Treatment Of Acute Hematogenous Osteomyelitis Research Articles

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

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. 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. 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. 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.

Effectiveness of Surgical Treatment Acute Hematogenic Osteomyelitis Children in the Complex With Ozone Therapy and Lymphogenic Technology

The results of operative treatment of acute hematogenous osteomyelitis in 96 children aged from 3 to 12 years are presented. The control group consisted of 52 patients who had traditional surgical treatment and 44 children who were operated according to the developed method in combination with ozone therapy and the use of lymphogenous technology. Transition to the chronic form in the control group was 13.4%, and in the primary group 6.8%.

Questions of diagnosis and treatment of acute hematogenous osteomyelitis of the hip joint bones in children

This article presents an analysis of both domestic and international publications, focusing on the aspects, diagnostics, and treatment of acute hematogenous osteomyelitis of the hip joint bones in children. While the etiology and pathogenesis of acute hematogenous osteomyelitis have generally been well-studied, the literature scarcely covers the early diagnosis and treatment of this disease as it impacts the bones of the hip joint in children. Modern diagnostic methods are often effective only after the disease has been present for three days, which is why traditional diagnostic methods continue to hold significance. The surgical treatment of acute hematogenous osteomyelitis of the hip joint bones in children remains an unresolved issue. The choice of surgical tactics is primarily complex because the disease often comes with complications such as osteomyelitic coxitis, which exacerbates the treatment process and hinders the prevention of orthopedic complications. Therefore, the selection of optimal surgical and preventive care, based on the stage of the disease, the extent of the purulent process, and the degree of destruction and compression of the osteoarticular system, is of utmost importance.

Differentiated disorders of the immune system in acute hematogenic and acute posttraumatic osteomyelitis in children

Osteomyelitis is an inflammation of bone and bone marrow caused by the spread of S. aureus from a local focus by the hematogenous route or from an open traumatic fracture; it is difficult to treat and remains a serious problem. The condition for spreading of the infectious process into bone is the effect of S. aureus and its impaired elimination due to immune system (IS) dysfunction. Controversial information on the immunopathogenetic mechanisms of acute osteomyelitis needs study, which would allow the development of sound immunotherapy. Purpose of the study: to specify the variants of antibacterial immune protection disorders in children with acute hematogenous and acute posttraumatic osteomyelitis. Materials and methods. Children 8-15 years old (n = 22) were studied: Study Group 1 (SG1, n = 12) – with acute hematogenous osteomyelitis (AHO); Study Group 2 (SG2, n = 10) – with acute post-traumatic osteomyelitis (APTO). The comparison group (CG) – 13 healthy children. Tested: Tlymphocytes (CD3+CD19- , CD3+CD4+, CD3+CD8+), B lymphocytes (CD3- CD19+), NK (CD3- CD16+CD56+) and TNK (CD3+CD16+CD56+) lymphocytes, neutrophil granulocytes (NG, CD16, CD32, CD64) (FC-500 Beckman Coulter, USA); the level of serum IgA, IgM, IgG (ELISA). Phagocytic function of NGs in relation to S. aureus was assessed: the number of actively phagocytizing NGs (%PhAN), capture processes (PhN, PhI) and killing activity (%D, DI). Results. In both groups was revealed a decrease of T lymphocytes, T helpers, TCTL and NK quantity (p1-4 < 0.05). In AHO, the levels of IgA, IgM, IgG did not differ from that in GS, while in APTO the levels of IgA and IgG increased (p1, 2 < 0.05). The density of CD64, CD16, CD32 receptor expression on NG in the studied groups has been a different equipping, predetermining an incompetence of the phagocytic function: in AHO associated with abnormalities in the function capture and killing, in APTO only with the S. aureus digestion. Conclusion. The revealed combined defects of IS functioning necessitate the development of new approaches in the treatment of AHO and APTO in children, pathogenetically substantiating the use of immunotherapy in the complex etiopathogenetic treatment. This approach will contribute to the restoration of mechanisms of anti-infective immunity, timely elimination of pathogens, improve the clinical course of the diseases, prevent the chronic inflammatory process.

