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Pediatric Osteomyelitis Treatment & Management

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

Medical Care

See the list below:

  • Optimal antibiotic selection, adequate dosing, and a sufficiently prolonged antibiotic course with monitoring for clinical response and for the toxicity of therapy are essential. The decision must be tailored to the age of the patient, local resistance patterns, pathogen suspected, and compliance with the agent prescribed.
  • Promptly initiate antibiotic treatment, preferably after obtaining blood and bone aspirates for culture. Initially, select one or more antimicrobial agents that provide adequate coverage for common pathogens, until therapy can be narrowed.
  • The usual choice is an antistaphylococcal antibiotic; nafcillin, vancomycin, clindamycin, and cefazolin are the preferred agents. Clindamycin may be used if resistance is less than or equal to 10% in the community setting after D-testing is performed.
  • Linezolid has good Gram-positive coverage, including MRSA and has excellent oral bioavailability and additional studies supporting its varied use. However, it is an expensive option and not well studied in the treatment of osteomyelitis.[14]
  • Intravenous therapy is still recommended for initial treatment. Various studies have started oral therapy after a few days of intravenous therapy. The entire duration of treatment remains between 3-6 weeks until normalization of the C-reactive protein level.[15, 16]
  • Consider vancomycin as an alternative to clindamycin for empiric therapy in patients who live in communities that have a higher incidence of penicillin-resistant S pneumoniae or CA-MRSA. Reports of CA-MRSA osteomyelitis are increasing worldwide, with IDSA guidelines now available to aide with management.[17] The severity of disease in infections with organisms carrying the Panton-Valentine leukocidin (PVL) gene is also increasing.[6]
  • Although Haemophilus influenzae type b (Hib) disease has virtually disappeared from the Hib-immune population, third-generation cephalosporins (eg, cefotaxime, ceftriaxone) are used in addition to nafcillin or clindamycin for empiric antibiotic therapy. This additional treatment is commonly used in children younger than 3 years.
  • Do not use third-generation cephalosporins alone to treat osteomyelitis because they are not optimal for treating serious S aureus infections.
  • Cefuroxime, a second-generation cephalosporin, can be used as a single agent against both methicillin-sensitive S aureus and Hib, if they are the suspected pathogens.
  • The increasing incidence of penicillin-resistant S pneumoniae warrants the use of a clindamycin and cefotaxime/ceftriaxone combination in infants and children.
  • When treating neonatal osteomyelitis, consider nafcillin and tobramycin or vancomycin and gentamicin combinations to provide coverage of bacteria from the Enterobacteriaceae family, in addition to group B streptococci and S. aureus.
  • In children and adolescents with penetrating trauma of the foot, perform surgical debridement before considering antipseudomonal treatment. Infection can occur days to weeks before initial presentation, as history is vital to the diagnosis.
  • For further details, see Follow-up.
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Surgical Care

See the list below:

  • As mentioned above, patients may require a bone biopsy to ensure a correct diagnosis and appropriate antimicrobial therapy.
  • Consultation with orthopedic surgeons is helpful in determining whether surgery is necessary for diagnosis and treatment.
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Consultations

See the list below:

  • Consultation with an orthopedic surgeon and infectious diseases specialist are helpful in the management of osteomyelitis.
  • Intervention radiologists with a focus on bone pathology would be very helpful to obtain a bone biopsy in a difficult location under fluoroscopic guidance.
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Diet

No specific diet is recommended.

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Activity

Weight bearing and aggressive physical activity should be restricted until the infection and treatment course are completed, as noted recently in S aureus infections.[3]

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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.

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. 2007 Jul. 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. 2007 Oct. 43(10):656-61. [Medline].

  3. Belthur MV, Birchansky SB, Verdugo AA, Mason EO Jr, Hulten KG, Kaplan SL, et al. Pathologic fractures in children with acute Staphylococcus aureus osteomyelitis. J Bone Joint Surg Am. 2012 Jan 4. 94(1):34-42. [Medline].

