1
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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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2
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Trobisch A, Schweintzger NA, Kohlfürst DS, Sagmeister MG, Sperl M, Grisold AJ, Feierl G, Herberg JA, Carrol ED, Paulus SC, Emonts M, van der Flier M, de Groot R, Cebey-López M, Rivero-Calle I, Boeddha NP, Agapow PM, Secka F, Anderson ST, Behrends U, Wintergerst U, Reiter K, Martinon-Torres F, Levin M, Zenz W. Osteoarticular Infections in Pediatric Hospitals in Europe: A Prospective Cohort Study From the EUCLIDS Consortium. Front Pediatr 2022; 10:744182. [PMID: 35601438 PMCID: PMC9114665 DOI: 10.3389/fped.2022.744182] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pediatric osteoarticular infections (POAIs) are serious diseases requiring early diagnosis and treatment. METHODS In this prospective multicenter cohort study, children with POAIs were selected from the European Union Childhood Life-threatening Infectious Diseases Study (EUCLIDS) database to analyze their demographic, clinical, and microbiological data. RESULTS A cohort of 380 patients with POAIs, 203 with osteomyelitis (OM), 158 with septic arthritis (SA), and 19 with both OM and SA, was analyzed. Thirty-five patients were admitted to the Pediatric Intensive Care Unit; out of these, six suffered from shock, one needed an amputation of the right foot and of four left toes, and two had skin transplantation. According to the Pediatric Overall Performance Score, 36 (10.5%) showed a mild overall disability, 3 (0.8%) a moderate, and 1 (0.2%) a severe overall disability at discharge. A causative organism was detected in 65% (247/380) of patients. Staphylococcus aureus (S. aureus) was identified in 57.1% (141/247) of microbiological confirmed cases, including 1 (0.7%) methicillin-resistant S. aureus (MRSA) and 6 (4.2%) Panton-Valentine leukocidin (PVL)-producing S. aureus, followed by Group A Streptococcus (18.2%) and Kingella kingae (8.9%). K. kingae and PVL production in S. aureus were less frequently reported than expected from the literature. CONCLUSION POAIs are associated with a substantial morbidity in European children, with S. aureus being the major detected pathogen. In one-third of patients, no causative organism is identified. Our observations show an urgent need for the development of a vaccine against S. aureus and for the development of new microbiologic diagnostic guidelines for POAIs in European pediatric hospitals.
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Affiliation(s)
- Andreas Trobisch
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Group for Neonatal Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Nina A Schweintzger
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Daniela S Kohlfürst
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Manfred G Sagmeister
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Matthias Sperl
- Department of Orthopedics and Traumatology, Pediatric Orthopedic Unit, Medical University of Graz, Graz, Austria
| | - Andrea J Grisold
- Diagnostic and Research Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Graz, Austria
| | - Gebhard Feierl
- Diagnostic and Research Institute of Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Graz, Austria
| | - Jethro A Herberg
- Section of Pediatric Infectious Disease, Imperial College London, London, United Kingdom
| | - Enitan D Carrol
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Stephane C Paulus
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Marieke Emonts
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.,National Institute for Health Research (NIHR) Newcastle Biomedical Research Centre Based at Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Newcastle upon Tyne, United Kingdom.,Pediatric Infectious Diseases and Immunology Department, Newcastle upon Tyne Hospitals Foundation Trust, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Michiel van der Flier
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Immunology and Laboratory of Infectious Diseases, Radboud Institute of Molecular Life Sciences, Nijmegen, Netherlands.,Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital University Medical Center Utrecht, Utrecht, Netherlands
| | - Ronald de Groot
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Immunology and Laboratory of Infectious Diseases, Radboud Institute of Molecular Life Sciences, Nijmegen, Netherlands
| | - Miriam Cebey-López
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago (IDIS), Genetics- Vaccines- Infectious Diseases and Pediatrics Research Group (GENVIP), Santiago de Compostela, Spain
| | - Irene Rivero-Calle
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago (IDIS), Genetics- Vaccines- Infectious Diseases and Pediatrics Research Group (GENVIP), Santiago de Compostela, Spain
| | - Navin P Boeddha
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Paul-Michael Agapow
- Section of Pediatric Infectious Disease, Imperial College London, London, United Kingdom
| | - Fatou Secka
- Medical Research Council Unit the Gambia, Banjul, Gambia
| | | | - Uta Behrends
- Department of Pediatrics and of Pediatric Surgery, Technische Universität München, Munich, Germany
| | - Uwe Wintergerst
- Department of Pediatrics, Hospital St. Josef, Braunau, Austria
| | - Karl Reiter
- Department of Pediatric Intensive Care, University Children's Hospital at Dr. von Haunersche Kinderklinik, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Federico Martinon-Torres
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Santiago de Compostela, Spain.,Instituto de Investigación Sanitaria de Santiago (IDIS), Genetics- Vaccines- Infectious Diseases and Pediatrics Research Group (GENVIP), Santiago de Compostela, Spain
| | - Michael Levin
- Section of Pediatric Infectious Disease, Imperial College London, London, United Kingdom
| | - Werner Zenz
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
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3
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Woods CR, Bradley JS, Chatterjee A, Copley LA, Robinson J, Kronman MP, Arrieta A, Fowler SL, Harrison C, Carrillo-Marquez MA, Arnold SR, Eppes SC, Stadler LP, Allen CH, Mazur LJ, Creech CB, Shah SS, Zaoutis T, Feldman DS, Lavergne V. 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. J Pediatric Infect Dis Soc 2021; 10:801-844. [PMID: 34350458 DOI: 10.1093/jpids/piab027] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee College of Medicine, Chattanooga, Tennessee, USA
| | - John S Bradley
- Division of Infectious Diseases, University of California San Diego School of Medicine, and Rady Children's Hospital, San Diego, California, USA
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew P Kronman
- Division of Infectious Diseases, Seattle Children's Hospital, Seattle, Washington, USA
