Acute Hematogenous Osteomyelitis in Children

Predictors of Methicillin-resistant Staphylococcus aureus infection in children with acute osteomyelitis

BACKGROUND

This study aims to identify risk factors associated with Methicillin-resistant Staphylococcus aureus (MRSA) infection in children diagnosed with acute osteomyelitis (AO) and to elucidate the laboratory characteristics of these MRSA-infected children to enhance early targeted therapeutic interventions.

METHODS

We conducted a retrospective analysis involving 123 children with acute osteomyelitis treated at our hospital. Upon admission, we measured white blood cell (WBC) counts, C-reactive protein (CRP) levels, erythrocyte sedimentation rates (ESR), and platelet counts. Patients were categorized into two groups: the non-MRSA group (n = 73) and the MRSA group (n = 50), with values assigned as follows (non-MRSA group = 0, MRSA group = 1).

RESULTS

The MRSA group had a significantly higher average age compared to the non-MRSA group (P < 0.05). Notably, the incidence of suppurative arthritis was significantly lower in the MRSA group (P < 0.05). At the time of admission, CRP levels in the MRSA group were markedly elevated compared to those in the non-MRSA group (P < 0.01). After three days of empirical therapy, both WBC and CRP levels remained significantly higher in the MRSA group compared to the non-MRSA group (P < 0.05).

CONCLUSIONS

In children newly admitted with acute osteomyelitis, a CRP level exceeding 73.23 µg/mL may indicate a high likelihood of MRSA infection. For children with AO who have been hospitalized for three days on empirical therapy, the presence of WBC > 10.95 × 10^9/L, CRP > 49.56 µg/mL, age > 3.5 years, and the absence of suppurative arthritis suggests a heightened risk of MRSA infection.

Acute Hematogenous Osteomyelitis in Pediatric Patients

This article focuses on the advancements made in diagnostic techniques and drug interventions of acute hematogenous osteomyelitis. A diagnosis necessitates a combination of factors, including inflammatory markers and imaging findings, as well as the collection of specimens for culture when feasible. Subsequently, treatment should be based on epidemiology, mechanisms of resistance, and susceptibility findings. A brief course of intravenous (IV) antibiotics, followed by oral antibiotics, may be employed for uncomplicated infections if there is improvement in the clinical condition and a decline in C-reactive protein levels. However, for complex infections caused by methicillin-resistant Staphylococcus aureus, prolonged administration of IV antibiotics is recommended, along with surgical intervention if necessary. [Pediatr Ann. 2024;53(10):e392-e395.].

Pediatric Trauma

Pediatric foot and ankle trauma includes a range of injuries affecting the lower extremities in children, typically aged from infancy to adolescence. These incidents can arise from various causes, including sports-related accidents, falls, and high-velocity injuries. Due to the dynamic growth and development of bones and soft tissues in pediatric patients, managing these injuries requires specialized knowledge and care. Early diagnosis and appropriate treatment are crucial to ensure optimal recovery and prevent potential long-term consequences. Treatment depends on severity and type of injury but may involve a combination of immobilization, physical therapy, or surgical intervention.

Chronic osteomyelitis of the clavicle in a pediatric patient: A case report

INTRODUCTION AND IMPORTANCE

Clavicular osteomyelitis, unlike the metaphysis of long bones, is a rare condition that poses a challenge for orthopedic surgeons in terms of diagnosis. The unique location of the clavicle makes it crucial to diagnose and effectively manage these non-traumatic clavicular lesions promptly. Localized pain and swelling are common symptoms experienced by patients with clavicular osteomyelitis.

CASE PRESENTATION

A 9-year-old boy presented with swelling and pain in the left clavicular area for 6 months. There was no fever or history of trauma. Physical examination revealed a tender, 2 cm by 3 cm swelling over the left clavicular area, with no abnormal findings in other body systems. This case was treated with surgical debridement and PO cloxacillin, and his condition improved.

CLINICAL DISCUSSION

To achieve an accurate diagnosis, a thorough analysis of the patient's clinical presentation, along with blood workups, radiologic studies, bacteriological studies, and histopathological studies, is essential. Treatment options for clavicular osteomyelitis may involve surgery, medical intervention, or a combination of both. Existing literature suggests that the cure rate does not significantly differ between patients who receive medical treatment and those who undergo surgery for clavicular osteomyelitis.

CONCLUSION

In evaluating non-traumatic clavicular lesions, considering chronic osteomyelitis as a potential diagnosis is important. The final diagnosis is determined through analysis of the clinical presentation, laboratory and radiographic tests, and confirmation with assistance from local culture and biopsy.