Педіатричні аспекти гострого гематогенного остеомієліту в дитини раннього віку: клінічний випадок

Acute hematogenous osteomyelitis is one of the common bacterial infections in children of early age, which is accompanied by mild symptoms at the initial stage of diagnosis. The onset of the disease is usually acute with fever, intoxication syndrome, focal signs of bone inflammation and limitation of limb function. Purpose - to show the features of diagnosis and treatment of acute hematogenous osteomyelitis in an infant based on clinical observation. Clinical case. The clinical case of a child of early age with acute hematogenous osteomyelitis, who was hospitalized with complaints of an increase in body temperature up to 40°C, restlessness, swelling and hyperemia of the lower part of the right thigh and right knee joint, and movement disorders in the right leg, was presented. The general condition of the child upon admission is severe due to intoxication, hyperthermic syndromes and local changes in the right lower limb, which was in a forced position, pronation. There were no active movements in the right leg, passives ones were painful. Rotational movements in the right leg are possible, but painful. The soft tissues in the area of the right hip and knee joints, as well as the thighs, were not changed in color, their swelling was noted. Conclusions. Symptoms of acute hematogenous osteomyelitis in young children are often nonspecific. Intoxication syndrome symptoms and local changes as movement disorders in the limb in children of this age group dominate. Pain can be detected during the examination, which is clearly localized with sensitivity over the infected bone; edema may be present. Changes of complete blood count are mild, while the determination of C-reactive protein during the initial evaluation can serve as a baseline value for sequential monitoring. The sensitivity of X-ray examination at the beginning of the disease is low, radiological changes appear only 7-21 days after infection. Empiric antimicrobial therapy aimed at Staphylococcus aureus should be prescribed immediately after the detection of acute hematogenous osteomyelitis clinical signs even before receiving results of additional research methods. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

The Utility of IR-Guided Biopsy in the Treatment of Pediatric Osteomyelitis

Accurate and efficient diagnosis, as well as a consistent and effective treatment of acute hematogenous osteomyelitis, are paramount to ensure successful clinical outcomes. Noninvasive measures of isolating the causative pathogen from blood cultures have low sensitivity, with published rates often <50%. The use of interventional radiology (IR)-guided percutaneous biopsy has gained traction as a nonsurgical means of obtaining tissue cultures with a reported increased sensitivity of >90%. This study aims to determine the utility of IR-guided biopsy in the management of pediatric patients with acute hematogenous pediatric osteomyelitis (OM). An IRB-approved retrospective review was completed of children younger than 18 years admitted to a single institution for treatment of magnetic resonance imaging or culture/biopsy-proven acute hematogenous OM. Patients were excluded for the diagnosis of chronic recurrent multifocal OM, incomplete documentation, treatment initiation at an outside institution, open surgical debridement, and concomitant septic arthritis. Patients who underwent IR-guided biopsy were compared with those treated empirically without biopsy. Fifty patients were included for analysis. Fifteen (30%) had IR-guided biopsies; 35 (70%) were treated empirically. The average age at diagnosis was 11.8 years old (SD: 4.9). Of the 15 patients who underwent IR-guided biopsy, a pathogen was identified in 12 cases (80%); 14 of these patients had concomitant blood cultures with only 1 (7%) positive result ( P <0.01). Of the 11 patients with positive IR-guided biopsy results in the setting of negative blood cultures, 9 (82%) had alterations in their antibiotic regimen as a result of the biopsy. The average time from blood sample collection to definitive antibiotic initiation was nearly double that of time from IR-guided biopsy collection to definitive antibiotic initiation (70.8 vs. 36h; P <0.01). IR-guided biopsy increased pathogen identification by 47% over blood cultures alone and decreased the time to definitive antibiotics. As such, IR-guided biopsy is an effective and safe diagnostic tool for pathogen identification and appropriate antibiotic selection. Orthopaedic surgeons are encouraged to incorporate IR-guided biopsy early in the treatment pathway for patients with acute OM without an indication for open surgical intervention. Level III; retrospective comparative study.