| | - Antonio Arrieta
- University of California Irvine School of Medicine and Children's Hospital of Orange County, Irvine, California, USA
| | - Sandra L Fowler
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stephen C Eppes
- Department of Pediatrics, ChristianaCare, Newark, Delaware, USA
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky, USA
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas, USA
| | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Feldman
- New York University Langone Medical Center, New York, New York, USA
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of Montreal Research Center, Montreal, Quebec, Canada
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4
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Alhinai Z, Elahi M, Park S, Foo B, Lee B, Chapin K, Koster M, Sánchez PJ, Michelow IC. Prediction of Adverse Outcomes in Pediatric Acute Hematogenous Osteomyelitis. Clin Infect Dis 2021; 71:e454-e464. [PMID: 32129457 DOI: 10.1093/cid/ciaa211] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/28/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinicians cannot reliably predict complications of acute hematogenous osteomyelitis (AHO). METHODS Consecutive cases of AHO from 2 pediatric centers in the United States were analyzed retrospectively to develop clinical tools from data obtained within 96 hours of hospitalization to predict acute and chronic complications of AHO. Two novel composite prediction scores derived from multivariable logistic regression modeling were compared with a previously published severity of illness (SOI) score, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) using area under the receiver operating characteristic curve analyses. RESULTS The causative organisms were identified in 73% of 261 cases. Bacteremia (45%), abscesses (38%), and associated suppurative arthritis (23%) were relatively common. Acute or chronic complications occurred in 24% and 11% of patients, respectively. Multivariable logistic regression identified bone abscess (odds ratio [OR], 2.3 [95% confidence interval {CI}, 1.0-5.2]), fever > 48 hours (OR, 2.7 [95% CI, 1.2-6.0]), suppurative arthritis (OR, 3.2 [95% CI, 1.3-7.5]), disseminated disease (OR, 4.6 [95% CI, 1.5-14.3]), and delayed source control (OR, 5.1 [95% CI, 1.4-19.0]) as strong predictors of acute complications. In a separate model, CRP ≥ 100 mg/L at 2-4 days after antibiotics (OR, 2.7 [95% CI, 1.0-7.3]), disseminated disease (OR, 3.3 [95% CI, 1.1-10.0]), and requirement for bone debridement (OR, 6.7 [95% CI, 2.1-21.0]) strongly predicted chronic morbidity. These variables were combined to create weighted composite prediction scores for acute (A-SCORE) and chronic (C-SCORE) osteomyelitis, which were superior to SOI, CRP, and ESR and had negative predictive values > 90%. CONCLUSIONS Two novel composite clinical scores were superior to existing tools to predict complications of pediatric AHO.
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Affiliation(s)
- Zaid Alhinai
- Department of Pediatrics, Division of Infectious Diseases, Warren Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Morvarid Elahi
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sangshin Park
- Graduate School of Urban Public Health, University of Seoul, Seoul, Republic of Korea
| | - Bill Foo
- Department of Pediatrics, Division of Hospital Medicine, Warren Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Brian Lee
- Department of Pediatrics, Division of Hospital Medicine, Warren Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Kimberle Chapin
- Department of Pathology and Laboratory Medicine, Laboratory of Clinical Microbiology, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island, USA
| | - Michael Koster
- Department of Pediatrics, Division of Hospital Medicine, Warren Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Pablo J Sánchez
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ian C Michelow
- Department of Pediatrics, Division of Infectious Diseases, Warren Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, Rhode Island, USA
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5
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Alder KD, Lee I, Munger AM, Kwon HK, Morris MT, Cahill SV, Back J, Yu KE, Lee FY. Intracellular Staphylococcus aureus in bone and joint infections: A mechanism of disease recurrence, inflammation, and bone and cartilage destruction. Bone 2020; 141:115568. [PMID: 32745687 DOI: 10.1016/j.bone.2020.115568] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/19/2020] [Accepted: 07/26/2020] [Indexed: 02/06/2023]
Abstract
Bone and joint infections are devastating afflictions. Although medical interventions and advents have improved their care, bone and joint infections still portend dismal outcomes. Indeed, bone and joint infections are associated with extremely high mortality and morbidity rates and, generally, occur secondary to the aggressive pathogen Staphylococcus aureus. The consequences of bone and joint infections are further compounded by the fact that although they are aggressively treated, they frequently recur and result in massive bone and articular cartilage loss. Here, we review the literature and chronicle the fact that the fundamental cellular components of the musculoskeletal system can be internally infected with Staphylococcus aureus, which explains the ready recurrence of bone and joint infections even after extensive administration of antibiotic therapy and debridement and offer potential treatment solutions for further study. Moreover, we review the ramifications of intracellular infection and expound that the massive bone and articular cartilage loss is caused by the sustained proinflammatory state induced by infection and offer potential combination therapies for further study to protect bone and cartilage.
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Affiliation(s)
- Kareme D Alder
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
| | - Inkyu Lee
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Department of Life Science, Chung-Ang University, Seoul, Republic of Korea; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
| | - Alana M Munger
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
| | - Hyuk-Kwon Kwon
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
| | - Montana T Morris
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
| | - Sean V Cahill
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
| | - JungHo Back
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
| | - Kristin E Yu
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
| | - Francis Y Lee
- Department of Orthopædics & Rehabilitation, Yale University, School of Medicine, New Haven, CT, USA; Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, 330 Cedar St, TMP 523, PO Box 208071, New Haven, CT 06520-8071, USA.
