatric Osteomyelitis: An External Validation

BACKGROUND

Pediatric acute hematogenous osteomyelitis (AHO) outcomes are highly dependent on the disease severity. Recently, the A-SCORE and C-SCORE, were proposed as predictors of an acute complicated course and chronic morbidity, respectively. The purpose of this study was to externally validate the A-SCORE and C-SCORE at a single institution.

METHODS

This IRB-approved retrospective chart review included AHO patients admitted at a tertiary referral hospital between October 1, 2015 and December 31, 2019. The inclusion criteria were ages 0 to 18 and clinical response to treatment. The exclusion criteria were immunocompromised status or penetrating inoculation.

RESULTS

The A-SCORE demonstrated an area under the receiver operator curve (ROC area) of >86% with regards to all acute complications. It also demonstrated sensitivities >85% and specificities >92% at the cut-off of 4 (Youden index) for all acute complications. The C-SCORE demonstrated an ROC area of 100% with regards to chronic osteomyelitis. It also demonstrated sensitivities >70% and specificities >93% for the chronic morbidity variables seen in our population at the cut-off of 3 (Youden index.).

CONCLUSIONS

These novel composite clinical scores, in combination with clinical judgment, could help guide early care decisions. The A-SCORE and C-SCORE are useful risk stratification tools in the management of pediatric AHO and in predicting acute complicated courses or chronic sequelae of AHO, respectively. These scoring systems, if integrated into standardized pediatric AHO guidelines, can allow clinicians to stratify the AHO population and guide clinical decision making.

LEVEL OF EVIDENCE

Level III (prognostic study, retrospective chart review).

Practice Variation in the Surgical Management of Children With Acute Hematogenous Osteomyelitis

INTRODUCTION

The surgical indications to manage children with acute hematogenous osteomyelitis (AHO) remain poorly defined. The purpose of this study was to identify if practice pattern variation exists in the surgical management of pediatric AHO among tertiary pediatric medical centers across the United States. A secondary purpose was to evaluate variables that may impact the rate of surgical intervention among these institutions.

METHODS

Children with AHO were retrospectively analyzed between January 1, 2010, and December 31, 2016, from 18 pediatric medical centers throughout the United States. The rates of surgery were identified. Admission vitals, labs, weight-bearing status, length of stay, and readmission rates were compared between those who did and did not undergo surgery. Multivariate regression and classification and regression tree analyses were performed to identify the variables that were associated with surgical intervention.

RESULTS

Of the 1003 children identified with AHO in this retrospective, multicenter database, 619/1003 (62%) were treated surgically. Multivariate analysis revealed institution, inability to ambulate, presence of multifocal infection, elevated admission C-reactive protein, increased admission platelet count, and location of the osteomyelitis were significant predictors of surgery (P<0.01). Patients who underwent surgery were more than twice as likely to have a recurrence or readmission and stayed a median of 2 days longer than those who did not have surgery. In the classification and regression tree analysis, 2 distinct patterns of surgical intervention were identified based on institution, with 12 institutions operating in most cases (72%), regardless of clinical factors. A second cohort of 6 institutions operated less routinely, with 47% receiving surgery overall. At these 6 institutions, patients without multifocal infection only received surgery 26% of the time, which increased to 74% with multifocal infection and admission erythrocyte sedimentation rate >37.5 mm/h.

CONCLUSIONS

This study is the first to objectively identify significant differences in the rates of surgical management of pediatric AHO across the United States. Variation in the surgical management of AHO appears to be driven primarily based on institutional practice. Twelve institutions operated on 72% of patients, regardless of the severity of disease, indicating that the institution custom or dogma may drive the surgical indications. Six institutions relied more on clinical judgment with significant variability in rates of surgical intervention (26% vs. 74%), depending on the severity of the disease. Surgical intervention is associated with increased recurrence, readmission, and hospital length of stay. As a result of these findings, it is essential to prospectively study the appropriate surgical indications and measure the outcomes in children with pediatric AHO.

LEVEL OF EVIDENCE

Level III.

Management and Prevention of Staphylococcus aureus Infections in Children

Staphylococcus aureus is a common skin commensal with the potential to cause severe infections resulting in significant morbidity and mortality. Up to 30% of individuals are colonized with S aureus, though infection typically does not occur without skin barrier disruption. Infection management includes promptly addressing the source of infection, including sites of metastatic infection, and initiation of effective antibiotics, which should be selected based on local antibiotic susceptibility patterns. Given that S aureus colonization is a risk factor for infection, preventive strategies are aimed at optimizing hygiene measures and decolonization regimens for outpatients and critically ill children with prolonged hospitalizations.

Characteristics of Children With Culture Negative Acute Hematogenous Musculoskeletal Infections

BACKGROUND

Identifying the causative pathogen for acute hematogenous musculoskeletal infections (MSKIs) allows for directed antimicrobial therapy and diagnostic confidence. However, 20% to 50% of children with acute MSKIs remain culture negative. The objective of this study was to compare characteristics of culture negative MSKI patients to those where a pathogen is identified.

METHODS

Electronic medical records of children admitted between July 2014 to September 2018 to a single quaternary care pediatric hospital with acute MSKIs were retrospectively reviewed. Clinical and demographic characteristics were compared between culture positive and culture negative MSKIs.

RESULTS

A total of 170 patients were included of whom 43 (25%) were culture negative. All culture negative patients had at least 1 culture type obtained, and the majority (84%) had both blood and source cultures performed. When compared with patients with a causative pathogen identified, culture negative patients were younger (2.3 vs. 9.8 y), smaller (13.5 vs. 31.6 kg), less likely to be febrile on arrival (56% vs. 77%), less likely to have an abscess on imaging (23% vs. 48%), and were more likely to have uncomplicated septic arthritis (35% vs. 8%). No critically ill patient was culture negative. Seven culture negative patients had additional Kingella kingae testing performed, none of which were positive.

CONCLUSIONS

Despite targeted and standardized efforts to identify causative bacteria, 25% of children with acute MSKIs never have a pathogen identified. Culture negative patients are younger, less febrile, are less likely to have an abscess, and more likely to have isolated septic arthritis.

