A Short Course of IV Antibiotics for Osteomyelitis?
Jalan W Burton MD, MPH (UNC Pediatric Resident, PGY 2) and James Antoon MD, PhD (UNC Pediatric Resident, PGY 2) reviewing multiple studies
Hematogenous osteomyelitis occurs in 1 in 5000 United States children each year, contributing to 1% of pediatric hospitalizations. Wide variations exist regarding length of treatment of parenteral versus enteral antibiotic treatment. If left untreated or undertreated, osteomyelitis is associated with significant morbidity and mortality. In their 2014 paper, Majewski and colleagues define acute hematogenous osteomyelitis (AHOM) as less than 2 weeks of symptoms associated with laboratory and radiologic findings without a source of exogenous infection or penetrating trauma. The authors performed a literature review of systematic reviews and meta-analyses using Pub Med and Google Scholar that were published after Le Saux and colleagues’ 2002 systematic review. Six studies, three prospective and three retrospective were selected including: Peltola 2010, Jagodzinski 2009, Zaoutis 2009, Bachur 2007 Jaberri 2002, and Vinod 2002. The majority of studies (n=4) showed an average length of 7 or less days of IV therapy. Long-term complications, defined as readmissions within 6 months, occurred in 2 studies. There was no difference in complication rates based upon duration of IV therapy. For all studies included, the total combined therapy was 20 to 38 days. Two prospective studies used clinical and laboratory criteria to guide length of therapy. Peltola and colleagues used improving clinical symptoms and c-reactive protein (CRP) less than 2 mg/dL. Jagodzinski and colleagues used improving clinical symptoms and normalization of erythrocyte sedimentation rate (ESR). The majority of patients included in the review had methicillin-sensitive Staph aureus (MSSA). Children infected with methicillin-resistant Staph (MRSA), generally have longer febrile illness and hospitalizations. The results of this study may be difficult to apply to children infected with MRSA.
Clinical bottom line: For uncomplicated hematogenous osteomyelitis, a total antibiotic course of 21 or more days can include early transition from IV to PO antibiotics at around 7 days. Clinicians should be guided by clinical improvement coupled with improving inflammatory markers such as CRP or ESR.
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