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6
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Watson E, Smith BT, Smoak MM, Tatara AM, Shah SR, Pearce HA, Hogan KJ, Shum J, Melville JC, Hanna IA, Demian N, Wenke JC, Bennett GN, van den Beucken JJJP, Jansen JA, Wong ME, Mikos AG. Localized mandibular infection affects remote in vivo bioreactor bone generation. Biomaterials 2020; 256:120185. [PMID: 32599360 PMCID: PMC7423761 DOI: 10.1016/j.biomaterials.2020.120185] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/05/2020] [Accepted: 06/07/2020] [Indexed: 12/30/2022]
Abstract
Mandibular reconstruction requires functional and aesthetic repair and is further complicated by contamination from oral and skin flora. Antibiotic-releasing porous space maintainers have been developed for the local release of vancomycin and to promote soft tissue attachment. In this study, mandibular defects in six sheep were inoculated with 106 colony forming units of Staphylococcus aureus; three sheep were implanted with unloaded porous space maintainers and three sheep were implanted with vancomycin-loaded space maintainers within the defect site. During the same surgery, 3D-printed in vivo bioreactors containing autograft or xenograft were implanted adjacent to rib periosteum. After 9 weeks, animals were euthanized, and tissues were analyzed. Antibiotic-loaded space maintainers were able to prevent dehiscence of soft tissue overlying the space maintainer, reduce local inflammatory cells, eliminate the persistence of pathogens, and prevent the increase in mandibular size compared to unloaded space maintainers in this sheep model. Animals with an untreated mandibular infection formed bony tissues with greater density and maturity within the distal bioreactors. Additionally, tissues grown in autograft-filled bioreactors had higher compressive moduli and higher maximum screw pull-out forces than xenograft-filled bioreactors. In summary, we demonstrated that antibiotic-releasing space maintainers are an innovative approach to preserve a robust soft tissue pocket while clearing infection, and that local infections can increase local and remote bone growth.
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Affiliation(s)
- Emma Watson
- Department of Bioengineering, Rice University, Houston, TX, USA; Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Brandon T Smith
- Department of Bioengineering, Rice University, Houston, TX, USA; Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Mollie M Smoak
- Department of Bioengineering, Rice University, Houston, TX, USA
| | - Alexander M Tatara
- Department of Bioengineering, Rice University, Houston, TX, USA; Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Sarita R Shah
- Department of Bioengineering, Rice University, Houston, TX, USA; Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Hannah A Pearce
- Department of Bioengineering, Rice University, Houston, TX, USA
| | - Katie J Hogan
- Department of Bioengineering, Rice University, Houston, TX, USA; Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Jonathan Shum
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - James C Melville
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Issa A Hanna
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Nagi Demian
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Joseph C Wenke
- Extremity Trauma & Regenerative Medicine, U.S. Army Institute of Surgical Research, San Antonio, TX, USA
| | | | | | - John A Jansen
- Department of Biomaterials, Radboudumc, Nijmegen, the Netherlands
| | - Mark E Wong
- Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Antonios G Mikos
- Department of Bioengineering, Rice University, Houston, TX, USA.
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7
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Clinical characteristics and outcomes of culture-negative versus culture-positive osteomyelitis in children treated at a tertiary hospital in central Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2020; 54:1061-1069. [PMID: 32891539 DOI: 10.1016/j.jmii.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/01/2020] [Accepted: 08/07/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The causative pathogen of pediatric osteomyelitis is often unidentified despite culturing attempts. This study evaluated and compared the clinical characteristics, therapeutic approach, and outcomes of osteomyelitis caused by unknown pathogens and identified microorganisms. METHOD This 17-year retrospective study was conducted at a tertiary hospital in central Taiwan. Medical records of children aged less than 18 years with a diagnosis of osteomyelitis between 2003 and 2019 were reviewed. RESULT In total, 70 patients (median age = 6.4 years; male = 65.7%) fulfilled the inclusion criteria, of whom 33 (47.1%) were culture negative. Staphylococcus aureus was the main pathogen (67.6% of identified bacteria). The proportion of methicillin-resistant S. aureus (MRSA) was 44% and 54.5% of the MRSA isolates exhibited clindamycin resistance. Compared to children with culture-positive osteomyelitis, those with culture-negative osteomyelitis had a lower rate of concomitant septic arthritis (40.5% vs. 15.2%, p = 0.019) and leukocytosis on presentation (45.9% vs. 21.2%, p = 0.030); they also required fewer surgical interventions (56.8% vs. 24.2%, p = 0.006) and received a shorter course of total antibiotic therapy (49.0 vs. 43.0 days, p = 0.045). In the culture-negative group, the MRSA coverage rate was 18.8% during initial empirical therapy and increased to 59.4% during further adjusted therapy. The overall complication rate was 18.6% and was lower in the culture-negative group (32.4% vs. 3.0%, p = 0.002). CONCLUSION In areas where community-associated MRSA and clindamycin resistance strains are a concern, empirical glycopeptide-based therapy is suggested in pediatric osteomyelitis, particularly in those with culture-negative infections.
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8
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Gornitzky AL, Kim AE, O’Donnell JM, Swarup I. Diagnosis and Management of Osteomyelitis in Children. JBJS Rev 2020; 8:e1900202. [DOI: 10.2106/jbjs.rvw.19.00202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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9
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Preiss H, Kriechling P, Montrasio G, Huber T, Janssen İ, Moldovan A, Lipsky BA, Uçkay İ. Oral Flucloxacillin for Treating Osteomyelitis: A Narrative Review of Clinical Practice. J Bone Jt Infect 2020; 5:16-24. [PMID: 32117685 PMCID: PMC7045523 DOI: 10.7150/jbji.40667] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/12/2019] [Indexed: 01/05/2023] Open
Abstract
Flucloxacillin (FLU) administered by the oral route is widely used for treating various infections, but there are no published retrospective or prospective trials of its efficacy, or its advantages or disadvantages compared to parenteral treatment or other antibiotics for treating osteomyelitis. Based on published in vitro data and expert opinions, other non-β-lactam oral antibiotics that have better bone penetration are generally preferred over oral FLU. We reviewed the literature for studies of oral FLU as therapy of osteomyelitis (OM), stratified by acute versus chronic and pediatric versus adult cases. In striking contrast to the prevailing opinions and the few descriptive data available, we found that treatment of OM with oral FLU does not appear to be associated with more clinical failures compared to other oral antibiotic agents. Because of its narrow antibiotic spectrum, infrequent severe adverse effects, and low cost, oral FLU is widely used in clinical practice. We therefore call for investigators to conduct prospective trials investigating the effectiveness and potential advantages of oral FLU for treating OM.
