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

C-reactive protein can be used to guide the empiric antimicrobial therapy of acute osteomyelitis in children

This study was to identify some indicators that could be used to distinguish methicillin-resistant Staphylococcus aureus (MRSA) from methicillin-sensitive Staphylococcus aureus (MSSA) to more accurately guide empirical antibiotics. Data of 91 cases of acute osteomyelitis in children with Staphylococcus aureus infection (including 29 cases of MRSA and 62 cases of MSSA) from July 2017 to March 2024 were retrospectively analyzed. Age, sex, duration of onset, maximum body temperature at onset, and inflammatory indicators detected after admission were compared between the MRSA group and the MSSA group. According to the receiver operating characteristic (ROC) curve, the diagnostic efficiency of MRSA infection was evaluated. Logistic regression analysis was used to determine independent risk factors for MRSA infection. There were no significant differences in age, sex, duration of onset, maximum body temperature, white blood cell count, neutrophil count, and erythrocyte sedimentation rate between the MRSA group and the MSSA group (P > 0.05). The median C-reactive protein in the MRSA group and the MSSA group was 97.93 and 58.10 mg/L, respectively, with statistical significance (P < 0.05). The sensitivity, specificity, and area under the curve of C-reactive protein for detecting MRSA infection were 41.4, 90.3, and 0.646%, respectively. Logistic regression analysis showed that C-reactive protein greater than 116.46 mg/L (odds ratio = 6.588, 95% confidence interval: 2.149-20.197) was an independent risk factor for predicting MRSA infection (P < 0.05). C-reactive protein greater than 116.46 mg/L can independently predict the likelihood of MRSA infection, and it is recommended to empirically select anti-MRSA treatment for such children.

Analysis of antimicrobial resistance and clinical features of Staphylococcus aureus-infected bone and joint infections in children

OBJECTIVE

This study investigates the antimicrobial resistance and clinical features of Staphylococcus aureus (S. aureus) in bone and joint infections (BJIs) among children under 14 years old, providing insights for optimal antibiotic usage.

METHODS

A retrospective analysis was conducted on the clinical data from children treated for BJIs at the Children's Hospital of Soochow University between January 2019 to December 2023. Bacterial cultures were examined, focusing on S. aureus. Clinical features of children with methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) infections were compared.

RESULTS

Among the 110 cases of culture-positive BJIs, 116 pathogenic strains were identified, with, S. aureus being the most prevalent (75.00%, 87/116). No resistance to quinupristin/dalfopristin, linezolid, vancomycin, tigecycline, rifampin or teicoplanin was detected. The resistance rate to penicillin was 90.80% (79/87), while resistance rates to clindamycin and erythromycin were 37.93% (33/87) and 36.78% (32/87), respectively. MRSA accounted for 28.74% (25/87) of S. aureus isolates. There were no significant differences in gender, age, infection site, clinical symptoms, laboratory indicators, hospital stay, or surgical intervention between MSSA and MRSA groups (p > 0.05). However, patients with positive X-ray findings were more likely to have MRSA infections (p = 0.033). Subgroup analysis revealed that children older than 48 months with positive X-ray results were more likely to have MRSA (p = 0.048).

CONCLUSION

In China, S. aureus remains the predominant pathogen in children under 14 years old with BJIs. Among children older than 48 months, nearly one-third of BJIs are caused by MRSA, and positive X-ray findings may indicate a higher likelihood of MRSA in this age group. Further studies are required to validate these findings before they can be widely applied.

CLINICAL TRIAL NUMBER

Not applicable.

Duration of onset, body temperature and C-reactive protein can be used to predict the results of pus culture in children with acute osteomyelitis of long bones

BACKGROUND

With the application of PCR testing and Metagenomic Next-Generation Sequencing(mNGS), the detection rate of causative organisms in paediatric bone and joint infections has been greatly improved. The aim of our study is to identify some indicators that could be used to distinguish the culture results to optimize the use of PCR and mNGS.

METHODS

In this study, a total of 117 cases of acute osteomyelitis of long bones in children who underwent pus culture were included. Patients were grouped as culture-negative (n:21) and culture-positive (n:96) groups according to the results of pus culture. Age, sex, duration of onset, maximum body temperature at onset, inflammatory indicators and D-dimer after admission were systematically collected for all patients and were compared for both groups. ROC curve (ROC) was used to evaluate the diagnostic efficiency of culture-negative. Logistic regression analysis was conducted to determine independent risk factors for culture-negative.

