Pediatric Osteomyelitis Follow-up

  • Author: Sabah Kalyoussef, DO; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jul 27, 2010
 

Further Inpatient Care

  • For successful treatment, ensure that high-dose antimicrobials are used for an optimal period and provide close follow-up care for the patient. When antibiotics are used for less than 3 weeks, recurrence rates are higher.
  • Clinical response, etiologic agent, and return of the ESR and C-reactive protein levels to the reference range govern duration of treatment. Prescribe a minimum antibiotic course of 4 weeks; most patients receive treatment for 4-8 weeks, depending on the pathogen, clinical course, and laboratory parameters.
  • Once the pathogen is identified and antibiotic susceptibility results are available, consider modifying antibiotic therapy.
  • Sequential intravenous-to-oral antibiotic regimens have proven safe and effective for treatment of bone and joint infections. Once symptoms and signs of inflammation have subsided and the ESR/CRP has started to fall, consider switching to oral antibiotics.
  • Studies have reported successful treatment of acute uncomplicated osteomyelitis with 4 days of intravenous antibiotics and 30 days of oral antibiotics.[6] Further studies are needed to aid with universal recommendations. The treatment regimen of choice is based on the clinical progression and the location of the osteomyelitis in the child.
  • Ensure the following criteria are met before switching from intravenous to oral therapy:
    • Availability of etiologic agent and reliable laboratory to perform serum-cidal assay (Schlichter test)
    • Availability of oral antibiotic capable of achieving adequate serum levels; usually 2-3 times usual oral dose
    • Absence of GI disease causing poor absorption of antibiotic
    • Family compliance (critical to success)
  • In older children, giving higher oral dosages of antibiotics is often not possible because they exceed the maximum allowable doses.
  • If the patient does not meet the above criteria for high-dose oral antibiotic course, continue treatment at home after establishing a peripherally inserted central catheter (PICC) line or another reliable long-term venous access. Parents often find it easier to administer intravenous antibiotics less frequently than every 6 hours. Cefazolin (Ancef, Kefzol), ceftazidime (Ceptaz, Fortaz, Tazicef, Tazidime), ceftriaxone (Rocephin), aminoglycosides, and clindamycin (Cleocin) provide this dosing convenience.
  • The patient may require repeat aspiration of the bone if fever, pain, and swelling fail to respond promptly or if radiography reveals significant periosteal elevation or periosteal abscess.
  • If chronicity of illness leads to necrotic bone, surgical debridement is usually required.
Next

Further Outpatient Care

  • Provide close follow-up care throughout treatment with weekly measurements of ESR, C-reactive protein levels, liver function tests, and CBC counts to monitor response and diagnose antibiotic-related neutropenia.
  • Oral antibiotic dosages may need to be increased to keep peak serum-cidal levels of 1:8 or greater. If serum-cidal levels are not adequate with oral antibiotics, the patient may need parenteral treatment.
Previous
Next

Complications

Possible complications from osteomyelitis include disturbances in bone growth, limb-length discrepancies, arthritis, abnormal gait, and pathologic fractures. In patients with chronic osteomyelitis, bone necrosis and fibrosis can occur.

Previous
Next

Prognosis

  • Despite adequate treatment and appropriate surgical intervention, 5-10% of patients may experience recurrence.
  • Aggressively treat any recurrence in consultation with an orthopedic surgeon and infectious diseases specialist. Recurrences may lead to chronic osteomyelitis with discharging sinuses and other systemic sequelae.
Previous
 
Contributor Information and Disclosures
Author

Sabah Kalyoussef, DO  Fellow in Pediatric Infectious Diseases, Children's Hospital at Montefiore

Sabah Kalyoussef, DO is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Specialty Editor Board

Gary J Noel, MD  Department of Pediatrics, Clinical Associate Professor, Weill Medical College of Cornell University

Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Joseph Domachowske, MD  Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

  1. Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL. Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am. Jul 2007;89(7):1517-23. [Medline].

  2. Nourse C, Starr M, Munckhof W. Community-acquired methicillin-resistant Staphylococcus aureus causes severe disseminated infection and deep venous thrombosis in children: literature review and recommendations for management. J Paediatr Child Health. Oct 2007;43(10):656-61. [Medline].

  3. Okubo T, Yabe S, Otsuka T, Takizawa Y, Takano T, Dohmae S, et al. Multifocal pelvic abscesses and osteomyelitis from community-acquired methicillin-resistant Staphylococcus aureus in a 17-year-old basketball player. Diagn Microbiol Infect Dis. Mar 2008;60(3):313-8. [Medline].

  4. Sdougkos G, Chini V, Papanastasiou DA, Christodoulou G, Tagaris G, Dimitracopoulos G. Methicillin-resistant Staphylococcus aureus producing Panton-Valentine leukocidin as a cause of acute osteomyelitis in children. Clin Microbiol Infect. Jun 2007;13(6):651-4. [Medline].

