Deep Venous Thrombosis In Children Research Articles

Incidence of Deep Venous Thrombosis in Children after Colectomy for Inflammatory Bowel Disease: A Multicenter Study

Traynor, Michael D. MD; Polites, Stephanie F. MD; Bence, Christina MD; Muenks, Peter MA; Ha, Derrick BS; St Peter, Shawn D. MD, FACS; Landman, Matthew P. MD, MPH, FAAP, FACS; Densmore, John C. MD, FACS; Potter, D Dean MD Author Information

Therapeutic aspects, determining the outcome of deep veins thrombosis (dvt) in children with hematological diseases

Deep venous thrombosis (DVT) is a frequent complication in hospitalized children with hematological cancer. Antithrombotic therapy is a main treatment option in these cases, but there is still a lack of data on its influence on DVT outcomes in children. Objective: to compare the frequency of favorable and unfavorable outcomes of DVT in children with hematological and hemato-oncological diseases, depending on the antithrombotic therapy performed. The study was approved by the Independent Ethics Committee of the Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology. 429 medical charts of patients, who received inpatient treatment in the Dmitry Rogachev National Research Center from 01/01/2013 - 12/31/17 were analyzed. There were used hemodynamic characteristics of DVT, also criteria for the correctness of management approach, therapy approach and criteria for DVT outcomes were developed. There were 122 symptomatic DVT (sDVT) and 408 asymptomatic DVT (aDVT). The treatment outcomes were analyzed in 424 (80%) cases of DVT, depending on the correctness of the therapy. In the group of sDVT, the number of favorable outcomes increases with correct therapy (66.7% for sDVT without treatment, 77.9% for treated sDVT, and 84.0% for sDVT, treated correctly, p < 0.05). In the group of aDVT there were no clear dependence between correctness of the treatment and thrombosis outcomes (45.2%, 57.9%, 57.2%, respectively, p = 0.09). Correctly performed antithrombotic treatment rises the favorable outcome rates by more than 20%. In contrast to sDVT, in cases of aDVT outcomes don't depend on therapy or its correctness. This fact could potentially rise the question of aDVT's nature and clinical significance. To determine the best therapy strategy, further research is needed.

Risk factors and diagnosis of severe deep venous thrombosis in children

Critically ill patients in PICU are at high risk of deep venous thromboembolism(DVT) and pulmonary embolism(PE). Sepsis and septic shock, central venous catheter, surgery and trauma, bed rest and immobilization, and the use of certain drugs(such as vasopressin) are high risk factors for DVT and PE.DVT or PE caused by mycoplasma infection is a new clinical problem in children.D-dimer is an important screening test for DVT, ultrasound doppler is the first choice of diagnostic examination, and venography is the gold standard for the diagnosis of DVT.In the current period, surveillance of high risk factors and earily diagnosis are the main strategies for DVT/PE.The efficacy of anticoagulants including unfractionated heparin and low-molecular-weight heparin in preventing DVT or PE in children needs further study. Key words: Deep venous thromboembolism; Pulmonary embolism; Risk factor; Critically ill; Children

Pediatric Deep Venous Thrombosis Associated With Staphylococcal Infections: Single Institutional Experience.

Deep venous thrombosis (DVT) has been previously reported in children with methicillin-resistant Staphylococcus aureus (MRSA). This study reviews our institutional experience by evaluating characteristics and outcomes of children with DVT and staphylococcal infections. Retrospective clinical data from 16 pediatric patients with DVT and staphylococcal infections over a 5-year period was obtained via medical record abstraction. Sixteen patients with a median age at diagnosis of 8 years were included. The most common infection encountered was osteomyelitis (56%). The most common isolated organism was MRSA (63%). Central venous catheters were present in 50% of cases. All patients received anticoagulation with low molecular weight heparin except 1 patient with superficial venous thrombosis who was managed conservatively. Fifty percent of patients had complete resolution of DVT by the end of treatment, 25% of the patients had early disappearance of the thrombus at 7 to 10 days. Only 2 patients (12.5%) had persistent thrombus at 6 months. Staphylococcal infections may increase the risk of DVT in children. Therefore, a high index of suspicion for DVT is warranted in children with Staphylococcal infections (particularly MRSA) to promptly diagnose, treat and minimize complications. Prophylactic anticoagulation in presence of staphylococcal infection, particularly MRSA, may be considered in future studies.

