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Bone and Joint Infections page 21 7.3.5 Oral therapy Oral therapy has been used as equivalent to prolonged IV therapy and may be associated with fewer complications (90,123). Switching to PO therapy after IV treatment Early oral switch has been used (30,81,82,97) if the child is showing clinical improvement (although there is limited evidence and variable practice) which may include: · Afebrile or clear decreased temperature for 24-48 hours · Improvement of symptoms · Decrease in CRP of about 30-50% from maximum value · No signs of complications, such as metastatic foci (endocarditis, pneumonia, etc.) or DVT · Absence of virulent pathogens, especially, MRSA or PVL+. · Negative blood cultures. Culture-negative infections In culture negative infections, the recommendation is to continue with an oral antibiotic similar to the class used in IV treatment. · In high MRSA regions: clindamycin ± cephalosporin (the latter in younger children) – alternatives for clindamycin may be cotrimoxazole, quinolones or linezolid, according to local resistance patterns. · In low MRSA regions: first/second generation cephalosporin. Clindamycin is a good alternative especially in > 2 years. Amoxicillin-clavulanate may be an alternative option but thorough evidence is lacking and the tolerance is worse. Culture-positive infections In culture-positive infections: follow the recommendations listed in Table 12. According to reviewed sources, there is no good data for how long younger infants and neonates need IV therapy. The younger the infant, the less clinicians are likely to choose to treat orally. Most experts would treat (in particular) newborns and young infants (e.g., < 3 months) with IV therapy and for a longer total duration (4 to 6 weeks). Nevertheless, there is some personal experience in switching to PO after a minimum duration of IV therapy (e.g., 10-14 days) beyond the neonatal period. 7.3.6 Duration of therapy The length of total therapy, IV plus PO, should be on average of 2-3 weeks for SA and 3-4 weeks for OM. Although the evidence is lower for pyomyositis, 2-6 weeks of total therapy (with a few days of IV therapy) may be appropriate for this infection (124) In the following situations, longer therapy may be required (although practice varies, some centers may go up to 4-6 weeks): · MRSA or PVL+ · Newborns and young infants · Slow/poor response or complications · Involvement of pelvis or spinal column (125) Before stopping treatment, most symptoms should have disappeared and the CRP should be normal (e.g., < 2 mg/dl). Many do not repeat CRP again in simple disease once it is reducing © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 22 towards normal, symptoms have completely resolved and the child is on oral therapy. However, children with complex disease, underlying problems, symptoms or immunodeficiency need careful consideration. 7.4 Adjuvant treatment One trial has suggested that symptomatic therapy for pain and fever with nonsteroidal antiinflammatory agents (NSAID) in large enough doses during the acute phase while signs of inflammation are present is of benefit (7). Although some studies (126,127), including a randomized, placebo controlled trial (128) appear to have shown a faster recovery in children with SA, widespread adoption of steroids is not recommended until larger prospective studies are performed. Corticosteroids may delay the diagnosis of non-infectious arthritis. 7.5 Surgical interventions Surgical interventions in OM Studies show that up to 90% of patients with an early OM can be cured with conservative treatment of antibiotics, especially when antibiotics are initiated during the first days of the onset of symptoms (7,36,129,130). Surgery is usually not needed (except if aspiration/drainage is required, for instance in the case of abscess formation) and could in some cases prolong recovery. However, surgery should be considered if the patient has not responded within a few days to antibiotic therapy or a complication is suspected. Consensus is lacking on the need, extent, timing, and procedures for surgical drainage. In the decision process the following is important: · Clinical response to antibiotic therapy (60): e.g., persistence of fever > 72-96 hours or its reappearance · Surgical drainage may be indicated in patients with a periosteal abscess and persistent fever and CRP elevation · Size and position of the abscess, such as in close proximity to a growth plate – although even abscesses > 3 mm may have good outcome with only antibiotics (27) · Sequestration · Identification of MRSA or PVL+ S. aureus may increase the need for surgery (56,131) · Chronic OM or presence of prosthetic material. Surgical interventions in SA (27,30,132–139) · Joint drainage and irrigation is recommended after the diagnosis of SA is suspected. A delay in effective therapy, including drainage, may be associated with worse outcomes. Drainage and antibiotic therapy should be initiated within 5-7 days of the onset of SA to achieve a more favourable prognosis according to some studies (30,136,139), and as soon as possible after the diagnosis is suspected. Drainage may be even more important in neonates and infants under 18 months of age with SA of the hip or shoulder joint. · In SA, the goal of drainage is to remove pus. · Classically, surgical drainage by arthrotomy has been
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