Logistic regression analysis of multiple rapid admission hematological indicators to determine the risk of osteomyelitis in infected children

To analyze the differences of multiple rapid admission hematological indicators between children with acute osteomyelitis (AO) and children with other orthopedic infectious diseases and clarify the characteristics of admission inspection hematological indicators of children with AO. Retrospective analysis of this pilot study was proceeded on 144 children with limbs infectious diseases, who were treated in our hospital. According to their final diagnosis, they were divided into osteomyelitis group (n = 57) and non-osteomyelitis group (n = 87). Case data were collected, including sex, age, body temperature, white blood cell (WBC), C-reactive protein (CRP), etc. The differences in these indexes between the two groups of patients were compared, and then, the index with significant differences was selected for univariate and multivariate logistic regression analysis. There were significant differences between the two groups in age, body temperature, CRP, ESR, fibrinogen, total bilirubin, alanine aminotransferase, aspartate aminotransferase (AST), glutamyl transpeptidase, creatinine, PCT, albumin (ALB), and ALB globulin ratio (A/G) ( P  < 0.05). The results of univariate and multivariate logistic regression analysis showed that the age of ≥5 years (4.592, 1.711-12.324), WBC (>1.5 × 10 9 /L) (0.271, 0.102-0.718), ESR (>50 mm/h) (6.410, 2.291-17.936), PCT (>0.06 µg/L) (3.139, 1.066-9.243), and AST (>40 U/L) (11.174, 1.718-72.666) was an independent risk factor of AO in children with orthopedic infectious diseases ( P  < 0.05). For newly admitted children with orthopedic infectious diseases, if the age ≥ 5 years, WBC ≤ 1.5 × 10 9 /L, ESR > 50 mm/h, PCT > 0.06 µg/L, and AST > 40 U/L, the occurrence of AO should be alerted.

Pseudoparalysis in an infant with otitis media: an evolving presentation of scapular osteomyelitis

A female infant presented to an Irish hospital with a 4-day history of fever, irritability and reduced oral intake. Initial inflammatory markers were significantly elevated, an erythematous tympanic membrane was noted on examination and an initial diagnosis of acute otitis media was made. By the third hospital day, the infant was noted to be irritable when being lifted up; pseudoparalysis of the right upper limb was observed. A radiograph of the right shoulder was normal; MRI identified acute scapular osteomyelitis with subperiosteal abscess formation. The child underwent 3 washout procedures and received 6 weeks of antibiotic therapy, with full clinical recovery at 3 months. This case highlights the importance of remaining flexible in the context of an evolving presentation and recognising hallmarks of musculoskeletal infection, fever, localised pain and pseudoparalysis. Additionally, we review the literature to highlight clues in diagnosis, treatment and outcome for paediatric acute scapular osteomyelitis.

A Case of Hematogenous Osteomyelitis in a 5-Week-Old Male

Pediatric osteomyelitis is a rare diagnosis associated with devastating consequences when treatment is delayed. We report a case of hematogenous osteomyelitis in a 5-week-old male presenting to the emergency department (ED) with a flaccid right upper extremity. In the ED, the patient was evaluated with comprehensive infectious and trauma workups. Initial CT imaging of the head and X-ray imaging of the extremity were unremarkable. C-reactive protein was elevated at 0.8; all other laboratory markers were within normal range. Over the course of the ED evaluation, the extremity weakness spontaneously resolved; however, the infant developed a fever of 100.5 F. Empiric broad spectrum antibiotics were initiated, and the infant was admitted to the pediatric service. At 48 hours following presentation, cultures resulted positive for Staphylococcus aureus and MRI imaging revealed osteomyelitis of the proximal right humeral metadiaphysis. Given the subtle presentation of early hematogenous osteomyelitis, emergency providers should maintain a high index of suspicion for infection as the underlying cause in infants presenting with a flaccid extremity.

Biofilm Producing Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in Humans: Clinical Implications and Management

Since its initial description in the 1960s, methicillin-resistant Staphylococcus aureus (MRSA) has developed multiple mechanisms for antimicrobial resistance and evading the immune system, including biofilm production. MRSA is now a widespread pathogen, causing a spectrum of infections ranging from superficial skin issues to severe conditions like osteoarticular infections and endocarditis, leading to high morbidity and mortality. Biofilm production is a key aspect of MRSA's ability to invade, spread, and resist antimicrobial treatments. Environmental factors, such as suboptimal antibiotics, pH, temperature, and tissue oxygen levels, enhance biofilm formation. Biofilms are intricate bacterial structures with dense organisms embedded in polysaccharides, promoting their resilience. The process involves stages of attachment, expansion, maturation, and eventually disassembly or dispersion. MRSA's biofilm formation has a complex molecular foundation, involving genes like icaADBC, fnbA, fnbB, clfA, clfB, atl, agr, sarA, sarZ, sigB, sarX, psm, icaR, and srtA. Recognizing pivotal genes for biofilm formation has led to potential therapeutic strategies targeting elemental and enzymatic properties to combat MRSA biofilms. This review provides a practical approach for healthcare practitioners, addressing biofilm pathogenesis, disease spectrum, and management guidelines, including advances in treatment. Effective management involves appropriate antimicrobial therapy, surgical interventions, foreign body removal, and robust infection control practices to curtail spread within healthcare environments.

