Outpatients with acute osteoarticular infections had favourable outcomes when they received just oral antibiotics without intravenous antibiotics

Optimal Duration of Antibiotic Therapy for Primary Osteomyelitis Discitis: A Systematic Review and Network Meta-Analysis

STUDY DESIGN

Systematic review and network meta-analysis.

OBJECTIVE

This study aimed to systematically review the literature on the management of primary osteomyelitis discitis and perform a network meta-analysis comparing the efficacy of different antibiotic treatment durations.

BACKGROUND

Primary osteomyelitis discitis is a challenging condition with varying management strategies.

MATERIALS AND METHODS

A comprehensive literature search was conducted. Studies reporting outcomes for the treatment of primary osteomyelitis discitis were included. A random-effect network meta-analysis was performed comparing antibiotic treatment durations of <4 weeks, 4 to 8 weeks, 8 to 12 weeks, and 12 to 16 weeks. The surface under the cumulative ranking curve (SUCRA) was used to rank treatment effectiveness.

RESULTS

Sixty-three articles with 4233 patients were included. Staphylococcus aureus was the most common causative agent (57.6%). The 4 to 8-week antibiotic duration ranked highest across fixed-effect and random-effect models (SUCRA: 0.8207 and 0.8343). The 12 to 16-week duration ranked highest in the fixed-effect model (SUCRA: 0.8460) but dropped substantially in the random-effect model (SUCRA: 0.3067). The <4-week duration showed mixed results. The 8 to 12-week duration consistently ranked lowest. No statistically significant differences were found between durations for symptomatic relief.

CONCLUSION

Antibiotic therapy for 4 to 8 weeks may provide the optimal balance of efficacy and treatment duration for most patients with primary osteomyelitis discitis. However, treatment should be individualized based on clinical response. Further prospective studies are needed to clarify optimal management strategies for this complex condition.

Clinical Utility of a Multiplex PCR Panel (BioFire Joint Infection®) in the Adjustment of Empiric Antimicrobial Therapy: Experience in Pediatric Osteoarticular Infections

BACKGROUND/OBJECTIVES

This study aims to evaluate the impact of the PCR multiplex panel (BioFire JI®) on the diagnosis and management of pediatric osteoarticular infections.

METHODS

This retrospective study analyzed data from pediatric patients diagnosed with osteoarticular infections between January 2023 and April 2024. The effectiveness of the PCR multiplex panel in identifying pathogens was compared with traditional culture methods.

RESULTS

In total, 50 patients were identified (66.6% male, 74% under 3 years of age). They were diagnosed as follows: septic arthritis in 46%, osteomyelitis in 26%, and septic osteoarthritis in 22%. An identifiable agent was isolated by conventional culture in 22 cases (44%). Kingella kingae was the predominant pathogen identified, accounting for 50% of cases (11/22), followed by Staphylococcus aureus (9/22). The BioFire JI® Panel PCR demonstrated a sensitivity of 93%, with a specificity of 63% when evaluated against synovial fluid culture as the reference standard. The panel identified seven additional pathogens not detected by conventional culture methods: 2/9 MSSA (22%), 1/1 S. pyogenes (100%), and 4/11 K. kingae (37%), increasing the yield by 14%. The rapid identification of pathogens facilitated timely and targeted therapeutic interventions.

CONCLUSIONS

The PCR multiplex panel (BioFire JI®) improved the diagnosis of pediatric osteoarticular infections.

Methods to Reduce Cost of Treatment in Childhood Bone and Joint Infection: A Systematic Review

BACKGROUND

Childhood bone and joint infection (BJI) is a potentially severe disease with consequences for growth and development. Critically unwell children may require prolonged hospitalization and multiple surgeries. Acknowledging rising healthcare costs and the financial impact of illness on caregivers, increased efforts are required to optimize treatment. This systematic review aims to characterize existing costs of hospital care and summarize strategies, which reduce treatment expense.

