Osteomyelitis in children

Steer AC, Carapetis JR. Acute hematogenous osteomyelitis in children recognition and management. Pediatr Drugs 2004 6 333-346. 

Dahl LB, Hoyland AL, Dramsdahl H, Kaaresen PI. Acute osteomyelitis in children A population-based rettospective smdy 1965 to 1994. Scand J Infect Dis 1998 30 573-577. 

Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg 2001 9 166-175. 

Clinical Applications. Lipophilic Tc-exametazime has been shown to label leukocytes without affecting cell viability (Mortelmans et al. 1989 Peters et al. 1986 Roddie et al. 1988). HMPAO-labeled leukocytes have been used to locate site(s) of focal infection (e.g., abdominal abscess, abdominal sepsis) (Kelbaek et al. 1985) it is also indicated in conditions of fever of unknown origin, and in conditions not associated with infection such as inflammatory bowel disease (Arndt et al. 1993 Lantto et al. 1991). Labeled leukocytes have offered superior information when compared with bone scanning for the detection of osteomyelitis in children (Lantto et al. 1992). In a retrospective study in 116 patients with infection suspected to involve orthopedic implants, osteomyelitis, and septic arthritis, HMPAO-labeled leukocytes have been an effective tool in the diagnosis of chronic osteomyelitis and joint infection involving implants (sensitivity > 97%, specificity > 89%) (Devillers et al. 1995). 

Chao HC, Lin SJ, Huang YC et al (1999) Color Doppler ultrasonographic evaluation of osteomyelitis in children. J Ultrasound Med 18 729-734... 

Davidson D, Letts M, Khoshhal K (2003) Pelvic osteomyelitis in children comparison of decades from 1980-1989 with 1990-2001. J Pediatr Orthop 23 514-521 Davies AP, Blewitt N (2005) Lipoma arborescens of the knee. Knee 12 394-396... 

Mah ET, LeQuesne GW, Gent RJ et al (1994) Ultrasonic features of acute osteomyelitis in children. J Bone Joint Surg Br 76 969-974... 

Bone infarcts or sickling in the periosteum usually is indicated by pain and swelling over an extremity. Osteomyelitis also should be considered. Salmonella species are the most common cause of osteomyelitis in SCD children, followed by Staphylococcus aureus. 27 Select an appropriate antibiotic to cover the suspected organisms empirically. 

The epidemiology of osteomyelitis has been changing over the past several decades.6 The incidence of acute hematogenous osteomyelitis, which is most often seen in children, has been declining.6,7 In contrast, the frequency of contiguous osteomyelitis has been increasing. This trend may be related to... 

Osteomyelitis may be acute or chronic and the causative bacteria arrive in the bloodstream or are implanted directly (through a compound fracture, chronic local infection of local tissue, or surgical operation). Staphylococcus aureus is the commonest isolate in all patient groups but Haemophilus influenzae is frequently seen in children (much reduced now by the Hib vaccine), and Salmonella species in the tropics. Chronic osteomyelitis of the lower limbs (especially when underlying chronic skin infection in the elderly) frequently involves obligate anaerobes (such as Bacteroides species) and coliforms. 

Definitive therapy is guided by the results of culture but commonly used regimens include flucloxacillin with or without fusidic acid (for Staphylococcus aureus), cefotaxime or co-amoxiclav (in children), and ciprofloxacin (for coliforms). Short courses of therapy (3 weeks) may suffice for acute osteomyelitis. 

The available data suggest that the incidence of arthro-toxicity in children taking ciprofloxacin is the same as in adults the use of other fluoroquinolones is too rare to obtain clear information about the risks in children (51). In 12 children with sickle cell disease treated successfully for acute osteomyelitis with oral ciprofloxacin, transient bilateral Achilles tendon tendinitis occurred in one 5-year old (52). Another case was reported in a hemodialysis patient with a ciprofloxacin-associated Achilles tendon rupture (53). 

Oral antimicrobial therapy may be used for osteomyelitis to complete a parenteral regimen in children who have had a good clinical response to intravenous antibiotics and in adults without diabetes mellitus or peripheral vascular disease when the organism is susceptible to the oral antimicrobial, a suitable oral agent is available, and compliance is ensured. 

In contrast to hematogenous osteomyelitis, which occurs most commonly in children, contiguous-spread osteomyelitis occurs most commonly in patients older than age 50. Most likely this is so be-canse important predisposing factors, such as hip fractures, are more common in this age group. 

