Predictive value of PAR and PNI for the acute complicated course of pediatric acute hematogenous osteomyelitis.

OBJECTIVE: Platelet to albumin ratio (PAR) and prognostic nutritional index (PNI) are potential indicators for evaluating nutritional and inflammatory status. This study aimed to examine the relationship between PAR and PNI and the acute complicated course of acute hematogenous osteomyelitis (AHO). METHODS: AHO patients were divided into the simple course group and the acute complicated course group. The patient's gender, age, site of infection, body temperature, laboratory results, and pathogen culture results were collected and compared. Multivariate logistic regression analysis was used to determine the independent risk factors of the acute complicated course group. The receiver operating characteristic curve was applied to determine the optimal cut-off value. RESULTS: In total, 101 AHO patients with a median age of 7.58 years were included. There were 63 cases (62.4 %) in the simple course group and 38 cases (37.6 %) in the complicated course group. Binary logistic regression analysis revealed that PAR and PNI were independent risk factors for predicting the acute complicated course of AHO (p = 0.004 and p < 0.001, respectively). Receiver operating characteristic curve analysis demonstrated that the combination of PAR and PNI had an area under the curve of 0.777 (95 % CI: 0.680-0.873, p < 0.001) with a cut-off value of 0.51. CONCLUSIONS: The incidence of acute complicated courses was significantly higher in patients with high PAR and low PNI. A combined factor greater than 0.51, derived from PAR and PNI measurements within 24 h of admission, may be useful for predicting AHO patients who are likely to develop severe disease.

Assessing Risk for Complications in Acute Hematogenous Osteomyelitis in Children: Validation of 2 Predictive Scores.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) can be associated with severe complications which can be difficult to predict in the clinical setting. The previously published predictive acute complication score ("A-SCORE") and chronic complication score ("C-SCORE") show promise, however, further external validation is needed. METHODS: We performed a retrospective study of 418 children with AHO and analyzed the performance of A-SCORE (variables included bone abscess, fever after 48 h of starting antibiotics, suppurative arthritis, disseminated disease, and delayed source control) to predict risk for acute complicated course (treatment failure, prolonged admission, and/or need for ≥2 bone debridements) and C-SCORE (includes disseminated disease, bone debridement, and CRP ≥10 mg/dL at 2-4 days after starting antibiotics) to predict chronic complications (growth restriction, pathologic fracture, chronic osteomyelitis, avascular necrosis, joint deformity, and/or frozen joint). RESULTS: An acute complicated course occurred in 106/418 (25.4%); 51/380 (13.5%) with complete follow-up data had a chronic complication. The A-SCORE performed with similar specificity (78%) and negative predictive value (NPV) (92%), and higher sensitivity (81%) and increased area under the receiver operating curve (AUC) (0.87) in our population. The C-SCORE performed with similar sensitivity (64%) and NPV (94%) but had lower specificity (86%) and AUC (0.71) than originally reported. Other variables associated with development of complications such as tibia involvement and bacteremia ≥2 days were identified but did not result in significantly improved predictive scores. CONCLUSIONS: Predictive A-SCORE and C-SCORE for AHO complications in children may help guide acute management and long-term follow-up decisions. Prospective studies are needed to determine their applicability.

A Child With Acute Hematogenous Osteomyelitis of the Distal Fibula and Infective Endocarditis.

Acute hematogenous osteomyelitis (AHO) commonly interests the pediatric population. It typically affects the metaphyses of long tubular bones. However, the fibula is rarely involved. Regarding the hematogenous inoculation, this infection may be associated with distant foci. Herein, we present the case of a 10-year-old girl who was initially diagnosed with atypical AHO of the distal fibula complicated by a subperiosteal abscess. Upon admission, the child showed a severe septic condition, including embolic infective endocarditis (IE), which was responsible for multiple cerebral, renal, and splenic loci. AHO was successfully resolved with appropriate intravenous antimicrobial treatment targeting Staphylococcus aureus, surgical drainage, and debridement. Due to the complexity of the lesions and the embolic nature, the IE was also managed operatively with a mechanical prosthesis. The distal fibula is a rare and challenging location for AHO. EI co-infection should always be sought and suspected because, in such instances, it will genuinely complicate diagnostic and therapeutic management.