METHODS

A systematic review of the literature was performed from January 1, 1980, to January 31, 2024. Data were extracted on hospitalization costs for pediatric BJI by decade and global region. Results have been converted to cost per day in US dollars with purchase parity for 2023. Studies reporting innovations in clinical care to reduce length of stay (LOS) and simplify treatment were identified. Studies trialing shorter antibiotic treatment were only included if they specifically reported changes in LOS.

RESULTS

Twenty-three studies met inclusion criteria; of these, a daily hospitalization cost could be derived from 7 publications. Overall hospitalization cost and inpatient charges rose steeply from the 1990s to the 2020s. By contrast, average LOS seems to have decreased. Cost per day was higher in the United States than in Europe and higher for cases with confirmed methicillin-resistant Staphylococcus aureus. Sixteen studies report innovations to optimize care. For studies where reduced LOS was achieved, early magnetic resonance imaging with immediate transfer to theater when necessary and discharge on oral antibiotics were consistent features.

CONCLUSION

Rising costs of hospital care and economic consequences for families can be mitigated by simplifying treatment for childhood BJI. Hospitals that adopt protocols for early advanced imaging and oral antibiotic switch may provide satisfactory clinical outcomes at lower cost.

LEVEL OF EVIDENCE

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

Appropriate Antibiotic Duration in Pediatric Bone and Joint Infection: A Systematic Review

Background: Optimal duration of antibiotic therapy for childhood bone and joint infection (BJI) remains controversial, despite recent literature in support of shorter courses and early oral switch. We have reviewed the literature to summarize current evidence for reduced duration of antibiotic therapy with particular attention to regional variation in pathogen type and treatment success. Methods: Systematic review was undertaken of studies examining acute pediatric bone and joint infection over the period January 1980-December 2022 for children aged up to 18 years. Cohort studies, systematic reviews, randomized controlled trials, and prospective studies were analyzed for data on treatment success rates and duration of therapy. Results: A total of 34 studies met inclusion criteria reporting treatment duration for 8337 cases of acute BJI. There were five prospective studies, 21 cohort studies, six randomized controlled trials, and three systematic reviews. The shortest duration of therapy tested prospectively was 10 days of combined IV and oral treatment. In the populations examined by this systematic review, there were no increased failure rates as a consequence of shorter therapy. Neonates and children with comorbid or complicated illness were routinely excluded from higher-level studies. Conclusions: There is moderate evidence for shortened duration of therapy with early switch to oral antibiotics in select patients. Studies reporting good success for reduced therapy included healthy patients with uncomplicated disease. Regional disease variation and study protocol heterogeneity limit widespread adoption of short-course treatment. Additionally, the experience of BJI is diverse. Although the majority of children respond well to treatment, there is a subset who demonstrate acute or chronically complicated disease. Further research is needed to define patient and disease factors that contribute to treatment failure. Level of Evidence: Systematic review Level III Key Concepts•In the populations examined in this systematic review, there was no evidence of increased failure rates as a consequence of shorter therapy.•It may be reasonable to recommend short course of IV therapy with early transition to oral medication in those >3 months of age without signs of complicated disease.•Clinicians need to be aware of regional disease variation and patient factors associated with treatment failure.•Pathogen and genetic variability likely contribute to the success of treatment in childhood BJI.

Early switch from intravenous to oral antibiotic treatment in bone and joint infections

OBJECTIVES

The timing of the switch from intravenous (i.v.) to oral antibiotic therapy for orthopaedic bone and joint infections (BJIs) is debated. In this narrative article, we discuss the evidence for and against an early switch in BJIs.

DATA SOURCES

We performed a PubMed and internet search investigating the association between the duration of i.v. treatment for BJI and remission of infection among adult orthopaedic patients.

CONTENT

Among eight randomized controlled trials and multiple retrospective studies, we failed to find any minimal duration of postsurgical i.v. therapy associated with clinical outcomes. We did not find scientific data to support the prolonged use of i.v. therapy or to inform a minimal duration of i.v.

THERAPY

Growing evidence supports the safety of an early switch to oral medications once the patient is clinically stable.

