Pediatric Osteomyelitis Treatment & Management

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

Medical Care

  • Optimal antibiotic selection, adequate dosing, and a sufficiently prolonged antibiotic course with monitoring for clinical response and for the toxicity of therapy are essential. 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.
  • The usual choice is an antistaphylococcal antibiotic; nafcillin, vancomycin, clindamycin, and cefazolin are the preferred agents.
  • Linezolid is a new medication on the market approved for skin and soft tissue infections, with gram positive coverage, including MRSA. Additional studies are needed before recommending general use, but this is a good future candidate due to its oral and intravenous availablity.[5]
  • Intravenous therapy is still recommended for at least 2-4 weeks prior to switching to oral therapy for the remainder 4-6 week duration and normalization of the CRP.
  • 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. The severity of disease in infections with organisms carrying the Panton-Valentine leukocidin (PVL) gene is also increasing.[4]
  • 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. 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.
  • For further details, see Follow-up.
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Surgical Care

  • Bone aspiration may be necessary to identify the pathogen.
  • Consider bone biopsy if other diagnoses are possible (eg, tumors).
  • Joint aspiration is recommended if signs and symptoms suggest pathology near shoulder or hip joints. This is critical because arthrotomy is indicated if evidence of hip or shoulder arthritis is present.
  • If signs and symptoms do not begin to resolve within 48-72 hours of initiation of appropriate antimicrobial treatment, consider bone aspiration to drain the pus, in consultation with the orthopedic surgeon.
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Consultations

  • Consultation with an orthopedic surgeon and infectious diseases specialist is necessary in the management of osteomyelitis.
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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.

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