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Affiliation(s)
- Helga Preiss
- Internal Medicine, Baden Hospital, Baden, Switzerland
| | | | | | - Tanja Huber
- Hospital Pharmacy, Balgrist University Hospital, Zurich, Switzerland
| | - İmke Janssen
- Internal Medicine, Zollikerberg Hospital, Zollikon, Switzerland
| | | | - Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - İlker Uçkay
- Infectiology, Balgrist University Hospital, Zurich, Switzerland
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10
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Abstract
Septic arthritis is an emergent condition caused by bacterial infection of a joint space. The most common etiology is hematogenous spread from bacteremia, but it can also occur from direct inoculation from bites, injection injuries, cellulitis, abscesses, or local trauma. Septic arthritis occurs most frequently in the lower extremities, with the hips and knees serving as the most common locations. The most sensitive findings include pain with motion of the joint, limited range of motion, tenderness of the joint, new joint swelling, and new effusion. Laboratory testing and imaging can support the diagnosis, but the criterion standard is diagnostic arthrocentesis. Treatment involves intravenous antibiotics and joint decompression.
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11
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Mishra V, Ajmera A, Solanki M, Lohokare R. Role of quantitative c-reactive protein and erythrocyte sedimentation rate for evaluation and management of acute osteoarticular infections in pediatric patients. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2019. [DOI: 10.4103/jotr.jotr_25_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Robinette ED, Brower L, Schaffzin JK, Whitlock P, Shah SS, Connelly B. Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis. Pediatrics 2019; 143:peds.2018-0387. [PMID: 30567715 DOI: 10.1542/peds.2018-0387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children. Quality improvement (QI) methods have been used to successfully improve care and decrease costs through standardization for numerous conditions, including pediatric AHO. We embarked on a QI initiative to standardize our approach to the inpatient management of AHO, with a global aim of reducing inpatient costs. METHODS We used existing literature and local consensus to develop a care algorithm for the inpatient management of AHO. We used the Model for Improvement as the framework for the project, which included process mapping, failure mode analysis, and key driver identification. We engaged with institutional providers to achieve at least 80% consensus regarding specific key drivers and tested various interventions to support uptake of the care algorithm. RESULTS Fifty-seven patients were included. There were 31 patients in the preintervention cohort and 26 in the postintervention cohort, of whom 19 were managed per the algorithm. Mean inpatient charges decreased from $45 718 in the preintervention cohort to $32 895 in the postintervention cohort; length of stay did not change. Adherence to recommended empirical antimicrobial agents trended upward. CONCLUSIONS A simple and low-cost QI project was used to safely decrease the cost of inpatient care for pediatric AHO at a tertiary care children's hospital. A robust local consensus process proved to be a key component in the uptake of standardization.
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Affiliation(s)
| | - Laura Brower
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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13
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DeRonde KJ, Girotto JE, Nicolau DP. Management of Pediatric Acute Hematogenous Osteomyelitis, Part I: Antimicrobial Stewardship Approach and Review of Therapies for Methicillin-Susceptible Staphylococcus aureus, Streptococcus pyogenes, and Kingella kingae. Pharmacotherapy 2018; 38:947-966. [PMID: 29920709 DOI: 10.1002/phar.2160] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute hematogenous osteomyelitis (AHO), often occurring in young children, is the most frequently diagnosed type of osteomyelitis in pediatric patients. Optimizing antibiotics is essential as delays to receipt of appropriate therapy can lead to chronic osteomyelitis, as well as impairments in bone growth and development. Antimicrobial stewardship programs (ASPs) are in a key position to help improve the care of patients with AHO as they contain a pharmacist with expertise in antibiotic drug selection, optimization of dosing, and microbiologic test review. A literature search of the MEDLINE database was conducted from initiation through January 2018. Articles selected for the review focus on pathogen identification, pharmacokinetics and pharmacodynamics, efficacy and safety in children, transition from intravenous to oral therapy, duration of treatment, and antimicrobial stewardship interventions. This review will highlight the potential roles ASPs can have in improving the management of AHO in pediatric patients. These roles include the creation of clinical pathways, improving testing algorithms, antibiotic choice and dosing, intravenous to oral transitions, duration of treatment, and therapy monitoring. Overall, patients are most effectively treated by focusing treatments on age, presentation, local sensitivities, and directed therapy with pathogen identification.
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Affiliation(s)
- Kailynn J DeRonde
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut.,Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Jennifer E Girotto
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut.,Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut.,Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut.,Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut
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14
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Le Saux N. Le diagnostic et la prise en charge des infections ostéoarticulaires aiguës chez les enfants. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxy050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nicole Le Saux
- Société canadienne de pédiatrie, comité des maladies infectieuses et d’immunisation, Ottawa (Ontario)
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15
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Le Saux N. Diagnosis and management of acute osteoarticular infections in children. Paediatr Child Health 2018; 23:336-343. [PMID: 30653632 DOI: 10.1093/pch/pxy049] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Acute hematogenous osteomyelitis and septic arthritis are not uncommon infections in children and should be considered as part of the differential diagnosis of limb pain and pseudoparalysis. Most bone infections in children arise secondary to hematogenous seeding of bacteria into bone. The most common pathogens are Staphylococcus aureus and Kingella kingae. Children with septic arthritis should be evaluated promptly by orthopedic specialists for aspiration and possible debridement of concomitant osteomyelitis. Optimal empiric therapy after appropriate cultures continues to be intravenous cefazolin. In most cases, conversion to oral antimicrobials should occur when the patient has clinically improved and has decreasing inflammatory markers. For most uncomplicated cases of osteomyelitis, current recommendations are 3 to 4 weeks of antimicrobial therapy compared with the 6 weeks previously recommended.
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Affiliation(s)
- Nicole Le Saux
- Canadian Paediatric Society, Infectious Diseases and Immunization Committee, Ottawa, Ontario
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16
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Improved Diagnosis and Treatment of Bone and Joint Infections Using an Evidence-based Treatment Guideline. J Pediatr Orthop 2018; 38:e354-e359. [PMID: 29727410 DOI: 10.1097/bpo.0000000000001187] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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 OF EVIDENCE Level III- retrospective comparative study.