LEVEL OF EVIDENCE

This is a retrospective cohort study interested in identifying patient characteristics that predict rate of culture positivity for acute MSKIs. This study meets criteria for Level II evidence.

Clinical guideline highlights for the hospitalist: Diagnosis and management of acute hematogenous osteomyelitis in children

Clinical practice guideline by the Pediatric Infectious Diseases Society and the Infectious Disease Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Children RELEASE DATE: August 5, 2021 PRIOR VERSION(S): n/a DEVELOPER: Pediatric Infectious Diseases Society (PIDS) and Infectious Disease Society of America (IDSA) FUNDING SOURCE: PIDS and IDSA TARGET POPULATION: Children with suspected or confirmed acute hematogenous osteomyelitis.

Clinical Presentation of Acute Osteomyelitis in the Pediatric Emergency Department

OBJECTIVES

Acute osteomyelitis is a challenging diagnosis to make in the pediatric emergency department (ED), in part because of variability in its presentation. There are limited data detailing the presenting features of pediatric osteomyelitis, factors that are essential to understand to inform diagnostic decision making. We sought to describe relevant clinical data that contributed to the diagnosis of acute osteomyelitis in children presenting to a pediatric ED.

METHODS

This was a 10-year retrospective cohort study of patients 18 years or younger diagnosed with acute osteomyelitis in the ED of a large tertiary care children's hospital. Collected data included demographics, clinical history, patient-reported symptoms, vital signs, physical examination findings, and results of basic laboratory, microbiologic, and imaging studies. Descriptive statistics were used to summarize key findings.

RESULTS

Two hundred eleven cases of acute osteomyelitis were identified during the study period. The median age was 8.4 years, with 61.1% male. One hundred twenty-seven patients (60.2%) presented to care more than once before being diagnosed. Common symptoms included pain (94.3%), functional limitation (83.9%), and fever (76.3%). Common examination findings included functional limitation (78.2%), focal tenderness (73.5%), and swelling (52.1%). One hundred seventeen patients (55.5%) were febrile during their ED evaluation. Elevated C-reactive protein (>0.8 mg/dL, 92.9%) and erythrocyte sedimentation rate (>10 mm/h, 94.3%) were the most sensitive laboratory markers.

CONCLUSIONS

Fever may be absent in up to a quarter of pediatric patients with acute osteomyelitis. Although highly sensitive, inflammatory marker elevations were more modest than those reported previously in cases of pediatric septic arthritis.

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.

Improving Care and Outcomes for Pediatric Musculoskeletal Infections

BACKGROUND

Pediatric musculoskeletal infection (MSKI) is a common cause of hospitalization with associated morbidity. To improve the care of pediatric MSKI, our objectives were to achieve 3 specific aims within 24 months of our quality improvement (QI) interventions: (1) 50% reduction in peripherally inserted central catheter (PICC) use, (2) 25% reduction in sedations per patient, and (3) 50% reduction in empirical vancomycin administration.

METHODS

We implemented 4 prospective QI interventions at our tertiary children's hospital: (1) provider education, (2) centralization of admission location, (3) coordination of radiology-orthopedic communication, and (4) implementation of an MSKI infection algorithm and order set. We included patients 6 months to 18 years of age with acute osteomyelitis, septic arthritis, or pyomyositis and excluded patients with complex chronic conditions or ICU admission. We used statistical process control charts to analyze outcomes over 2 general periods: baseline (January 2015-October 17, 2016) and implementation (October 18, 2016-April 2019).

RESULTS

In total, 224 patients were included. The mean age was 6.1 years, and there were no substantive demographic or clinical differences between baseline and implementation groups. There was an 81% relative reduction in PICC use (centerline shift 54%-11%; 95% confidence interval 70-92) and 33% relative reduction in sedations per patient (centerline shift 1.8-1.2; 95% confidence interval 21-46). Empirical vancomycin use did not change (centerline 20%).

CONCLUSIONS

Our multidisciplinary MSKI QI interventions were associated with a significant decrease in the use of PICCs and sedations per patient but not empirical vancomycin administration.

Factors influencing the implementation of clinical pharmacy services on paediatric patient care in hospital settings

OBJECTIVES

This systematic review (SR) was undertaken to identify and summarise any factors which influence the implementation of paediatric clinical pharmacy service (CPS) from service users' perspectives in hospital settings.

METHODS

Literature search from EMBASE, MEDLINE, Web of Science (Core Collection), Cochrane Library, Scopus and CINAHL databases were performed in order to identify any relevant peer-reviewed quantitative and qualitative studies from inception until October 2019 by following the inclusion criteria. Boolean search operators were used which consisted of service, patient subgroup and attribute domains. Studies were screened independently and included studies were quality assessed using Mixed Methods Appraisal Tool. The study was reported against the 'Enhancing Transparency in Reporting the Synthesis of Qualitative Research' statement.

RESULTS

4199 citations were screened by title and abstract and 6 of 32 full publications screened were included. There were two studies that were graded as 'high' in quality, with four graded as 'moderate'. The analysis has led to the identification of seven factors categorised in five predetermined overarching themes. These were: other healthcare professionals' attitudes and acceptance; availability of clinical pharmacist on ward or outpatient settings; using drug-related knowledge to perform clinical activities; resources for service provision and coverage; involvement in a multidisciplinary team; training in the highly specialised areas and development of communication skills.

CONCLUSION

Evidence for paediatric CPS was sparse in comparison to a similar SR conducted in the adult population. An extensive knowledge gap within this area of practice has therefore been identified. Nevertheless, majority of the factors identified were viewed as facilitators which enabled a successful implementation of CPS in paediatrics. Further research is needed to identify more factors and exploration of these would be necessary in order to provide a strong foundation for strategic planning for paediatric CPS implementation and development.

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.

Deciding without data: clinical decision-making in pediatric orthopedic surgery

OBJECTIVE

Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision-making, national guidelines and clinical pathways for many conditions in pediatric orthopedic surgery are limited. This study investigated decision-making rationale and quantified the evidence supporting decisions made by pediatric orthopedic surgeons in an outpatient clinic.