Гострий гематогенний остеомієліт у дітей: питання діагностики та лікування

Purpose – to analyze treatment results and to improve algorithms of diagnostic, treatment and rehabilitation of children with acute hematogenous osteomyelitis (AHO). Materials and methods. A study of 884 patients with AHO, who were treated at the Zhytomyr Regional Children’s Clinical Hospital and O. F. Gerbachevsky Zhytomyr Regional Hospital surgical department (child surgical department has been at the adult regional hospital until 1986) in the period from 1978 to 2019. 60.5% patients were boys, the vast majority – 488 (55.1%) – villagers. School-age children (7–15 years) – 353 (39.9%), first-year children – 228 (25.8%). General clinical and laboratory tests, X-ray, ultrasound, CT and MRI, microbiological and immunological test were used to control the course of the disease and the treatment effectiveness. Results. The most common AHO pathogen remains the same – Staphylococcus aureus, however it’s frequency dropped from 60.4% to 46.1% because of increased Kl. pneumoniae, sticks of blue-green pus, to a lesser extent – Klebsiella and mixed flora. Also we established dependence AHO form from the pathogens number and age. The most often AHO determinants (provocation or trigger) were limb traumas (352 patients – 39.8%), lesser – respiratory diseases, skin and soft tissue inflammation. In 37.4% cases (341 patients) there was no such symptoms. Differences in the immunological characteristics of the three clinical forms of AHO disease become clear only during comparative assessment of the dynamics of immunological parameters by stages of the disease. The main subpopulations of T lymphocytes and their interrelated indicator, the helper-suppressor index, are the structural basis for the formation of differences in the immune response. Phlegmon disclosure (subperiosteal, paraosal, periarticular) in total was performed in 863 patients (97.6%), of which 84 children (9.5%) had recurrence. Bone needles puncture was performed in 613 patients (69.3%), of which osteoperforation – in 589 (66.5%). In newborns, antibiotic administration into the bone (metaepiphysis, close to the affected joint) and into the joint was performed by puncture 1–2 times a day for 7–10 days. In young children, decompression of the inflammatory focus in the bone was achieved by setting Dufox needles. Soft tissue abscesses were opened as they appeared, and in purulent pleurisy and pyopneumothorax (in 25 of 52 patients) pleural cavities were drained. There was reduction of local edema, hyperemia in children of experimental groups with generalized forms (septicopia and toxicoseptic) during the first week in 44.4% and 45.4% in the control group – 0.0%-15.9%, p&lt;0.05). The reparation activity increased in 2.5–4.5 times. During the first week, right after starting liposomal therapy, body temperature in children with generalized AHO normalized, while in the control group it occurred only in 12.5–23.1% of patients. The duration of hospital treatment was reduced In the experimental group: 90.0% patients with local forms were treated less than 32 days, 88.9% patients with toxicoseptic and 72.7% of patients with septicopiaemic forms (in the control group, accordingly 92.8%, 37.5%, 38.5%, p1&lt;0.05, p2–3&lt;0.05). Conclusions. Diagnosis of AHO requires today a comprehensive examination: history, local changes and generalization of the process, MRI, ultrasound, radiography at a later date. Decisive in the treatment of AHO in children is the timely and complete irrigation of the lesion area, so the leading specialists in the treatment of acute hematogenous osteomyelitis should be pediatric surgeons. Consultation of related specialists proceeding if necessary. Empirical antibiotic therapy should be planned with consideration of sterile body fluid cultures in patients with various forms of the disease and their antibiotic sensitivity. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: hematogenous osteomyelitis, children, diagnostic, treatment and rehabilitation.

Culture-negative chronic hematogenous osteomyelitis in a two months old girl: a case report

BackgroundPrevious articles have focused on the diagnosis and treatment of acute hematogenous osteomyelitis. Here, we present a case of chronic hematogenous osteomyelitis in a 2-month-old girl. The diagnostic procedure was unusual and difficult due to negative culture results.Case presentationA girl aged 2 months and 23 days had fever and swelling in her right lower leg for 7 days. On the basis of her medical history, physical, and histological examination results; and radiologic and magnetic resonance imaging findings, a diagnosis of chronic osteomyelitis was made. The patient underwent surgical treatment and was discharged successfully. The patient showed good recovery and no sequelae at the 12-month follow-up.ConclusionHematogenous osteomyelitis in babyhood is different from that at any other age. Hematogenous osteomyelitis-related bone destruction in babyhood is more serious and occurs faster. The transition from acute hematogenous osteomyelitis to chronic hematogenous osteomyelitis takes only 7 days. To the best of our knowledge, this chronic hematogenous osteomyelitis patient is the youngest ever reported.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics.