First-Generation Cephalosporins for Treatment of Acute Hematogenous Osteomyelitis in Children: A Study of Efficacy and Adverse Effects

Background

Acute hematogenous osteomyelitis (AHO) is a relatively infrequent but significant infection in pediatric patients. As Staphylococcus aureus is the most common cause of AHO, intravenous and oral first-generation cephalosporins are common therapies. Cephalexin is a commonly prescribed oral therapy for pediatric AHO, although it requires frequent dosing that may affect adherence. Cefadroxil is a comparable oral first-generation cephalosporin with a more desirable dosing schedule.

Methods

We reviewed pediatric patients admitted to Mayo Clinic between March 2002 and September 2020 for management of AHO who received treatment with a first-generation cephalosporin. We reviewed timing of oral therapy transition, therapy-associated adverse effects, and recurrence of disease after completion of therapy.

Results

There were 59 patients included in the study. There was similar occurrence of adverse effects in patients receiving cefadroxil and cephalexin, although use of cefadroxil coincided with more gastrointestinal adverse effects and leukopenia and use of cephalexin with more rash and neutropenia. One secondary treatment failure occurred in our study, in a patient receiving cephalexin for treatment of septic arthritis.

Conclusions

Cefadroxil may be a reasonable alternative oral therapy for methicillin-susceptible S aureus or culture-negative AHO in pediatric patients, particularly when a less frequent dosing schedule is desired. Future study with a larger sample size is warranted.

A Child With Acute Hematogenous Osteomyelitis of the Distal Fibula and Infective Endocarditis

Acute hematogenous osteomyelitis (AHO) commonly interests the pediatric population. It typically affects the metaphyses of long tubular bones. However, the fibula is rarely involved. Regarding the hematogenous inoculation, this infection may be associated with distant foci. Herein, we present the case of a 10-year-old girl who was initially diagnosed with atypical AHO of the distal fibula complicated by a subperiosteal abscess. Upon admission, the child showed a severe septic condition, including embolic infective endocarditis (IE), which was responsible for multiple cerebral, renal, and splenic loci. AHO was successfully resolved with appropriate intravenous antimicrobial treatment targeting Staphylococcus aureus, surgical drainage, and debridement. Due to the complexity of the lesions and the embolic nature, the IE was also managed operatively with a mechanical prosthesis. The distal fibula is a rare and challenging location for AHO. EI co-infection should always be sought and suspected because, in such instances, it will genuinely complicate diagnostic and therapeutic management.

Development and performance of a multiplex PCR assay for the detection of bacteria in sterile body fluids

Aim: To assess the performance characteristics of a lab-developed multiplex PCR assay for the detection of common bacterial pathogens associated with infections in pediatric patients from normally sterile sites, such as cerebrospinal fluid, synovial and pleural fluids. Materials & methods: A total of 272 specimens were tested by PCR and traditional culture methods to assess the presence of Neisseria meningitidis, Streptococcus pneumoniae, Streptococcus pyogenes, methicillin-sensitive and methicillin-resistant Staphylococcus aureus, and Kingella kingae. Results: Compared with culture, the overall positive and negative percentage agreement of the PCR were 95.9% and 74.1%, respectively. Conclusion: This sterile body fluid PCR affords a rapid and sensitive alternative for bacterial detection, allowing for more timely pathogen-directed antimicrobial therapy.

Acute osteomyelitis of the patella due to Pseudomonas aeruginosa in an immunocompetent child: A case report

RATIONALE

Plentiful vascularity and lack of the physis are thought to render the patella less vulnerable to osteomyelitis. Pseudomonas aeruginosa (PA) is an opportunistic pathogen predominantly affecting immunocompromised hosts. Despite the ubiquitous nature of PA, osteomyelitis of the patella caused by PA has been rarely reported in children.

PATIENT CONCERNS

A 5-year-old boy who had presented with a prolonged history of the left anterior knee pain following minor trauma was diagnosed with prepatellar bacterial cellulitis and bursitis. Afterward, a focal osteolytic lesion emerged at the ventral surface of the patella despite oral and intravenous antibiotic therapy lasting for weeks. We described clinical presentation as well as medical and surgical management of pediatric patellar osteomyelitis secondary to prepatellar septic bursitis.

DIAGNOSES

Pseudomonas aeruginosa-associated osteomyelitis of the patella. Magnetic resonance imaging of the left knee showed a focal destructive change of the ventral half of the cartilaginous patella and a suprapatellar joint effusion. Bacterial culture from the bursa revealed Pseudomonas aeruginosa.

INTERVENTIONS

Systemic inflammation, patellar osteochondral destruction, and purulent synovial fluid of the knee were prolonged for 6 weeks despite antibiotics use deemed appropriate and reparative surgical debridement, whereas they were eventually resolved with a 6-week course of intravenous ceftazidime and cessation of continuous intracapsular irrigation.

