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Edelbach B, Glaser D, Almekkawi AK, Caruso JP, Sbaiti G, Aoun SG, Bagley CA. Optimal Duration of Antibiotic Therapy for Primary Osteomyelitis Discitis: A Systematic Review and Network Meta-Analysis. Spine (Phila Pa 1976) 2025; 50:636-644. [PMID: 39722225 DOI: 10.1097/brs.0000000000005244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Accepted: 11/18/2024] [Indexed: 12/28/2024]
Abstract
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.
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Affiliation(s)
| | - Dylan Glaser
- Department of Neurosurgery, School of Medicine, University of Missouri-Kansas City
| | - Ahmad K Almekkawi
- Department of Neurosurgery, Saint Luke's Marion Bloch Neuroscience Institute, Kansas City, MO
| | - James P Caruso
- Department of Neurosurgery, The University of Texas Southwestern, Dallas, TX
| | - Ghewa Sbaiti
- Department of Pharmacy, The University of Texas Southwestern, Dallas, TX
| | - Salah G Aoun
- Department of Neurosurgery, The University of Texas Southwestern, Dallas, TX
| | - Carlos A Bagley
- Department of Neurosurgery, School of Medicine, University of Missouri-Kansas City
- Department of Neurosurgery, Saint Luke's Marion Bloch Neuroscience Institute, Kansas City, MO
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Udaondo C, Alcobendas Rueda RM, Diaz-Delgado B, Remesal A, Quiles-Melero I, Calvo C. Clinical Utility of a Multiplex PCR Panel (BioFire Joint Infection ®) in the Adjustment of Empiric Antimicrobial Therapy: Experience in Pediatric Osteoarticular Infections. CHILDREN (BASEL, SWITZERLAND) 2024; 11:1236. [PMID: 39457201 PMCID: PMC11506507 DOI: 10.3390/children11101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 10/07/2024] [Accepted: 10/09/2024] [Indexed: 10/28/2024]
Abstract
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.
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Affiliation(s)
- Clara Udaondo
- Pediatric Rheumatology, Hospital Universitario La Paz, 28046 Madrid, Spain
- CIBERINFEC, Consorcio de Investigación Biomédica en Red, Hospital Carlos III, 28029 Madrid, Spain
| | - Rosa María Alcobendas Rueda
- Pediatric Rheumatology, Hospital Universitario La Paz, 28046 Madrid, Spain
- Pediatric Rheumatology Unit, University Hospital Ruber International, 28034 Madrid, Spain
| | | | - Agustin Remesal
- Pediatric Rheumatology, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Inmaculada Quiles-Melero
- Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Cristina Calvo
- CIBERINFEC, Consorcio de Investigación Biomédica en Red, Hospital Carlos III, 28029 Madrid, Spain
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, 28046 Madrid, Spain
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Hunter S, Crawford H, Ao BT, Grant C. Methods to Reduce Cost of Treatment in Childhood Bone and Joint Infection: A Systematic Review. JBJS Rev 2024; 12:01874474-202405000-00007. [PMID: 38814570 DOI: 10.2106/jbjs.rvw.24.00043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
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.
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Affiliation(s)
- Sarah Hunter
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Orthopaedic Department, Starship Hospital, Auckland, New Zealand
| | - Haemish Crawford
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Orthopaedic Department, Starship Hospital, Auckland, New Zealand
| | - Braden Te Ao
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- School of Population Health and Health Economics, University of Auckland, Auckland, New Zealand
| | - Cameron Grant
- University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Department of Child and Youth Health, Starship Hospital, Auckland, New Zealand
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Sendi P, Lora-Tamayo J, Cortes-Penfield NW, Uçkay I. Early switch from intravenous to oral antibiotic treatment in bone and joint infections. Clin Microbiol Infect 2023; 29:1133-1138. [PMID: 37182643 DOI: 10.1016/j.cmi.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/25/2023] [Accepted: 05/06/2023] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
| | - Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica 'i+12' Hospital 12 de Octubre, Madrid, Spain; CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Bybeck Nielsen A, Borch L, Damkjaer M, Glenthøj JP, Hartling U, Hoffmann TU, Holm M, Helleskov Rasmussen A, Schmidt LS, Schmiegelow K, Stensballe LG, Nygaard U. Oral-only antibiotics for bone and joint infections in children: study protocol for a nationwide randomised open-label non-inferiority trial. BMJ Open 2023; 13:e072622. [PMID: 37263683 DOI: 10.1136/bmjopen-2023-072622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
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.