DESIGN/SETTING/PARTICIPANTS/INTERVENTION(S)/MAIN OUTCOME MEASURE(S)

We recorded decisions made by eight pediatric orthopedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. 'Experience/anecdote,' 'First principles,' 'Trained to do it,' 'Arbitrary/instinct,' 'General study,' 'Specific study').

RESULTS

Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were 'First principles' (n = 310, 27.0%) and 'Experience/anecdote' (n = 253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. As high as 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions.

CONCLUSIONS

With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence and help create clinical care pathways in pediatric orthopedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools and aids could also be implemented to guide these decisions.

Acute Hematogenous Osteomyelitis in Children: Clinical Presentation and Management

Acute hematogenous osteomyelitis (AHO) is a common invasive infection encountered in the pediatric population. In addition to the acute illness, AHO has the potential to create long-term morbidity and functional limitations. While a number of pathogens may cause AHO, Staphylococcus aureus is the most common organism identified. Despite the frequency of this illness, little high-quality data exist to guide providers in the care of these patients. The literature is reviewed regarding the epidemiology, microbiology and management of AHO in children. A framework for empiric therapy is provided drawing from the available literature and published guidelines.

Staphylococcus aureus Osteomyelitis: Bone, Bugs, and Surgery

Osteomyelitis, or inflammation of bone, is most commonly caused by invasion of bacterial pathogens into the skeleton. Bacterial osteomyelitis is notoriously difficult to treat, in part because of the widespread antimicrobial resistance in the preeminent etiologic agent, the Gram-positive bacterium Staphylococcus aureus Bacterial osteomyelitis triggers pathological bone remodeling, which in turn leads to sequestration of infectious foci from innate immune effectors and systemically delivered antimicrobials. Treatment of osteomyelitis therefore typically consists of long courses of antibiotics in conjunction with surgical debridement of necrotic infected tissues. Even with these extreme measures, many patients go on to develop chronic infection or sustain disease comorbidities. A better mechanistic understanding of how bacteria invade, survive within, and trigger pathological remodeling of bone could therefore lead to new therapies aimed at prevention or treatment of osteomyelitis as well as amelioration of disease morbidity. In this minireview, we highlight recent developments in our understanding of how pathogens invade and survive within bone, how bacterial infection or resulting innate immune responses trigger changes in bone remodeling, and how model systems can be leveraged to identify new therapeutic targets. We review the current state of osteomyelitis epidemiology, diagnostics, and therapeutic guidelines to help direct future research in bacterial pathogenesis.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States

Objective

Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States.

Study design

Eighteen institutions from the Children’s ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported.

Results

87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI.

Conclusion

At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 ‘rule-out’ MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution’s pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Team Approach: Pediatric Musculoskeletal Infection

A team approach is optimal in the evaluation and treatment of musculoskeletal infection in pediatric patients given the complexity and uncertainty with which such infections manifest and progress, particularly among severely ill children. The team approach includes emergency medicine, pediatric intensive care, pediatric hospitalist medicine, infectious disease service, orthopaedic surgery, radiology, anesthesiology, pharmacology, and hematology. These services follow evidence-based clinical practice guidelines with integrated processes of care so that children and their families may benefit from data-driven continuous process improvement. Important principles based on our experience in the successful treatment of pediatric musculoskeletal infection include relevant information gathering, pattern recognition, determination of the severity of illness, institutional workflow management, closed-loop communication, patient and family-centered care, ongoing dialogue among key stakeholders within and outside the context of direct patient care, and periodic data review for programmatic improvement over time. Such principles may be useful in almost any setting, including rural communities and developing countries, with the understanding that the team composition, institutional capabilities or limitations, and specific approaches to treatment may differ substantially from one setting or team to another.

Musculoskeletal Infection in Pediatrics: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection

The Second International Consensus Meeting (ICM) on Musculoskeletal Infection was held in July 2018 in Philadelphia, Pennsylvania. This meeting involved contributions from an international multidisciplinary consortium of experts from orthopaedic surgery, infectious disease, pharmacology, rheumatology, microbiology, and others. Through strict delegate engagement in a comprehensive 13-step consensus process based on the Delphi technique, evidence-based consensus guidelines on musculoskeletal infection were developed. The 2018 ICM produced updates to recommendations from the inaugural ICM that was held in 2013, which primarily focused on periprosthetic infection of the hip and the knee, and added new guidelines with the expansion to encompass all subspecialties of orthopaedic surgery. The following proceedings from the pediatrics section are an overview of the ICM consensus recommendations on the prevention, diagnosis, and treatment of pediatric musculoskeletal infection.

Quality Improvement of Magnetic Resonance Imaging for Musculoskeletal Infection in Children Results in Decreased Scan Duration and Decreased Contrast Use

BACKGROUND

Magnetic resonance imaging (MRI) is a heavily utilized resource to evaluate children suspected to have a musculoskeletal infection. Complex interdisciplinary workflows are involved with decision-making with regard to indications, anesthesia, contrast use, and procedural timing relative to the scan. This study assesses the impact of a quality improvement endeavor on MRI workflows at a tertiary pediatric medical center.

METHODS

A registry of consecutively enrolled children for a multidisciplinary musculoskeletal infection program identified those evaluated with MRI from 2012 to 2018. Annual MRI process improvement feedback was provided to the key stakeholders. Demographic characteristics, laboratory parameters, MRI indications, anesthesia use, MRI findings, final diagnoses, scan duration, imaging protocol, surgical intervention following MRI, and length of stay were retrospectively compared between the 3 cohorts (initial, middle, and final) representing 2-year increments to assess the impact of the initiative.

RESULTS

There were 526 original MRI scans performed to evaluate 1,845 children with suspected musculoskeletal infection. Anesthesia was used in 401 children (76.2%). When comparing the initial, middle, and final study period cohorts, significant improvement was demonstrated for the number of sequences per scan (7.5 sequences for the initial cohort, 5.8 sequences for the middle cohort, and 4.6 sequences for the final cohort; p < 0.00001), scan duration (73.6 minutes for the initial cohort, 52.1 minutes for the middle cohort, and 34.9 minutes for the final cohort; p < 0.00001), anesthesia duration (94.1 minutes for the initial cohort, 68.9 minutes for the middle cohort, and 53.2 minutes for the final cohort; p < 0.00001), and the rate of contrast use (87.6% for the initial cohort, 67.7% for the middle cohort, and 26.3% for the final cohort; p < 0.00001). There was also a trend toward a higher rate of procedures under continued anesthesia immediately following the MRI (70.2% in the initial cohort, 77.8% in the middle cohort, and 84.6% in the final cohort). During the final 6-month period, the mean scan duration was 24.4 minutes, anesthesia duration was 40.9 minutes, and the rate of contrast administration was 8.5%.

