hematogenous osteomyelitis
Acute Hematogenous Osteomyelitis in Children. This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care, Medical Knowledge, and Practice-Based Learning and Improvement. Inflammatorychangeswithoedemasignalandmildmuscleenlargementareseen within the distal thigh and periarticular musculature with hypointense T1 and hyperintense T2 and PDFS signal. [10][13]. Crary SE, Buchannan GR, Drake CE, Journeycake JM. Ruebner R, Keren R, Coffin S, Chu J, Horn D, Zaoutis TE. Diabetes is a significant contributing factor in osteomyelitis, particularly when patients have concomitant neurologic or vascular abnormalities.33 A wide variety of organisms (e.g., P. aeruginosa, staphylococci, anaerobes) are frequently isolated from these infections. The lumbar spine is most commonly affected, followed by the . Therefore, most recommendations for the treatment of osteomyelitis are based on expert opinion rather than the results of randomized, controlled trials. After completing this article, readers should be able to: The most common type of osteomyelitis, an infection of bone, that occurs in children is acute hematogenous osteomyelitis. The lower extremity, especially the femur, is involved more often than the upper extremity, where the humerus is most likely to be infected. The findings are those of distal femoral osteomyelitis with subperiosteal abscess and inflammatory myositis of the distal thigh muscles. Belthur MV, Birchansky SB, Verdugo AA, et al.. Pathologic fractures in children with acute Staphylococcus aureus osteomyelitis. Le Saux N, Howard A, Barrowman NJ, Gaboury I, Sampson M, Moher D. Shorter courses of parenteral antibiotic therapy do not appear to influence response rates for children with acute hematogenous osteomyelitis: a systematic review. Individuals are at increased risk of osteomyelitis following trauma, placement of surgical implants or hardware, or if they are Vancomycin Therapeutic Guidelines: A Summary of Consensus Recommendations from the Infectious Diseases Society of America, the American Society of HealthSystem Pharmacists, and the Society of Infectious Diseases Pharmacists. Therefore, the therapeutic approach proposed by the authors may not be applicable to settings where MRSA osteomyelitis is common. ; choice of further imaging depends on patient characteristics. Diagnosis of osteomyelitis: Laboratory tests: Blood culture is recommended prior to antibiotic administration. However, for complicated AHO (eg, multifocal disease, abscesses, venous thrombosis) due to resistant bacteria such as MRSA, prolonged parenteral therapy in conjunction with surgical intervention as appropriate may be necessary. Prognosis varies depending on how quickly an infection is identified, and what other underlying conditions exist to complicate the infection. Diagnosis is supported via laboratory tests, imaging, and/or biopsy. [1] Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. Introduction Bone infection is called osteomyelitis. Early antibiotic therapy, before extensive destruction of bone, produces the best results in patients with osteomyelitis. Features of underlying disease (e.g., peripheral neuropathy, signs of peripheral arterial disease) may be seen in both acute and chronic osteomyelitis. The axial skeleton is less likely to be the site of acute hematogenous osteomyelitis. Conclusion: Given the evolution of pathogens, the variability in clinical presentations and course ranging from simple to complex disease, and response to treatment, the management of AHO continues to evolve and warrants an individualized, multidisciplinary approach. Adult patients with osteomyelitis of the spine usually have a longer period of dull, aching pain in the back, and no fever. The most common form of hematogenous osteomyelitis is vertebral; patients often have back or neck pain and muscle. Over time, the result can be destruction of the bone itself. These areas occur when the infection interferes with blood flow to a particular part of the bone. Osteomyelitis. When pockets of pus are available, or overlaying soft tissue infection exists, these can serve as sources for samples which can be cultured to allow identification of bacteria present. Osteomyelitis is an infection of the bone; it occurs following hematogenous (seeded from a remote source) or exogenous (expansion from nearby tissue) spread of pathogens, most commonly Staphylococcus aureus . Gornitzky AL, Kim AE, ODonnell JM, Swarup I. Treatment with antistaphylococcal antibiotics is usually effective against culture-negative osteomyelitis; in addition, therapy against K kingae should be considered in children <4 years.5,26, Despite the considerable variability in the management of pediatric AHO, a growing body of evidence indicates that a shorter course of intravenous (IV) antibiotic therapy followed by an early transition to oral antibiotic therapy may offer a similar success rate in children with uncomplicated osteomyelitis compared to prolonged IV therapy alone while avoiding the complications related to the use of a venous catheter.27-34, Studies have documented substantial risks associated with use of prolonged IV therapy for AHO. In one US study of 99 children with septic arthritis, the diagnosis of K kingae infection was made in 10 children aged 4 years; polymerase chain reaction (PCR) alone detected the pathogen in 8 cases.8, Osteomyelitis caused by Haemophilus influenzae type b (Hib) is very rare in high-income countries since the widespread implementation of the vaccination program in the 1990s9; historically, Hib accounted for 10%-15% of cases of osteomyelitis in unvaccinated children <3 years in low-income countries.5 Likewise, children who are not immunized or who are incompletely immunized against Streptococcus pneumoniae have a greater risk of developing invasive disease (eg, bacteremia, meningitis, pneumonia, and bone and joint infections).6, AHO caused by community-associated methicillin-resistant S aureus (CA-MRSA) has become common in many