OUTCOMES

He was clinically asymptomatic at the latest follow-up but exhibited a minor leg length discrepancy <2 cm associated with overgrowth of the affected femur.

LESSONS

This is a rare case of Pseudomonas osteomyelitis of the patella in a healthy pediatric patient. Uncommon osteochondral sequelae occurred probably because of a protracted arthritis of the affected knee. We would like to emphasize the ineffectiveness of continuous irrigation without antibiotics for Pseudomonas aeruginosa-associated osteomyelitis.

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.

Murine models of orthopedic infection featuring Staphylococcus aureus biofilm

Introduction: Osteomyelitis remains a major clinical challenge. Many published rodent fracture infection models are costly compared with murine models for rapid screening and proof-of-concept studies. We aimed to develop a dependable and cost-effective murine bone infection model that mimics bacterial bone infections associated with biofilm and metal implants. Methods: Tibial drilled hole (TDH) and needle insertion surgery (NIS) infection models were compared in C57BL/6 mice (female, N = 150 ). Metal pins were inserted selectively into the medullary canal adjacent to the defect sites on the metaphysis. Free Staphylococcus aureus (ATCC 12600) or biofilm suspension (ATCC 25923) was locally inoculated. Animals were monitored for physiological or radiographic evidence of infection without prophylactic antibiotics for up to 14 d. At the end point, bone swabs, soft-tissue biopsies, and metal pins were taken for cultures. X-ray and micro-CT scans were performed along with histology analysis. Results: TDH and NIS both achieved a 100 % infection rate in tibiae when a metal implant was present with injection of free bacteria. In the absence of an implant, inoculation with a bacterial biofilm still induced a 40 %-50 % infection rate. In contrast, freely suspended bacteria and no implant consistently showed lower or negligible infection rates. Micro-CT analysis confirmed that biofilm infection caused local bone loss even without a metal implant as a nidus. Although a metal surface permissive for biofilm formation is impermeable to create progressive bone infections in animal models, the metal implant can be dismissed if a bacterial biofilm is used. Conclusion: These models have a high potential utility for modeling surgery-related osteomyelitis, with NIS being simpler to perform than TDH.

Magnitude of chronic osteomyelitis and its associated factors in children as diagnosed on X-ray visiting at Felege Hiwot Comprehensive Specialized Hospital, Northwest Ethiopia: A cross-sectional study

Objectives

To assess the magnitude of chronic osteomyelitis and its associated factors in children at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia, in 2022.

Methods

A hospital-based cross-sectional study was done between April 15, 2022 and August 15, 2022, in children with an age of 18 years or below, who visited Felege Hiwot Comprehensive Specialized Hospital. A total sample size of 168 participants was involved in the study. The random sampling technique was applied to select the study participants. The data were collected from the patients, their charts, and X-ray requests. The data were cleaned, stored, checked for completeness, and entered into EpiData Version 3.1, which were then exported to SPSS Version 23 for analysis. Descriptive analysis was done, and bivariable and multivariable logistic regression were used for analysis.

Results

The prevalence of chronic osteomyelitis was found to be 86.3%. The tibia and femur were the most commonly involved bones, and metaphyseal involvement was very common. The most common radiological findings were sequestrum (56%) and involucrum (53%). Of the total patients with radiological evidence of chronic osteomyelitis, 16.6% had complications, the most common of which was a pathologic fracture (12.4%). Being male (adjusted odds ratio = 6.162, 95% confidence interval: 1.12-34.147), being over 10 years old (adjusted odds ratio = 4.048, 95% confidence interval: 1.032-15.886), living in a rural area (adjusted odds ratio = 4.046, 95% confidence interval: 1.236-13.364), having a discharging sinus (adjusted odds ratio = 5.237, 95% confidence interval: 1.393-19.693), having a clinical complaint lasting more than 1 year (adjusted odds ratio = 5.189, 95% confidence interval: 1.247-21.588), and a preceding event of trauma (adjusted odds ratio = =10.363, 95% confidence interval: 1.101-97.509) were the factors associated with chronic osteomyelitis.

Conclusion

The prevalence of chronic osteomyelitis is high. In this study, being male, being in the age group above 10 years, having rural residency, having a discharging sinus, having a clinical complaint duration of more than 1 year, and having a preceding event of trauma were the factors associated with chronic osteomyelitis. Therefore, healthcare providers should have a high index of suspicion of chronic osteomyelitis in older male children from rural areas with a chronic discharging sinus following trauma.

Efficacy and safety of vancomycin-loaded calcium sulfate versus conventional surgical debridement for pediatric acute osteomyelitis: a retrospective study

BACKGROUND

The purpose of this study was to evaluate the safety and efficacy of vancomycin-loaded calcium sulfate beads and negative-pressure wound therapy (NPWT) in treating children with acute hematogenous osteomyelitis (AHOM).