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Affiliation(s)
- Allan Bybeck Nielsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Luise Borch
- Department of Paediatrics and Adolescent Medicine, Gødstrup Hospital, Herning, Denmark
- NIDO - Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Mads Damkjaer
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark
- Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jonathan Peter Glenthøj
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hillerød, Denmark
| | - Ulla Hartling
- Department of Paediatrics and Adolescent Medicine, Odense University Hospital, Odense, Denmark
| | - Thomas Ulrik Hoffmann
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark
| | - Mette Holm
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Annett Helleskov Rasmussen
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark
| | - Lisbeth Samsø Schmidt
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Herlev, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Lone Graff Stensballe
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
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Davar K, Clark D, Centor RM, Dominguez F, Ghanem B, Lee R, Lee TC, McDonald EG, Phillips MC, Sendi P, Spellberg B. Can the Future of ID Escape the Inertial Dogma of Its Past? The Exemplars of Shorter Is Better and Oral Is the New IV. Open Forum Infect Dis 2022; 10:ofac706. [PMID: 36694838 PMCID: PMC9853939 DOI: 10.1093/ofid/ofac706] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Kusha Davar
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Devin Clark
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Robert M Centor
- Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Alabama, Birmingham, Alabama, USA
| | - Fernando Dominguez
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | | | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Matthew C Phillips
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Brad Spellberg
- Correspondence: Brad Spellberg, MD, Hospital Administration, 2051 Marengo Street, Los Angeles, CA 90033 ()
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Impact of a pediatric infectious disease consultation service on timely step-down to oral antibiotic treatment for bone and joint infections. Infection 2022:10.1007/s15010-022-01934-4. [PMID: 36201153 DOI: 10.1007/s15010-022-01934-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/23/2022] [Indexed: 11/05/2022]
Abstract
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.
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Alcobendas Rueda RM, Núñez E, Martín L, Hernández MB, Saavedra-Lozano J, Udaondo C, Murias S, Remesal A, Calvo C. Oral Versus Intravenous Antibiotics for Pediatric Osteoarticular Infection: When and to Whom? Pediatr Infect Dis J 2022; 41:e351-e357. [PMID: 35763692 DOI: 10.1097/inf.0000000000003619] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
| | - Esmeralda Núñez
- Pediatrics Department, Hospital Materno-Infantil, Málaga, Spain
| | - Laura Martín
- Pediatrics Department, Hospital Materno-Infantil, Málaga, Spain
| | | | - Jesús Saavedra-Lozano
- Pediatric Infectious Diseases Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid
| | - Clara Udaondo
- From the, Pediatric Rheumatology Unit, Hospital Universitario La Paz
| | - Sara Murias
- From the, Pediatric Rheumatology Unit, Hospital Universitario La Paz
| | - Agustin Remesal
- From the, Pediatric Rheumatology Unit, Hospital Universitario La Paz
| | - Cristina Calvo
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, Madrid, Spain
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Alcobendas RM, Núñez E, Calvo C. Minimally invasive management of pediatric osteoarticular infections. Front Pediatr 2022; 10:1017035. [PMID: 36440331 PMCID: PMC9692125 DOI: 10.3389/fped.2022.1017035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Esmeralda Núñez
- Pediatrics Department, Hospital Materno-Infantil, Málaga, Spain
| | - Cristina Calvo
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, Fundación IdiPaz, Madrid, Spain.,Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain.,CIBER Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
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10
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Martín Espín I, Murias Loza S, Lacasta Plasin C, Niño Saco MD, Alcolea Sánchez A, de Ceano-Vivas la Calle M. Characteristics of Upper Limb Osteoarticular Infections at the Emergency Department of a Tertiary University Hospital in Spain. Pediatr Emerg Care 2022; 38:e251-e253. [PMID: 32925699 DOI: 10.1097/pec.0000000000002238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
| | - Sara Murias Loza
- Unit of Pediatric Rheumatology, University Hospital La Paz, Madrid, Spain
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11
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Sananta P, Huwae TECJ, Ronadi D, Dhakka Siahaan L. The Antibiotic Use in Osteomyelitis Infection: A Systematic Review. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Krzysztofiak A, Chiappini E, Venturini E, Gargiullo L, Roversi M, Montagnani C, Bozzola E, Chiurchiu S, Vecchio D, Castagnola E, Tomà P, Rossolini GM, Toniolo RM, Esposito S, Cirillo M, Cardinale F, Novelli A, Beltrami G, Tagliabue C, Boero S, Deriu D, Bianchini S, Grandin A, Bosis S, Ciarcià M, Ciofi D, Tersigni C, Bortone B, Trippella G, Nicolini G, Lo Vecchio A, Giannattasio A, Musso P, Serrano E, Marchisio P, Donà D, Garazzino S, Pierantoni L, Mazzone T, Bernaschi P, Ferrari A, Gattinara GC, Galli L, Villani A. Italian consensus on the therapeutic management of uncomplicated acute hematogenous osteomyelitis in children. Ital J Pediatr 2021; 47:179. [PMID: 34454557 PMCID: PMC8403408 DOI: 10.1186/s13052-021-01130-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Andrzej Krzysztofiak
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Elena Chiappini
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Elisabetta Venturini
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Livia Gargiullo
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Roversi
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carlotta Montagnani