The use of natural language processing on pediatric diagnostic radiology reports in the electronic health record to identify deep venous thrombosis in children.

Venous thromboembolism (VTE) is a potentially life-threatening condition that includes both deep vein thrombosis (DVT) and pulmonary embolism. We sought to improve detection and reporting of children with a new diagnosis of VTE by applying natural language processing (NLP) tools to radiologists' reports. We validated an NLP tool, Reveal NLP (Health Fidelity Inc, San Mateo, CA) and inference rules engine's performance in identifying reports with deep venous thrombosis using a curated set of ultrasound reports. We then configured the NLP tool to scan all available radiology reports on a daily basis for studies that met criteria for VTE between July 1, 2015, and March 31, 2016. The NLP tool and inference rules engine correctly identified 140 out of 144 reports with positive DVT findings and 98 out of 106 negative reports in the validation set. The tool's sensitivity was 97.2% (95% CI 93-99.2%), specificity was 92.5% (95% CI 85.7-96.7%). Subsequently, the NLP tool and inference rules engine processed 6373 radiology reports from 3371 hospital encounters. The NLP tool and inference rules engine identified 178 positive reports and 3193 negative reports with a sensitivity of 82.9% (95% CI 74.8-89.2) and specificity of 97.5% (95% CI 96.9-98). The system functions well as a safety net to screen patients for HA-VTE on a daily basis and offers value as an automated, redundant system. To our knowledge, this is the first pediatric study to apply NLP technology in a prospective manner for HA-VTE identification.

Invasive community-acquired methicillin-resistant Staphylococcus aureus infection causing bacteremia and osteomyelitis simultaneously in two Saudi siblings

Methicillin-resistant Staphylococcus aureus (MRSA) has been now recognized as major pathogen in adults and children, causing a variety of infections including osteomyelitis. Deep venous thrombosis in children with S. aureus osteomyelitis occurs rarely. Two siblings of a Saudi family who acquired MRSA bacteremia and osteomyelitis concurrently are described in this report. The second patient had an invasive infection characterized by bacteremia, multifocal osteomyelitis and septic arthritis complicated by deep venous thrombosis of the left popliteal vein, necessitating anticoagulant treatment with heparin. To my best knowledge, such simultaneous occurrence of MRSA bacteremia and osteomyelitis affecting two family members has not been reported. Also, deep venous thrombosis complicating osteomyelitis is rare and has not been reported from this region of the world.

Deep venous thrombosis in children with sickle cell disease.

Deep venous thrombosis (DVT) is rare in children compared to adults. Its incidence and risk factors in children are not well known. This study determined these aspects of DVT in children with sickle cell disease (SCD). A retrospective, observational and descriptive study was performed. Patients born between October 2000 and October 2012 with SCD and registered in HEMORIO, including those who died in HEMORIO, were included in this study. Patients whose medical records were inaccessible, who died in institutions other than HEMORIO, who died with implanted deep venous catheters, and those who were not monitored in HEMORIO for a period of 1 year or more were excluded from the study. Of a total of 1,519 patients, 456 were excluded and 1,063 patients were included in the study. Data were obtained from the computer system and the medical records at HEMORIO. Of the 1,063 patients, 2 (0.2%) developed DVT with both cases being related to central venous catheters (CVCs) (P-value <0.001). Of the patients who required CVCs, the prevalence of DVT was 10%. No other variable was clinically or statistically significant with respect to DVT. The establishment of CVCs in children with SCD poses a high risk for DVT. If this procedure is necessary, the internal jugular vein should be utilized instead of the subclavian and femoral veins. The identification of associated risk factors may justify antithrombotic prophylaxis.

Outcomes in children with deep vein thrombosis managed with percutaneous endovascular thrombolysis.