Efficacy and safety of vancomycin-loaded calcium sulfate versus conventional surgical debridement for pediatric acute osteomyelitis: a retrospective study.

BACKGROUND: The purpose of this study was to evaluate the safety and efficacy of vancomycin-loaded calcium sulfate beads and negative-pressure wound therapy (NPWT) in treating children with acute hematogenous osteomyelitis (AHOM). METHODS: A retrospective cohort study was conducted from January 2017 to January 2020 examining children (n = 60) with AHOM who were treated with surgical debridement followed by vancomycin-loaded calcium sulfate beads and NPWT (n = 32) and compared to treatment by conventional surgical debridement (n = 28) followed by NPWT. Conventional surgical treatment consisted of fenestration of necrotic infected bone, debridement of surrounding soft tissue, and washing of the medullary canal before the application of NPWT. In the vancomycin group, the antibiotic-loaded beads were implanted after washing the medullary canal and before the application of NPWT. Epidemiological factors, complications during the procedure, outcomes at last follow-up (30.0 ± 11.7 months, range 13-58 months), and laboratory parameters were documented and compared between the two groups. RESULTS: Good outcomes were achieved at last follow-up in 71.4% of the conventional treatment group and 75% of the vancomycin group. In the vancomycin group, it took a mean of 4.8 ± 2.5 days for CRP levels to decrease to 50% of initial inflammatory levels compared to 13 ± 9.6 days for the conventional treatment group (p = 0.001, t-test). The conventional group also had seven patients who underwent four or more surgeries whereas no patients in the vancomycin group underwent more than three surgeries (p = 0.013, chi-square test). CONCLUSION: Localized vancomycin delivery with NPWT effective for treating cases of AHOM that required. No perioperative adverse reactions or complications occurred from this treatment method. Based on the shortened recovery period of CRP levels, prolonged administration of post-operational parenteral antibiotics can possibly be reduced with this treatment method.

Acute hematogenous osteomyelitis in children: Management of pandiaphysitis with extensive bone destruction: A case series of thirteen child.

Introduction: and Importance: Acute hematogenous osteomyelitis (AHO) poses a public health problem in severe forms from the outset or with delayed diagnosis. The aim of this work is to describe the management of pandiaphysitis with extensive bone destruction by the Ilizarov external fixator and antibiotics and to evaluate the results. Methods: This is a retrospective, descriptive, cross-sectional and single-center study. It was performed over a seven-year period. We included children with acute hematogenous osteomyelitis complicated by pandiaphysitis of the long bones with extensive bone necrosis. All patients underwent stabilization with an Ilizarov external fixator and antibiotic therapy adapted to the antibiogram in ten cases. One patient had the induced membrane technique. All the patients underwent dynamization of the Ilizarov external fixator followed by immobilization with a cast or a splint for the lower limb. Outcomes: 13 medical files were collected during the study period. The sex ratio was 1.6, the average age was 7.56 years. Three localization sites: humerus for 3 cases, femur for 3 cases and tibia for 7 cases. The germ has been identified in ten cases. Methicillin-resistant staphylococcus aureus was the most common. Bone consolidation is obtained in all cases with an average delay of ten months. Conclusion: The Ilizarov external fixator associated with antibiotics has proven its effectiveness in the management of pandiaphysitis with extensive bone destruction. This method is an alternative in the therapeutic arsenal available to pediatric orthopedic surgeons. Level of evidence: IV, Case series.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics.

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Clinical practice guideline by the pediatric infectious diseases society and the Infectious diseases society of america: 2021 guideline on diagnosis and management of Acute Hematogenous Osteomyelitis in pediatrics

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Infecciones osteoarticulares en niños / Osteoarticular infections in children

Las infecciones osteorticulares (IOA) en el niño son una causa importante de morbilidad y secuelas. Su pesquisa oportuna y el tratamiento eficiente pueden lograr excelentes resultados. La mejoría en las condiciones de salud de la población, y el cambio de los agentes etiológicos han variado la forma de presentación y tratamiento. La existencia de gérmenes como Kingella kingae y Staphilococcus aureus multiresistente, contribuyen a la variabilidad de presentación de las infecciones osteoarticulares.El manejo de estas patologías requiere de un conocimiento del cuadro clínico, de los métodos de diagnóstico y las herramientas terapéuticas. Para obtener buenos resultados es requisito básico el enfrentamiento de estos pacientes en un equipo multidisciplinario de especialistas.En este manuscrito revisaremos los aspectos fundamentales de las infecciones osteoarticulares, según el enfoque que aplicamos en nuestros pacientes.

