Osteomyelitis In Children Research Articles

Pediatric Q Fever.

The non-specific presentation of acute Q fever makes it difficult to diagnose in children, but untreated Q fever can result in chronic infections that have severe complications. Pediatric Q fever cases continue to be infrequently reported in the literature, and primarily document cases of persistent infections with Coxiella burnetii. Standardized treatment protocols for chronic Q fever in children still do not exist. Doxycycline and hydroxychloroquine are the treatment combination most utilized by healthcare providers to treat Q fever endocarditis or osteomyelitis in children, but a variety of other antibiotic combinations have been reported with varying results. The use of adjunctive therapies, such as such as interferon gamma, has produced mixed outcomes. The true impact of Coxiella burnetii on the health of children remains unknown; long-term longitudinal follow-up of children with acute or chronic Q fever has not been reported. Both the acute and chronic forms of Q fever are underreported and underdiagnosed. Healthcare providers should consider Q fever in pediatric patients with culture-negative endocarditis or osteomyelitis.

Characteristics and outcomes of osteomyelitis in children with sickle cell disease: A 10-year single-center experience.

Patients with sickle cell disease (SCD) are at increased risk for osteomyelitis (OM). Diagnosis of OM in SCD is challenging as the clinical presentation is similar to a vasoocclusive crisis (VOC) with no diagnostic gold standard. We report characteristics and outcomes of OM in SCD patients treated at our center over 10-year period. We conducted a retrospective analysis of patients with SCD who were treated for OM at our center over a 10-year period (2006-2016). Cases were identified utilizing radiology data mining software. Radiology reports and medical charts of potential OM cases were reviewed. Twenty-eight children with SCD were treated for OM at our institution. Patients treated for OM were largely similar to patients treated for a VOC. However, patients treated for OM had significantly higher C-reactive protein (10 mg/dL vs 5.58 mg/dL, P = 0.03) and erythrocyte sedimentation rate (60 mm/h vs 47 mm/h, P = 0.02). Magnetic resonance imaging (MRI) findings were consistent with OM in 18 (64%) patients and indeterminate in the remaining. Based on clinical, laboratory, and radiological findings, the diagnosis of OM was considered confirmed in 3 patients, probable in 6 patients, and presumed in 19 patients. Nontyphoidal Salmonella was isolated from cultures in 9 (32%) patients, while no organism was identified in 19 (67%) patients. All patients were treated with antibiotics. Six patients (21%) required surgical interventions. OM continues to pose diagnostic challenges. Most patients are treated for OM without definitive confirmation. Nontyphoidal Salmonella was the only organism identified in our cohort.

Systematic Review of Kingella kingae Musculoskeletal Infection in Children: Epidemiology, Impact and Management Strategies.

Kingella kingae, a pathogen often responsible for musculoskeletal infections in children is the most common cause of septic arthritis and osteomyelitis in children 6 to 36 months of age. The aim of this study was to perform a systematic review of previous studies to determine the proportion of K. kingae in bacteriologically proven musculoskeletal infections among the pediatric population. A secondary objective was to describe the diagnostic strategies and outcome of patients with musculoskeletal infections caused by K. kingae. A systematic review was conducted to identify publications that report on musculoskeletal infections caused by K. kingae in the pediatric population (patients 0 to <18 years old with microbiologic culture and/or polymerase chain reaction (PCR) confirmation of K. kingae and a description of the musculoskeletal infection involved). Of 144 studies included in this review, we sought to determine the proportion of K. kingae pediatric musculoskeletal infections. A total of 711 (30.8%) out of 2308 pediatric cases with culture and/or PCR proven musculoskeletal infections had K. kingae successfully identified from twenty-nine studies. Of the 1070 patients who were aged less than 48 months, K. kingae was the organism identified in 47.6% of infections. We found the average age from the collated studies to be 17.73 months. Of 520 pediatric musculoskeletal patients in which K. kingae infections were identified and where the studies reported the sites of infection, a large proportion of cases (65%) were joint infections. This was followed by 18.4% osteoarticular infection (concomitant bone and joint involvement), with isolated bone and spine at 11.9% and 3.5%, respectively. Twenty-one papers reported clinical and laboratory findings in children with confirmed K. kingae infection. The median temperature reported at admission was 37.9°C and mean was 38.2°C. Fourteen studies reported on impact and treatment, with the majority of children experiencing good clinical outcome and function following antibiotic treatment with no serious orthopaedic sequelae.