Our center has developed a multidisciplinary approach to percutaneous endovascular thrombolysis with the goal of improving outcomes in children with thrombosis. There is little data describing the safety and efficacy of endovascular thrombolysis and the frequency of post-thrombotic syndrome after thrombolysis in children. Retrospective analysis of children undergoing percutaneous endovascular thrombolysis to determine (1) the safety and efficacy of this procedure and (2) the frequency of the diagnosis of post-thrombotic syndrome after thrombolysis. We reviewed the medical and imaging databases for children who underwent percutaneous endovascular thrombolysis for deep venous thrombosis (DVT) between November 2008 and June 2013 at our institution. Demographic data were reviewed for the technical success and complications of thrombolysis and the last assigned post-thrombotic syndrome score using standardized scoring tools. Forty-one children ages 3 months to 21 years (median age: 15 years; 44% male) underwent percutaneous endovascular thrombolysis between November 2008 and June 2013. Upper extremity DVT occurred in 13 patients (32%); lower extremity DVT occurred in 28 patients (68%). All 41 patients received thrombolysis grading; 90% of those patients achieved greater than 50% thrombus lysis. Twenty-eight patients received formal post-thrombotic syndrome scoring and 4 (14%) met diagnostic criteria for post-thrombotic syndrome. One major bleeding episode and one pulmonary embolism occurred with no long-term sequelae. Endovascular thrombolysis for DVT in children is safe, effective at thrombus removal and may reduce the incidence of post-thrombotic syndrome. Randomized or larger clinical trials would be needed to determine the long-term benefits of endovascular thrombolysis.

No impact of endogenous prothrombotic conditions on the risk of central venous line‐related thrombotic events in children: results of the KIDCAT study (KIDs with Catheter Associated Thrombosis)

Central venous lines (CVLs) are the major exogenous risk factor for deep venous thrombosis (DVT) in children. The study objective was to assess whether endogenous prothrombotic conditions contribute to the risk of CVL-related DVT in children. This was a cohort study of consecutive children with heart disease requiring CVLs for perioperative care. CVLs were inserted percutaneously in the upper venous system and patients received prophylaxis with continuous unfractionated heparin (50ukg(-1) d(-1) ). Blood samples to test for prothrombotic conditions were collected prospectively and assayed in a blinded fashion. Outcome assessment was by screening for DVT by venography, venous ultrasound and echocardiography. The study population consisted of 90 children, median age 2.7years (0months-18years). Prevalence rates of antithrombin deficiency, protein C deficiency, protein S deficiency, heterozygous factor V Leiden, prothrombin G20210A mutation, methylentetrahydrofolate C677TT genotype, hyperhomocysteinemia, lupus anticoagulant, anticardiolipin antibodies and increased levels of lipoprotein (a) were within the range reported for the general population. At least one prothrombotic condition was present in 38% of children and combined abnormalities in 8%. The incidence of DVT was 28% (25/90), and most DVTs were asymptomatic. None of the prothrombotic conditions showed a significant association with DVT. The population attributable risk (i.e. the risk of DVT in the overall population attributable to a specific condition) did not exceed 2.2%. Prothrombotic conditions did not have an important impact on the risk of DVT in children with short-term CVLs. The results of the study suggest that screening for prothrombotic conditions is not justified in this setting.

Evaluation of the Interpretation of Serial Ultrasound Examinations in the Diagnosis of Deep Venous Thrombosis in Children: A Retrospective Cohort Study

PurposeTo assess ultrasound intrascan variability and the potential error rate of serial ultrasounds in the diagnosis of deep venous thrombosis in children. MethodsA retrospective cohort review of imaging results of children having at least 3 serial ultrasound examinations of the same region within a 2-month period. The results were interpreted as either (1) inadequately visualized or (2) the absence or presence of deep venous thrombosis, and were categorized by location. Serial imaging findings then were further categorized based on results and clinical information. ResultsSixty-four patients and 157 vessel segments were included in the study. Deep venous thrombosis was documented in 58 patients. Concordant results were observed in 26 patients (40.1%), clot resolution in 17 patients (26.6%), clot formation in 12 patients (18.8%), and discordant results in 9 patients (14%). Twenty-one of 64 patients (32.8%) had at least 1 vessel inadequately imaged. ConclusionsThe inconsistency of serial ultrasound results in up to 25% of patients calls attention to the potential inaccuracy of ultrasound for diagnosis and follow-up of deep venous thrombosis in children. The high proportion of patients with at least 1 inadequately visualized vessel also highlights the limitation of ultrasound in the diagnosis of pediatric deep venous thrombosis.

