Management of Acute Haematogenous Osteomyelitis SAPOS ICL 2017 Anthony Robertson
Diagnosis
Diagnosis RED FLAGS: Nunn, Rollinson;; SAMJ 2007 Acute hip pain in a child Infant with loss of movement in a limb Acute limb pain in a febrile child Acute limb swelling in a febrile child Swollen limb with a normal radiograph Preventable!
Diagnosis Clinical History Examination Blood tests X-rays Additional investigations
Diagnosis Clinical History Examination Blood tests X-rays Additional investigations Trauma often a red herring Careful exam localises the site FBC, ESR, CRP, U&E Blood Culture, HIV Often normal If indicated and available
Diagnosis Clinical History Examination Blood tests Reliable only in combination X-rays Additional investigations
Categorise / Classify Hoffman (SA Bone & Joint Surgery, 1992): Usual acute osteomyelitis Neonatal Disseminated
Categorise / Classify Hoffman (SA Bone & Joint Surgery, 1992): Usual acute osteomyelitis Neonatal Disseminated Copley (Paed. Inf. Diseases Journal, 2014): Objective scoring system based on clinical & lab findings Stratify according to severity of illness
Categorise / Classify Hoffman (SA Bone & Joint Surgery, 1992): Usual acute osteomyelitis Neonatal Disseminated ü Copley (Paed. Inf. Diseases Journal, 2014): Objective scoring system based on clinical & lab findings Stratify according to severity of illness
My Treatment Usual acute osteomyelitis Proceed alone Neonate In ICU From home With paediatrician Septic workup Disseminated With paediatrician
My Treatment Supportive Intravenous fluids Analgesia Splint & elevate Intravenous antibiotics Cloxacillin 200mg/kg/24hrs Consider others by age group Surgical decompression Drill bone if necessary Specimens for culture, histology Close wounds, Portovac, splint
My Treatment Supportive Intravenous fluids Analgesia Splint & elevate Intravenous antibiotics Cloxacillin 200mg/kg/24hrs Consider others by age group Surgical decompression Drill bone if necessary Specimens for culture, histology Close wounds, Portovac, splint Modify antibiotics according to culture and sensitivity Monitor for complications Switch to oral antibiotics asap Continue oral antibiotics for three weeks Protect the limb. Follow up.
My Treatment If patient not settling: Consider other systems lungs, heart, etc Consider other orthopaedic sites Consider re-collection of pus Re-operate Investigate: CXR Cardiac echo Bone scan Other
Discussion No definitive guidelines Expert opinions, case series Systematic reviews
Essential SA Literature Primary septic focus General condition General acute inflammation Septicaemia Severe toxaemia Local condition Inflammation no pus Intra-osseous pus Extra-osseous pus
Essential SA Literature No tourniquet Drilled the bone vigorously Avoid periosteal stripping
Essential SA Literature Spectrum of disease Clinical groups Antibiotic choices Role of surgery
Treat with Antibiotics Alone? Worldwide: Trend towards medical Rx Effective if started early Surgery indicated only in specific situations Pelvis, calcaneus respond well
Treat with Antibiotics Alone? Worldwide: Trend towards medical Rx Effective if started early Surgery indicated only in specific situations Pelvis, calcaneus respond well Surgical indications: Child not improving Tenderness, Temperature, CRP Disseminated sepsis Abscess, X-ray changes Aspiration of pus Sub-periosteal collection on MRI Concurrent septic arthritis MRSA
Treat with Antibiotics Alone? Most literature reviewed comes from developed nations Is it universally applicable?
Treat with Antibiotics Alone? In South Africa Du Plessis Noted intra-osseous pus <48hrs Majority of cases present in public sector Frequently present late Delays to theatre Low socio-economic status;;? nutritional & immune status Virulence of Staph. aureus Most literature reviewed comes from developed nations Is it universally applicable?