IMPLICATIONS

After surgery for BJI, a switch to oral antibiotics within a few days is reasonable in most cases. We recommend making the decision on the time point based on clinical criteria and in an interdisciplinary team at the bedside.

Oral-only antibiotics for bone and joint infections in children: study protocol for a nationwide randomised open-label non-inferiority trial

INTRODUCTION

Children with bone and joint infections are traditionally treated with intravenous antibiotics for 3-10 days, followed by oral antibiotics. Oral-only treatment has not been tested in randomised trials.

METHODS AND ANALYSIS

Children (3 months to 18 years) will be randomised 1:1 with the experimental group receiving high-dose oral antibiotics and the control group receiving intravenous antibiotics with a shift in both groups to standard oral antibiotics after clinical and paraclinical improvement. Children in need of acute surgery or systemic features requiring intravenous therapy, including septic shock, are excluded. The primary outcome is defined as a normal blinded standardised clinical assessment 6 months after end of treatment. Secondary outcomes are non-acute treatment failure and recurrent infection. Outcomes will be compared by a non-inferiority assumption with an inferiority margin of 5%.

ETHICS AND DISSEMINATION

The trial has the potential to reduce unnecessary hospitalisation and use of intravenous antibiotics in children with bone or joint infections. Due to the close follow-up, exclusion of severely ill children and predefined criteria for discontinuation of the allocated therapy, we expect the risk of treatment failure to be minimal.

TRIAL REGISTRATION NUMBER

NCT04563325.

Can the Future of ID Escape the Inertial Dogma of Its Past? The Exemplars of Shorter Is Better and Oral Is the New IV

Like all fields of medicine, Infectious Diseases is rife with dogma that underpins much clinical practice. In this study, we discuss 2 specific examples of historical practice that have been overturned recently by numerous prospective studies: traditional durations of antimicrobial therapy and the necessity of intravenous (IV)-only therapy for specific infectious syndromes. These dogmas are based on uncontrolled case series from >50 years ago, amplified by the opinions of eminent experts. In contrast, more than 120 modern, randomized controlled trials have established that shorter durations of therapy are equally effective for many infections. Furthermore, 21 concordant randomized controlled trials have demonstrated that oral antibiotic therapy is at least as effective as IV-only therapy for osteomyelitis, bacteremia, and endocarditis. Nevertheless, practitioners in many clinical settings remain refractory to adopting these changes. It is time for Infectious Diseases to move beyond its history of eminent opinion-based medicine and truly into the era of evidenced-based medicine.

Impact of a pediatric infectious disease consultation service on timely step-down to oral antibiotic treatment for bone and joint infections

PURPOSE

In recent years an earlier step down to oral antibiotic therapy has been advocated for numerous infections. Trained infectious disease specialists regularly consulting their colleagues may speed up the implementation of such recommendations into clinical practice and thus may improve treatment.

METHODS

We retrospectively analyzed bone and joint infections in children admitted to the University Hospital of Cologne between 2010 and 2021. We assessed clinical, imaging, and microbiological findings and treatment modalities. Additionally, we assessed both the impact of a newly implemented pediatric infectious diseases consultation service and publications on revised treatment recommendations by comparing antibiotic therapy in two periods (2010-2016 versus 2017 to 2021).

RESULTS

In total, 29 children presented with osteomyelitis, 16 with bacterial arthritis and 7 with discitis. In period 2 (2017-2021) we observed shorter duration of intravenous treatment (p = 0.009) and a higher percentage of oral antibiotic treatment in relation to the total duration of antibiotics (25% versus 59%, p = 0.007) compared to period 1 (2010-2016). Yet, no differences were identified for the total length of antibiotic treatment. Additionally, biopsies or synovial fluid samples were retrieved and cultured in more children in period 2 (p = 0.077). The main pathogen identified in osteomyelitis and bacterial arthritis was Staphylococcus aureus (MSSA), diagnosis was confirmed predominantly with MRI.