Primary study on deep venous thrombosis in children after neurosurgery

Objective To study the incidence and related causes of deep venous thrombosis of lower extremities in children after neurosurgery. Methods The children with or without deep venous thrombosis of lower extremities after neurosurgery in our hospital from January 2007 to December 2011 were selected.The clinical data including primary diseases and operation time were collected to be compared to find the related causes of deep vein thrombosis.Results There were 18 children with postoperative deep venous thrombosis.All of them had deep venouscatheter invasive operation.The major primary disease was craniopharyngioma.They all had longer operation time compared with those without thrombosis.Conclusions The causes of deep venous thrombosis in neurosurgical children involve not only deep venous catheter -related but also neurological primary disease and operation time. Key words: Neurosurgery ; Children; Deep venous thrombosis; Craniopharyngioma

When should DVT be suspected in children with osteomyelitis?

There is increasing recognition that deep venous thrombosis (DVT) is a complicating factor in some children with acute hematogenous osteomyelitis. The similarity in signs and symptoms of osteomyelitis and DVT make clinical recognition of this complicating condition difficult. It would be helpful to the clinician to identify by other means which children with osteomyelitis are at greatest risk for DVT. We reviewed the available literature regarding osteomyelitis and DVT in children to identify potential characteristics of children with osteomyelitis that puts them at risk for concurrent DVT. We performed searches of the PubMed, Cochrane, CINAHL, and National Guideline Clearinghouse databases on the topic of osteomyelitis and thrombosis in children 0 to 18 years of age from 2001 to the present. Four studies were included: 3 retrospective and 1 prospective. Studies varied in terms of clinical, laboratory, and imaging parameters evaluated. Overall they suggest trends toward increased incidence of DVT in children who were critically ill at presentation, had positive blood cultures, were infected with methicillin-resistant Staphylococcus aureus, had an elevated C-reactive protein, and had central venous catheters placed. Strong consideration should be given to evaluating children with osteomyelitis for DVT if they are critically ill at presentation, particularly if they have pulmonary findings, are persistently bacteremic, especially with methicillin-resistant S aureus.

Emergency Ultrasound Diagnosis of Deep Venous Thrombosis in the Pediatric Emergency Department

The diagnosis of deep venous thrombosis (DVT) in patients presenting to the emergency department (ED) has traditionally been limited to examinations by radiologists and ultrasound technicians. Although contrast venography is considered the criterion standard for diagnosis of DVT, time, personnel, cost, exposure to radiation, and the invasive nature of the study (need for venous access) potentially limit the ability to perform the study in an emergent setting. Ultrasonography is an alternative method for thrombus detection and is widely preferred. However, in many health care settings, consultative ultrasound services may not be available immediately, especially after hours and on weekends. Based on recent studies demonstrating accuracy in adult patients, emergency sonographic evaluation of DVT by emergency physicians is considered a core emergency ultrasound application and is recently recommended as standard training to all emergency medicine residents. The diagnosis of DVT in children by emergency ultrasound in the pediatric ED has not been previously described. We present 3 cases of DVT in adolescents identified by emergency ultrasound evaluation in the pediatric ED.

Predisposing Factors for Deep Venous Thrombosis in Children and Adolescents with Nephrotic Syndrome

Nephrotic syndrome (NS) is a state of hypercoagulability. In this paper, we sought to determine risk factors for the occurrence of deep vein thrombosis (DVT) in children with NS. The “with DVT” group included patients with decompensated NS and diagnosed with DVT. The “without DVT” group included the same patients, six to eighteen months prior to the episode of DVT, with decompensated NS but without DVT. Different prediction variables were analyzed. The odds ratio for the occurrence of DVT in patients with triglyceride levels ≥300 mg/dL was 3.14 (95% CI 1.14 to 8.64). For hematocrit levels ≥43% and for the presence of infection or a severe systemic event, the odds ratio was 4.37 (95% CI 1.23 to 15.53). The presence of significant risk factors for the occurrence of DVT in children with NS may serve as a warning for the occurrence of venous thrombosis.

Risk factors and management of deep venous thrombosis in children following post‐surgical hypopituitarism in craniopharyngioma

AbstractPost‐operative hypopituitarism following craniopharyngioma (CP) surgery is treated by replacement of various hormones. The risk of deep venous thrombosis (DVT) following CP surgery and initiation of hormones has not been well studied and recognized. We present three patients with DVT who had family history of DVT and procoagulant risk factors such as inherited thrombophilia and elevated Von Willebrand factor levels due to treatment with desmopressin. We discuss the individualized management of anticoagulation and the dilemma of starting estrogen and progesterone replacement therapy in them. Pediatr Blood Cancer 2011;57:175–177. © 2011 Wiley‐Liss, Inc.