P646 Cardiac tamponade as initial manifestation of small cell lung carcinoma

Abstract We report the case of a 69 years old woman, ex-smoker, with a history of hypertension, dyslipidemia, diabetes and right leg partial amputation after childhood osteomyelitis, presented at the emergency department for dyspnoea, posterior thoracic pain and progressive distention of the abdomen. She was tachycardic, slightly hypoxemic but normotensive. Electrocardiography: sinus tachycardia, normal axis, diffuse microvoltage and electric alternans. Chest X-ray showed enlarged cardiac silouhette, bilateral pleural effusion and upper right pulmonary lobe consolidation. Transthoracic echocardiography revealed large pericardial effusion, swinging heart, right atrial and right ventricular colapse, significant respiratory variation of transmitral and transtricuspidian flow, dilated inferior vena cava without respiratory variation, all suggesting cardiac tamponade. Computed tomography showed a mediastinal and pulmonary mass in the upper right pulmonary lobe, invading the posterior right thoracic wall and multiple mediastinal voluminous lymphadenopaty and ascites. She became hypotensive and was transferred to a tertiary hospital for urgent drainage of pericardial effusion. Over 1200 mL of serohematic fluid was evacuated with the removal of the drainage catheter in the following 48 hours. A biopsy was performed through bronchoscopy and small cell carcinoma of the lung was diagnosed. Considering the advanced stage of the carcinoma the option of pallative treatment was pursued. Discussions Chronic accumulation of large amounts of pericardial fluid is well tolerated, especially in patients that have limited physical activity. Ecocardiography allows early detection of cardiac tamponade. Development of cardiac tamponade in the evolution of malignancy confers a poor prognosis. The particularity of the case Cardiac tamponade as initial manifestation of lung cancer is a very rare occurrence and only limited data exist in literature. Conclusion Simultaneous presence of ascites, pleural and pericardial effusion should rise the suspicion of malignancy. Abstract P646 Figure.

The peculiarities and treatment outcomes of the spinal form of chronic non-bacterial osteomyelitis in children: a retrospective cohort study.

Chronic non-bacterial osteomyelitis (CNO) is a group of immune-mediated diseases which appears in bone inflammation, destruction and some orthopaedic consequences, especially in the cases of spinal involvement. This study is to compare characteristics and treatment outcomes of CNO patients with spinal involvement. The retrospective cohort study included data from 91 pediatric patients with CNO. The diagnosis is based on Jannson's criteria with morphological confirmation (nonspecific chronic inflammation). Spine involvement detected by X-ray, computed tomography, magnetic resonance imaging, and bone scan in 29 (31.9%) patients. No differences in the family history, concomitant immune-mediated diseases between spinal (SpCNO) and peripheral (pCNO) forms of CNO have been revealed. Only 5 (10.2%) SpCNO patients (10.2%) had monofocal monovertebral involvement. The main risk factors of spinal involvement were female sex: RR = 2.0 (1.1; 3.9), sensitivity (Se) = 0.66, specificity (Sp) = 0.6; multifocal involvement: RR = 2.1 (0.9; 5.0), Se = 0.83, Sp = 0.37; no foot bones involvement: RR = 3.1 (1.3; 7.5), Se = 0.83, Sp = 0.5; sternum involvement RR = 2.3 (1.3; 4.1), Se = 0.24, Sp = 0.94. In the linear regression analysis only female sex (p = 0.005), multifocal involvement (p = 0.000001) and absence of foot bones involvement (p = 0.000001) were independent risk factors of spinal involvement (p = 0.000001). The response rate on bisphosphonates and tumor necrosis factor-a inhibitors was 90.9% and 66.7%, consequently. Only 4/29 (13.8%) SpCNO patients underwent surgery due to severe spinal instability or deformities. The spinal involvement is frequent in CNO and could be crucial for choosing a treatment strategy. Bisphosphonates and TNFa-inhibitors could be effective treatment options for severe SpCNO.