countries.4-6,9-11 The prevalence of MRSA varies significantly with geography. CVC malfunction or displacement occurred in 17 (23%) patients, catheter-associated bloodstream infection occurred in 8 (11%), fever with negative blood culture results was noted in 8 (11%), and local skin infection at the site of catheter insertion occurred in 4 (5%) patients.35, In another report, children with AHO sent home on IV therapy were 2.1 times more likely to experience catheter-related adverse events compared with children on oral antibiotics only.36 The study suggested that institutional culture and tradition rather than patient characteristics were driving therapeutic choices regarding prolonged IV therapy.36 Oral antibiotic therapy is less expensive and more convenient than IV therapy, and it can be instituted as stepdown treatment when the patient's clinical status has improved (eg, resolution of fever and pain), when bacteremia resolves (if initially positive), when CRP level declines to <3 mg/dL, and when compliance with therapy and follow-up is excellent.10,37,38, A randomized controlled trial conducted in Finland showed that most cases of childhood AHO can be treated with 2-4 days of IV antibiotics followed by 20 or 30 days of oral antibiotics (large doses of clindamycin or a first-generation cephalosporin) in patients who respond quickly and whose CRP values normalize within 10 days.32 In this study, all cases of osteomyelitis were caused by MSSA. The selection is not exhaustive. Infective pyomyositis and myositis in children in the era of community-acquired methicillin-resistant Staphylococcus aureus infection, Increasing pyomyositis presentations among children in Queensland, Prolonged intravenous instead of oral antibiotics for acute hematogenous osteomyelitis in children, Polymicrobial (gram-negative, gram-positive, and anaerobic bacteria), Linezolid, daptomycin, trimethoprim-sulfamethoxazole. Infection occurs . A review of 163 cases, Pediatric bone and joint infections caused by Panton-Valentine leukocidin-positive Staphylococcus aureus. Hirschfeld CB, Kapadia SN, Bryan J, et al. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systemic review of the literature, Differentiating between methicillin-resistant and methicillin-sensitive Staphylococcus aureus osteomyelitis in children: an evidence-based clinical prediction algorithm. Chronic osteomyelitis: what the surgeon needs to know. Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton LJ 3rd, Huddleston PM 3rd. Panton-Valentine leukocidin genes are associated with enhanced inflammatory response and local disease in acute hematogenous Staphylococcus aureus osteomyelitis in children. ]), CBC (may show mild-moderate leukocytosis, although, Plain Radiographs: Early in disease will show soft tissue swelling. It is an acute or chronic inflammatory process involving the bone and its structures secondary to infection with pyogenic organisms, including bacteria, fungi, and mycobacteria. Dr Conrad has disclosed no financial relationships relevant to this article. Osteomyelitis in adults often assumes a chronic course and requires prolonged treatment, whereas children typically make a quick and full recovery. Expert Panel on Musculoskeletal Imaging:., Beaman FD, von Herrmann PF, et al. For optimal results, antibiotic therapy must be started early, with antimicrobial agents administered parenterally for at least four to six weeks. Recent data suggests that 3 week courses may be appropriate in carefully selected patients (Peltola et al, Song et al). Very few studies have investigated the treatment of osteomyelitis. Neisseria gonorrhoeae must be considered in neonates and sexually active adolescents.5 In the child with sickle cell anemia, in addition to S aureus, Salmonella spp frequently cause osteoarticular infections.5 In some countries (eg, Spain, France, United Kingdom, Israel, and Switzerland), Kingella kingae is being recognized increasingly as a common etiology of pediatric osteoarticular infections, especially in children <5 years.7 Data on the epidemiology of K kingae infection in the United States are limited. Diagnostic Accuracy of Probe to Bone to Detect Osteomyelitis in the Diabetic Foot: A Systematic Review. Marais LC, Ferreira N, Aldous C, Sartorius B, Le Roux T. A modified staging system for chronic osteomyelitis. Histopathologic and microbiologic examination of bone is the gold standard for diagnosing osteomyelitis. In many instances, a bone scan will be positive despite the absence of bone or joint abnormality. official website and that any information you provide is encrypted In uncomplicated cases following initial IV treatment, oral regimens have been shown to be as effective as IV regimens. negative Staph, Children presenting with fever, localized pain, who appear acutely ill (likely septic), A more indolent course, with gradual onset of pain and concurrent loss of function. 1 Infection of the vertebrae and intervertebral disks is typically hematogenous. Jagodzinski NA, Kanwar R, Graham K, Bache CE. Most cases of AHO occur in children with no known risk factors.10 For uncomplicated AHO due to MSSA, a short parenteral antibiotic course followed by oral therapy for a minimum total duration of 3-4 weeks is adequate. Surgical hardware may decrease image quality. Erythrocyte sedimentation rate has a limited diagnostic role, although it can be helpful in longitudinal follow-up. [1] Table 1 depicts the various microorganisms causing osteomyelitis in patients with specific risk factors. The site is secure. Microbiology of bone and joint infections in injecting drug abusers. https://doi.org/10.1542/pir.31-11-464. Inclusion in an NLM database does not imply endorsement of, or agreement with, Patients with chronic osteomyelitis may require antibiotics periodically for the rest of their lives. When the culture results are known, the antibiotic regimen is revised. Prado S MA, Lizama C M, Pea D A, Valenzuela M C, Viviani S T. 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