Thrombotic disease in critically ill children

To summarize a) epidemiology of arterial and venous thromboembolism, pulmonary embolism, and deep venous thrombosis in children; b) the risk factors for thrombosis in the pediatric intensive care unit; c) diagnostic techniques for arterial/venous thromboembolism; and d) the current recommendations for management and prevention of thromboembolic disease in critically ill children. Literature review, using National Library of Medicine PubMed and the following terms: arterial, venous thromboembolism; deep venous thrombosis; pulmonary embolism; thrombosis; as well as citations of interest from these articles. Both pediatric and adult literature addressing thrombotic disease were reviewed. Articles were chosen for more extensive discussion when containing prospective studies, guidelines for practice, or data in critically ill patients. When data in children were unavailable, applicable data in adults were referenced. Due to the paucity of data in critically ill children, available adult and pediatric data were combined with institutional experience to provide suggestions for current practice and future inquiry. Increasing awareness regarding the recognition and current approaches to management and prevention of thromboembolic disease in children is needed among pediatric intensivists, so outcome of these life-threatening processes might be improved.

Risk for Post Thrombotic Syndrome (PTS) Development in Children with Extremity Deep Venous Thrombosis (DVT): Results of the US Centers for Disease Control and Prevention (CDC) Pediatric Thrombosis and Hemostasis Centers.

Abstract 4000Poster Board III-936 BackgroundThere is insufficient information regarding the epidemiology and outcomes of DVT in children. The CDC began a consented registry in August 2003 at eight pilot Centers for Thrombosis and Thrombophilia including six pediatric sites in order to assess the scope and severity of DVT morbidity in children. MethodsData for this analytic project were extracted from the CDC thrombosis registry. We performed a nested case-control study within the registry cohort. Children and adults are eligible to enroll onto this consented registry if they have a history of thrombosis, thrombophilia or a positive family history or either. DVT site, extent, recurrence and BMI were determined clinically. In addition, thrombophilia testing batteries, imaging protocols and determinations of PTS outcomes of DVT were made locally and criteria were not standardized among participating centers. ResultsAs of March 2009 the CDC registry included 316 cases of DVT in infants and children (ages 0-21), and 2414 cases in adults (> 21). There were 16 cases reported to have lower extremity (LE) PTS in children and 184 in adults. Table 1 displays effects of thrombus site, recurrence and BMI on PTS prevalence. The proportion of LE DVT involving the inferior vena cava (IVC) was 5.5-fold higher in children compared to adults (11% vs 2%). Furthermore, among cases of IVC involvement, the prevalence of PTS following IVC thrombosis was remarkably higher in children compared with adults (38.9 vs 6.3%, P < 0.001). The prevalence of PTS following LE DVT overall in children did not differ from adults. Results for upper extremity DVT and resultant PTS were similar. Fifteen percent of children had recurrence. Increasing number of DVT events was associated with an increased risk of PTS. BMI was higher in children who developed PTS (p = 0.06; BMI > 28, OR 3.3 [1.08, 9.59]). In addition, thrombophilia was a risk factor for developing PTS in children (p = 0.02; OR = 2.9 [CI 1.03, 8.05]), with the highest risk determined with antiphospholipid syndrome (p = 0.02; OR = 3.4 [1.09, 9.93]) and protein C deficiency (p = 0.02, OR = 10.9 [0.84, 99.3]). DiscussionChildren with LE DVT demonstrate a high rate of IVC thrombosis, and a higher relative risk of PTS in cases of IVC involvement. Elevated BMI and thrombophilia augment the risk of PTS in children. The limitations of this study include the lack of standardization in DVT diagnostic and PTS evaluations. The study findings support application of standardized approaches to the diagnosis and follow-up evaluation of children with DVT in order to more meaningfully determine outcomes for future interventive trials.Table 1Effects of Thrombus Site, Recurrence and BMI on PTS PrevalenceDVT site :Children PTS/No PTSAdults PTS/No PTSPTS Prevalence Children/Adultsp- valueLower extremity16/136184/139310.5%/11.7%0.67Inferior vena cava7/111/3339%/3.0%<0.001Upper extremity3/4427/1996.4%/12%0.26Superior vena cava2/61/1525%/6.3%0.25Number of DVT Events in Children (Includes sites not at risk for PTS):# of DVT eventsPTSNo PTSFrequencyp value1122554%253214%32529%41150%Mean BMI28.722.80.06 Disclosures:Moll:Ovation: Consultancy; GTC Biotherapeutics: Consultancy; Talecris: Consultancy.