  4. Bouchoucha S, Benghachame F, Trifa M, Saied W, Douira W, Nessib MN, et al. Deep venous thrombosis associated with acute hematogenous osteomyelitis in children. Orthop Traumatol Surg Res. 2010 Dec. 96(8):890-3. [Medline].

  5. 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. 2008 Mar. 60(3):313-8. [Medline].

  6. 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. 2007 Jun. 13(6):651-4. [Medline].

  7. Hawkshead JJ 3rd, Patel NB, Steele RW, Heinrich SD. Comparative severity of pediatric osteomyelitis attributable to methicillin-resistant versus methicillin-sensitive Staphylococcus aureus. J Pediatr Orthop. 2009 Jan-Feb. 29(1):85-90. [Medline].

  8. Ranson M. Imaging of pediatric musculoskeletal infection. Semin Musculoskelet Radiol. 2009 Sep. 13(3):277-99. [Medline].

  9. Schallert KE, Kan HJ, Monsalve J, et al. Metaphyseal osteomyelitis in children: how often does MRI-documented joint effusion or epiphyseal extension of edema indicate coexisting septic arthritis?. Pediatr Radiol. 2015 Jul. 45 (8):1174-81. [Medline].

  10. Schmit P, Glorion C. Osteomyelitis in infants and children. Eur Radiol. 2004 Mar. 14 Suppl 4:L44-54. [Medline].

  11. Blickman JG, van Die CE, de Rooy JW. Current imaging concepts in pediatric osteomyelitis. Eur Radiol. 2004 Mar. 14 Suppl 4:L55-64. [Medline].

  12. McNeil JC, Forbes AR, Vallejo JG, et al. Role of Operative or Interventional Radiology-Guided Cultures for Osteomyelitis. Pediatrics. May 2016. 137(5):

  13. Mader JT, Shirtliff M, Calhoun JH. Staging and staging application in osteomyelitis. Clin Infect Dis. 1997 Dec. 25(6):1303-9. [Medline].

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

  15. Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics. 2009 Feb. 123(2):636-42. [Medline].

  16. Peltola H, Pääkkönen M, Kallio P, Kallio MJ. Short- versus long-term antimicrobial treatment for acute hematogenous osteomyelitis of childhood: prospective, randomized trial on 131 culture-positive cases. Pediatr Infect Dis J. 2010 Dec. 29(12):1123-8. [Medline].

  17. Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011 Feb 1. 52(3):285-92. [Medline].

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

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

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

  21. 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. 2007 Dec. 96(12):1849-52. [Medline].

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

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

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

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

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

  27. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. J Bone Joint Surg Br. 2012 May. 94(5):584-95. [Medline].

  28. Faust SN, Clark J, Pallett A, Clarke NM. Managing bone and joint infection in children. Arch Dis Child. 2012 Jun. 97(6):545-53. [Medline].

  29. Fisher RG. Neonatal osteomyelitis. NeoReviews. July, 2011. 12(7):e374-e380.

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

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

  32. Herigon JC, Hersh AL, Gerber JS, Zaoutis TE, Newland JG. Antibiotic management of Staphylococcus aureus infections in US children's hospitals, 1999-2008. Pediatrics. 2010 Jun. 125(6):e1294-300. [Medline].

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

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

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

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

  37. Pääkkönen M, Kallio PE, Kallio MJ, Peltola H. Management of Osteoarticular Infections Caused by Staphylococcus aureus Is Similar to That of Other Etiologies: Analysis of 199 Staphylococcal Bone and Joint Infections. Pediatr Infect Dis J. 2012 May. 31(5):436-8. [Medline].

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

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

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

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

  42. Thomsen I, Creech CB. Advances in the diagnosis and management of pediatric osteomyelitis. Curr Infect Dis Rep. 2011 Oct. 13(5):451-60. [Medline].

  43. 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. 1994 Jan. 93(1):59-62. [Medline].

  44. 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. 1987 Aug. 83(2):218-22. [Medline].

  45. 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. 1995 Dec. 14(12):1047-53. [Medline].

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