CONCLUSIONS

Progressive quality improvement through collaborative interdisciplinary communication and workflow redesign led to improved utilization of MRI and minimized contrast use for suspected musculoskeletal infection. There was a high rate of procedural intervention under continued anesthesia for children with confirmed musculoskeletal infection.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Experience With a Care Process Model in the Evaluation of Pediatric Musculoskeletal Infections in a Pediatric Emergency Department

OBJECTIVES

Care process models (CPMs) for certain conditions have improved clinical outcomes in children. This study describes the implementation and impact of a CPM for the evaluation of musculoskeletal infections in a pediatric emergency department (ED).

METHODS

A retrospective pre-post intervention study was performed to analyze the impact of a musculoskeletal infection CPM. Patients were identified retrospectively through electronic order history for imaging of an extremity or joint and recommended laboratory tests. Clinical outcomes evaluated included hospital length of stay (LOS), time to magnetic resonance imaging (MRI), time to administration of antibiotics, hospital admission rate, and 30-day readmission rate.

RESULTS

Musculoskeletal infection evaluations completed in the ED were reviewed from 1 year before implementation (n = 383) and 2 years after implementation (n = 1219) of the CPM. A significant improvement in the time to antibiotic administration for all patients (4.3 vs 3.7 hours, P < 0.05) and for patients with confirmed musculoskeletal infections (9.5 vs 4.9 hours, P < 0.05) was observed after the implementation of the CPM. The overall time to MRI (13.2 vs 10.3 hours, P = 0.29) and hospital LOS (4.7 vs 3.7 days, P = 0.11) were improved for all patients but were not statistically significant. The admission rate and 30-day readmission were similar before and after the implementation of the CPM.

CONCLUSIONS

The implementation of a musculoskeletal infection CPM has standardized the approach to the evaluation and diagnosis of musculoskeletal infections resulting in a significant decrease in the time to administer antibiotics and a downward trend in time to MRI and hospital LOS.

A Clinical Prediction Algorithm to Stratify Pediatric Musculoskeletal Infection by Severity

OBJECTIVE

There are currently no algorithms for early stratification of pediatric musculoskeletal infection (MSKI) severity that are applicable to all types of tissue involvement. In this study, the authors sought to develop a clinical prediction algorithm that accurately stratifies infection severity based on clinical and laboratory data at presentation to the emergency department.

METHODS

An IRB-approved retrospective review was conducted to identify patients aged 0 to 18 who presented to the pediatric emergency department at a tertiary care children's hospital with concern for acute MSKI over a 5-year period (2008 to 2013). Qualifying records were reviewed to obtain clinical and laboratory data and to classify in-hospital outcomes using a 3-tiered severity stratification system. Ordinal regression was used to estimate risk for each outcome. Candidate predictors included age, temperature, respiratory rate, heart rate, C-reactive protein (CRP), and peripheral white blood cell count. We fit fully specified (all predictors) and reduced models (retaining predictors with a P-value ≤0.2). Discriminatory power of the models was assessed using the concordance (c)-index.

RESULTS

Of the 273 identified children, 191 (70%) met inclusion criteria. Median age was 5.8 years. Outcomes included 47 (25%) children with inflammation only, 41 (21%) with local infection, and 103 (54%) with disseminated infection. Both the full and reduced models accurately demonstrated excellent performance (full model c-index 0.83; 95% confidence interval, 0.79-0.88; reduced model 0.83; 95% confidence interval, 0.78-0.87). Model fit was also similar, indicating preference for the reduced model. Variables in this model included CRP, pulse, temperature, and an interaction term for pulse and temperature. The odds of a more severe outcome increased by 30% for every 10 U increase in CRP.

CONCLUSIONS

Clinical and laboratory data obtained in the emergency department may be used to accurately differentiate pediatric MSKI severity. The predictive algorithm in this study stratifies pediatric MSKI severity at presentation irrespective of tissue involvement and anatomic diagnosis. Prospective studies are needed to validate model performance and clinical utility.

LEVEL OF EVIDENCE

Level II-prognostic study.

Validation and Modification of a Severity of Illness Score for Children With Acute Hematogenous Osteomyelitis

BACKGROUND

Children with osteomyelitis demonstrate a wide spectrum of illness. Objective measurement of severity is important to guide resource allocation and treatment decisions, particularly for children with advanced illness. The purpose of this study is to validate and improve a previously published severity of illness scoring system for children with acute hematogenous osteomyelitis (AHO).

METHODS

Children with AHO were prospectively studied during evaluation and treatment by a multidisciplinary team who provided care according to evidence-based guidelines to reduce variation. A severity of illness score was calculated for each child and correlated with surrogate measures of severity. Univariate analysis was used to assess the significance of each parameter within the scoring model along with new parameters, which were evaluated to improve the model. The scoring system was then modified by the addition of band count to replace respiratory rate. The modified score was calculated and applied to the prospective cohort followed by correlation with the surrogate measures of severity.

RESULTS

One hundred forty-eight children with AHO were consecutively studied. The original severity of illness score correlated well with length of stay and other established measures of severity. Band percent of the white blood cell differential ≥1.5% was found to be significantly associated with severity and chosen to replace respiratory rate in the model. The modified calculated severity scores correlated well with the chosen surrogate measures and significantly differentiated children with osteomyelitis on the basis of causative organism, length of stay, intensive care, surgeries, bacteremia, and disseminated or multifocal disease.

CONCLUSIONS

The findings of this study validate the previously published severity of illness scoring tool in large cohort of children who were prospectively evaluated. The replacement of respiratory rate with band count improved the scoring system.