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17
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de Graaf H, Sukhtankar P, Arch B, Ahmad N, Lees A, Bennett A, Spowart C, Hickey H, Jeanes A, Armon K, Riordan A, Herberg J, Hackett S, Gamble C, Shingadia D, Pallett A, Clarke SC, Henman P, Emonts M, Sharland M, Finn A, Pollard AJ, Powell C, Marsh P, Ballinger C, Williamson PR, Clarke NM, Faust SN. Duration of intravenous antibiotic therapy for children with acute osteomyelitis or septic arthritis: a feasibility study. Health Technol Assess 2018; 21:1-164. [PMID: 28862129 DOI: 10.3310/hta21480] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There is little current consensus regarding the route or duration of antibiotic treatment for acute osteomyelitis (OM) and septic arthritis (SA) in children. OBJECTIVE To assess the overall feasibility and inform the design of a future randomised controlled trial (RCT) to reduce the duration of intravenous (i.v.) antibiotic use in paediatric OM and SA. DESIGN (1) A prospective service evaluation (cohort study) to determine the current disease spectrum and UK clinical practice in paediatric OM/SA; (2) a prospective cohort substudy to assess the use of targeted polymerase chain reaction (PCR) in diagnosing paediatric OM/SA; (3) a qualitative study to explore families' views and experiences of OM/SA; and (4) the development of a core outcome set via a systematic review of literature, Delphi clinician survey and stakeholder consensus meeting. SETTING Forty-four UK secondary and tertiary UK centres (service evaluation). PARTICIPANTS Children with OM/SA. INTERVENTIONS PCR diagnostics were compared with culture as standard of care. Semistructured interviews were used in the qualitative study. RESULTS Data were obtained on 313 cases of OM/SA, of which 218 (61.2%) were defined as simple disease and 95 (26.7%) were defined as complex disease. The epidemiology of paediatric OM/SA in this study was consistent with existing European data. Children who met oral switch criteria less than 7 days from starting i.v. antibiotics were less likely to experience treatment failure (9.6%) than children who met oral switch criteria after 7 days of i.v. therapy (16.1% when switch was between 1 and 2 weeks; 18.2% when switch was > 2 weeks). In 24 out of 32 simple cases (75%) and 8 out of 12 complex cases (67%) in which the targeted PCR was used, a pathogen was detected. The qualitative study demonstrated the importance to parents and children of consideration of short- and long-term outcomes meaningful to families themselves. The consensus meeting agreed on the following outcomes: rehospitalisation or recurrence of symptoms while on oral antibiotics, recurrence of infection, disability at follow-up, symptom free at 1 year, limb shortening or deformity, chronic OM or arthritis, amputation or fasciotomy, death, need for paediatric intensive care, and line infection. Oral switch criteria were identified, including resolution of fever for ≥ 48 hours, tolerating oral food and medicines, and pain improvement. LIMITATIONS Data were collected in a 6-month period, which might not have been representative, and follow-up data for long-term complications are limited. CONCLUSIONS A future RCT would need to recruit from all tertiary and most secondary UK hospitals. Clinicians have implemented early oral switch for selected patients with simple disease without formal clinical trial evidence of safety. However, the current criteria by which decisions to make the oral switch are made are not clearly established or evidence based. FUTURE WORK A RCT in simple OM and SA comparing shorter- or longer-course i.v. therapy is feasible in children randomised after oral switch criteria are met after 7 days of i.v. therapy, excluding children meeting oral switch criteria in the first week of i.v. therapy. This study design meets clinician preferences and addresses parental concerns not to randomise prior to oral switch criteria being met. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Hans de Graaf
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Priya Sukhtankar
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Barbara Arch
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Nusreen Ahmad
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Public Health England, Southampton, UK
| | - Amanda Lees
- Health and Wellbeing Research and Development Group, University of Winchester, Winchester, UK
| | - Abigail Bennett
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Catherine Spowart
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Helen Hickey
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Annmarie Jeanes
- Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Armon
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Andrew Riordan
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jethro Herberg
- Section of Paediatrics, Imperial College London, St Mary's Campus, London, UK
| | - Scott Hackett
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carrol Gamble
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Delane Shingadia
- Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, UK
| | - Ann Pallett
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stuart C Clarke
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Philip Henman
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Marieke Emonts
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Mike Sharland
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Adam Finn
- Bristol Children's Vaccine Centre, School of Clinical Sciences, University of Bristol, Bristol, UK.,Paediatric Infectious Diseases and Immunology, Bristol Royal Hospital for Children, Bristol, UK
| | - Andrew J Pollard
- Department of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Colin Powell
- School of Medicine, University of Cardiff, Cardiff, UK.,Department of Paediatrics, University Hospital of Wales, Cardiff, UK
| | - Peter Marsh
- Public Health England, South East Public Health England Regional Laboratory, Southampton, UK
| | - Claire Ballinger
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Paula R Williamson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Nicholas Mp Clarke
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Paediatric Orthopaedics, University of Southampton, Southampton, UK
| | - Saul N Faust
- National Institute for Health Research Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton, UK
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18
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Acute Hematogenous Osteomyelitis in a Five-Month-Old Male with Rickets. Case Rep Pediatr 2018; 2017:4627905. [PMID: 29348957 PMCID: PMC5733763 DOI: 10.1155/2017/4627905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/09/2017] [Indexed: 11/18/2022] Open
Abstract
Osteomyelitis is defined as an infection of the bone, bone marrow, and the surrounding soft tissues. Most cases of acute hematogenous osteomyelitis in children are caused by Gram-positive bacteria, principally Staphylococcus aureus. We present a case where a 5-month-old male had an acute onset of decreased movement of his left leg and increased irritability and was subsequently diagnosed with rickets and hematogenous osteomyelitis with bacteremia. The case explores a possible association between hematogenous osteomyelitis and rickets.