METHODS

A retrospective cohort study was conducted from January 2017 to January 2020 examining children (n = 60) with AHOM who were treated with surgical debridement followed by vancomycin-loaded calcium sulfate beads and NPWT (n = 32) and compared to treatment by conventional surgical debridement (n = 28) followed by NPWT. Conventional surgical treatment consisted of fenestration of necrotic infected bone, debridement of surrounding soft tissue, and washing of the medullary canal before the application of NPWT. In the vancomycin group, the antibiotic-loaded beads were implanted after washing the medullary canal and before the application of NPWT. Epidemiological factors, complications during the procedure, outcomes at last follow-up (30.0 ± 11.7 months, range 13-58 months), and laboratory parameters were documented and compared between the two groups.

RESULTS

Good outcomes were achieved at last follow-up in 71.4% of the conventional treatment group and 75% of the vancomycin group. In the vancomycin group, it took a mean of 4.8 ± 2.5 days for CRP levels to decrease to 50% of initial inflammatory levels compared to 13 ± 9.6 days for the conventional treatment group (p = 0.001, t-test). The conventional group also had seven patients who underwent four or more surgeries whereas no patients in the vancomycin group underwent more than three surgeries (p = 0.013, chi-square test).

CONCLUSION

Localized vancomycin delivery with NPWT effective for treating cases of AHOM that required. No perioperative adverse reactions or complications occurred from this treatment method. Based on the shortened recovery period of CRP levels, prolonged administration of post-operational parenteral antibiotics can possibly be reduced with this treatment method.

Fever and Knee Effusion in the Pediatric Patient

ABSTRACT

The pediatric patient with fever and knee effusion is always a cause for clinical concern. A thorough history and physical examination is required to guide appropriate diagnostic evaluation and management. Although pediatric knee effusions are common in the setting of trauma, the presence of fever should prompt consideration of infectious, rheumatologic, vasculitic, and malignant etiologies. This review covers the key components of the history, physical examination, diagnostic strategies, common etiologies, and initial management of the pediatric patient with fever and knee effusion.

Skeletal infections: microbial pathogenesis, immunity and clinical management

Osteomyelitis remains one of the greatest risks in orthopaedic surgery. Although many organisms are linked to skeletal infections, Staphylococcus aureus remains the most prevalent and devastating causative pathogen. Important discoveries have uncovered novel mechanisms of S. aureus pathogenesis and persistence within bone tissue, including implant-associated biofilms, abscesses and invasion of the osteocyte lacuno-canalicular network. However, little clinical progress has been made in the prevention and eradication of skeletal infection as treatment algorithms and outcomes have only incrementally changed over the past half century. In this Review, we discuss the mechanisms of persistence and immune evasion in S. aureus infection of the skeletal system as well as features of other osteomyelitis-causing pathogens in implant-associated and native bone infections. We also describe how the host fails to eradicate bacterial bone infections, and how this new information may lead to the development of novel interventions. Finally, we discuss the clinical management of skeletal infection, including osteomyelitis classification and strategies to treat skeletal infections with emerging technologies that could translate to the clinic in the future.

A Journey into Animal Models of Human Osteomyelitis: A Review

Osteomyelitis is an infection of the bone characterized by progressive inflammatory destruction and apposition of new bone that can spread via the hematogenous route (hematogenous osteomyelitis (HO)), contiguous spread (contiguous osteomyelitis (CO)), and direct inoculation (osteomyelitis associated with peripheral vascular insufficiency (PVI)). Given the significant financial burden posed by osteomyelitis patient management, the development of new preventive and treatment methods is warranted. To achieve this objective, implementing animal models (AMs) of infection such as rats, mice, rabbits, avians, dogs, sheep, goats, and pigs might be of the essence. This review provides a literature analysis of the AMs developed and used to study osteomyelitis. Historical relevance and clinical applicability were taken into account to choose the best AMs, and some study methods are briefly described. Furthermore, the most significant strengths and limitations of each species as AM are discussed, as no single model incorporates all features of osteomyelitis. HO's clinical manifestation results in extreme variability between patients due to multiple variables (e.g., age, sex, route of infection, anatomical location, and concomitant diseases) that could alter clinical studies. However, these variables can be controlled and tested through different animal models.

Is Early Surgical Intervention Necessary for Acute Neonatal Humeral Epiphyseal Osteomyelitis: A Retrospective Study of 31 Patients

Objective: To review the treatment experience of neonatal humeral epiphyseal osteomyelitis retrospectively. Study design: Retrospective cohort study of infants with neonatal humeral epiphyseal osteomyelitis. Patients were divided into conservative group and surgical group, and the surgical group was subdivided into early and delayed surgical group. Results: In total, there were 7 patients in the conservative group and 24 in the surgical group. The length of hospital stay and intravenous course of antibiotic therapy were both significantly shorter in the surgical group (p < 0.001). The full recovery rate was also higher in the surgical group (83.3%) than the conservative group (14.3%) (p < 0.001). Early surgery group (n = 14) had an insignificantly higher positive rate of pus/aspirate culture and full recovery rate than delayed surgery group (n = 10). Conclusion: Surgical treatment for neonatal humeral epiphyseal osteomyelitis demonstrated significantly higher rates of positive culture for the pathogen, a shorter course of intravenous oral antibiotics, and lower incidence of growth abnormality than conservative treatment. In our institution, most of culture outcome Gram-positive bacteria, and early surgical treatment was recommended with better outcome than delayed surgical group. Empirical antibiotics should be tailored to the epidemiological characteristics of local virulent bacteria.

