Acute Bacterial Bone and Joint Infections in Children

Abstract and Introduction

Abstract

The treatment of acute hematogenous bone and joint infections of children – osteomyelitis (OM), septic arthritis (SA) and OM–SA combination (OM+SA) – has simplified over the past years. The old approach included months-long antibiotic treatment, started intravenously for at least a week, followed by oral completion of the course. Recent prospective randomized trials show that most cases heal with a total course of 3 weeks (OM, OM+SA) or 2 weeks (SA) of an appropriate antibiotic, provided the clinical response is good and C-reactive protein level has normalized. If the prevalence of methicillin-resistant Staphylococcus aureus and Kingella kingae is low, clindamycin and a first-generation cephalosporin are safe, inexpensive and effective alternatives. They should be administered in large doses and four times a day. Clindamycin, vancomycin and expensive linezolid are options against methicillin-resistant Staphylococcus aureus. Extensive surgery beyond a diagnostic sample by aspiration is rarely needed in uncomplicated cases.

Introduction

Acute hematogenous bone and joint infections are rare but potentially devastating diseases that are more prevalent in children.^[1] Depending on the localization, they manifest as osteomyelitis (OM), septic arthritis (SA) or their combination OM+SA. The disease is considered acute if time from the onset of symptoms is less than 2 weeks.^[2] Any bone or joint can be affected, but the long bones and joints of the lower limbs are most commonly involved.^[3] Boys are more prone than girls, which is explained by physical activity leading to repeating minitraumata; the gender ratio is approximately 1.7:1.^[1] The traditional treatment comprises of long courses of antibiotics, started with large doses intravenously for a week or so, followed by completion of the course orally for a month or even longer.^[2] Aggressive surgery, and in case of SA in the hip or shoulder, routine arthrotomy have been favoured.^[1,2] As alternatives to open arthrotomy in SA, arthroscopy^[4] and repeated joint aspirations are recommended.^[5–8]

We challenged the traditional treatment of OM and SA in our large prospective and randomized treatment trial.^[9–11] The aim was to simplify the entire treatment approach of OM, SA and OM+SA by making things simpler than before. Useful evidence-based information was obtained for future guidelines.

Table 1. Recommendations for the duration of antibiotic treatment for uncomplicated acute bone and joint infections in children.
Study (year)	Country	OM or SA	Intravenous administration (days)	Total antibiotic course	Ref.
Prado et al. (2008)	Chile	OM or SA	7	4–6 weeks	[37]
Peltola et al. (2010)	Finland	OM	2–5	3 weeks	[10]
Peltola et al. (2009)		SA	2–5	10 days–2 weeks	[9]
Lorrot et al. (2011)	France	OM or SA	4–7	3 weeks	[40]
Jaberi et al. (2002)	Iran	OM SA	10 7	5.5 weeks 5 weeks	[36]
Jagodzinski et al. (2009)	UK	OM or SA	3–6	3.5–4 weeks	[38]
Liu et al. (2011)	USA	OM	7	3–4 weeks	[18]
Ballock et al. (2010)		SA	7	4–6 weeks	[41]

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Simplifying the Treatment of Acute Bacterial Bone and Joint Infections in Children

Abstract and Introduction

Abstract

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