CONCLUSION

Recent guidelines addressing the safety of an earlier step-down (to oral) antibiotic therapy have influenced clinical practice in the treatment of bone and joint infections in our hospital. A newly implemented pediatric infectious diseases consultation service might have accelerated this progress resulting in a faster step down to oral treatment.

Oral Versus Intravenous Antibiotics for Pediatric Osteoarticular Infection: When and to Whom?

BACKGROUND

Osteoarticular infections (OAIs) are typically treated initially with intravenous antibiotics. The objective of this study was to evaluate whether an exclusive oral treatment in selected children may be appropriate.

METHODS

The Spanish Network of Osteoarticular Infections is a nationwide multicenter registry comprising 37 hospitals in Spain. The registry prospectively includes clinical characteristics and outcome of children with OAI. One of the hospitals from RioPed offers oral treatment to children meeting certain criteria. Patients were classified into 2 groups. Group 1: management with initial intravenous antibiotic therapy. Group 2: patients exclusively treated with oral antibiotics. A comparison between the 2 groups was performed.

RESULTS

We compared 893 children who initially received intravenous antibiotics (group 1) with 64 children who received exclusively oral therapy (group 2). Patients from group 2 were younger (33.9 vs. 20.3 months; P = 0.001), had a lower percentage of Staphylococcus aureus (23.3% vs. 3.1%; P < 0.001), a higher proportion of Kingella kingae (12.1% vs. 28.1%; P = 0.001), higher erythrocyte sedimentation rate/C-reactive protein (CRP) ratio (1.4 interquartile range 0.6-3.6 vs. 3.3 interquartile range 1.7-5.7; P < 0.001) and showed lower rate of fever (63% vs. 48.8%; P = 0.024) than in group 1. Complications were not found in group 2.

CONCLUSIONS

An exclusively oral administration could be a safe option in selected patients with OAI. Low-risk criteria are proposed: good general condition, no underlying disease, 6 months to 3 years old, appropriate oral tolerance, C-reactive protein <80 mg/L, erythrocyte sedimentation rate/C-reactive protein ratio ≥0.67, no skin injury, no recent surgery, no cervical spondylodiscitis and no local complications at onset.

Characteristics of Upper Limb Osteoarticular Infections at the Emergency Department of a Tertiary University Hospital in Spain

OBJECTIVES

Osteoarticular infections are infrequent in pediatric patients, although their incidence seems to be increasing. They usually affect children younger than 5 years and tend to localize in the lower limbs. Because of their nonspecific symptoms, especially at onset, a timely diagnosis is difficult to achieve, with the subsequent risk of a delay in treatment. We hereby report the management of osteoarticular infections in our pediatric emergency department.

METHODS

This is a retrospective descriptive study of patients diagnosed with osteoarticular upper limb infection in the pediatric emergency department of a tertiary hospital from January 2011 to December 2016.

RESULTS

From an initial global sample of 170 patients diagnosed with osteomyelitis or septic arthritis at any location at the pediatric emergency department, 32 children (18.82%) with upper limb involvement were included in the study. Of them, 22 were male and the mean age at diagnosis was 14.5 months (interquartile range, 2-106). Eighteen patients (56%) were diagnosed with septic arthritis, and 14 (44%) had a diagnosis of osteomyelitis.The most frequent symptom was pain (50%). More than one third of patients (11) had received a different diagnosis in a previous hospital visit. A traumatic etiology was suspected in 7 cases (21%).Regarding acute phase reactants, the mean value for C-reactive protein was 21.3 mg/L, and erythrocyte sedimentation rate was elevated in 27 cases (84%). In 28 patients, blood cultures were obtained, 24 of which came back negative. All children received antibiotic treatment and achieved a full recovery.

CONCLUSIONS

One third of patients were misdiagnosed at the first consultation, which stresses the importance of a high clinical suspicion to avoid delays in diagnosis and treatment of osteoarticular infections. This study also shows a lower mean age of children with upper limb infection as compared with those with lower limb infection. All patients recovered fully with oral antibiotics.