Molecular Tools for Guiding Therapy in Patients With Staphylococcal Bone and Joint Infections: A Diagnostic Test Accuracy Meta-analysis

BACKGROUND

Timely detection of causative pathogens and their antimicrobial resistance are essential for guiding targeted therapies in bone and joint infections (BJI) patients. We performed a systematic review and meta-analysis to assess the diagnostic value of testing osteoarticular samples with the nucleic acid amplification tests (NAAT) for effective staphylococcal strain identification and the administration of appropriately targeted antimicrobial agents in BJI patients.

METHODS

Five databases, including PubMed, Embase, Scopus, Web of Science, and the Cochrane Library, were searched for related publications from inception to July 24, 2021. Studies comparing the diagnostic accuracy of NAAT to a microbiological culture reference standard of osteoarticular specimens were eligible. Pooled summary values of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) of NAAT compared to the microbiological culture reference standard were calculated using bivariate random-effects meta-analyses.

RESULTS

From 906 citations, 11 studies were included. Eleven studies comprising 13 datasets (n = 1047) evaluated NAAT accuracy for methicillin-sensitive Staphylococcus aureus (MSSA) identification, while seven studies comprising nine datasets (n = 727) evaluated methicillin-resistant Staphylococcus aureus (MRSA) identification. Against the microbiological culture reference standard, the pooled summary estimates for detection of both MSSA [sensitivity: 0.89 (95% confidence interval [CI] 0.84-0.93), specificity: 0.99 (95% CI 0.97-0.99), PLR: 34.13 (95% CI 20.54-56.73), NLR: 0.19 (95% CI 0.12-0.3), and DOR: 283.37 (95% CI 129.49-620.1)] and MRSA [sensitivity: 0.81 (95% CI 0.67-0.91), specificity: 1.0 (95% CI 0.99-1.0), PLR: 62.1 (95% CI 24.5-157.6), NLR: 0.33 (95% CI 0.16-0.69), and DOR: 300.25 (95% CI 85.01-1060.5)] were comparable. Heterogeneity was moderate. GeneXpert was frequently used among NAA tests, and its diagnostic accuracy was in line with the overall pooled summary estimates. The heterogeneity in diagnostic efficacy (P >0.05) could not be explained by a meta-regression and subgroup analysis of the research design, sample condition, and patient selection technique.

CONCLUSIONS

Our study suggested that NAAT can be applied as the preferred prescreening test for the timely diagnosis of staphylococcal strains associated with BJI in osteoarticular samples for successful antimicrobial therapy.

Osteomyelitis in Immunocompromised children and neonates, a case series

BACKGROUND

Osteomyelitis in immunocompromised children can present differently from immunocompetent children and can cause devastating sequelae if treated inadequately. We aim to review the aetiology, clinical profile, treatment and outcomes of immunocompromised children with osteomyelitis.

METHODS

Retrospective review of all immunocompromised children aged < 16 years and neonates admitted with osteomyelitis in our hospital between January 2000 and January 2017, and referred to the Paediatric Infectious Disease Service.

RESULTS

Fourteen patients were identified. There were 10 boys (71%), and the median age at admission was 70.5 months (inter-quartile range: 12.3-135.0 months). Causal organisms included, two were Staphylococcus aureus, two were Mycobacterium bovis (BCG), and one each was Mycobacterium tuberculosis, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia pseudomallei and Rhizopus sp. One patient had both Clostridium tertium and Clostridium difficile isolated. Treatment involved appropriate antimicrobials for a duration ranging from 6 weeks to 1 year, and surgery in 11 patients (79%). Wherever possible, the patients received treatment for their underlying immunodeficiency. For outcomes, only three patients (21%) recovered completely. Five patients (36%) had poor bone growth, one patient had recurrent discharge from the bone and one patient had palliative care for underlying osteosarcoma.

CONCLUSIONS

Although uncommon, osteomyelitis in immunocompromised children and neonates can be caused by unusual pathogens, and can occur with devastating effects. Treatment involves prolonged administration of antibiotics and surgery. Immune recovery also seems to be an important factor in bone healing.