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

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

Our institution created a multidisciplinary guideline for treatment of acute hematogenous osteomyelitis (AHO) and septic arthritis (SA) in response to updates in evidence-based literature in the field and existing provider variability in treatment. This guideline aims to improve the care of these patients by standardizing diagnosis and treatment and incorporating up to date evidence-based research into practice. The primary objective of this study is to compare cases before versus after the implementation of the guideline to determine concrete effects the guideline has had in the care of patients with AHO and SA. This is an Institutional Review Board-approved retrospective study of pediatric patients age 6 months to 18 years hospitalized between January 2009 and July 2016 with a diagnosis of AHO or SA qualifying for the guideline. Cohorts were categorized: preguideline and postguideline. Exclusion criteria consisted of: symptoms >14 days, multifocal involvement, hemodynamic instability, sepsis, or history of immune deficiency or chronic systemic disease. Cohorts were compared for outcomes that described clinical course. Data were included for 117 cases that qualified for the guideline: 54 preguideline and 63 postguideline. Following the successful implementation of the guideline, we found significant decrease in the length of intravenous antibiotic treatment (P<0.001), decrease in peripherally inserted central catheter use (P<0.001), and an increase in bacterial identification (P=0.040). Bacterial identification allowed for targeted antibiotic therapy. There was no change in length of hospital stay or readmission rate after the implementation of the guideline. Utilizing an evidence-based treatment guideline for pediatric acute hematogenous bone and joint infections can lead to improved bacterial diagnosis and decreased burden of treatment through early oral antibiotic use. Level III- retrospective comparative study.

Epidemiology and Antibacterial Treatment of Acute Hematogenous Osteomyelitis in Patients Hospitalized at Children’s Clinical University Hospital in Riga, Latvia

Abstract Introduction.Acute hematogenous osteomyelitis (AHO) is one of the most serious bacterial infections in children that may result in severe complications, such as sepsis, septic shock, bone and joint destruction, disruption of longitudinal bone growth, and even death. Early recognition and evaluation of severity of AHO, awareness of the local prevalence of different microorganisms, as well as timely initiated adequate treatment are crucial for prevention of serious complications. Aim of the Study. To identify the main causative agents of AHO and their antibacterial susceptibility, and to evaluate the applied treatment strategies of AHO in pediatric patients in Clinical Children’s University Hospital (CCUH) in Riga, Latvia. Material and methods. All patients diagnosed with AHO and treated at CCUH were included in retrospective, descriptive study conducted between 1st of January 2014 and 31st of December 2017. Results. The main causative agent for AHO in the study patients was methicillin-sensitive Staphylococcus aureus (MSSA), which was isolated from blood cultures of 40% (n=24) of patients and from 79% (n=57) of intraoperative cultures. The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) was low (found only in one patient, or 1.4%). Thirteen different antibiotics were applied for treatment of AHO, of which Oxacillin was the most common (received by 89.4% of patients). In 57% of cases (n=54) the patients received monotherapy, and 43% of patients (n=40) received a combination of two or more antimicrobials. The most commonly used combination of antibiotics was Oxacillin plus Clindamycin, which was applied in 25.5% of cases (n=24). In 77% of cases (n=72). a transition from one antibiotic to another was observed. On discharge, oral treatment with Cefuroxime or Clindamycin was most commonly prescribed (in 52.5% and 36% of cases, respectively). The total duration of treatment varied between 5 and 20 days, with a median of 25 days. Conclusions. The main causative agent of acute hematogenous osteomyelitis in children treated at Children’s Clinical University Hospital was Methicillin-sensitive Staphylococcus aureus (MSSA). The prevalence of MRSA at CCUH was very low, which must be considered when prescribing empirical antibacterial treatment, giving preference to narrow spectrum antibiotics. Establishment of local guidelines for management of AHO in children at CCUH, including necessary investigations, treatment algorithm for inpatient and outpatient use with defined duration of treatment and time of conversion to oral antibiotics, follow-up and clinical endpoint criteria, and information for parents or carers.