Osteoarticular infections are a substantial cause of morbidity and sequelae in children. Early diagnosis and efficient treatment can achieve excellent results. The improvement in the health conditions of the population and the change in the etiological agents have produced changes in their presentation and their required treatment. The existence of germs like Kingella kingae and Staphilococcus aureus multiresistant contribute to the variability of presentation of osteoarticular infections.The appropriate management of these pathologies requires knowledge of the clinical picture, diagnostic methods, and therapeutic tools. To obtain good results, it is a basic requirement that these patients be confronted by a multidisciplinary team of specialists.In this manuscript we will review the most fundamental aspects of osteoarticular infections according to the approach we apply to our patients

[Acute haematogenous osteomyelitis of the pelvis with multifocal pyogenic abscesses in an adult]. / Ostryi gematogennyi osteomielit taza u vzroslogo s mnozhestvennymi gnoinymi metastazami.

Acute hematogenous osteomyelitis (AHO) in adults is a rare disease complicating timely diagnosis. Even greater difficulties are observed in case of pelvic bone lesion. The authors report AHO of the pelvis an adult. Osteomyelitis was complicated by generalized infection and multiple pyogenic abscesses in subcutaneous adipose tissue of the upper and lower extremities. Detection of primary infectious focus was complicated by extreme severity of the patient's condition and low informative value of X-ray and ultrasound at the early stage of disease. Staphylococcus aureus was obtained from blood culture and infectious foci. Surgical debridement along with complex intensive care ensured a positive outcome.

Acute hematogenous pelvic osteomyelitis: appropriate timing for magnetic resonance imaging.

BACKGROUND: The precise time of appearance of bone marrow edema in acute hematogenous pelvic osteomyelitis (AHPO) is unknown. The purpose of the present research is to clarify the time of appearance of bone marrow edema on magnetic resonance imaging (MRI) in AHPO. Our hypothesis was that onset is slower than in long-bone osteomyelitis. METHODS: We selected 12 patients (mean, 11.8 years) with MRI findings and clinical diagnosis of AHPO. The signal ratios of bone marrow (BM) and gluteus maximus muscle (M, BM/M ratio) in fat-suppressed T2- and T1-weighted images (T2WI, T1WI) were calculated to evaluate changes in bone-marrow signals. The correlation between BM/M ratios and days from onset was evaluated statistically and compared with lower extremity osteomyelitis. RESULTS: Bone marrow/M ratio of T2WI increased over time after the onset of the primary symptom in all patients and showed a statistically positive correlation (r = 0.36). In seven patients in whom an MRI scan was conducted twice, all showed higher values for the second MRI, and changes were more pronounced over time. The mean BM/M ratio of T2WI was 4.1 when 7 days or less had elapsed from the primary symptom, and 6.4 when more than 7 days had elapsed. The BM/M ratios in the sacroiliac joint group were lower than in the non-sacroiliac joint group. CONCLUSIONS: Unlike long-bone osteomyelitis, it took 1 week before findings for AHPO became fully evident. A definitive diagnosis can be made in patients with suspected sacroiliitis by performing a further MRI scan at 7 days or later.

Kingella kingae Osteoarticular Infections Approached through the Prism of the Pediatric Orthopedist.

Nowadays, Kingella kingae (K. kingae) is considered as the main bacterial cause of osteoarticular infections (OAI) in children aged less than 48 months. Next to classical acute hematogenous osteomyelitis and septic arthritis, invasive K. kingae infections can also give rise to atypical osteoarticular infections, such as cellulitis, pyomyositis, bursitis, or tendon sheath infections. Clinically, K. kingae OAI are usually characterized by a mild clinical presentation and by a modest biologic inflammatory response to infection. Most of the time, children with skeletal system infections due to K. kingae would not require invasive surgical procedures, except maybe for excluding pyogenic germs' implication. In addition, K. kingae's OAI respond well even to short antibiotics treatments, and, therefore, the management of these infections requires only short hospitalization, and most of the patients can then be treated safely as outpatients.

