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Therefore, when this bactery is isolated, a closer, and probably longer, follow up should be completed. It is important to look out for DVT in severe S. aureus OM and especially MRSA/PVL+ infection (149,150). In case of DVT, it is recommended to discuss the best treatment options with a paediatric haematologist (151). Low molecular weight heparin may be started and maintained until the DVT is resolved; no prophylaxis is recommended. For patients with DVT, antibiotics are typically administered for longer periods of time. Some authors claim for 6 weeks of IV and then orally until the thrombosis has resolved as demonstrated by Doppler examination. This often requires 4 or more months of therapy (152). Nevertheless, there is no evidence for this recommendation and, thus, the most appropriate length of therapy for this situation is unclear. Table 13 – Clinical outcome BJI: possible complications and sequelae. Outcome & complications Notes/remarks Persistent fever · Look out for complications or resistant pathogen OM-SA · In certain S. aureus infections – relatively common in < 18 months and hip/shoulder* · It may be associated with higher rate of complications or sequelae (8) Pyomyositis · More frequent in pelvic involvement and with MRSA/PVL+ Discitis/vertebral OM · Supportive corset might be beneficial Abscess, sequestrum · Surgery may be needed Deep vein thrombosis (DVT) · May be life-threatening and high risk of pulmonary thromboembolism · Risk factors: femoral OM, male sex, MRSA/PVL+ (150,152) · Some experts may recommend low-weight molecular heparin until resolved Relapse or chronic infection · If eradication of infection failed (153) © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 25 Chronic OM · Important early diagnosis and therapy to avoid it · Surgery and prolonged antibiotic therapy frequently needed · Major health problem in the resource-poor settings · Most common cause of pathologic fracture (154) Reinfections with another agent (not recurrence) · Possible but very unusual (155) · Not a sign of treatment failure Bone deformity, e.g., avascular necrosis of the femoral head, joint cartilage destruction in SA · Feared sequelae · More frequent if patient presents late after symptoms (139) Decreased movement, residual pain, rigidity · Physical therapy may be needed Mortality · Very unusual in an immunocompetent host in highincome countries Note - OM-SA = osteomyelitis-associated septic arthritis. - * = Some studies have shown that OM-SA may be more common in older children (8,156) 8 Appendix 8.1 Etiology in BJI – summary Table 14 – Summary of pathogens in BJI with geographical prevalence. Microorganism Regional data Remarks S. aureus, methicillin sensitive (MSSA) · UK: 44-80% (26) · Spain: 62% (8) · Greece: common · Romania: common · France: 11-61% · Finland$ : >90% · By far most common cause of BJI Methicillin-resistant S. aureus (MRSA) · UK: rare (26) · US: 40-50% (26) · Spain: 2.5% (8) · Germany: sporadic in children · Romania and Greece: common · France: 8.5% · Resistant to beta-lactams (except ceftaroline) · Associated more frequently with complications (131,140,141) Coagulase-negative Staphylococcus · Special situations, such as prosthetic material PVL producing S. aureus (148) · PVL toxin was reported to be produced by less than 2% of S aureus (PVL-SA) but new data points to higher percentages in some European countries (56,157) · PVL-S. aureus poses a serious risk – severe osteoarticular infection, sometimes multifocal · Associated with myositis, thrombophlebitis and deep venous thrombosis, and/or pneumonia · More common in MRSA (depending on the location)(34,96,107) Group A streptococcus · France: 7%(158) - 9%(69) · Spain: 7-10% (8) · Toxic shock, rash – In general very purulent · More common in > 3-5 years Streptococcus pneumoniae · Spain: rare · France: 3-7.5%% (158,159) · Vaccination not yet as successful as in Hib due to non-vaccine serotypes (160) · First two years of life (161) H. influenzae type b · Germany: rare · Romania, Greece, Spain: none · In 1980s second most common cause of SA in young children – now largely eliminated by vaccination (only in non-immunized or immunodeficient children) · Rarely causes OM © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 26 Microorganism Regional data Remarks K. kingae · Common in the UK (26), Spain (8,40), France (45,69,158,159), Israel · Occasional in Germany · Rare in Scandinavian countries · Greece: first BJI case (162) reported · Romania: no data · Gram-negative coccobacillus respiratory pathogen · Seems an emerging pathogen – common cause of OM and SA in some areas (40,58) · May cause bacteraemia in infants and endocarditis in school-aged children · K. kingae infection diagnosis can be increased by using PCR · K. kingae is highly susceptible to b-lactam antibiotics – a recent paper described for the first time a K. kingae beta-lactamaseproducing strain in continental Europe (163). E. coli, Klebsiella spp., other Gram negative bacilli Variable rates · Neonates (< 3 months) and immunocompromised children Fusobacterium · Often multifocal. Very rare Group B streptococci · Neonates (164)
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