Severity Adjusted Risk of Long-term Adverse Sequelae Among Children With Osteomyelitis

BACKGROUND

The purpose of this investigation was to evaluate the risk for long-term, adverse outcomes among children with osteomyelitis.

METHODS

Children with osteomyelitis were prospectively enrolled from 2012 to 2014. Care was accomplished by a multidisciplinary team according to an institutional algorithm. Data were collected to define the severity of illness during the initial hospitalization and assess short, intermediate and long-term outcomes. Clinical examination, radiographic assessment and functional outcome survey administration were performed at a minimum of 2 year follow-up. A comparison cohort analysis was performed according to initial severity of illness score of mild (0-2), moderate (3-6) and severe (7-10).

RESULTS

Of 195 children enrolled, 139 (71.3%) returned for follow-up at an average of 2.4 years (range, 2.0-5.0 years). Children with severe illness were less likely to have normal radiographs (severe, 4.0%; moderate, 38.2%; mild, 53.2%, P < 0.0001), and more likely to have osteonecrosis, chondrolysis, or deformity (severe, 32.0%; moderate, 5.9%; mild, 1.3%, P < 0.0001). Functional outcome measures did not significantly differ between severity categories. By regression analysis severity of illness score, plus age less than 3 years and Methicillin-resistant Staphylococcus aureus predicted severe sequelae with an area under the curve of 0.8617 and an increasing odds ratio of 1.34 per point of increase in severity score.

CONCLUSION

Long-term severe adverse outcomes among children with osteomyelitis occurred in 11 of 139 (7.9%) children and were predicted by initial severity of illness. Other risks that diminished the likelihood of complete resolution or increased the risk of severe sequelae included Methicillin-resistant Staphylcoccus aureus etiology and young age. The majority of children with osteomyelitis do not require long-term follow-up beyond the initial treatment period.

Comparison of Methicillin-resistant Versus Susceptible Staphylococcus aureus Pediatric Osteomyelitis

BACKGROUND

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) pediatric osteomyelitis has risen and been associated with a more severe clinical course than methicillin-susceptible Staphylococcus aureus (MSSA) infections. National databases have been underutilized to describe these trends. We compared demographics, clinical course, and outcomes for patients with MRSA versus MSSA osteomyelitis.

METHODS

We queried the 2009 and 2012 Healthcare Cost and Utilization Project Kids Inpatient Database for discharge records with diagnosis codes for osteomyelitis and S. aureus. We explored demographics predicting MRSA and evaluated MRSA versus MSSA as predictors of clinical outcomes including surgery, sepsis, thrombophlebitis, length of stay, and total charges.

RESULTS

A total of 4214 discharge records were included. Of those, 2602 (61.7%) had MSSA and 1612 (38.3%) had MRSA infections. Patients at Southern and Midwestern hospitals were more likely to have MRSA than those at Northeastern hospitals. Medicaid patients' odds of MRSA were higher than those with private insurance, and black patients were more likely to have MRSA compared with white patients. MRSA patients were more likely to undergo multiple surgeries compared with MSSA patients and were more likely to have complications including severe sepsis, thrombophlebitis, and pulmonary embolism. Patients with MRSA had longer lengths of stay than those with MSSA and higher total charges after controlling for length of stay.

CONCLUSION

Review of a national database demonstrates MRSA is more prevalent in the South and Midwest regions and among black patients. MRSA patients have more surgeries, complications, and longer lengths of stay.

LEVEL OF EVIDENCE

Level III.

Management of Pediatric Acute Hematogenous Osteomyelitis, Part I: Antimicrobial Stewardship Approach and Review of Therapies for Methicillin-Susceptible Staphylococcus aureus, Streptococcus pyogenes, and Kingella kingae

Acute hematogenous osteomyelitis (AHO), often occurring in young children, is the most frequently diagnosed type of osteomyelitis in pediatric patients. Optimizing antibiotics is essential as delays to receipt of appropriate therapy can lead to chronic osteomyelitis, as well as impairments in bone growth and development. Antimicrobial stewardship programs (ASPs) are in a key position to help improve the care of patients with AHO as they contain a pharmacist with expertise in antibiotic drug selection, optimization of dosing, and microbiologic test review. A literature search of the MEDLINE database was conducted from initiation through January 2018. Articles selected for the review focus on pathogen identification, pharmacokinetics and pharmacodynamics, efficacy and safety in children, transition from intravenous to oral therapy, duration of treatment, and antimicrobial stewardship interventions. This review will highlight the potential roles ASPs can have in improving the management of AHO in pediatric patients. These roles include the creation of clinical pathways, improving testing algorithms, antibiotic choice and dosing, intravenous to oral transitions, duration of treatment, and therapy monitoring. Overall, patients are most effectively treated by focusing treatments on age, presentation, local sensitivities, and directed therapy with pathogen identification.

Improved Diagnosis and Treatment of Bone and Joint Infections Using an Evidence-based Treatment Guideline

BACKGROUND

Our institution created a multidisciplinary guideline for treatment of acute hematogenous osteomyelitis (AHO) and septic arthritis (SA) in response to updates in evidence-based literature in the field and existing provider variability in treatment. This guideline aims to improve the care of these patients by standardizing diagnosis and treatment and incorporating up to date evidence-based research into practice. The primary objective of this study is to compare cases before versus after the implementation of the guideline to determine concrete effects the guideline has had in the care of patients with AHO and SA.

METHODS

This is an Institutional Review Board-approved retrospective study of pediatric patients age 6 months to 18 years hospitalized between January 2009 and July 2016 with a diagnosis of AHO or SA qualifying for the guideline. Cohorts were categorized: preguideline and postguideline. Exclusion criteria consisted of: symptoms >14 days, multifocal involvement, hemodynamic instability, sepsis, or history of immune deficiency or chronic systemic disease. Cohorts were compared for outcomes that described clinical course.

RESULTS

Data were included for 117 cases that qualified for the guideline: 54 preguideline and 63 postguideline. Following the successful implementation of the guideline, we found significant decrease in the length of intravenous antibiotic treatment (P<0.001), decrease in peripherally inserted central catheter use (P<0.001), and an increase in bacterial identification (P=0.040). Bacterial identification allowed for targeted antibiotic therapy. There was no change in length of hospital stay or readmission rate after the implementation of the guideline.

