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· SA – to exclude underlying OM · May give false negative results in infancy, and with virulent pathogens such as MRSA (72). · * = Dose range equal to 200-750 chest X-rays; see also Section 2.2 and the American Nuclear Society website (http://www.ans.org/) Table 7 – BJI diagnosis: summary of recommended imaging studies for SA and OM BJI Imaging test recommendations All patients Always perform an X-ray study as baseline and to rule out other possible conditions SA – Ultrasonography is the most sensitive (but less specific) and an easy test to apply. – Other tests should be ordered in case of diagnostic doubts or if complications are suspected. OM – Focal symptoms/clear location: MRI – Systemic or less focal symptoms: consider bone scan (Tc99 scintigraphy). Some institutions may use total body MRI. – If MRI is not available, apply bone scan or CT-scan, the latter in case of focal disease – In less severe cases with favourable initial outcome no additional imaging test may be needed Notes – Not all technical options are equally accessible throughout Europe. – Regionally, radiation exposure reduction programs and availability of different imaging studies may influence the choice of imaging options. – When needed, it is encouraged that individual cases are discussed with an experienced radiologist. 6.4 Differential diagnosis Table 8 – Differential diagnosis of BJI Differential diagnosis OM SA - Traumatic or stress fracture - Cellulitis, pyomyositis - Septicaemia (newborns) - Rheumatic fever - Thrombophlebitis - Leukaemia - Benign/malignant tumours - Sickle cell infarction - Child abuse - Chronic recurrent multifocal osteomyelitis - Tuberculosis and other chronic infections - Scurvy - Other bone inflammatory processes such as hypophosphatasia, - Transient synovitis - Viral arthritis - Reactive arthritis - Juvenile idiopathic arthritis - Tuberculosis - Henoch-Schoenlein purpura - Perthes disease - Septic bursitis - Slipped capital femoral epiphysis - Sickle cell anaemia, infarction - Malignancy - Arthralgia Note – Based on: Pääkkönen M, Peltola H. Bone and joint infections (27) and Faust et al. Managing bone and joint infection in children (26) 7 Management See Chapter 2 for a summary of recommendations for the management of paediatric BJI. © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 17 7.1 Introduction The treatment in most cases of childhood OM, SA and OM-SA can be simplified from the regimen reportedly practiced in many hospitals (7,9,81,82). Early diagnosis and prompt treatment are needed to avoid complications (8,83). Key factors in the management approach are regional prevalence of CA-MRSA and age of the patient. · Initial management includes adequate drainage of pus, collection of specimens for culture and other microbiological studies including antibiotic susceptibility testing, and prompt initiation of empiric antibiotic therapy. · The choice of empiric antimicrobial therapy is based on the most likely causative pathogens according to patient age, immunization status, underlying disease, Gram stain of the aspirate, and other clinical and epidemiological considerations, including prevalence of MRSA in the community. · Suggested treatment of uncomplicated (rapid resolution of fever and other symptoms) childhood BJI could include a short IV therapy followed by a high dose oral antibiotics for an average total duration of 3-4 weeks for OM and 2-3 weeks for SA. Treatment of less than 3 (OM) and 2 (SA) weeks is not advised. · This may not be the case for the management of: – Complex infections – Significant bone destruction or complications, such as abscesses – Resistant or unusual pathogens (MRSA, PVL+, Salmonella) – Sepsis or in immunocompromised children – Neonates and very young infants (i.e., < 3 months). · Oral antibiotics should be well absorbed, provide good bone penetration and be given in sufficiently high doses; beta-lactams at least 2-3 times the regular doses (30,81,84–86). · Suspect PVL-positive S. aureus (including MRSA) disease if infection fails to respond to empirical treatment, is recurrent, multifocal, or associated with a necrotising process. Note – See the Appendix for a summary of antibiotic recommendations. 7.2 Hospitalisation Most children are hospitalised at the start of the infection as intravenous therapy is generally used. It is recommended that children with suspected BJI be admitted at the start of therapy and generally started on intravenous therapy except in exceptional circumstances. This may be especially important in regions with a high rate of MRSA or PVL-positive S. aureus; worse clinical severity; and in high-risk patients such as infants and immunocompromised patients. Children should be given IV therapy until clinical improvement, including disappearance of fever and decreased inflammation and pain. A decrease of CRP is also an important parameter to follow. Furthermore, blood cultures may prove to be sterile if initially positive. Oral switch may be done after 2-4 days, unless risk factors are present (7,26,30,81,87). An alternative approach used by some centres, when IV antibiotics are still needed for specific situations, is the insertion of a peripheral inserted central (PIC) line for once/daily antibiotic treatment at home – outpatient parenteral antimicrobial therapy (OPAT) (88,89), with the care being managed
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