Clinical and Magnetic Resonance Imaging (MRI) Decision Making Rules in Differentiating Vaso-Occlusive Crises (VOCs) from Osteomyelitis in Paediatric Sickle Cell Population: Is MRI Pathognomonic?

Objectives: Distinguishing between acute presentations of osteomyelitis (OM) and vaso-occlusive crisis (VOC) bone infarction in children with sickle cell disease (SCD) remains challenging for clinicians, particularly in culture-negative cases. VOC and osteomyelitis have a very similar presentation in the acute stage, and both are associated with a rise in C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR). The gold standard to diagnose osteomyelitis is obtaining a positive blood culture and bone/joint biopsy which is invasive and not frequently done. Standard magnetic resonance imaging (MRI) with fat suppression sequencing (subtraction technique) may help to confirm osteomyelitis in SCD patients; however, this is frequently not done in a timely manner and is associated with false positive and false negative results. The objective of this study is to assess the discriminative impact of baseline variable and build a score to assess the diagnosis of osteomyelitis in pediatric patients with SCD. Methods: A retrospective study of all patients with SCD, aged 1 to 18 years old with suspected osteomyelitis. The study covered a period of over 4 years (January 2015- June 2019) at Sultan Qaboos University Hospital, which is the main tertiary care and referral facility in Oman. All the patients were subjected to a complete clinical assessment, laboratory blood tests including, CBC, CRP, blood and aspirated fluid (if applicable) culture, and standard MRI with fat suppression sequencing of the affected bone. A clinical and laboratory score was designed to test whether it can help to prove or disprove the diagnosis in likely cases (Table 1). Results: A total of 43 patients fulfilled the inclusion criteria. Their mean age was 8.7 years +/-3.4. Male to female ratio was 1.87:1. All patients have been initiated on antibiotic therapy as osteomyelitis based on the clinical suspicion and MRI findings. The mean score in the 11 patients with confirmed osteomyelitis was 11/13. Thirteen patients were classified as likely osteomyelitis. Their mean score was 7.5/13. Seventeen patients were confirmed to have VOC by the clinical course (fast resolution of fever, local signs of inflammation and the drop in inflammatory markers). Their mean score was 5.7/13 (Table 2). Conclusion: Differentiating VOC from osteomyelitis in children with SCD who present with fever and bone pain is a difficult task. Our proposed score assigned different mean score to different clinical entity (confirmed OM vs. likely OM vs. VOC). This score may assist clinicians to differentiate these entities. A larger prospective study is needed to confirm and validate the score. Disclosures Tbaileh: Sultan Qaboos University Hospital: Other: Data Collection, Data Input , Discussion of data with my seniors. Al-Khabori:Roche: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; SOBI: Honoraria; AstraZeneca: Honoraria; NovoNardisk: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees; Shire (Takeda): Membership on an entity's Board of Directors or advisory committees. Wali:Sultan Qaboos University Hospital: Employment.

391. Septic Arthritis and Acute Hematogenous Osteomyelitis in Children: Disease-Specific Antibiogram and Implications for Treatment