CONCLUSION

Utilizing an evidence-based treatment guideline for pediatric acute hematogenous bone and joint infections can lead to improved bacterial diagnosis and decreased burden of treatment through early oral antibiotic use.

LEVEL OF EVIDENCE

Level III- retrospective comparative study.

Pediatric Methicillin-Resistant Staphylococcus aureus Osteoarticular Infections

Osteoarticular infections (OSI) are a significant cause of hospitalizations and morbidity in young children. The pediatric patient with OSI presents unique challenges in diagnosis and management due to higher morbidity, effect on growth plate with associated long-lasting sequelae, and challenges in early identification and management. Methicillin-resistant Staphylococcus aureus (MRSA), first described in the 1960s, has evolved rapidly to emerge as a predominant cause of OSI in children, and therefore empiric treatment for OSI should include an antibiotic effective against MRSA. Characterizing MRSA strains can be done by antimicrobial susceptibility testing, detection of Panton–Valentine leukocidin (PVL) gene, staphylococcal cassette chromosome mec (SCCmec) typing, pulsed-field gel electrophoresis (PFGE), and multilocus sequence typing (MLST). Worldwide, community-onset methicillin-resistant staphylococcal disease is widespread and is mainly associated with a PVL-producing clone, ST8/USA300. Many studies have implied a correlation between PVL genes and more severe infection. We review MRSA OSI along with the pertinent aspects of its pathogenesis, clinical spectrum, diagnosis, and current guidelines for management.

EPIDEMIOLOGICAL STUDY OF OSTEOARTICULAR INFECTIONS IN CHILDREN

OBJECTIVE

To analyze the characteristics of patients diagnosed with pediatric osteoarticular infections treated in a level III trauma center in São Paulo, Brazil.

METHODS

We retrospectively analyzed patients admitted between September 2012 and August 2014. The outcomes analyzed were: age, sex, diagnosis, etiologic agent, anatomic location, time to diagnosis, history of previous trauma and infection, laboratory tests, treatment, and complications.

RESULTS

Twenty patients were included, 50% with septic arthritis, 35% with osteomyelitis, and 15% with both. Boys were predominant (80%), and the mean age was 6.6 years. The most common etiologic agent was Staphylococcus aureus. C-reactive protein value and erythrocyte sedimentation rate were elevated. The infections were treated with antibiotic therapy (intravenous and oral) and oxacillin was most frequently used. Most patients underwent at least one surgical procedure, and 35% of patients had complications.

CONCLUSION

This epidemiological mapping identified clinical and demographic characteristics which are useful for improving preparation for care. Future prospective studies with longer patient follow-up and the development of treatment protocols are needed to improve therapeutic decision-making and the prognosis of children with suspected osteoarticular infections. Evidence Level II; Prognostic studies - Investigation of the effect of patient characteristics on the outcome of the disease.

Validating an Algorithm to Predict Adjacent Musculoskeletal Infections in Pediatric Patients With Septic Arthritis

BACKGROUND

Septic arthritis is frequently associated with adjacent infections including osteomyelitis and subperiosteal and intramuscular abscesses. While often clinically indiscernible from isolated septic arthritis, the diagnosis of adjacent infections is important in determining the need for additional surgical intervention. MRI has been used as the diagnostic gold standard for assessing adjacent infection. Routine MRI, however, can be resource-intensive and delay surgical treatment. In this context, there is need for additional diagnostic tools to assist clinicians in determining when to obtain preoperative MRI in children with septic arthritis. In a previous investigation by Rosenfeld et al., an algorithm, based on presenting laboratory values and symptoms, was derived to predict adjacent infections in septic arthritis. The clinical applicability of the algorithm was limited, however, in that it was built from and applied on the same population. The current study was done to address this criticism by evaluating the predictive power of the algorithm on a new patient population.

QUESTIONS/PURPOSES

(1) Can a previously created algorithm used for predicting adjacent infection in septic arthritis among pediatric patients be validated in a separate population?

METHODS

Records for all pediatric patients (1-18 years old) surgically treated for suspected septic arthritis during a 3-year period were retrospectively reviewed (109 patients). Of these patients, only those with a diagnosis of septic arthritis confirmed by synovial fluid analysis were included in the study population. Patients without confirmation of septic arthritis via synovial fluid analysis, Gram stain, or culture were excluded (34 patients). Patients with absence of MRI, younger than 1 year, insufficient laboratory tests, or confounding concurrent illnesses also were excluded (18 patients), resulting in a total of 57 patients in the study population. Five variables which previously were shown to be associated with risk of adjacent infection were collected: patient age (older than 4 years), duration of symptoms (> 3 days), C-reactive protein (> 8.9 mg/L), platelet count (< 310 x 10 cells/µL), and absolute neutrophil count (> 7.2 x 10 cells/µL). Adjacent infections were determined exclusively by preoperative MRI, with all patients in this study undergoing preoperative MRI. MR images were read by pediatric musculoskeletal radiologists and reviewed by the senior author. According to the algorithm we considered the presence of three or more threshold-level variables as a "positive" result, meaning the patient was predicted to have an adjacent infection. Comparing against the gold standard of MRI, the algorithm's accuracy was evaluated in terms of sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

In the new population, the sensitivity and specificity of the algorithm were 86% (95% CI, 0.70-0.95) and 85% (95% CI, 0.64-0.97), respectively. The positive predictive value was determined to be 91% (95% CI, 0.78-0.97), with a negative predictive value of 77% (95% CI, 0.61-0.89). All patients meeting four or more algorithm criteria were found to have septic arthritis with adjacent infection on MRI.

CONCLUSIONS

Critical to the clinical applicability of the above-mentioned algorithm was its validation on a separate population different from the one from which it was built. In this study, the algorithm showed reproducible predictive power when tested on a new population. This model potentially can serve as a useful tool to guide patient risk stratification when determining the likelihood of adjacent infection and need of MRI. This better-informed clinical judgement regarding the need for MRI may yield improvements in patient outcomes, resource allocation, and cost.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Chronic non-bacterial osteitis from the patient perspective: a health services research through data collected from patient conferences

OBJECTIVE

Although chronic non-bacterial osteitis (CNO) is an ever-increasingly recognised illness in the paediatric community and the adult healthcare community, a study to assess diagnosing, treatment and the psychosocial aspect of CNO from a large population pool was not available. We aimed to investigate CNO from the patient perspective.