The Antibiotic Use in Osteomyelitis Infection: A Systematic Review

Introduction: Osteomyelitis is a serious infection of the bone. One of the therapies for osteomyelitis is antibiotic treatment. Antibiotic treatment has evolved substantially, but bone infections are still a challenge. Antimicrobial therapy is also difficult, caused by antibiotic-resistant organisms.  Therefore, a systematic review is needed to assess antibiotic use in osteomyelitis infection. Method: Articles were searched using Pubmed with keywords “antibiotics”, “osteomyelitis”, and its combination. The authors used five years publication date and English language to select the appropriate journal. Result: The author identified 13 relevant articles with antibiotics use in osteomyelitis. All of the cases were about chronic osteomyelitis and osteomyelitis in diabetic foot ulcers. Osteomyelitis in other sites of long bones needs longer duration treatment than long bone osteomyelitis. In acute osteomyelitis in children, antibiotic treatment can switch from IV to oral antibiotics. Furthermore, chronic osteomyelitis needs longer treatment to resolve than acute osteomyelitis. Conclusion: Antibiotics still mainstay treatment with surgery for osteomyelitis treatment. With acute, children, and long bone only need shorter treatment than chronic, adult, and non-long bone osteomyelitis.

Predicting adjacent infections in pediatric septic arthritis: Do predictive criteria extrapolate across geographic regions?: Predicting Periarticular Infection in the Southeast

Purpose

This study aims to assess previously determined predictive criteria for presence of adjacent infection in septic arthritis within a Southeastern United States (US) pediatric population.

Results

The sensitivity, specificity, positive predictive value, and negative predictive value of the Rosenfeld criteria were: 91.7%, 22.7%, 39.3%, and 83.3%, respectively. The patients with periarticular infection were more likely to have positive blood cultures than those with isolated septic arthritis. There was no difference in likelihood of secondary surgical intervention.

Conclusions

Previously defined criteria to predict adjacent infection in pediatric septic arthritis did not demonstrate external validity in a Southeastern US pediatric population.

Fusobacterial Pelvic Osteomyelitis with Brodie's Abscess in a 10-Year-Old Boy Requiring Surgical Evacuation: A Case Report

CASE

A 10-year-old boy presented with pain in the lateral hip and buttock area and fever. Magnetic resonance imaging revealed osteomyelitis of the pelvis with extensive Brodie's abscess (2.6 × 4.5 × 10.0 cm) continuing into the pelvic cavity. Surgical evacuation through the ilioinguinal approach was performed. In prolonged culture and in polymerase chain reaction of pus, the Fusobacterium nucleatum was found.

CONCLUSION

Pelvic osteomyelitis caused by Fusobacterium is very rare. In this case, surgical treatment was required after conservative treatment with antibiotics was ineffective.

Updates and Advances: Pediatric Musculoskeletal Infection Imaging Made Easier for Radiologists and Clinicians

Infants and children often present with a wide range of musculoskeletal (MSK) infections in daily clinical practice. This can vary from relatively benign superficial infections such as cellulitis to destructive osseous and articular infections and life-threatening deep soft tissue processes such as necrotizing fasciitis. Imaging evaluation plays an essential role for initial detection and follow-up evaluation of pediatric MSK infections. Therefore, a clear and up-to-date knowledge of imaging manifestations in MSK infections in infants and children is imperative for timely and accurate diagnosis that, in turn, can result in optimal patient management. This article reviews an up-to-date practical imaging techniques, the differences between pediatric and adult MSK infections, the spectrum of pediatric MSK infections, and mimics of pediatric MSK infections encountered in daily clinical practice by radiologists and clinicians.

A Rare Presentation of Brodie Abscess in the Clavicle

A 12-year-old otherwise healthy boy presented with acute shoulder pain and remote history of trauma. Despite an unimpressive clinical examination, laboratory workup, and initial radiographic evaluation, the patient was ultimately diagnosed with a Brodie abscess of the distal clavicle. Complete resolution was achieved with débridement and tailored antibiotic therapy. These abscesses are rare, often presenting surreptitiously with nonspecific symptoms and without systemic signs of infection. Therefore, maintaining a broad differential and high clinical suspicion is crucial to mitigate the increased morbidity that can result from a delayed diagnosis.

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.

Acute Hematogenous Escherichia coli Osteomyelitis of the Fibula in an Adolescent Girl

Introduction: Acute hematogenous osteomyelitis (AHO) usually occurs in the first two decades of life. Evidence shows that 50% of patients with AHO are younger than five years. This infection typically affects the metaphyseal region of long tubular bones, whereas the fibula is rarely involved. Staphylococcus aureus is the causative agent of AHO in the majority of cases, while Escherichia coli is isolated rather uncommonly beyond the neonatal period. Case Presentation: Herein, we describe the case of an adolescent girl who was treated medically and surgically for AHO with an unusual location in the proximal fibula, caused by E. coli. The source of the causative agent remained unknown after the patient had been evaluated for possible urinary tract infection and underlying immune system defect. Conclusions: The fibula is a rare anatomic location for AHO, and such cases may pose a diagnostic challenge. Lack of response to empiric antibiotic treatment in patients with AHO may indicate the involvement of an uncommon pathogen, which is not susceptible to standard empiric antimicrobials aimed to target S. aureus as the most likely pathogen. In such instances, prompt surgical intervention can help determine the causative pathogen and optimize antimicrobial treatment.