BackgroundOsteomyelitis and septic arthritis are common pediatric musculoskeletal infections with potential to cause significant morbidity. Empiric antibiotic selection is made prior to the availability of microbiologic data. The aim of this study was to compare the epidemiology of osteoarticular infections (OAI) to antibiotic regimens and local antibiograms.MethodsA retrospective study was performed on patients aged 6 months to 18 years with a diagnosis of septic arthritis or acute hematogenous osteomyelitis in a large, free-standing children’s hospital between July 2012 and July 2017. Exclusion criteria were chronic osteomyelitis, prior trauma or surgery at the site, noninfectious arthritis, and Lyme arthritis. Data collected from the electronic medical record included demographics, initial and discharge antibiotic therapy, and microbiologic results. Data were compared with the local antibiogram during the same time period.ResultsA total of 207 patients were included: 66 patients <4 years (< 4Y) and 141 patients ≥4 years (≥4Y). Causative pathogens were identified in 70% of patients. Staphylococcus aureus comprised 55% of positive results in children < 4Y and 73% in children ≥4Y. Among S. aureus cultures, 70–76% were methicillin sensitive (MSSA). Overall clindamycin susceptibility was 97%, with all resistant strains detected in children ≥4Y with MSSA. This is strikingly different than the institutional antibiogram showing 79% overall clindamycin sensitivity in S. aureus [82% in MSSA, 72% in methicillin resistant (MRSA)]. Kingella kingae was exclusively identified in children <4Y (21% of positives), which was also the group with the highest rate of culture-negative infection (41%). Intravenous clindamycin alone was the most frequent initial antibiotic regimen, prescribed for 41% of all patients. Initial antibiotic regimens matched organism susceptibilities in 90% of MRSA and 100% of MSSA infections.ConclusionOur study revealed high rates of clindamycin-susceptible S. aureus in older children and K. kingae and culture-negative infection in children < 4 years with OAI. Antibiotic susceptibilities differing from our institutional antibiogram suggest that disease-specific antibiograms will aid with empiric treatment decisions.Disclosures All authors: No reported disclosures.

Overview of Paediatric Bone and Joint Infections

Paediatric bone and joint infections are common, and can be challenging to diagnose due to significant variation in the signs and symptoms depending on the age of the patient, site of infection and causative organism. Both septic arthritis and osteomyelitis are common, often co-existing. Surgeons must have a consistent approach to investigation and management of these patients to minimise morbidity from unrecognised or undertreated infection. We provide an overview of the epidemiology, presentation, investigation and management of both septic arthritis and osteomyelitis in children.

Chronic nonbacterial osteomyelitis in children: a multicenter case series.

Chronic nonbacterial osteomyelitis (CNO) is a primary autoinflammatory bone disease that presents more frequently in children and is characterized by inflammatory bone lesions in the absence of an infectious etiology. There is little information of this disease in Latin America. The objective of the study was to evaluate demographic, clinical, laboratory, imaging, histopathology characteristics, and treatment responses of pediatric CNO patients. The clinical records of 19 patients with CNO diagnosed between 2007 and 2019 at three tertiary centers in Santiago, Chile were reviewed. The median age of onset was 10years and 47% were female. Median delay in diagnosis was 12months. All patients had a pattern of recurrent multifocal disease. 37% of patients had positive antinuclear antibodies and 16% HLA-B27 positivity. 21% of patients presented arthritis or other rheumatologic comorbidity, although no association with psoriasis, inflammatory bowel disease (IBD) or palmoplantar pustulosis (PPP) was observed. Eighteen patients received treatment with nonsteroidal anti-inflammatory drugs with partial response. Twelve patients received methotrexate, and half of them received steroids at the same time reaching remission in 50%. Of the five patients who received bisphosphonates, 60% achieved remission. All four patients who received adalimumab had comorbid arthritis and 75% achieved remission. In a series of Chilean children with CNO, all patients presented with multifocal lesions. Comorbid autoimmune diseases including arthritis were frequent, but no association was observed with psoriasis, IBD, or PPP.