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19
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Spruiell MD, Searns JB, Heare TC, Roberts JL, Wylie E, Pyle L, Donaldson N, Stewart JR, Heizer H, Reese J, Scott HF, Pearce K, Anderson CJ, Erickson M, Parker SK. Clinical Care Guideline for Improving Pediatric Acute Musculoskeletal Infection Outcomes. J Pediatric Infect Dis Soc 2017; 6:e86-e93. [PMID: 28419275 DOI: 10.1093/jpids/pix014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/24/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute pediatric musculoskeletal infections are common, leading to significant use of resources and antimicrobial exposure. In order to decrease variability and improve the quality of care, Children's Hospital Colorado implemented a clinical care guideline (CCG) for these infections. The purpose of this study is to evaluate clinical and resource outcomes PRE and POST this CCG. METHODS Retrospective chart review evaluated patients admitted to a large pediatric quaternary referral center (CHCO) diagnosed with acute osteomyelitis, septic arthritis, pyomyositis, and/or musculoskeletal abscess prior to and after guideline implementation. Primary outcomes included length of stay and overall antibiotic use, with additional secondary clinical, process, and therapeutic outcomes examined. RESULTS 82 patients were identified in both the pre-CCG and post-CCG cohorts. There was a reduction in the median of all primary outcomes, including length of stay (0.6 median days decrease, P = .04), length of IV antibiotic therapy (4.9 median days decrease, P < .0001), and days of IV antibiotic therapy (6.4 median days decrease, P = .0004). Our median length of stay post-CCG was 4.9 days, the shortest reported length of stay for pediatric acute musculoskeletal infections to date. Additionally, there was a 24.5 hour reduction in median length of fever (P = .02), faster CRP normalization (P < .0001), 50% decrease in the number of related readmissions (P = .02), 34% decrease in central venous catheters placed (P < .0001), decreased time to first culture (P = .02), and 79% pathogen identification post-CCG (P = .056). CONCLUSIONS Implementation of a CCG for acute musculoskeletal infections improves patient, process and resource outcomes.
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Affiliation(s)
- Murray D Spruiell
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | | | - Travis C Heare
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | - Jesse L Roberts
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | - Erin Wylie
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Children's Hospital Colorado, Aurora
| | - Laura Pyle
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Nathan Donaldson
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | | | | | - Jennifer Reese
- Division of Pediatric Hospital Medicine, Department of Pediatrics
| | | | - Kelly Pearce
- Department of Epidemiology, Children's Hospital Colorado, Aurora
| | - Colin J Anderson
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
| | - Mark Erickson
- Department of Orthopedic Surgery, University of Colorado Denver School of Medicine, Aurora
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20
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Funk SS, Copley LAB. Acute Hematogenous Osteomyelitis in Children: Pathogenesis, Diagnosis, and Treatment. Orthop Clin North Am 2017; 48:199-208. [PMID: 28336042 DOI: 10.1016/j.ocl.2016.12.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Acute hematogenous osteomyelitis (AHO) in children is an ideal condition to study due to its representation of a wide spectrum of disorders that comprise pediatric musculoskeletal infection. Proper care for children with AHO is multidisciplinary and collaborative. AHO continues to present a significant clinical challenge due to evolving epidemiology and complex pathogenesis. A guideline-driven, multidisciplinary approach has been introduced and shown to effectively reduce hospital stay, improve the timing and selection of empirical antibiotic administration, reduce delay to initial MRI, reduce the rate of readmission, and shorten antibiotic duration.
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Affiliation(s)
- Shawn S Funk
- Department of Orthopaedic Surgery, The Children's Hospital of San Antonio, Baylor College of Medicine, 315 North San Saba Street, Suite 1135, San Antonio, TX 78207, USA
| | - Lawson A B Copley
- Department of Orthopaedic Surgery, Children's Medical Center of Dallas, University of Texas Southwestern, 1935 Medical District Drive, Dallas, TX 75235, USA.
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21
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Abstract
Despite advances in understanding and management, paediatric osteoarticular infections continue to pose diagnostic difficulties for clinicians. Delays in diagnosis can lead to potentially devastating morbidity.No single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively paediatric bone and joint infection. Diagnosis should be based on a combination of clinical signs, imaging and laboratory investigations. Algorithms should supplement, and not replace, clinical decision making in all cases.The roles of aspiration, arthrotomy and arthroscopy in the treatment of septic arthritis are not clearly defined. There is a very limited role for surgery in the management of acute haematogenous osteomyelitis.The ideal duration and mode of administration of antibiotic therapy for osteoarticular paediatric infection is not yet fully defined but there is increasing evidence that shorter courses (three weeks) and early conversion (day four) to oral administration is safe and effective in appropriate cases. Clear and concise antibiotic guidelines should be available based on local population characteristics, pathogens and their sensitivities.Kingella kingae is increasingly identified through polymerase chain reaction and is now recognised as the commonest pathogen in children aged under four years. Methicillin-resistant Staphylococcus aureus and Panton-Valentine leukocidin-producing strains of Staph. aureus are being increasingly reported.A multidisciplinary integrated evidence-based approach is required to optimise outcomes.Further large-scale, multicentre studies are needed to delineate the optimal management of paediatric osteoarticular infection. Cite this article: EFORT Open Rev 2017;1:7-12. DOI: 10.1302/2058-5241.2.160027.
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Affiliation(s)
- Alexios D Iliadis
- Centre for Orthopaedics, The Royal London and Barts and The London Children's Hospitals, Barts Health NHS Trust, London, UK
| | - Manoj Ramachandran
- Centre for Orthopaedics, The Royal London and Barts and The London Children's Hospitals, Barts Health NHS Trust, London, UK
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22
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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Dhanireddy S, Neme S. Acute and Chronic Osteomyelitis. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00044-7] [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: 11/29/2022] Open
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24
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Batchelder N, So TY. Transitioning antimicrobials from intravenous to oral in pediatric acute uncomplicated osteomyelitis. World J Clin Pediatr 2016; 5:244-250. [PMID: 27610339 PMCID: PMC4978616 DOI: 10.5409/wjcp.v5.i3.244] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/05/2016] [Accepted: 04/22/2016] [Indexed: 02/06/2023] Open
Abstract
Osteomyelitis is a bone infection that requires prolonged antibiotic treatment and potential surgical intervention. If left untreated, acute osteomyelitis can lead to chronic osteomyelitis and overwhelming sepsis. Early treatment is necessary to prevent complications, and the standard of care is progressing to a shorter duration of intravenous (IV) antibiotics and transitioning to oral therapy for the rest of the treatment course. We systematically reviewed the current literature on pediatric patients with acute osteomyelitis to determine when and how to transition to oral antibiotics from a short IV course. Studies have shown that switching to oral after a short course (i.e., 3-7 d) of IV therapy has similar cure rates to continuing long-term IV therapy. Prolonged IV use is also associated with increased risk of complications. Parameters that help guide clinicians on making the switch include a downward trend in fever, improvement in local tenderness, and a normalization in C-reactive protein concentration. Based on the available literature, we recommend transitioning antibiotics to oral after 3-7 d of IV therapy for pediatric patients (except neonates) with acute uncomplicated osteomyelitis if there are signs of clinical improvement, and such regimen should be continued for a total antibiotic duration of four to six weeks.
