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40%) – In neonates and young infants with OM, blood culture may be positive on suspected sepsis without local signs – The presence of S. aureus in the blood should prompt a consideration of occult BJI Synovial fluid /bone sample: Gram-staining, culture – If sample taken, obtain it before initiation of antibiotic treatment (especially for synovial fluid). – Bone sample not always required; to be considered if subperiostal pus is present or infection is not improving as expected – Important also for the diagnosis of non-infectious processes – Drainage, e.g., of purulent fluid or abscess, may also serve as an important form of therapy Bacterial PCR (when available) – Including molecular detection of K. kingae, S. aureus or others by using eubacterial rRNA amplification in tissue sample or synovial fluid (12). It may significantly increase the yield of a microorganism in SA, especially in previous use of antibiotics. Specific primers may be more sensitive (13,14) Notes – Procalcitonin (PCT) has not been proven to be of value for the diagnosis of BJI in children because of its low sensitivity (15–17) and the wide availability of the existing tests CRP and ESR. – In some settings (for example, high rates of MRSA), initial bone puncture for diagnosis may be appropriate to better adjust therapy. This procedure may be performed under CT direction (18). – * = Radiation dose (19–21) o Conventional X-ray: Thorax one dimension post-anterior 0.02 mSv; Thorax 2 dimensions 0.1-0.2 mSv. Knee in 2 dimensions 0.001-0.01 mSv, o CT scan: Thorax 3-5 mSv. Abdomen 5-8 mSv. Extremity 4-5 mSv. Spine 8-10 mSV o Bone Scintigram using Tc-99m: 3-6 mSv (same as 200-750 chest-X rays) 2.3 BJI management recommendations Table 2 – Principle scheme for management of simple or uncomplicated and complex BJI See text for details © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 7 Suspected diagnosis u qManagement components Uncomplicated OM or SA Complex$ OM or SA 1. Hospitalisation Yes Yes 2. Blood tests CBC, CRP, ESR 3. Bacteriology Blood culture – Generally, 4 ml minimum, 2 ml for neonates (22) Culture of any possible material, especially joint fluid; consider bone sample in certain circumstances (it may be crucial in complex BJI); PCR from synovial fluid, abscesses or tissue when feasible 4. Imaging OM – Always plain X-ray. Consider MRI SA – US, MRI to document suspected OM in SA and perifocal disease OM – Always plain X-ray. MRI, US SA– US, MRI, consider 99Tc bone scan if no MRI is available 5. Surgery Avoid if possible – indications include need for pus or effusion drainage, bone destruction Always arthrocentesis/arthrotomy for SA Consider – indications include need for pus or effusion drainage, bone destruction or diagnostic purposes 6. Antibiotic treatment See Chapter 7 7. Monitoring When pathogen is not known: · Switch to oral antibiotic monotherapy following local microbiological or clinical infectious diseases standards · Choose oral antibiotic spectrum similar to IV if initial IV response was favourable Consider 2nd line or additional antibiotics, especially as long as gram-negative bacteria or MRSA are not ruled out 8. Switch IV to oral treatment – Criteria for time to switch – – pathogen is unknown Afebrile 24-48 hrs, improved clinical condition (reduction of pain, mobility, inflammation) >24 hrs and significantly decreased CRP (30-50% of highest value) Similar parameters but consider a minimum of 1 week of IV therapy – Up to 3 months old – time to switch and duration Consider switch after 14-21 days, especially under 1-month age; some experts consider switching earlier àOM and SA – 4-6 wks total antibiotic treatment Consider switch after 21 days àOM and SA – 4-6 wks to several months oral antibiotic treatment based on individual response – 3 months and older – time to switch and duration Consider switch after 24-48 hrs of improvement àOM – minimum 3-4 weeks total àSA – minimum 2-3 weeks total* Consider 10-14 days of IV antibiotics depending on severity and outcome, but may be switched to PO earlier. àOM and SA – 4-6 wks up to several months oral antibiotic treatment based on individual response and other specific characteristics 9. Follow-up · CRP measurements – reliable and inexpensive in the follow-up of OM and SA. No need to repeat inflammatory markers once normalized unless new clinical findings · Long-term beta-lactam therapy may produce leukopenia, usually mild to moderate · Clinical investigation – longer follow up: infants, physis involvement and complex disease · X-ray, sonography or MRI may be needed · End point therapy: Normal CRP, asymptomatic or minor symptoms# and after minimum length of treatment – see above. The end point may be more difficult to determine in complex OM/SA · Orthopaedic follow up at end of course of treatment more important than PID to address any ongoing sequelae of the bone or joint infection. © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 8 Notes – CBC=Complete blood count. CRP=C-reactive protein. ESR=Erythrocyte sedimention rate. OM=Osteomyelitis. SA=Septic arthritis. PID=Pediatric infectious disease specialist. – Consultation and treatment should not be delayed while waiting for a bone scan or MR in suspected OM – Arthrocentesis or arthrotomy should be promptly performed in suspected SA before
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