Acute hematogenous osteomyelitis in children: a case series

Background Chronic osteomyelitis is still a major cause of morbidity and disability in children living in developing countries. Neglect of acute osteomyelitis and its progression to chronic osteomyelitis leads to significant morbidity. This report is the first series to describe such cases in Indonesia.&#x0D; Objective To describe 12 pediatric cases of chronic osteomyelitis in order to remind clinicians about the debilitating complications of musculoskeletal infection.&#x0D; Methods This report is a case series of 12 children with chronic osteomyelitis admitted to dr. Soetomo General Hospital, Surabaya, East Java, in 2011-2017. We acquired data from medical records. The patients’ quality of life was measured using the Child Health Assessment Questionnaire Disability Index (C-HAQ-DI).&#x0D; Results The patients’ mean age was eight years and they were predominantly male. The most common infection location was the femur (7/12). Microbial cultures were positive in 9/12 of cases, predominantly with Staphylococcus aureus. Erythrocyte sedimentation rate (ESR) was elevated in 11 patients. All patients were diagnosed late, with an average delay of presentation to Orthopedics of 10.5 months. Most of patients experienced mild to moderate disability after the disease, as assessed by the C-HAQ-DI.&#x0D; Conclusion Diagnosis of osteomyelitis in children is quite difficult, given the lack of specific diagnostic tests. Delayed diagnosis and inappropriate treatment may result in long-term morbidity and disability. Clinicians should have an increased awareness of the clinical features of osteomyelitis, including unusual presentations such as calcaneal osteomyelitis.

Chronic recurrent multifocal osteomyelitis in children with hypophosphatasia explained by anti-inflammatory nucleotidase activity of tissue nonspecific alkaline phosphatase in mesenchymal and hematopoietic cells

Chronic recurrent multifocal osteomyelitis in children with hypophosphatasia explained by anti-inflammatory nucleotidase activity of tissue nonspecific alkaline phosphatase in mesenchymal and hematopoietic cells

Tobramycin-impregnated calcium sulfate pellets for the treatment of chronic osteomyelitis in children and adolescents.

The aim of this work was to evaluate the outcome and efficacy of treatment in a homogeneous group of skeletally immature patients with chronic osteomyelitis of the long bones managed by a combination of radical debridement and insertion of tobramycin-impregnated calcium sulfate pellets to fill the bone defect in a single-stage procedure. Between 2011 and 2016, 12 skeletally immature patients were treated surgically by the reported technique. Single-stage surgery using tobramycin-impregnated calcium sulfate pellets in association with systemic antibiotic therapy yields satisfactory outcomes in skeletally immature children presenting chronic osteomyelitis by reducing the risk of occurrence of comorbidities, hospital stays, and healthcare costs.

Hematogenous Osteomyelitis in Childhood Can Relapse Dozens of Years in Adulthood

Hematogenous Osteomyelitis in Childhood Can Relapse Dozens of Years in Adulthood

An untapped potential for imaging of peripheral osteomyelitis in paediatrics using [18F]FDG PET/CT\xa0\u2014the inference from a juvenile porcine model

PurposeTo examine parameters affecting the detection of osteomyelitis (OM) by [18F]FDG PET/CT and to reduce tracer activity in a pig model.Background[18F]FDG PET/CT is recommended for the diagnosis of OM in the axial skeleton of adults. In children, OM has a tendency to become chronic or recurrent, especially in low-income countries. Early diagnosis and initiation of therapy are therefore essential. We have previously demonstrated that [18F]FDG PET/CT is promising in juvenile Staphylococcus aureus (S. aureus) OM of peripheral bones in a pig model, not failing even small lesions. When using imaging in children, radiation exposure should be balanced against fast diagnostics in the individual case.MethodsTwenty juvenile pigs were inoculated with S. aureus. One week after inoculation, the pigs were [18F]FDG PET/CT scanned. PET list-mode acquired data of a subgroup were retrospectively processed in order to simulate and examine the image quality obtainable with an injected activity of 132 MBq, 44 MBq, 13.2 MBq, and 4.4 MBq, respectively.ResultsAll lesions were detected by [18F]FDG PET and CT. Some lesions were very small (0.01 cm3), and others were larger (4.18 cm3). SUVmax was higher when sequesters (p = 0.023) and fistulas were formed (p < 0.0001). The simulated data demonstrated that it was possible to reduce the activity to 4.4 MBq without compromising image quality in pigs.Conclusions[18F]FDG PET/CT localized even small OM lesions in peripheral bones. It was possible to reduce the injected activity considerably without compromising image quality, impacting the applicability of PET/CT in peripheral OM in children.