Induced membrane technique for the treatment of chronic hematogenous tibia osteomyelitis

BackgroundChronic hematogenous osteomyelitis often results from the improper treatment of acute hematogenous osteomyelitis. At present, there is lack of uniform standards for the treatment, and the clinical features of the disease are unclear. The purpose of this study was to explore the clinical efficacy and complications of chronic hematogenous tibia osteomyelitis treated with the induced membrane technique.MethodsA retrospective analysis of the chronic hematogenous tibia osteomyelitis patients in our department admitted from January 2013 to February 2014 and treated with the induced membrane two-stage surgical technique was performed. The defects were filled with antibiotic-loaded polymethyl methacrylate (PMMA) cement after radical debridement, and bone grafts were implanted to repair the defects after 6 to 8 weeks.ResultsA total of 15 cases were admitted in this study, including 13 men and 2 women with a mean age of 34 years (6 to 51). The mean duration of bone infection was 142 months (3 to 361). All patients were cured with an average follow-up of 25 months (24 to 28). Radiographic bone union occurred in 5.3 months (3 to 8), and full weight bearing occurred in 6.7 months (4 to 10). No recurrence of infection was noted at the last follow-up. Two cases required repeated debridement before grafting due to recurrent infection. One patient had a small bone diameter due to insufficient grafting, and one patient had limitation of knee activity.ConclusionsThe induced membrane technique for the treatment of chronic hematogenous tibia osteomyelitis is an effective and reliable method. Thorough debridement and wound closure at the first stage is essential for infection control as well as sufficient grafting at the second stage to ensure bone union.

Oral Ambulatory Treatment of Acute Osteomyelitis in Children: A Case-Control Study.

The treatment of acute hematogenous osteomyelitis has evolved in recent years to a shorter parenteral treatment with an early switch to the oral route. Current publications recommend a 2- to 4-day parenteral treatment before the oral switch. We retrospectively analyzed a series of 45 children aged 1 to 11 years and treated in our department for acute osteomyelitis without severity criterion. Nineteen of 45 patients were treated by an exclusive ambulatory oral treatment by amoxicillin and clavulanic acid. Twenty six of 45 patients had a 2- to 4-day parenteral treatment before the oral switch. The minimum follow-up was 6 months. The primary endpoint was a clinical, radiographic, and biologic healing, 6 months after the beginning of the treatment. The secondary endpoints evaluated were the length of hospitalization, the total duration of treatment, and the type of antibiotic used. On the primary endpoint, we did not find any significant difference between the 2 treatments (P = 0.38). On the duration of treatment, we found a significant difference (P = 0.049) in favor of oral treatment. The ambulatory oral treatment by amoxicillin and clavulanic acid seems to be a valid alternative to the classical parenteral then oral sequence in the treatment of acute hematogenous osteomyelitis in children without severity criterion.

Laser osteoperforation for the treatment of acute osteomyelitis. 10 years experience

The results of treatment of acute hematogenous osteomyeLitis (CSO) were analyzed into two groups. For general group (142 children) was used laser osteoperforation with diode lasers with wave length of 0.8, 1.64, 1.9 microns. In the comparison group (93 children) was performed the mechanical osteoperforation by electric drill. The Laser osteoperforation was performed into both walls of the medullary chanal in the affected metaepiphysis and the adjacent part of the bone shaft with the formation of 8 to 20 holes. For ekstramedullar phase additionly was used small incisions for opening purulent streaks. The proposed method let to reduce frequency of complications for children with CSOs up 16.1 % to 7.0 %. The stable remission was observed for 96.3 % of children after usage laser technology, after traditional surgery it was observed in 91.4 %. The transition to the chronic phase of the disease in the general group was marked two times less than after traditional operations. The advantages of the method of Laser osteoperforation are fewer frequency of complications, faster recovery period, good tolerance and good functional results.

