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Pediatric Osteomyelitis Follow-up

  • Author: Sabah Kalyoussef, DO; Chief Editor: Russell W Steele, MD  more...
 
Updated: May 02, 2016
 

Further Outpatient Care

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  • 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.
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Further Inpatient Care

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  • 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 3 weeks; this is adequate except for patients with MRSA infection where 4-6 weeks of therapy are often required.
  • Once the pathogen is identified and antibiotic susceptibility results are available, consider narrowing 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 in a nontoxic child.
  • Studies have reported successful treatment of acute uncomplicated osteomyelitis with 3-5 days of intravenous antibiotics and 16-18 days of oral antibiotics.[18, 16] 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. Newer, expensive antibiotics may also be used such as linezolid and daptomycin.
  • The patient may require repeat aspiration of the bone if fever, pain, and swelling or 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.
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Inpatient & Outpatient Medications

It is important to ensure familial compliance with proper dosing of antibiotics when choosing an appropriate oral regimen.

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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.

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Prognosis

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  • 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.
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Patient Education

It is important to discuss age-appropriate care with the patient to ensure compliance with medical therapy.

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Contributor Information and Disclosures
Author

Sabah Kalyoussef, DO Attending Physician, Pediatric Infectious Diseases and Hospital Medicine, The Children's Hospital at St Peter's University Hospital

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Gary J Noel, MD Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician, New York-Presbyterian Hospital

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

Disclosure: Nothing to disclose.

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