If a patient with hematogenous osteomyelitis does not respond by having a decrease in fever, local swelling, redness, and pain following the initiation of adequate antibiotic therapy, the patient should undergo surgical debridement of the infected area. It is important to emphasize the priority of starting antibiotics immediately after the cultures have been obtained. No treatment failures have been reported when injectable antibiotics were started within 48 hours of the onset of symptoms in children with osteomyelitis. 

The specific dnration of antibiotic therapy needed in the management of osteomyelitis is usually 4 to 6 weeks. Failures approaching 20% have been observed in children treated with injectable antibiotics for 3 weeks or less. Thus, with the data indicating a minimum of 3 weeks of antibiotic therapy, the standard treatment for osteomyelitis has been parenteral antibiotics for 4 to 6 weeks. Although these data were determined in children, this duration-of-therapy recommendation is also used in adults. A trial assessing ceftriaxone 2 g intravenously once daily for at least 6 weeks for S. aureus osteomyelitis achieved a cure rate of 11% The failures in this study were in patients with infected necrotic bone or infected hardware (wires, plates, screws, and rods) that could not be removed. 

Trobs R, Moritz R, BuhUgen U, et al. Changing pattern of osteomyelitis in infants and children. PediatrSurg Int 1999 15 363-372. 

Vinod MB, Matussek J, Curtis N, et al. Duration of antibiotics in children with osteomyelitis and septic arthritis. J Paediat Child Health 2002 38 363-367. 

Bacterial superinfection of pox lesions was relatively uncommon except in the absence of proper hygiene and medical care. Arthritis and osteomyelitis developed late in the course of disease in about 1% to 2% of patients, more frequently occurred in children, and was often manifested as bilateral joint involvement, particularly of the elbows.70 Viral inclusion bodies could be demonstrated in the joint effusion and bone marrow of the involved extremity. This complication reflected infection and inflammation of a joint followed by spread to contiguous bone metaphyses, and sometimes resulted in permanent joint deformity.71 Cough and bronchitis were occasionally reported as prominent manifestations of smallpox, with attendant implications for spread of contagion however, pneumonia was unusual.72 Pulmonary edema occurred frequently in hemorrhagic- and flat-type smallpox. Orchitis was noted in approximately 0.1% of patients. Encepha-... 

Osteomyelitis is not uncommon in children. Bacteria may enter the bone via one of four different mechanisms ... 

Seabold JE, Nepola JV, Conrad GR, Marsh JL et al. (1991) Postoperative bone marrow alterations potential pitfalls in the diagnosis of osteomyelitis with In-lll-labelled leukocyte scintigraphy. Radiology 180 741-747 Wallace ME, Hoffman EB (1992) Remodelling of angular deformity after femoral shaft fractures in children. J Bone Joint Surg (Br) 74-B 765-769... 

Jaramillo D, Treves ST, Kasser JR (1995) Osteomyelitis and septic arthritis in children appropriate use of imaging to guide treatment. AJR Am J Roentgenol 165 399-403 Johnson K (2006) Imaging of juvenile idiopathic arthritis. Pediatr Radiol 36 743-758... 

Wright NB, Abbott GT, Carthy HM (1995) Ultrasound in children with osteomyelitis. Clin Radiol 50 623-627 Zawin JK, Hoffer FA, Rand FF et al (1993) Joint effusion in children with an irritable hip US diagnosis and aspiration. Radiology 187 459-463... 

Most cases of food-bome gastrointestinal illness resolve spontaneously. Shigella and Salmonella infections have also been associated with Reiter s syndrome or reactive arthritis. Salmonella may also lead to osteomyelitis and endocarditis. They are also associated with haemolytic uraemic syndrome (HUS) in children. 

Rifampin is used in a variety of other clinical situations. An oral dosage of 600 mg twice daily for 2 days can eliminate meningococcal carriage. Rifampin, 20 mg/kg/d for 4 days, is used as prophylaxis in contacts of children with Haemophilus influenzae type b disease. Rifampin combined with a second agent is used to eradicate staphylococcal carriage. Rifampin combination therapy is also indicated for treatment of serious staphylococcal infections such as osteomyelitis and prosthetic valve endocarditis. Rifampin has been recommended also for use in combination with ceftriaxone or vancomycin in treatment of meningitis caused by highly penicillin-resistant strains of pneumococci. 

Hematogenous osteomyelitis is described classically as a disease of children because most cases occur in patients younger than 16 years of age. Table 116-1 summarizes the primary characteristics of osteomyelitis. Less commonly, these infections occur in adults. One exception, vertebral osteomyelitis, involves the vertebrae and occurs most frequently in patients older than 50 years of age. 

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