RESULTS

There was no significant difference in age, sex and erythrocyte sedimentation rate between culture-negative group and culture-positive group (P > 0.05). The duration of onset was longer, and the temperature, white blood cells, neutrophils count, C-reactive protein and D-dimer were less elevated in culture-negative acute osteomyelitis (P < 0.05). Duration of onset, maximum body temperature at onset, white blood cell count, neutrophil count, C-reactive protein, and D-dimer have certain diagnostic efficacy in judging the efficacy of negative culture. Logistic regression analysis indicated that the duration of onset more than 6.5 days, the maximum body temperature at onset lower than 38.35℃ and C-reactive protein lower than 78.40 mg/L were independent risk factors for negative culture (P < 0.05).

CONCLUSIONS

Our study revealed that duration of onset more than 6.5 days, maximum body temperature at onset lower than 38.35℃ and C-reactive protein lower than 78.40 mg/L were independent risk factors for predicting negative culture. In children with this type of acute osteomyelitis, we recommend that the pus be tested by PCR or mNGS as a priority.

Acute Hematogenous Osteomyelitis in Pediatric Patients

This article focuses on the advancements made in diagnostic techniques and drug interventions of acute hematogenous osteomyelitis. A diagnosis necessitates a combination of factors, including inflammatory markers and imaging findings, as well as the collection of specimens for culture when feasible. Subsequently, treatment should be based on epidemiology, mechanisms of resistance, and susceptibility findings. A brief course of intravenous (IV) antibiotics, followed by oral antibiotics, may be employed for uncomplicated infections if there is improvement in the clinical condition and a decline in C-reactive protein levels. However, for complex infections caused by methicillin-resistant Staphylococcus aureus, prolonged administration of IV antibiotics is recommended, along with surgical intervention if necessary. [Pediatr Ann. 2024;53(10):e392-e395.].

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

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

Surveillance of osteoarticular infections caused by Staphylococcus aureus in a paediatric hospital in Mexico City

Staphylococcus aureus is the main aetiologic agent of osteoarticular infections (OAIs) in paediatric patients. The aim of this prospective unicenter study was to describe the phenotypic and genotypic characteristics of S. aureus isolates obtained from OAIs in paediatric patients admitted to tertiary care hospital. Through a surveillance program called OsteoCode, a multidisciplinary team was created and we identified 27 patients with OAIs caused by S. aureus from 2019 to 2021. The susceptibility profile, virulence factors, biofilm formation, pulsed-field gel electrophoresis (PFGE), clonal complex (CC) and sequence type (ST) were determined. In addition, the clinical characteristics and evolution of the patients presented six months after the diagnosis of OAIs were described. Ninety-two percent of the isolates were methicillin-sensitive S. aureus (MSSA). In methicillin-resistant S. aureus (MRSA), SCCmec-II and SCCmec-V were detected. The pvl gene was only observed in MSSA (18.5%) and was associated with highest fever (p=0.015), multiple localization (p=0.017), and soft tissue sites of infection beyond the bone (pyomyositis, pulmonary abscess) (p=0.017). Biofilm formation was detected in 55.6% of isolates. The most common CC were CC5 and CC30 which represent the most common linages for bone and joint infections worldwide. The isolates were distributed in different STs, and ST672 was predominant. MRSA were associated with a longer duration of intravenous treatment and a prolonged hospital stay (p=0.023). Recurrent infection occurred in five children and orthopaedic complications in 33.3% of patients. This is the first study that reflects the epidemiology of S. aureus in OAIs in paediatric patients in Mexico; a clear predominance of MSSA distributed in different STs was observed. Our findings highlight that a multidisciplinary team is required for the diagnosis and treatment of OAIs.

New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine

In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.

Risk Factors Affecting Development and Persistence of Preschool Wheezing: Consensus Document of the Emilia-Romagna Asthma (ERA) Study Group

Wheezing at preschool age (i.e., before the age of six) is common, occurring in about 30% of children before the age of three. In terms of health care burden, preschool children with wheeze show double the rate of access to the emergency department and five times the rate of hospital admissions compared with school-age asthmatics. The consensus document aims to analyse the underlying mechanisms involved in the pathogenesis of preschool wheezing and define the risk factors (i.e., allergy, atopy, infection, bronchiolitis, genetics, indoor and outdoor pollution, tobacco smoke exposure, obesity, prematurity) and the protective factors (i.e., probiotics, breastfeeding, vitamin D, influenza vaccination, non-specific immunomodulators) associated with the development of the disease in the young child. A multidisciplinary panel of experts from the Emilia-Romagna Region, Italy, addressed twelve key questions regarding managing preschool wheezing. Clinical questions have been formulated by the expert panel using the PICO format (Patients, Intervention, Comparison, Outcomes). Systematic reviews have been conducted on PubMed to answer these specific questions and formulate recommendations. The GRADE approach has been used for each selected paper to assess the quality of the evidence and the degree of recommendations. Based on a panel of experts and extensive updated literature, this consensus document provides insight into the pathogenesis, risk and protective factors associated with the development and persistence of preschool wheezing. Undoubtedly, more research is needed to improve our understanding of the disease and confirm the associations between certain factors and the risk of wheezing in early life. In addition, preventive strategies must be promoted to avoid children's exposure to risk factors that may permanently affect respiratory health.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical report and predictors of sequelae of 319 cases of pediatric bacterial osteomyelitis