Acute Hematogenous Osteomyelitis

1. Dennis A. Conrad, MD* 1. *Professor of Pediatrics and Associate Chairman for Continuing Medical Education, Department of Pediatrics/Division of Infectious Diseases, University of Texas Health Science Center at San Antonio; Medical Director, Infection Control, CHRISTUS Santa Rosa Children's Hospital, San Antonio, Tex. After completing this article, readers should be able to: 1. Describe the pathophysiology of acute hematogenous osteomyelitis. 2. Correlate most common infectious causes of osteomyelitis with the age of the patient. 3. Recognize the typical clinical manifestations of acute hematogenous osteomyelitis. 4. Explain the appropriate use of ancillary information obtained by laboratory determinations and imaging studies to establish the diagnosis of acute hematogenous osteomyelitis. 5. Discuss the medical and surgical principles of management in the treatment of acute hematogenous osteomyelitis. The most common type of osteomyelitis, an infection of bone, that occurs in children is acute hematogenous osteomyelitis. Infection initially is established in the metaphyseal region of tubular bones, beginning as a metaphysitis following seeding by bacteria. The appendicular skeleton is the most common site of osteomyelitis. The lower extremity, especially the femur, is involved more often than the upper extremity, where the humerus is most likely to be infected. The pelvic bones or clavicles are less likely to be involved than the long bones of the extremities. The most common bone involved in acute hematogenous osteomyelitis in children is the femur. The axial skeleton is less likely to be the site of acute hematogenous osteomyelitis. Manifestations of osteomyelitis involving the axial skeleton are most commonly discitis, vertebral osteomyelitis, and infection involving the ribs and cranial bones. In most cases, the preceding bacteremia leading to acute hematogenous osteomyelitis is cryptic and asymptomatic, although osteomyelitis can be a focal complication of clinically symptomatic bacteremia and even overt septicemia. The nidus of infection begins in the valveless sinusoidal loops of the venules at their reflection at the epiphysis and is attributed to slow and nonlaminar blood flow through this vascular …

What Would Pediatric Infectious Disease Consultants Recommend for Management of Culture-Negative Acute Hematogenous Osteomyelitis?

To assess the opinion of pediatric infectious disease (PID) specialists regarding the management of culture-negative acute hematogenous osteomyelitis. A questionnaire that included a hypothetical case scenario of a 4-year-old boy with culture-negative osteomyelitis was distributed via a Web-based system to PID specialists across the United States. Of 481 eligible participants surveyed, 147 (31%) responded. For initial therapy of osteomyelitis, 37% of respondents chose a beta-lactam, 24% chose clindamycin, 10% chose vancomycin as the sole therapy, and 29% chose a combination of these. The initial choice of antibiotics was correlated with the reported incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in the institution (P < 0.01). In areas where the prevalence of CA-MRSA was intermediate (between 25% and 50%), the choice of antibiotics was more heterogeneous. For change from intravenous to oral therapy, approximately 70% of respondents would change to oral therapy sooner than 3 weeks depending on clinical, laboratory, and social factors. After significant clinical and laboratory (sedimentation rate and C-reactive protein) improvements, most respondents (69%) chose to treat for a total duration (intravenous and oral) of 3 to 4 weeks. This study illustrates that the empiric choice of antibiotics for treatment of acute hematogenous osteomyelitis was driven by the local prevalence of CA-MRSA. When the prevalence of CA-MRSA was intermediate, the recommendations for management of bone infections were more heterogeneous. Clinical trials are needed to compare the effect of different management strategies on outcome, side effects, and costs. Level V.