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25
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Majewski J, Del Vecchio M, Aronoff S. Route and length of therapy of acute uncomplicated hematogenous osteomyelitis: do we have the answers yet? Hosp Pediatr 2014; 4:44-7. [PMID: 24435601 DOI: 10.1542/hpeds.2013-0035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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26
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Kim BN, Kim ES, Oh MD. Oral antibiotic treatment of staphylococcal bone and joint infections in adults. J Antimicrob Chemother 2013; 69:309-22. [DOI: 10.1093/jac/dkt374] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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27
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Howard-Jones AR, Isaacs D. Systematic review of duration and choice of systemic antibiotic therapy for acute haematogenous bacterial osteomyelitis in children. J Paediatr Child Health 2013; 49:760-8. [PMID: 23745943 DOI: 10.1111/jpc.12251] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 12/22/2022]
Abstract
AIM Historically, children with acute osteomyelitis received 4-6 weeks of parenteral antibiotics; however, evidence to guide optimal duration of therapy is limited. This study aims to summarise the available evidence on the duration and choice of antimicrobial therapy for acute haematogenous osteomyelitis in children. METHODS We systematically reviewed the literature on children with acute osteomyelitis to determine if shorter durations of antibiotic treatment compared with protracted treatment gave different cure rates. We also analysed studies for choice of antibiotics to determine differences in success rates. Randomised controlled trials, cohort studies, case-control studies and case series were eligible for inclusion. RESULTS We identified six randomised controlled trials, three of which addressed duration of antibiotic use and three choice of antibiotic for acute osteomyelitis in children. We found 28 observational studies, 20 of which focused on duration and 22 of which allowed analysis of choice of antibiotic. A range of therapy durations and types of antibiotics were assessed. Only one small study looked at treatment of neonates. CONCLUSIONS The quality of evidence on antibiotic treatment for acute osteomyelitis is limited, allowing only weak (GRADE 2B) recommendations. Our review suggests that early transition from intravenous to oral therapy, after 3-4 days in patients responding well, followed by oral therapy to a total of 3 weeks may be as effective as longer courses for uncomplicated acute osteomyelitis. This recommendation does not apply to neonates.
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28
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Copley LAB, Kinsler MA, Gheen T, Shar A, Sun D, Browne R. The impact of evidence-based clinical practice guidelines applied by a multidisciplinary team for the care of children with osteomyelitis. J Bone Joint Surg Am 2013; 95:686-93. [PMID: 23595066 DOI: 10.2106/jbjs.l.00037] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Care of children with osteomyelitis requires multidisciplinary collaboration. This study evaluates the impact of evidence-based guidelines for the treatment of pediatric osteomyelitis when utilized by a multidisciplinary team. METHODS Guidelines for pediatric osteomyelitis were developed and were implemented by a multidisciplinary team comprised of individuals from several hospital services, including orthopaedics, pediatrics, infectious disease, nursing, and social work, who met daily to conduct rounds and make treatment decisions. With use of retrospective review and statistical analysis, we compared children with osteomyelitis who had been managed at our institution from 2002 to 2004 (prior to the implementation of the guidelines), referred to as Group I in this study, with those who were managed in 2009 according to the guidelines, referred to as Group II. RESULTS Two hundred and ten children in Group I were compared with sixty-one children in Group II. No significant differences between the two cohorts were noted for age, sex, incidence of methicillin-resistant Staphylococcus aureus infection (18.1% in Group I compared with 26.2% in Group II), incidence of methicillin-sensitive Staphylococcus aureus infection (23.8% in Group I compared with 27.9% in Group II), bacteremia, or surgical procedures. Significant differences (p < 0.05) between cohorts were noted for each of the following: the delay in magnetic resonance imaging after admission (2.5 days in Group I compared with one day in Group II), the percentage of patients who had received clindamycin as the initial antibiotic (12.9% in Group I compared with 85.2% in Group II), the percentage of patients who had had a blood culture before antibiotic administration (79.5% in Group I compared with 91.8% in Group II), the percentage of patients who had had a culture of tissue from the infection site (62.9% in Group I compared with 78.7% in Group II), the percentage of patients in whom the infecting organism was identified on tissue or blood culture (60.0% in Group I compared with 73.8% in Group II), the number of antibiotic changes (2.0 changes in Group I compared with 1.4 changes in Group II), and the mean duration of oral antibiotic use (27.7 days in Group I compared with 43.7 days in Group II). When compared with Group I, Group II had clinically important trends of a shorter total length of hospital stay (12.8 days in Group I compared with 9.7 days in Group II; p = 0.054) and a lower hospital readmission rate (11.4% in Group I compared with 6.6% in Group II; p = 0.34). CONCLUSIONS Evidence-based treatment guidelines applied by a multidisciplinary team resulted in a more efficient diagnostic workup, a higher rate of identifying the causative organism, and improved adherence to initial antibiotic recommendations with fewer antibiotic changes during treatment. Additionally, there were trends toward lower hospital readmission rates and a shorter length of hospitalization.
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Affiliation(s)
- Lawson A B Copley
- Department of Orthopedics, Children's Medical Center of Dallas, Dallas, TX 75235, USA.