Treat with Antibiotics Alone? In South Africa Du Plessis Noted intra-osseous pus <48hrs Majority of cases present in public sector Frequently present late Delays to theatre Low socio-economic status;;? nutritional & immune status Virulence of Staph. aureus Local evidence supports early surgery
Initial Antibiotic Choice Worldwide: Liaison with microbiologist Flucloxacillin - Staph. aureus MRSA - Clindamycin H. influenza - vaccine 1990 s Kingella kingae fastidious Gram -ve
Initial Antibiotic Choice Worldwide: Liaison with microbiologist Flucloxacillin - Staph. aureus MRSA - Clindamycin H. influenza - vaccine 1990 s Kingella kingae fastidious Gram -ve In South Africa: Majority: Staph. aureus Cloxacillin 200mg/kg/day ivi Consider adding: Gram ve cover in neonates Ampicillin / cephalosporin in unvaccinated infants and toddlers
Duration of Intravenous Antibiotics Historically, long parenteral Rx: 19% complication rate < 3/52 1% complication rate > 3/52 (Dich et al, Am J Dis Child, 1975) Complications of ivi line: Sepsis Blockage, re-siting
Duration of Intravenous Antibiotics Historically, long parenteral Rx: 19% complication rate < 3/52 1% complication rate > 3/52 (Dich et al, Am J Dis Child, 1975) Complications of ivi line: Sepsis Blockage Today: In uncomplicated case Short course ivi antibiotic (2-4 days) Guided by clinical & blood marker response (Peltola et al, Ped Infec Dis J, 2010. Howard-Jones et al, J of Paed & Child Health 2013)
Duration of Intravenous Antibiotics Indications for longer ivi course: Need for surgical debridement Limited clinical response Limited haematological response Medical co-morbidities Radiological abnormalities MRSA Panton-Valentine leukocydin+ Staph. aureus (Dartnell, Systematic Review, JBJS 2012)
Total Duration of Antibiotics Historically: Classically 6 weeks Du Plessis Sterilization of bone after 2/52 Continue 21 days after clinical response
Total Duration of Antibiotics Historically: Classically 6 weeks Du Plessis Sterilization of bone after 2/52 Continue 21 days after clinical response Today: Uncomplicated case 3 weeks after initial clinical response (Howard-Jones et al, Review, J of Paed & Child Health 2013)
Drilling of Bone Du Plessis In Favour: Pus frequently under tension in bone Hoffman Prevents spread of toxins & bacteria Avoids further periosteal stripping Against: Emslie & Nade (Pathology, 1986, quoted by Hoffman) Harmful in avian model
Other Issues Bone aspiration Radical debridement
Other Issues Bone aspiration Radical debridement Not of bone in acute stage
Algorithms Copley (Paed. Inf. Diseases Journal, 2014): Applicable to known osteomyelitis Based on data obtained during hospitalisation Mild: no surgery Moderate: one surgery Severe: multiple surgeries Useful to stratify and compare according to severity
Algorithms Benvenuti / Schoenecker (JPO, 2016, awaiting print) Stratifies severity on admission Inflammatory Localised Disseminated Guides treatment Identifies patients with higher risk of complications
Algorithms Benvenuti / Schoenecker (JPO, 2016, awaiting print) Stratifies severity on admission Inflammatory Localised Disseminated Guides treatment Identifies patients with higher risk of complications Variables CRP Pulse Temperature Specific for authors hospital Remains untested
Algorithms Haematogenous acute and subacute paediatric osteomyelitis. A systematic review of the literature. Dartnell / Ramachandran. JBJS 2012.
Management - Summary Adopt a pragmatic approach: High index of suspicion Clinical diagnosis supported by appropriate investigation Categorise / classify Supportive treatment Intravenous antibiotics Surgical decompression Modify antibiotics according to culture and sensitivity Anticipate and treat general complications Switch to oral antibiotics asap continue 3 weeks Protect the limb. Follow up.