Some aspects of long-term results of treatment of acute hematogenous osteomyelitis

The aim of the study was to evaluate the treatment results of acute hematogenous osteomyelitis over 10 years and to determine the relationship between them and clinical course of the disease. The patients with acute hematogenous osteomyelitis diagnosed 10 years ago (1995-1996) were enrolled in the study. The post mail or phone contacts with them or their parents were obtained, the questions were submitted, and the patients were invited for medical examination. The current complaints and limitations in physical activity were assessed. The amplitude of joint movements, tenderness during palpation, and deformations were evaluated during physical examination. Patients were divided into two groups: with and without complaints. The duration and severity of the disease, age, gender, presence of sepsis, arthritis, and subperiosteal abscess, the type of bone affected and bone lesion on x-ray, duration of fever, and maximal erythrocyte sedimentation rate during the acute period were compared between groups. We made 50 phone calls and sent seven letters to the patients with acute hematogenous osteomyelitis who were treated in our department. In 14 (28%) cases, phone contact was obtained, and 7 of them were examined. Five answers (71%) to the letters were received. The overall response rate was 33%. Thirteen (68%) former patients had no any complaints; six (32%) had minor complaints, which were probably linked to acute hematogenous osteomyelitis. Fifteen (79%) former patients had no limitations in any physical activities, and four (21%) of them limit their physical activities. Seven patients were examined, but neither visible deformities and tenderness nor limitations in movement amplitude were found. Comparing the groups with complaints and without complaints by age, gender, presence of sepsis and arthritis, duration of the disease, and the presence of periosteal abscess, no statistically significant difference in any of variables was found. According to our data, 37% of the patients have complaints 10 years after acute hematogenous osteomyelitis, and these complaints are not associated with the clinical course of the disease.

Complications of Central Venous Catheters Used for the Treatment of Acute Hematogenous Osteomyelitis

To determine the complications and risk factors for complications associated with using central venous catheters (CVCs) for the treatment of acute hematogenous osteomyelitis (AHO). We conducted a retrospective cohort study of all patients admitted to the Children's Hospital of Philadelphia between January 1, 2000, and December 31, 2003, with a diagnosis of AHO. Eighty patients with AHO met inclusion criteria. The median age was 5 years, and 66% of the patients were male. The most commonly affected bones were the femur (25%), tibia (20%), and pelvis (16%). Staphylococcus aureus was the most common organism identified from cultures of bone (67%) and blood (30%). Seventy-five patients (94%) received >2 weeks of intravenous (IV) antibiotic therapy via a CVC and 5 (6%) received <2 weeks of IV antibiotic therapy before conversion to oral therapy for a median of 25 days. None of the patients who switched to oral therapy within 2 weeks was rehospitalized or returned to the emergency department. Of the 75 patients who received >2 weeks of IV therapy, 41% had > or =1 CVC-associated complication. Seventeen patients (23%) had a CVC malfunction or displacement, 8 (11%) had a catheter-associated bloodstream infection, 8 (11%) had fever with negative blood culture results, and 4 (5%) had a local skin infection at the site of catheter insertion. Older age was protective against the development of a CVC-associated complication, whereas the lowest median household income was associated with development of a CVC-associated complication. Interventions to reduce CVC-associated complications should be developed and evaluated, particularly for young children and those from families with low household incomes. Clinical trials are needed to evaluate the safety and efficacy of oral antibiotic therapy after a short course of IV therapy as an alternative to prolonged IV therapy.

Laboratory considerations in the surgical treatment of acute hematogenous osteomyelitis of the calcaneus

Surgical treatment of acute hematogenous osteomyelitis of the calcaneus is uncommon in the literature. Laboratory considerations to aid diagnosis as well as methods of diagnosis, surgical intervention, and management with a review of the literature are presented. A case of a 10-year-old female with acute hematogenous osteomyelitis of the calcaneus treated by surgical drainage, bone biopsy, and management with 12-month follow-up is discussed.

Evaluation of New Anti-Infective Drugs for the Treatment of Acute Hematogenous Osteomyelitis in Children

Most children with acute hematogenous osteomyelitis have no preceding illness. Their early symptoms are pain and fever. A bacterial etiology is established in approximately 75% of cases by needle aspiration of the affected site or blood culture. Clinical trials should be limited to cases of bacterial origin. The antimicrobial agents studied should be active against Staphylococcus aureus and streptococci. If children < 5 years of age are included, the drug should also be active against beta-lactamase-negative and -positive strains of Haemophilus influenzae. Randomized, prospective, double-blind comparative studies are preferable to open, evaluator-blinded trials. Clinical outcome is appraised by physical signs and symptoms. A successful microbiological outcome consists of presumptive eradication. The final assessment should be made 1 year after completion of therapy.