Behandlung von akuter und chronischer Osteomyelitis im Kindesalter

Clinical Efficacy of the Antibiotic-Loaded Collagen Sponge During Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee

Background:

To completely eliminate an infection, the antibiotic concentration must exceed the minimum inhibitory concentration for the causative pathogens. The antibiotic-loaded collagen sponge (ALCS) has been used to manage an infection through a high local concentration of antibiotics.

Purpose:

To evaluate the clinical efficacy of ALCS in the arthroscopic treatment of patients with acute septic arthritis of the native knee.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors retrospectively reviewed the data for 132 consecutive patients with acute septic arthritis of the knee who underwent arthroscopic debridement between 2013 and 2019. Patients with a history of surgery in the affected joint, concomitant osteomyelitis, or accompanying medical infection were excluded. The study patients were divided into 2 groups based on the use of ALCS during surgery. C-reactive protein (CRP) levels were temporally measured to normalization and the duration of intravenous antibiotic administration was recorded, and the mean length of hospital stay was compared between the groups. Independent t test and chi-square test were performed to assess differences between the groups, and univariate analysis was used to analyze factors affecting recurrence of septic arthritis.

Results:

Of the 132 patients, 88 were ultimately included in this study; 51 patients were managed without ALCS and 37 were treated with ALCS. There were statistically significant differences between groups in the mean period for CRP-level normalization (15.2 ± 8.2 days [ALCS] vs 26.2 ± 14.7 days [without ALCS]; P = .004), mean duration of intravenous antibiotic use (18.4 ± 7.3 days [ALCS] vs 26.6 ± 16.1 days [without ALCS]; P = .046), and mean length of hospital stay (21.1 ± 11.6 days [ALCS] vs 30.3 ± 18.3 days [without ALCS]; P = .045). The preoperative CRP level was the only significant risk factor for recurrence or treatment failure after single arthroscopic debridement.

Conclusion:

The results of this study indicated that ALCS was able to reduce the duration of CRP-level normalization, intravenous antibiotic use, and hospitalization in patients who underwent arthroscopic irrigation and debridement for acute septic arthritis of the native knee.

Antibiotic-Loaded Collagen Sponges in Clinical Treatment of Chronic Osteomyelitis: A Systematic Review

BACKGROUND

Chronic osteomyelitis is caused by bacterial infection of the bone and is a major problem in orthopaedic surgery. Treatment of chronic osteomyelitis requires surgical debridement accompanied by local and systemic administration of antibiotics. A widely established biodegradable local antibiotic carrier is antibiotic-loaded collagen sponges (fleeces). These sponges are commonly used in the treatment of chronic osteomyelitis, but a systematic review of their clinical efficacy and assessment of the quality of evidence have not been conducted, to our knowledge.

METHODS

This systematic review, performed according to the PRISMA statement, examined the clinical efficacy of and quality of evidence regarding different antibiotic-loaded collagen sponges in the clinical treatment of chronic osteomyelitis. Clinical efficacy was defined as eradication of infection with bone and wound-healing. In addition, the in vivo pharmacokinetics of the various collagen sponges were evaluated. Quality was based on the Level of Evidence, methodological quality, and risks of bias.

RESULTS

A total of 813 articles were screened, and 10 were included. Gentamicin-sulfate sponges and gentamicin-sulfate/gentamicin-crobefate sponges were studied. A total of 413 patients were treated, with a success rate of 91%. Reported complications were fistulas, prolonged wound drainage, and wound-healing problems. In vivo pharmacokinetic profiles showed an average local antibiotic concentration that was above the minimum inhibitory concentration for only 5 days. The general quality of the included studies was low to moderate, and there was a moderate to high risk of bias.

CONCLUSIONS

The evidence quality and Level of Evidence of the included studies were low, and the risk of bias in these studies was high. This makes the evidence regarding these sponges inconclusive, and no clinical decision-making can be based on these studies. Utilization of antibiotic-loaded collagen sponges in the treatment of chronic osteomyelitis should only be carried out with caution; studies with high-level evidence are needed.