04:03 PM Abstract No. 303 Percutaneous image-guided bone biopsy for suspected pediatric osteomyelitis

Osteomyelitis in children can produce significant debilitation and broadly includes infectious (acute and chronic) and non-infectious osteomyelitis, including chronic recurrent multifocal osteomyelitis (CRMO). Biopsy is often performed to aid in diagnosis and to identify the pathogen, frequently in cases wherein best management, based on clinical presentation, is ambiguous. The aim of our study was to characterize the yield and assess efficacy of image-guided bone biopsy for pediatric osteomyelitis. This was a retrospective review of patients with suspected osteomyelitis based on clinical data and imaging who underwent percutaneous bone biopsy in interventional radiology over a 10-year period at a tertiary pediatric hospital. Review parameters included procedural technical data and clinical data, including details of clinical presentation and microbiology and pathology results. 40 patients (mean age 9.5y, range 0.4-25.8y) underwent biopsy. Fluoroscopy was used in 29 cases, with rotational CT in 16 cases. Of these 16, Syngo iGuide guidance software was used in 9 cases, and MRI overlay was used in 4. CT guidance was used in 9. Additional US guidance for adjacent soft tissue component was used in 17 cases. Mean procedure time was 85 minutes, and mean fluoroscopy time was 3.6 min. A 16G bone biopsy cannula was utilized in 34 cases; a 13G cannula in 5; and an 11G in 1 case. The mean number of bone cores obtained was 3.6. Biopsy culture yielded a pathogen in 4 of 40 cases, and culture results did not show significant correlation with lesion location, fever, leukocytosis/blood culture, ESR/CRP, number of cores, instrument gauge, or aspiration of marrow. There was pathology adequacy in 100%. Based on culture and pathology results, 22 patients were diagnosed with infectious osteomyelitis (13 chronic and 9 acute) and were placed on antibiotic therapy. Fifteen patients were diagnosed with CRMO, based on pathology result. Although culture yield of bone biopsy was low, pathology results showed adequacy and aided in management of patients with suspected osteomyelitis. Results support bone biopsy as a safe and effective means to aid in management of pediatric osteomyelitis.

The challenge of differentiating vaso-occlusive crises from osteomyelitis in children with sickle cell disease and bone pain: A 15-year retrospective review.

PurposeThe paediatric sickle cell disease (SCD) osteomyelitis (OM) incidence is 0.3% to 12%. Differentiating vaso-occlusive crises (VOC) from OM is a diagnostic challenge, with limited evidence guiding management. We present a 15-year review of a paediatric sickle cell cohort. We aim to identify OM incidence and provide a management protocol for these children presenting with bone pain.MethodsA prospective database of children with haemoglobinopathies (2002 to 2017) was analyzed for temperature, C-reactive protein (CRP) and white cell count (WCC) on admission as well as imaging, treatment and cultures. OM diagnosis was supported by imaging and blood cultures. VOC was defined as bone pain that improved without antibiotics.ResultsOver 15 years, 96 children with SCD presented 358 times to hospital. Empirical antibiotics were given in 308 presentations. There were five cases of OM (1.4%); two acute and three chronic. In all, 50 presentations of VOC were identified. No significant differences in age were noted between the OM and VOC group. Temperature and CRP were significantly elevated in the OM group with no significant difference in WCC. Cultures were only positive in the chronic OM admissions. There were no cases of septic arthritis. No surgical intervention was required.ConclusionIn children with SCD presenting with persistent bone pain, fever, elevated CRP and WCC, OM should be suspected and prompt antibiotic treatment started. Our treatment pathway was successful avoiding OM in 98.6% and septic arthritis in 100%. Further research on novel biological markers distinguishing OM from VOC should be investigated.Level of EvidenceIII

The challenge of differentiating vaso-occlusive crises from osteomyelitis in children with sickle cell disease and bone pain: A 15-year retrospective review