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Elena Bozzola
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sara Chiurchiu
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Davide Vecchio
- Rare Disease and Medical Genetics, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elio Castagnola
- Infectious Disease Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Paolo Tomà
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Renato Maria Toniolo
- Surgery Department, Traumatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | - Marco Cirillo
- Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Cardinale
- Department of Pediatrics and Emergency, Pediatric Allergy and Pulmunology Unit, Azienda Ospedaliera-Universitaria "Consorziale-Policlinico", Ospedale Pediatrico Giovanni XXIII, Bari, Italy
| | - Andrea Novelli
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, Florence, Italy
| | - Giovanni Beltrami
- Department of Orthopaedic Oncology and Reconstructive Surgery, AOU Careggi, Florence, Italy
| | - Claudia Tagliabue
- Pediatric Highly Intensive Care Unit, Fondazione Ca' Granda Ospedale Maggiore Policlinico, IRCCS, Milan, Italy
| | - Silvio Boero
- Department of Pediatric Orthopaedics, IRCCS Istituto 'Giannina Gaslini', Children's Hospital, Genova, Italy
| | - Daniele Deriu
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sonia Bianchini
- Department of Pediatrics, ASST Santi Paolo e Carlo Hospital, Milan, Italy
| | - Annalisa Grandin
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Samantha Bosis
- Pediatric Highly Intensive Care Unit, Fondazione Ca' Granda Ospedale Maggiore Policlinico, IRCCS, Milan, Italy
| | - Martina Ciarcià
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Daniele Ciofi
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Chiara Tersigni
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Barbara Bortone
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Giulia Trippella
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | | | - Andrea Lo Vecchio
- Section of Paediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Paola Musso
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Elena Serrano
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Paola Marchisio
- Pediatric Highly Intensive Care Unit, Fondazione Ca' Granda Ospedale Maggiore Policlinico, IRCCS, Milan, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Silvia Garazzino
- Pediatric Infectious Disease Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Luca Pierantoni
- Pediatric Emergency Unit, Policlinico di Sant'Orsola, Bologna, Italy
| | | | - Paola Bernaschi
- Microbiology Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | | | | | - Luisa Galli
- Paediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Alberto Villani
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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13
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Evaluation of the impact of the Spanish Consensus Document on the approach to osteoarticular infections in Spain through the Paediatrics Osteoarticular Infections Network (RIOPED). ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
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.
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15
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Wong M, Williams N, Cooper C. Systematic Review of Kingella kingae Musculoskeletal Infection in Children: Epidemiology, Impact and Management Strategies. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2020; 11:73-84. [PMID: 32158303 PMCID: PMC7048951 DOI: 10.2147/phmt.s217475] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 12/07/2019] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Maria Wong
- Department of Orthopaedic Surgery, Women and Children's Hospital, Adelaide, SA, Australia
| | - Nicole Williams
- Department of Orthopaedic Surgery, Women and Children's Hospital, Adelaide, SA, Australia.,Center for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, SA, Australia
| | - Celia Cooper
- Department of Infectious Diseases, Women and Children's Hospital, Adelaide, SA, Australia
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16
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Núñez Cuadros E, Calvo Rey C, Saavedra-Lozano J. [Evaluation of the impact of the Spanish consensus document on the approach to osteoarticular infections in Spain through the Paediatrics Osteoarticular Infections Network (RIOPED)]. An Pediatr (Barc) 2020; 93:289-296. [PMID: 31980415 DOI: 10.1016/j.anpedi.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/13/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022] Open
Abstract
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.
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Affiliation(s)
- Esmeralda Núñez Cuadros
- Hospitalización Pediátrica, Unidad de Reumatología Pediátrica, Unidad Asistencial de Pediatría, Hospital Regional Universitario de Málaga, Málaga, España
| | - Cristina Calvo Rey
- Servicio de Pediatría y Enfermedades Infecciosas, Hospital Universitario La Paz, Fundación IdiPaz. TEDDY Network (European Network of Excellence for Pediatric Clinical Research), Madrid, España; Red de Investigación Traslacional en Infectología Pediátrica (RITIP), España.
| | - Jesús Saavedra-Lozano
- Red de Investigación Traslacional en Infectología Pediátrica (RITIP), España; Sección de Enfermedades Infecciosas, Servicio de Pediatría, Hospital Universitario Gregorio Marañón, Universidad Complutense, Madrid, España
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17
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Peltola H, Pääkkönen M. Searching for a simpler treatment for paediatric osteoarticular infections. Acta Paediatr 2018; 107:1669-1670. [PMID: 29979813 DOI: 10.1111/apa.14458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Heikki Peltola
- Children's Hospital; Helsinki University Central Hospital, and University of Helsinki; Helsinki Finland
| | - Markus Pääkkönen
- Department of Pediatric Orthopaedics and the Clinic of Hand and Upper Limb Surgery; University of Turku, and Turku University ORTO Hospital; Turku Finland
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