Acute infectious osteomyelitis in children: new treatment strategies for an old enemy

BACKGROUND

Acute osteomyelitis still represents a significant clinical challenge, with an increasing incidence in paediatric population. A careful assessment and a rapid diagnosis with proper timing and choice of empirical antimicrobial therapy are necessary to avoid sequelae. The initial treatment should consist of empirical antibiotic therapy, to cover the major responsible pathogens in each age group.

DATA SOURCES

We made a literature search with PubMed and Cochrane database from 2000 to 2019 in English, French, and Spanish languages using the key words "osteomyelitis, children, clinical, diagnosis, and treatment".

RESULTS

The child's clinical features, age, and the microbiological profile of the geographic area should be evaluated for diagnosis and in the choice of antibiotic treatment. Latest data suggest the administration of intravenous antibiotics for a short period, with subsequent oral therapy, according to the improvement of clinical status and inflammatory markers. For children older than 3 months, the shift to oral medications is already possible after a short course of intravenous therapy, until recovery. The timing for the shift from cefazolin to cephalexin or cefuroxime, intravenous clindamycin to oral clindamycin, and intravenous ceftriaxone + oxacillin to oral equivalents will be decided according to the improvement of clinical status and inflammatory markers. We also present the approach to osteomyelitis due to difficult pathogens, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Panton-Valentine leukocidin (PVL)-positive S. aureus infections.

CONCLUSION

In this review, we present the current approach to the clinical diagnosis and management of osteomyelitis in childhood, with an update on recent recommendations, as a useful instrument to understand the rationale of antibiotic therapy.

Chitosan-based drug delivery systems: From synthesis strategy to osteomyelitis treatment - A review

Osteomyelitis is a complex disease in orthopedics mainly caused by bacterial pathogens invading bone or bone marrow. The treatment of osteomyelitis is highly difficult and it is a major challenge in orthopedic surgery. The long-term systemic use of antibiotics may lead to antibiotic resistance and has limited effects on eradicating local biofilms. Localized antibiotic delivery after surgical debridement can overcome the problem of antibiotic resistance and reduce systemic toxicity. Chitosan, a special cationic polysaccharide, is a product extracted from the deacetylation of chitin. It has numerous advantages, such as nontoxicity, biocompatibility, and biodegradability. Recently, chitosan has attracted significant attention in bacterial inhibition and drug delivery. Because chitosan contains many functional bioactive groups conducive to chemical reaction and modification, some chitosan-based biomaterials have been applied as the local antibiotic delivery systems in the treatment of osteomyelitis. This review aims to introduce recent advances in the biomedical applications of chitosan-based drug delivery systems in osteomyelitis treatment and to highlight the perspectives for further studies.

Vertebral osteomyelitis in an adolescent girl

We present a case of a 13-year-old girl with vertebral osteomyelitis. She had been experiencing lower back pain for 5 weeks, initially thought to be due to muscular causes. The blood culture showed no bacterial growth, and she was treated empirically only with antibiotics. She responded well to treatment and required no surgical intervention. Vertebral osteomyelitis should be in the differential diagnosis in an adolescent who complains of worsening lower back pain. Early diagnosis and treatment are essential in avoiding complications.

The Many Faces of Pediatric Chronic Recurrent Multifocal Osteomyelitis (CRMO): A Practical Location- and Case-Based Approach to Differentiate CRMO From Its Mimics

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease of childhood and adolescence characterized by episodic bone pain. Diagnosis relies heavily on whole-body MRI and is made by excluding a wide variety of other disorders with overlapping imaging features, depending on location, marrow distribution, and the presence or absence of multifocality. We present an overview of the clinical and imaging features of CRMO and, through various clinical scenarios, provide tips for tailoring the differential diagnosis based on location and distribution of encountered abnormalities. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

Gonococcal osteomyelitis in a pediatric patient with disseminated gonococcal infection: Implications for antimicrobial management

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Cases of gonococcal osteomyelitis are rare but potentially debilitating, with little consensus on risk factors or treatment.

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We present a case of septic arthritis complicated by gonococcal osteomyelitis in an adolescent.

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Prolonged treatment relative to gonococcal arthritis might be needed for ideal outcomes in secondary osteomyelitis.

We report a case of a female teenager with gonococcal septic arthritis of the right shoulder that also caused osteomyelitis of the humeral head. Infection with Neisseria gonorrhoeae is a frequently diagnosed sexually transmitted infection in the sexually active teenage population and disseminated gonococcal infection (DGI) is the most common systemic manifestation of acute gonorrhea. DGI commonly involves acute arthritis, tenosynovitis and dermatitis with less common complications of endocarditis, hepatitis and meningitis. In contrast, osteomyelitis has only rarely been reported as a result of gonococcal infection. Clinicians need to be aware of this unusual manifestation of DGI as a prolonged duration of antimicrobial treatment may be needed to assure complete resolution of this infection.