  5. Chiappini E, Conti C, Galli L, de Martino M. Clinical efficacy and tolerability of linezolid in pediatric patients: a systematic review. Clin Ther. Jan 2010;32(1):66-88. [Medline].

  6. Bachur R, Pagon Z. Success of short-course parenteral antibiotic therapy for acute osteomyelitis of childhood. Clin Pediatr (Phila). Jan 2007;46(1):30-5. [Medline].

  7. Jacobs RF, Adelman L, Sack CM, Wilson CB. Management of Pseudomonas osteochondritis complicating puncture wounds of the foot. Pediatrics. Apr 1982;69(4):432-5. [Medline].

  8. Ozbek Z, Makay B, Unsal E, Durak I, Gunes D, Anal O. Conjunctival involvement in chronic recurrent multifocal osteomyelitis. Cornea. Jan 2008;27(1):117-9. [Medline].

  9. Catalano-Pons C, Raymond J, Chalumeau M, Armengaud JB, Kalifa G, Gendrel D. Case 2: paediatric chronic osteomyelitis: report of two cases. Case 1 diagnosis: pulmonary TB complicated by pneumomediastinum. Case 2 diagnosis: osteomyelitis caused by actinomyces. Acta Paediatr. Dec 2007;96(12):1849-52. [Medline].

  10. Asensi V, Alvarez V, Valle E, et al. IL-1alpha (- 889) promoter polymorphism is a risk factor for osteomyelitis. Am J Med Genet. Jun 1 2003;119A(2):132-6. [Medline].

  11. Auh JS, Binns HJ, Katz BZ. Retrospective assessment of subacute or chronic osteomyelitis in children and young adults. Clin Pediatr (Phila). Jul-Aug 2004;43(6):549-55. [Medline].

  12. Bradley JS, Kaplan SL, Tan TQ, et al. Pediatric pneumococcal bone and joint infections. The Pediatric Multicenter Pneumococcal Surveillance Study Group (PMPSSG). Pediatrics. Dec 1998;102(6):1376-82. [Medline].

  13. Burnett MW, Bass JW, Cook BA. Etiology of osteomyelitis complicating sickle cell disease. Pediatrics. Feb 1998;101(2):296-7. [Medline].

  14. Cushing AH. Diskitis in children. Clin Infect Dis. Jul 1993;17(1):1-6. [Medline].

  15. Gallagher KT, Roberts RL, MacFarlane JA, Stiehm ER. Treatment of chronic recurrent multifocal osteomyelitis with interferon gamma. J Pediatr. Sep 1997;131(3):470-2. [Medline].

  16. Gutierrez K. Bone and joint infections in children. Pediatr Clin North Am. Jun 2005;52(3):779-94, vi. [Medline].

  17. Kaplan SL. Osteomyelitis in children. Infect Dis Clin North Am. Dec 2005;19(4):787-97, vii. [Medline].

  18. Klein JD, Leach KA. Pediatric pelvic osteomyelitis. Clin Pediatr (Phila). Nov 2007;46(9):787-90. [Medline].

  19. Kohli R, Hadley S. Fungal arthritis and osteomyelitis. Infect Dis Clin North Am. Dec 2005;19(4):831-51. [Medline].

  20. Lew DP, Waldvogel FA. Osteomyelitis. N Engl J Med. Apr 3 1997;336(14):999-1007. [Medline].

  21. Raz R, Miron D. Oral ciprofloxacin for treatment of infection following nail puncture wounds of the foot. Clin Infect Dis. Jul 1995;21(1):194-5. [Medline].

  22. Schauwecker DS, Braunstein EM, Wheat LJ. Diagnostic imaging of osteomyelitis. Infect Dis Clin North Am. Sep 1990;4(3):441-63. [Medline].

  23. Scott RJ, Christofersen MR, Robertson WW Jr, et al. Acute osteomyelitis in children: a review of 116 cases. J Pediatr Orthop. Sep-Oct 1990;10(5):649-52. [Medline].

  24. Taylor MN, Chaudhuri R, Davis J, Novelli V, Jaswon MS. Childhood osteomyelitis presenting as a pathological fracture. Clin Radiol. Mar 2008;63(3):348-51. [Medline].

  25. Unkila-Kallio L, Kallio MJ, Eskola J. Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics. Jan 1994;93(1):59-62. [Medline].

  26. Weinstein MP, Stratton CW, Hawley HB, et al. Multicenter collaborative evaluation of a standardized serum bactericidal test as a predictor of therapeutic efficacy in acute and chronic osteomyelitis. Am J Med. Aug 1987;83(2):218-22. [Medline].

  27. Wong M, Isaacs D, Howman-Giles R, Uren R. Clinical and diagnostic features of osteomyelitis occurring in the first three months of life. Pediatr Infect Dis J. Dec 1995;14(12):1047-53. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.