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Bouchoucha S, Gafsi K, Trifa M, Saied W, Ammar C, Nessib MN, Smida M, Ben Ghachem M. [Intravenous antibiotic therapy for acute hematogenous osteomyelitis in children: short versus long course]. Arch Pediatr 2013; 20:464-9. [PMID: 23566577 DOI: 10.1016/j.arcped.2013.02.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Revised: 01/09/2013] [Accepted: 02/10/2013] [Indexed: 11/26/2022]
Abstract
The aim of this study was to evaluate the results of two antibiotic therapy protocols for osteomyelitis with different durations of intravenous treatment. This was a prospective randomized study of children treated for acute hematogenous osteomyelitis. Patients in group 1 (G1) received 7 days of intravenous antibiotics, whereas patients in group 2 (G2) received 14 days. Treatment was deemed effective if there were no signs of chronic osteomyelitis at the last follow-up. Fifty-three patients were included in the study (G1=27, G2=26). After a mean follow-up of 11.5 months, none of the patients in either group showed signs of chronic osteomyelitis. In conclusion, a shortened treatment of 7 days of intravenous antibiotic therapy is as effective as a longer treatment.
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Affiliation(s)
- S Bouchoucha
- Service d'orthopédie de l'enfant et de l'adolescent, hôpital d'enfants de Tunis, 1007 Tunis Jabbari, Bab Saadoun, Tunisie.
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30
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Characteristics and outcomes of outpatient parenteral antimicrobial therapy at an academic children's hospital. Pediatr Infect Dis J 2013; 32:346-9. [PMID: 23249915 DOI: 10.1097/inf.0b013e31827ee1c2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of outpatient parenteral antimicrobial therapy (OPAT) in pediatrics is widespread and may be increasing. Recent data quantifying use and characteristics of pediatric OPAT are lacking. METHODS To evaluate the number of children receiving OPAT each year and their associated characteristics and outcomes, we conducted a retrospective review of all patients discharged with OPAT from the Mayo Clinic Children's Hospital between August 1, 2010 and December 31, 2011. RESULTS During the study period, there were 126 pediatric hospital discharges with OPAT (2.5% of all discharges). OPAT was used most commonly to treat bone and joint (21%), bloodstream (15%), intra-abdominal (13%) and soft tissue (9%) infections. A positive culture or serology result was found in 86 (68%) OPAT courses. The most frequently used antibiotics were ceftriaxone (17%), cefazolin (16%) and cefepime (13%). The median duration of OPAT was 12 days. Thirty-six courses (29%) resulted in catheter- or antibiotic-associated complications. Weekly laboratory monitoring was more common when OPAT was managed by the infectious disease service (88%) versus other services (20%). Among 123 courses with follow-up, 109 (89%) resulted in cure, and 13 (11%) were treatment failures. CONCLUSION At our children's hospital, 2.5% of hospitalized patients were discharged with OPAT. In one-third of OPAT courses children developed catheter- or antibiotic-associated complications. Opportunities to increase the role of pediatric infectious disease in OPAT initiation and management should be explored.
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31
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Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. ACTA ACUST UNITED AC 2012; 94:584-95. [PMID: 22529075 DOI: 10.1302/0301-620x.94b5.28523] [Citation(s) in RCA: 184] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations. Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment.
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Affiliation(s)
- J Dartnell
- Maidstone and Tunbridge Wells NHS Trust, Pembury, UK
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32
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Wheeler AM, Heizer HR, Todd JK. Influence of Culture Results on Management and Outcome of Pediatric Osteomyelitis and/or Septic Arthritis. J Pediatric Infect Dis Soc 2012; 1:152-6. [PMID: 26619168 DOI: 10.1093/jpids/pis035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 01/23/2012] [Indexed: 11/12/2022]
Abstract
Children with uncomplicated osteomyelitis and/or septic arthritis were more likely (P < .01) to have positive focus than blood cultures. Those who grew a pathogen and/or started on a single antibiotic were more likely to be discharged on a single antibiotic, and those sent home on oral therapy had fewer adverse events.
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Affiliation(s)
| | - Heather R Heizer
- Department of Pediatrics, University of Colorado School of Medicine Department of Epidemiology, Children's Hospital Colorado, Aurora
| | - James K Todd
- Colorado School of Public Health Department of Pediatrics, University of Colorado School of Medicine Department of Epidemiology, Children's Hospital Colorado, Aurora
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Le J, San Agustin M, Hernandez EA, Tran TT, Adler-Shohet FC. Complications associated with outpatient parenteral antibiotic therapy in children. Clin Pediatr (Phila) 2010; 49:1038-43. [PMID: 20724346 DOI: 10.1177/0009922810374210] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The authors sought to determine the prevalence, risk factors, and clinical impact of complications associated with outpatient parenteral antimicrobial therapy (OPAT) in children. METHODS A cohort of patients ≤18 years old with infections, who received OPAT were evaluated retrospectively. Antibiotic-associated complications (AACs), catheter-associated complications (CACs), and unplanned medical care visits were the main outcome measures. RESULTS Overall, 36 complications (25 CACs and 11 AACs) occurred in 32 of 98 patients. Mean age of patients, race, gender, and infecting organism did not differ between study groups. The use of OPAT for osteomyelitis was associated with complications (odds ratio = 2.69; 95% confidence interval = 0.99-7.35; P = .05). All patients, except for 4 who had complications, clinically improved by the end of OPAT. Unplanned medical visits occurred in 17 patients, 15 of which were because of CACs. CONCLUSION Complications occurred commonly in children receiving OPAT and resulted in unplanned medical visits.
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Affiliation(s)
- Jennifer Le
- University of California San Diego, La Jolla, USA.
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34
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Maraqa NF, Rathore MH. Pediatric outpatient parenteral antimicrobial therapy: an update. Adv Pediatr 2010; 57:219-45. [PMID: 21056740 DOI: 10.1016/j.yapd.2010.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Nizar F Maraqa
- Pediatric Infectious Diseases and Immunology, University of Florida-Jacksonville, 653-1 West 8th Street, LRC-3, Pediatrics, L-13, Jacksonville, FL 32209, USA
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35
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Acute and chronic osteomyelitis. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00041-1] [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: 11/17/2022] Open
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36
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Musculoskeletal infection in children: literature review and update 2007–2009. CURRENT ORTHOPAEDIC PRACTICE 2009. [DOI: 10.1097/bco.0b013e3181bbd459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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