The Antibiotic Use in Osteomyelitis Infection: A Systematic Review

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

Italian consensus on the therapeutic management of uncomplicated acute hematogenous osteomyelitis in children

BACKGROUND

Acute hematogenous osteomyelitis (AHOM) is an insidious infection of the bone that more frequently affects young males. The etiology, mainly bacterial, is often related to the patient's age, but it is frequently missed, owing to the low sensitivity of microbiological cultures. Thus, the evaluation of inflammatory biomarkers and imaging usually guide the diagnosis and follow-up of the infection. The antibiotic treatment of uncomplicated AHOM, on the other hand, heavily relies upon the clinician experience, given the current lack of national guidelines for the management of this infection.

METHODS

A systematic review of the studies on the empirical treatment of uncomplicated AHOM in children published in English or Italian between January 1, 2009, and March 31, 2020, indexed on Pubmed or Embase search engines, was carried out. All guidelines and studies reporting on non-bacterial or complicated or post-traumatic osteomyelitis affecting newborns or children older than 18 years or with comorbidities were excluded from the review. All other works were included in this study.

RESULTS

Out of 4576 articles, 53 were included in the study. Data on different topics was gathered and outlined: bone penetration of antibiotics; choice of intravenous antibiotic therapy according to the isolated or suspected pathogen; choice of oral antibiotic therapy; length of treatment and switch to oral therapy; surgical treatment.

CONCLUSIONS

The therapeutic management of osteomyelitis is still object of controversy. This study reports the first Italian consensus on the management of uncomplicated AHOM in children of pediatric osteomyelitis, based on expert opinions and a vast literature review.

Sacroilitis in Preschool Children: A Case Series and Review of the Literature

Pyogenic sacroilitis is an infrequent osteoarticular infection, and its diagnosis is a challenge in young children. A series of 20 cases is described. The median age was 15 months, 75% of them being under 2 years old. Fourteen (70%) reported fever. Refusal to sit was the main reason for consultation. Final diagnosis was confirmed by bone scintigraphy. All patients achieved a complete resolution without sequelae.

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.

[Evaluation of the impact of the Spanish consensus document on the approach to osteoarticular infections in Spain through the Paediatrics Osteoarticular Infections Network (RIOPED)]

INTRODUCTION

In 2014 the Consensus Document produced by the Spanish Paediatric Societies (SEIP-SERPE-SEOP) was published to help in the diagnosis and treatment of osteoarticular infections (OAI). In 2015 the RIOPed was considered as a multidisciplinary national network for the investigation into OAI. The aim of this study was to assess the level of adaption to the recommendations established in the Consensus during one year of follow-up.

MATERIAL AND METHODS

A prospective, national multicentre study was carried out in 37 hospitals between September 2015 and September 2016. The study included patients >16years-old with a diagnosis of OAI, confirmed by microbiological isolation, or probable: septic arthritis (SA) with >40,000 white cells in synovial fluid, or osteomyelitis (OM)/spondylodiscitis (SD) with a compatible imaging test. The results were compared with those obtained in a retrospective study conducted between 2008 and 2012.

RESULTS

A total of 235 cases were included, of which 131 were OM, 79 SA, 30 OA, and 15 SD. As regards the complementary tests that the Consensus considered mandatory to perform, radiography was carried out on 87.8% of the cases, a blood culture on 91.6%, and culture of the synovial fluid in 99% of SA. A magnetic resonance (MR) was performed on 71% of the OM cases. The choice of intravenous empirical antibiotic treatment was adapted to the recommendations in 65.1% of cases, and in 62.3% for the oral treatment. Surgery was performed in 36.8% of SA cases (85.7% arthrotomy), with a significant decrease compared to the retrospective study (P=.014). Only 58.5% of cases followed the recommendations on the duration of the treatment; however, a lower duration of intravenous treatment was observed.

CONCLUSIONS

In general, the level of adaptation to the recommendations that were set by the Expert Group, is good for the complementary tests, and acceptable as regards the choice of antibiotic treatment, although inadequate in almost 40% of cases. A decrease in hospital stay was achieved.