Pediatric pharmaceutical care with anti-infective medication in a patient with acute hematogenous osteomyelitis caused by methicillin-resistant Staphylococcus aureus.

The infection of the bone marrow system caused by methicillin-resistant Staphylococcus aureus (MRSA) leads to a variety of common diseases which usually occur in children under the age of 12. Vancomycin (VCM) is the first-line therapy for MRSA-caused serious infections such as bacteremia, infective endocarditis, osteomyelitis, meningitis, pneumonia, and severe skin and soft-tissue infection (e.g. necrotizing fasciitis) with a recommended dosage of 15-20 µg/mL. In this study, we first report a case of a child with MRSA-caused osteomyelitis who was successfully cured by VCM at a concentration of 4.86 µg/mL. VCM's clinical daily dose of more than 4 g was of concern in light of recent evidence suggesting the increased risks of nephrotoxicity and red man syndrome when Cmin ⩾15 µg/mL and doses ⩾10 mg/kg in children. As far as we know, this is the first report on the lower dose of VCM in children with MRSA osteomyelitis.

Practical Issues in Early Switching from Intravenous to Oral Antibiotic Therapy in Children with Uncomplicated Acute Hematogenous Osteomyelitis: Results from an Italian Survey.

Background: The European Society of Pediatric Infectious Diseases (ESPID) guidelines for acute hematogenous osteomyelitis (AHOM) have been published recently. In uncomplicated cases, an early (2-4 days) switch to oral empirical therapy, preferentially with flucloxacillin, is recommended in low methicillin-resistant Staphylococcus aureus settings. We conducted a survey with the aim of evaluating the behaviors of Italian pediatricians at this regard. Methods: An open-ended questionnaire investigating the empiric therapy adopted in uncomplicated AHOM children according to age was sent by email to 31 Italian pediatric clinics taking care of children with infectious diseases, and results were analyzed. Results: The preferred intravenous (IV) regimen was a penicillin plus an aminoglycoside (n = 10; 32.3%) in children aged <3 months, and a combination of a third-generation cephalosporin plus oxacillin (n = 7; 22.6%), or oxacillin alone (n = 6; 19.4%) in those ≥3 months. In every age class, amoxicillin-clavulanate was the first-choice oral antibiotic. Other antibiotics largely used orally included clindamycin, rifampicin, and trimethoprim/sulfamethoxazole. Flucloxacillin was never prescribed. Only 3 centers switched to oral therapy within 7 days in children ≥3 months of age. The most commonly reported reason influencing the time to switch to oral therapy concerned caregivers' adherence to oral therapy. Conclusion: Adherence to guidelines was poor, and early transition to oral therapy in the clinical practice was rarely adopted. Given the large use of potentially effective, but poorly studied, oral antibiotics such as amoxicillin/clavulanate, trimethoprim/sulfamethoxazole, and rifampicin, our data may stimulate further studies of this regard.

Management of Pediatric Acute Hematogenous Osteomyelitis, Part II: A Focus on Methicillin-Resistant Staphylococcus aureus, Current and Emerging Therapies.

Methicillin-resistant Staphylococcus aureus (MRSA) has become the most prevalent cause of acute hematogenous osteomyelitis (AHO) in pediatric patients. This increase in MRSA is due to the rise in community-acquired MRSA. Therefore, it is important that clinicians are aware of the various and upcoming therapies that cover this bacterium. A literature search of the Medline database was performed from creation through January 2018. Articles chosen for the review emphasize well-established MRSA treatment options for pediatric AHO, newer therapies on the horizon, and important pharmacokinetics and pharmacodynamic concepts for treatment. Traditional therapies, including vancomycin and clindamycin, remain effective for the treatment of pediatric AHO. When these agents cannot be used, evidence in AHO has been growing for daptomycin, linezolid, and ceftaroline. Further initial pediatric data with the long-acting lipoglycopeptides show promise and in the future may provide a role in AHO treatment in children.

