Further Outpatient Care
Provide close follow-up care throughout treatment with weekly measurements of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, liver function tests, and complete blood cell (CBC) counts to monitor response and diagnose antibiotic-related neutropenia.
Patients with complicated osteomyelitis are encouraged to be followed up for 1 year for those at risk for long-term adverse sequelae. [9]
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 CRP levels to the reference range govern duration of treatment. Prescribe a minimum antibiotic course of 3 weeks; this is adequate except for patients with methicillin-resistant Staphylococcus aureus (MRSA) infection, for whom 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. Family structure and ease of compliance should be factored into the treatment route of administration and frequency. Family need to understand the commitment to the treatment prescribed in terms of frequency and timing and the risk if this is not met.
Studies have reported successful treatment of acute uncomplicated osteomyelitis with 3-5 days of intravenous antibiotics and 16-18 days of oral antibiotics. [20, 18] 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:
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Availability of etiologic agent
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Availability of oral antibiotic capable of achieving adequate serum level
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Absence of GI disease causing poor absorption of antibiotic
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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.