LEVEL OF EVIDENCE

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

Suppurative complications of acute hematogenous osteomyelitis in children

We carried out a case-control study in children with acute hematogenous osteomyelitis (AHO) with and without suppurative complications discharged from our institution over an 11-year period to test the hypothesis that abscess formation was associated with a delayed presentation to care. Of 102 children with AHO, 54 abscesses were documented in 46 patients (25 bone, 29 muscle). A delay in presentation was not associated with abscess formation (6.5 vs. 5.0 days, P=0.26). Overall, 78% of all bone abscesses were visible on initial MRI. Consistent use of MRI at presentation may identify children with suppurative complications of AHO.

Osteomyelitis of Maxilla in Infantile With Periorbital Cellulitis: A Case Report

Infantile osteomyelitis (IO) is an uncommon and life-threatening disease that can be misdiagnosed. Early diagnosis and treatment can reduce the incidence of sequel. In this case report, we present a 25-day-old male infant with apparent edema in the entire left periorbital region. Intraorally, the edema occurred in the mucosa of the upper left alveolar region, and 2 draining fistulas with exuded yellow-white pus were present in the left alveolar region. The patient received constant monitoring after admission, and was diagnosed as IO of the maxilla with periorbital cellulitis and sepsis. He also received incision and drainage and anti-inflammatory treatment. After discharge, the patient was followed up for 3 months by phone call, but no recurrence of symptoms was found. Infantile osteomyelitis is rare in clinic. This case report reminds us of the significance of IO and provides some implications on its diagnosis and treatment.

Antibiotic treatment for acute haematogenous osteomyelitis of childhood: moving towards shorter courses and oral administration

Acute haematogenous osteomyelitis (AHOM) of childhood usually affects the long bones of the lower limbs. Although almost any agent may cause AHOM, Staphylococcus aureus is the most common bacterium, followed by Streptococcus pneumoniae and, in some countries, Salmonella spp. and Kingella kingae. Magnetic resonance imaging (MRI) has improved the diagnostic accuracy of traditional radiography and scintigraphy. Except for the pre-treatment diagnostic sample from bone before the institution of antibiotic therapy, no other surgery is usually required. Traditionally, non-neonatal AHOM has been treated with a 1-3-month course of antibiotics, including an intravenous (i.v.) phase for the first weeks, but recent prospective randomised studies challenge this approach. For most uncomplicated cases, a course of 20 days including an i.v. period of 2-4 days suffices, provided large enough doses of a well-absorbed agent (clindamycin or a first-generation cephalosporin, local resistance permitting) are used, administration is four times daily and most symptoms and signs subside within a few days. Serum C-reactive protein (CRP) is a good guide in monitoring the course of illness, and the antimicrobial can usually be discontinued if CRP has decreased to <20 mg/L. Newer and costly agents, such as linezolid, should be reserved for cases due to resistant S. aureus strains. AHOM in neonates and immunocompromised patients probably requires a different approach. Because sequelae may develop slowly, follow-up for at least 1 year post hospitalisation is recommended.

Systematic review of systemic antibiotic treatment for children with chronic and sub-acute pyogenic osteomyelitis

BACKGROUND

There is a lack of consensus on the most appropriate antibiotics to treat children with chronic or sub-acute pyogenic bacterial osteomyelitis and on the optimal duration of antibiotic therapy.

AIM

To review the published evidence on the duration of antibiotic therapy and outcomes in children with chronic and sub-acute pyogenic bacterial osteomyelitis.

METHODS

Systematic review of the literature.

RESULTS

We found no randomised controlled trials comparing different antibiotic regimens or comparing duration of antibiotic treatment for chronic or sub-acute osteomyelitis in children. We found 14 observational case series published between 1973 and 2008. Most children with chronic osteomyelitis received 4-6 weeks of parenteral antibiotics followed by oral antibiotics to a total duration of 3-6 months. Small observational studies suggest that a shorter duration of parenteral and oral antibiotics may be equally effective.

CONCLUSION

There is no high level evidence on the optimal duration of parenteral and oral antibiotics for children with chronic or sub-acute osteomyelitis. A large randomised controlled trial is needed comparing short course parenteral and oral antibiotics with longer antibiotic duration.