DESIGN

Health services research, patient survey.

SETTING

Ludwig-Maximilians-University (LMU) Pediatric Rheumatology Department CNO Conferences held in June 2013 and June 2015.

PARTICIPANTS

Using a patient survey developed by the LMU Pediatric Rheumatology Department, 105 patients from ages 5 to 63 years were assessed regarding CNO to include epidemiological data, medical history and treatment, initial symptoms, diagnostic procedures, current symptoms, associated diseases, current treating physicians, absences in school and work due to illness and the impact of illness on patient, family and friends.

RESULTS

Active CNO was reported in 90% of patients present, with 73% being women and 27% being men. An overwhelming majority (70%) reported being diagnosed within 18 months of onset of symptoms; however, the initial diagnoses were wide-ranged to include malignancies in 36% to bacterial osteomyelitis in 30%, where the majority were treated with an antibiotic and/or were biopsied. When asked about the psychosocial aspect of this illness, 83% reported that non-bacterial osteitis (NBO) negatively impacted the family, 79% reported that NBO has negatively affected either school or work and 56% reported a negative impact on friendships.

CONCLUSION

Delay of diagnosis, living with differential diagnoses like malignancies and finding specialists for medical care are a few examples of what leads patients into searching for more information. The negative impact on daily life including family relationships, friendships and work/school highlights a need for better psychosocial support such as guidance counselling or psychological support due to three-quarters of patients receiving no such said support.

Clinical Care Guideline for Improving Pediatric Acute Musculoskeletal Infection Outcomes

BACKGROUND

Acute pediatric musculoskeletal infections are common, leading to significant use of resources and antimicrobial exposure. In order to decrease variability and improve the quality of care, Children's Hospital Colorado implemented a clinical care guideline (CCG) for these infections. The purpose of this study is to evaluate clinical and resource outcomes PRE and POST this CCG.

METHODS

Retrospective chart review evaluated patients admitted to a large pediatric quaternary referral center (CHCO) diagnosed with acute osteomyelitis, septic arthritis, pyomyositis, and/or musculoskeletal abscess prior to and after guideline implementation. Primary outcomes included length of stay and overall antibiotic use, with additional secondary clinical, process, and therapeutic outcomes examined.

RESULTS

82 patients were identified in both the pre-CCG and post-CCG cohorts. There was a reduction in the median of all primary outcomes, including length of stay (0.6 median days decrease, P = .04), length of IV antibiotic therapy (4.9 median days decrease, P < .0001), and days of IV antibiotic therapy (6.4 median days decrease, P = .0004). Our median length of stay post-CCG was 4.9 days, the shortest reported length of stay for pediatric acute musculoskeletal infections to date. Additionally, there was a 24.5 hour reduction in median length of fever (P = .02), faster CRP normalization (P < .0001), 50% decrease in the number of related readmissions (P = .02), 34% decrease in central venous catheters placed (P < .0001), decreased time to first culture (P = .02), and 79% pathogen identification post-CCG (P = .056).

CONCLUSIONS

Implementation of a CCG for acute musculoskeletal infections improves patient, process and resource outcomes.

Acute Hematogenous Osteomyelitis in Children: Pathogenesis, Diagnosis, and Treatment

Acute hematogenous osteomyelitis (AHO) in children is an ideal condition to study due to its representation of a wide spectrum of disorders that comprise pediatric musculoskeletal infection. Proper care for children with AHO is multidisciplinary and collaborative. AHO continues to present a significant clinical challenge due to evolving epidemiology and complex pathogenesis. A guideline-driven, multidisciplinary approach has been introduced and shown to effectively reduce hospital stay, improve the timing and selection of empirical antibiotic administration, reduce delay to initial MRI, reduce the rate of readmission, and shorten antibiotic duration.

Diagnostic strategies for posttraumatic osteomyelitis: a survey amongst Dutch medical specialists demonstrates the need for a consensus protocol

Introduction

Posttraumatic osteomyelitis (PTO) is a feared complication after surgical fracture care. Late diagnosis can result in interrupted and prolonged rehabilitation programmes, inability to work, medical dependency, unnecessary hospital admissions, and high medical and non-medical costs. Primary aim of this study was to assess preferred diagnostic imaging strategies for diagnosing PTO amongst orthopaedic and trauma surgeons, radiologists, and nuclear medicine physicians. Secondary aims were to determine the preferred serum inflammatory marker for diagnosing PTO and the existence of a local hospital protocol to diagnose and manage PTO.

Materials and methods

This study utilised an online survey based on four clinical scenarios, varying from early to late onset of PTO. It was designed to assess individual practitioners’ current preferred diagnostic strategy for diagnosing PTO. Eligible study participants were medical specialists and registrars in orthopaedic and trauma surgery, musculoskeletal (MSK) radiology, and nuclear medicine.

Results

There were 346 responders: 155 trauma surgeons, 102 orthopaedic surgeons, 57 nuclear medicine physicians, and 33 MSK radiologists. Trauma surgeons favour FDG-PET to image PTO, while orthopaedic surgeons prefer WBC scintigraphy. A similar difference was seen between radiologists and nuclear medicine physicians (MRI versus nuclear medicine imaging). CRP was regarded as the most useful serum inflammatory marker. Only one-third of all responders was aware of a local hospital protocol for the treatment of osteomyelitis.

Conclusions

The availability of and awareness towards local protocols to diagnose and treat PTO is poor. The results of this study support the need for future randomised controlled trials on optimal diagnostic strategies for PTO.

