Pediatric Osteomyelitis Follow-up

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

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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