Treatment of deep venous thrombosis with low molecular weight heparin in pediatric cancer patients: safety and efficacy

Few complete reports exist regarding treatment of venous thromboembolism in children undergoing chemotherapy. We designed this study to unify the treatment of venous thromboembolism in oncology pediatric patients at our department. At the same time, we wanted to evaluate the safety and efficacy of our newly designed treatment schedule. Data from pediatric oncology patients with deep venous thrombosis (DVT) treated at the Department of Pediatric Oncology, Brno, was collected prospectively over a 2-year period (1 January 2006 to 31 December 2007). All patients received low molecular weight heparin (LMWH) at an initial dose of 1.2-1.5 mg/kg body weight subcutaneously (s.c.) twice daily for the first 7-10 days. Afterwards, the dose was lowered to 1.5 mg/kg s.c. once daily. We kept this dose unchanged for a minimum of 3 months. For the first 6 weeks of treatment, the platelet count was maintained 20 x 10/l or more with no concomitant LMWH withdrawal. For the rest of the treatment, LMWH was interrupted once platelets dropped below 20 x 10/l. A total of 33 patients were followed for a median of 6 months. DVT was symptomatic in 15 of 33 patients (46%) and asymptomatic in 18 of 33 (54%) patients. Complete thrombus resolution occurred in 22 of 33 (67%) patients, partial or no recanalization was achieved in 11 of 33 (33%) patients. Eight patients (eight of 33, 24%) were diagnosed with postthrombotic syndrome (PTS). The risk of PTS was significantly higher for patients with symptomatic DVT than in those with asymptomatic DVT. Neither patency rates nor the risk of PTS showed a positive correlation with the achievement of therapeutic anti-Xa activity. Thrombocytopenia less than 20 x 10/l occurred at least once during LMWH treatment in 30/33 (91%) patients. None of the patients experienced severe bleeding, whereas mild bleeding episodes were observed in five of 33 (15%) patients. Our treatment schedule has proved to be both well tolerated and reasonably efficient in treating DVT in children undergoing chemotherapy. Further studies on larger patient groups are warranted.

Incidence and Diagnosis of Thrombosis in Children With Short-Term Central Venous Lines of the Upper Venous System

Deep venous thrombosis in children is frequently related to central venous lines. Study objectives were to determine objectively the incidence of deep venous thrombosis in children with short-term central venous lines and to assess the diagnostic value of venography, venous ultrasonography, and echocardiography, in a prospective cohort study. Consecutive children with congenital heart disease requiring short-term central venous lines in the upper venous system were screened systematically for deep venous thrombosis by using venography, venous ultrasonography, and echocardiography, according to standardized protocols. The study population consisted of 90 children (median age: 2.7 years; range: birth to 18 years). Most central venous lines (97%) were located in the jugular veins. The overall incidence of deep venous thrombosis was 25 cases (28%) among 90 children. Venography identified deep venous thrombosis located in the subclavian and central veins but missed most deep venous thrombosis in the jugular veins. Venous ultrasonography had good sensitivity in the jugular veins but did not detect deep venous thrombosis in central veins. Echocardiography detected only 1 case of central deep venous thrombosis. The incidence of central venous line-related deep venous thrombosis in children with short-term central venous lines is high and comparable to reports for children with long-term central venous lines. Sensitivities of venography, venous ultrasonography, and echocardiography in children vary depending on the affected venous segment. A combination of diagnostic tests is required for sensitive detection of central venous line-related deep venous thrombosis in the upper venous system.

Community‐acquired methicillin‐resistant Staphylococcus aureus causes severe disseminated infection and deep venous thrombosis in children: Literature review and recommendations for management

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection in children is increasingly common and can be associated with dissemination and life-threatening complications. Empiric therapy for presumed severe Staphylococcus aureus infection should be reviewed. Four children with severe invasive CA-MRSA infection causing osteomyelitis and pneumonia complicated by pulmonary embolus and deep venous thrombosis are described. The literature is reviewed and recommendations for management are provided.