Paediatric bone and joint infection

Despite advances in understanding and management, paediatric osteoarticular infections continue to pose diagnostic difficulties for clinicians. Delays in diagnosis can lead to potentially devastating morbidity.No single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively paediatric bone and joint infection. Diagnosis should be based on a combination of clinical signs, imaging and laboratory investigations. Algorithms should supplement, and not replace, clinical decision making in all cases.The roles of aspiration, arthrotomy and arthroscopy in the treatment of septic arthritis are not clearly defined. There is a very limited role for surgery in the management of acute haematogenous osteomyelitis.The ideal duration and mode of administration of antibiotic therapy for osteoarticular paediatric infection is not yet fully defined but there is increasing evidence that shorter courses (three weeks) and early conversion (day four) to oral administration is safe and effective in appropriate cases. Clear and concise antibiotic guidelines should be available based on local population characteristics, pathogens and their sensitivities.Kingella kingae is increasingly identified through polymerase chain reaction and is now recognised as the commonest pathogen in children aged under four years. Methicillin-resistant Staphylococcus aureus and Panton-Valentine leukocidin-producing strains of Staph. aureus are being increasingly reported.A multidisciplinary integrated evidence-based approach is required to optimise outcomes.Further large-scale, multicentre studies are needed to delineate the optimal management of paediatric osteoarticular infection. Cite this article: EFORT Open Rev 2017;1:7-12. DOI: 10.1302/2058-5241.2.160027.

Community-acquired Methicillin-resistant Staphylococcus aureus Musculoskeletal Infections: Emerging Trends Over the Past Decade

BACKGROUND

The emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has altered the management of pediatric musculoskeletal infections. Yet, institution-to-institution differences in MRSA virulence may exist, suggesting a need to carefully examine local epidemiological characteristics. The purpose of this study was to compare MRSA and methicillin-sensitive S. aureus (MSSA) musculoskeletal infections with respect to prevalence and complexity of clinical care over the past decade at a single children's hospital.

METHODS

We retrospectively reviewed a series of patients presenting to The Children's Hospital of Philadelphia with a diagnosis of osteomyelitis, septic arthritis, or both over a 10-year period. Inclusion criteria were S. aureus (SA) infections proven by positive culture of blood, bone, or joint aspirate. Exclusion criteria were non-SA infectious etiologies. Hospital-acquired infections were also not included to exclusively evaluate acute, community-acquired cases. Data related to hospital course, laboratory values, and number of surgical interventions were collected and compared between MRSA and MSSA cohorts.

RESULTS

In our series of pediatric patients, we identified 148 cases of acute, community-acquired musculoskeletal SA infections (MRSA, n=37 and MSSA, n=111). The prevalence of MRSA musculoskeletal infections increased from 11.8% in 2001 to 2002 to 34.8% in 2009 to 2010. Compared with MSSA, MRSA infections resulted in higher presenting C-reactive protein levels (10.4 vs. 7.8 mg/L, P=0.04), longer inpatient stays (10 vs. 5 d, P<0.01), multiple surgical procedures (n>1) (38% vs. 14%, P<0.01), increased sequelae (27% vs. 6%, P<0.01), and more frequent admissions to the intensive care unit (16% vs. 3%, P<0.01).

CONCLUSIONS

At our institution over the past decade, we found an approximate 3-fold rise in community-acquired pediatric MRSA musculoskeletal infections accompanied by an elevated risk for complications during inpatient management. Awareness of the epidemiological trends of MRSA within the local community may guide parental counseling and facilitate timely and accurate clinical diagnosis and treatment.

LEVEL OF EVIDENCE

Level II-prognostic retrospective study.

Sequential Parenteral to Oral Clindamycin Dosing in Pediatric Musculoskeletal Infection: A Retrospective Review of 30 mg/kg/d Versus 40 mg/kg/d

BACKGROUND

Children with musculoskeletal infection in methicillin-resistant Staphylococcus aureus (MRSA) prevalent communities are often treated with oral clindamycin. Current guidelines recommend approximately 40 mg/kg/d for MRSA infections. This study investigates the clinical practice of using 30 mg/kg/d of clindamycin as an alternative for outpatient dosing.

METHODS

Children with musculoskeletal infection treated with outpatient clindamycin from 2009 to 2014 were studied by retrospective review. The amount of clindamycin administered was determined from dose, interval and duration of outpatient treatment. Hospital readmission, surgeries and sequelae were assessed. Severity of illness was determined for children with osteomyelitis. The readmission rate of 25 children treated with 40 mg/kg/d was compared with that of 190 children treated with 30 mg/kg/d. The reason for readmission was evaluated to consider whether antibiotic dosing strategy was a potential factor.

RESULTS

Among 215 children studied, the average outpatient duration of treatment was 32.8 days. There was no significant difference in the rate of readmission between dosing cohorts. Severity of illness scores (0-10 scale) was significantly higher among readmitted children with osteomyelitis (mean 9.8 ± 0.4) than among those with osteomyelitis who were not readmitted (mean 2.9 ± 3.2), P = 0.001. Sequelae were more common in the high-dose group and were noted in 3 children (12%) in that cohort compared with 6 children (3.2%) in the low-dose cohort (P > 0.05).

CONCLUSION

Oral dosing of 30 mg/kg/d was effective for musculoskeletal infection in children in an MRSA prevalent community. Illness severity appeared to have greater impact on readmission and sequelae than did antibiotic dosing.

Update in Pediatric Musculoskeletal Infections: When It Is, When It Isn't, and What to Do

Musculoskeletal infections, including osteomyelitis, septic arthritis, and pyomyositis, are a substantial cause of morbidity in children and adolescents. The increased virulence of infectious agents and the increased prevalence of antimicrobial-resistant pathogens, particularly methicillin-resistant Staphylococcus aureus, have resulted in a more complicated clinical course for diagnosis and management, which is evidenced by an increased length of hospital stays, incidence of complications, and number of surgical interventions. Musculoskeletal infections are a challenge for surgeons because they vary substantially in their presentation and in their required treatment, which is based on the causative organism, the location of the infection, and the age of the patient. The necessity for a prompt diagnosis is complicated by several diseases that may mimic musculoskeletal infection, including transient synovitis, autoimmune arthritis, and tumors. Recent innovations in diagnosis and management have provided surgeons with new options to differentiate musculoskeletal infections from these rapidly evolving disease pathologies. As diagnostic and treatment modalities improve, collaboration among surgeons from multiple disciplines is required to develop evidence-based clinical practice guidelines that minimize the effect of musculoskeletal infection and optimize clinical outcomes for patients.