Pediatric osteomyelitis is an insidious disease that can lead to permanent sequelae, the management of which still relies on lengthy intravenous antibiotic therapy. The purpose of this study is to report and describe the clinical course and outcome of pediatric bacterial osteomyelitis in our experience. We reported the clinical, diagnostic, and treatment characteristics of all cases of osteomyelitis in children younger than 18 years of age who were hospitalized between January 2010 and December 2021 at the Bambino Gesù Children’s Hospital in Rome, Italy, we compared patients with and without complications at follow-up, to identify any predictive factor for sequelae. The study sample included 319 cases of pediatric bacterial osteomyelitis. The median age was 7.77 years. Males (60.8%) were more affected than females. The most affected bones were the femur, tibia, and spine. Etiology was identified in 40.1% of cases, with S.aureus as the most common causative agent. Sequelae were reported in 43 cases (13.5%). The main predictors of sequelae were sepsis on admission and hypergammaglobulinemia. Our results show that a severe presentation with sepsis and hypergammaglobulinemia on admission may be associated with a higher frequency of late sequelae. Early recognition and aggressive treatment of this subgroup of patients may lead to a reduction in complications.

What Do We Know about Spondylodiscitis in Children? A Retrospective Study

Pediatric spondylodiscitis (PSD) is a rare disease with a major impact on mobility and functional status. Data concerning demographic and microbiological characteristics, clinical course, treatment, and outcome are scarce. Therefore, the aim of this study was to present clinical experiences of a third-level hospital (2009–2019) in PSD and compare these with adult spondylodiscitis (ASD). Of a total of 10 PSD patients, most of the infants presented with unspecific pain such as hip pain or a limping, misleading an adequate diagnosis of spine origin. Eight patients could be treated conservatively whereas surgery was performed in two cases with one case of tuberculous PSD (tPSD). The causative agent was detected in three of the patients. The diagnosis of PSD is often difficult since clinical symptoms are unspecific and causative pathogens often remain undetected. Nevertheless, empirical anti-infective therapy also seems to be effective. Based on recent studies, clinicians should be encouraged to keep the duration of anti-infective therapy in children short. Since comorbidities are not presented in PSD it is unclear which children suffer from PSD; thus, studies are necessary to identify predisposing factors for PSD. In our study, PSD differs from ASD in diagnostic and especially in therapeutic aspects. Therefore, specific guidelines for PSD would be desirable.

Paediatric Osteomyelitis and Septic Arthritis Pathogen Distribution and Antimicrobial Resistance in a Single Centre: A 15-Year Retrospective Analysis

BACKGROUND

The epidemiological characteristics of the common pathogens underlying acute haematogenous osteoarticular infection (AHOI) and their resistance to drugs have temporal and regional differences.

AIMS

To determine the antimicrobial treatment most effective for culture-negative AHOI patients and those without bacterial cultures.

METHODS

Retrospective analysis of clinical data of children with AHOI who were culture positive from January 2007 to December 2021. And the distribution of the main pathogens and the drug resistance Staphylococcus aureus were analysed in different time periods, age groups and infection types.

RESULTS

A total of 188 cases met the inclusion criteria, including 97 cases of acute haematogenous osteomyelitis (AHO), 75 cases of septic arthritis (SA) and 16 cases of AHO concomitant with SA. The commonest causative pathogen in local children was S. aureus of Gram-positive cocci, followed by Streptococcus, and occasionally Gram-negative bacilli. The distribution of S. aureus had no significant correlation with age or infection type. Staphylococcus aureus accounted for 81.82%, 90.91% and 96.15% of all pathogens, and methicillin-resistant S. aureus (MRSA) accounted for 24.22%, 53.33% and 76.00% of S. aureus in 2007-11, 2012-16 and 2017-21, respectively. The frequency of MRSA infection showed an increasing trend over time.

CONCLUSION

Staphylococcus aureus is still the main pathogen of AHOI in local children. The proportion of MRSA in S. aureus has also increased over time to 76% in the last 5 years, and the increased proportion of MRSA can affect the choice of initial empirical medication.