Management of Pediatric Acute Hematogenous Osteomyelitis, Part I: Antimicrobial Stewardship Approach and Review of Therapies for Methicillin-Susceptible Staphylococcus aureus, Streptococcus pyogenes, and Kingella kingae.

Acute hematogenous osteomyelitis (AHO), often occurring in young children, is the most frequently diagnosed type of osteomyelitis in pediatric patients. Optimizing antibiotics is essential as delays to receipt of appropriate therapy can lead to chronic osteomyelitis, as well as impairments in bone growth and development. Antimicrobial stewardship programs (ASPs) are in a key position to help improve the care of patients with AHO as they contain a pharmacist with expertise in antibiotic drug selection, optimization of dosing, and microbiologic test review. A literature search of the MEDLINE database was conducted from initiation through January 2018. Articles selected for the review focus on pathogen identification, pharmacokinetics and pharmacodynamics, efficacy and safety in children, transition from intravenous to oral therapy, duration of treatment, and antimicrobial stewardship interventions. This review will highlight the potential roles ASPs can have in improving the management of AHO in pediatric patients. These roles include the creation of clinical pathways, improving testing algorithms, antibiotic choice and dosing, intravenous to oral transitions, duration of treatment, and therapy monitoring. Overall, patients are most effectively treated by focusing treatments on age, presentation, local sensitivities, and directed therapy with pathogen identification.

Acute Hematogenous Osteomyelitis in Children: Pathogenesis, Diagnosis, and Treatment.

Acute hematogenous osteomyelitis (AHO) in children is an ideal condition to study due to its representation of a wide spectrum of disorders that comprise pediatric musculoskeletal infection. Proper care for children with AHO is multidisciplinary and collaborative. AHO continues to present a significant clinical challenge due to evolving epidemiology and complex pathogenesis. A guideline-driven, multidisciplinary approach has been introduced and shown to effectively reduce hospital stay, improve the timing and selection of empirical antibiotic administration, reduce delay to initial MRI, reduce the rate of readmission, and shorten antibiotic duration.

Analysis on curative effect of new type irrigation pump use in acute hematogenous osteomyelitis / 重庆医学

Objective To investigate the curative effect of using new irrigation pump in acute hematogenous osteomyelitis.Methods Forty patients with acute hematogenous osteomyelitis were divided into the control group and observation group,20 cases in each group.The control group adopted the conventional lavage for drainage,while the observation group used self-made irrigation pump.Then the clinical curative effect and cure time were compared between the two groups.Results The total effective rate in the observation group was 100.00 ％,which was significantly higher than 80.00 ％ in the control group(P＜0.05),and the difference was statistically significant(P＜0.05).The cure time in the observation group was(10.13 ± 8.03)d,which was significantly shorter than (18.14-±5.43)in the control group,and the difference was statistically significant(P＜0.05).Conclusion The curative effect of new type irrigation pump in acute hematogenous osteomyelitis is more acurate than that of conventional lavage for vacuum darianage.

A Case of Acute Osteomyelitis: An Update on Diagnosis and Treatment.

Osteomyelitis in children is a serious disease in children requiring early diagnosis and treatment to minimize the risk of sequelae. Therefore, it is of primary importance to recognize the signs and symptoms at the onset and to properly use the available diagnostic tools. It is important to maintain a high index of suspicion and be aware of the evolving epidemiology and of the emergence of antibiotic resistant and aggressive strains requiring careful monitoring and targeted therapy. Hereby we present an instructive case and review the literature data on diagnosis and treatment.

Acute Primary Hematogenous Osteomyelitis in the Epiphysis of the Distal Tibia: A Case Report With Review of the Literature.

Osteomyelitis originating in the epiphysis of the long bones is quite rare and is usually found at either the distal femur or the proximal tibia. We report the case of a 12-year-old male with epiphyseal osteomyelitis that had developed in the distal tibia. To the best of our knowledge, this is the first published case report. The patient's history of a trauma that resembled an ankle sprain had delayed the diagnosis and subsequently led him to develop septic arthritis. The ankle is a common site of simple trauma; however, epiphyseal osteomyelitis is rare at this site. Therefore, if the symptoms continue or worsen after trauma, the clinician should check the affected site and take a more aggressive approach to make an early diagnosis.