Purpose The paediatric sickle cell disease (SCD) osteomyelitis (OM) incidence is 0.3% to 12%. Differentiating vaso-occlusive crises (VOC) from OM is a diagnostic challenge, with limited evidence guiding management. We present a 15-year review of a paediatric sickle cell cohort. We aim to identify OM incidence and provide a management protocol for these children presenting with bone pain. Methods A prospective database of children with haemoglobinopathies (2002 to 2017) was analyzed for temperature, C-reactive protein (CRP) and white cell count (WCC) on admission as well as imaging, treatment and cultures. OM diagnosis was supported by imaging and blood cultures. VOC was defined as bone pain that improved without antibiotics. Results Over 15 years, 96 children with SCD presented 358 times to hospital. Empirical antibiotics were given in 308 presentations. There were five cases of OM (1.4%); two acute and three chronic. In all, 50 presentations of VOC were identified. No significant differences in age were noted between the OM and VOC group. Temperature and CRP were significantly elevated in the OM group with no significant difference in WCC. Cultures were only positive in the chronic OM admissions. There were no cases of septic arthritis. No surgical intervention was required. Conclusion In children with SCD presenting with persistent bone pain, fever, elevated CRP and WCC, OM should be suspected and prompt antibiotic treatment started. Our treatment pathway was successful avoiding OM in 98.6% and septic arthritis in 100%. Further research on novel biological markers distinguishing OM from VOC should be investigated. Level of Evidence III

The role of real-time PCR testing in the investigation of paediatric patients with community-onset osteomyelitis and septic arthritis.

Culture yield in osteomyelitis and septic arthritis is low, emphasising the role for molecular techniques. The purpose of this study was to review the laboratory investigation of childhood osteomyelitis and septic arthritis. A retrospective review was undertaken in an acute tertiary referral paediatric hospital from January 2010 to December 2016. Cases were only included if they had a positive culture or bacterial PCR result from a bone/joint specimen or blood culture, or had radiographic evidence of osteomyelitis. Seventy-eight patients met the case definition; 52 (66%) were male. The median age was 4.8years. Blood cultures were positive in 16 of 56 cases (29%), with 11 deemed clinically significant (Staphylococcus aureus = 8, group A Streptococcus = 3). Thirty-seven of 78 (47%) bone/joint samples were positive by culture with S. aureus (n = 16), coagulase-negative Staphylococcus (n = 9) and group A Streptococcus (n = 4), being the most common organisms. Sixteen culture-negative samples were sent for bacterial PCR, and four were positive (Kingella kingae = 2, Streptococcus pneumoniae= 1, group A Streptococcus = 1). Sequential culture and PCR testing can improve the detection rate of causative organisms in paediatric bone and joint infections, particularly for fastidious microorganisms such as K. kingae. PCR testing can be reserved for cases where culture is negative after 48h. These results have been used to develop a standardised diagnostic test panel for bone and joint infections at our institution.

Mycobacterium avium paratuberculosis and Mycobacterium avium complex and related subspecies as causative agents of zoonotic and occupational diseases.

Mycobacterium avium complex (MAC) and Mycobacterium avium paratuberculosis (MAP) cause zoonotic infections transmitted by birds and livestock herds. These pathogens have remained as serious economic and health threats in most areas of the world. As zoonotic diseases, the risk of development of occupational disease and even death outcome necessitate implementation of control strategies to prevent its spread. Zoonotic MAP infections include Crohn's disease, inflammatory bowel disease, ulcerative colitis, sarcoidosis, diabetes mellitus, and immune-related diseases (such as Hashimoto's thyroiditis). Paratuberculosis has classified as type B epidemic zoonotic disease according to world health organization which is transmitted to human through consumption of dairy and meat products. In addition, MAC causes pulmonary manifestations and lymphadenitis in normal hosts and human immunodeficiency virus (HIV) progression (by serotypes 1, 4, and 8). Furthermore, other subspecies have caused respiratory abscesses, neck lymph nodes, and disseminated osteomyelitis in children and ulcers. However, the data over the occupational relatedness of these subspecies is rare. These agents can cause occupational infections in susceptible herd breeders. Several molecular methods have been recognized as proper strategies for tracking the infection. In this study, some zoonotic aspects, worldwide prevalence and control strategies regarding infections due to MAP and MAC and related subspecies has been reviewed.

Osteomyelitis in Children, What to do?

Osteomyelitis in Children, What to do?