Osteomyelitis

To evaluate for weight-based differences in clinical outcomes and antibiotic dosing variability for children hospitalized with acute hematogenous osteomyelitis (AHO). We performed a retrospective cohort study of children aged 2 to 17 years and hospitalized with a primary AHO International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision diagnosis code between 2010 and 2017 using the Cerner Health Facts database. Weight categories (healthy, overweight, obesity) were determined by using Centers for Disease Control and Prevention age- and sex-specific BMI percentiles. Rates of procedures, complications, and length of stay (LOS) were compared between groups. Dosing variability between groups was assessed by comparing the initial milligrams per kilogram per day of prescribed antibiotics. We identified 755 children with AHO for inclusion. Children with overweight and obesity were more likely to undergo surgical procedures (19% and 17%, respectively) compared with children with a healthy weight (10%; P = .009). They also had a longer LOS (5.7 and 5.8 days) than children with a healthy weight (4.9 days; P = .03). There were no differences in complication rates between weight categories. Mean weight-adjusted daily dose for the most frequently prescribed antibiotics was different by weight category, with children in higher weight categories more likely to receive lower weight-based doses. Children with overweight and obesity hospitalized for AHO were more likely to undergo procedures, have longer LOS, and receive lower weight-based antibiotic dosing compared with children with a healthy weight. Our findings suggest that weight should be carefully considered when treating children with AHO.

IntroductionThis study conducted statistical analysis of clinical data from cases of acute hematogenous osteomyelitis (AHO) with or without concomitant septic arthritis, with the objective of identifying factors that are indicative of concomitant septic arthritis. Predictive models will be developed to predict coexisting infections, with one that is independent of MR findings and another that incorporates MRI data.MethodsA retrospective review of 127 children (132 cases of AHO) treated for AHO was performed. All patients underwent MRI. The data encompassed various demographic, clinical, and diagnostic factors. Graphical and logistical regression analysis was used to determine variables independently predictive of adjacent infection. Optimal cutoff values were determined for each variable and a prediction model was created. Finally, the model was applied to our patient database and each patient with isolated AHO, or concomitant infection was stratified based upon the number of positive predictive factors.ResultsThe overall incidence of coexisting septic arthritis in patients with AHO was 52.2% (69/132). Four risk factors (age below 4 years, a history of preceding infection, platelet count > 390.5 × 10^9/L, and absolute neutrophil count < 5.45 × 10^3 cells/ml) were found to be predictive of concomitant infection and were included in the algorithm. Patients with ≥ 2 risk factors were classified as high risk for AHO with concomitant infection (Sensitivity: 79.41% (95% CI: [64.10%, 94.71%]), Specificity: 76.56% (95% CI: [58.61%, 94.51%]), Positive Predictive Value (PPV): 78.26% (95% CI: [63.43%, 93.09%]), and Negative Predictive Value (NPV): 77.78% (95% CI: [61.02%, 94.54%]). In MRI, joint effusion was the primary indicator of concomitant septic arthritis in patients with AHO, followed by the absence of subperiosteal abscess. The presence of subperiosteal abscess in the absence of joint effusion was highly correlated with isolated AHO, showing a 100% occurrence rate (39/39).ConclusionsOur study successfully identified several risk factors and radiologic signs associated with concomitant septic arthritis in patients with AHO. These findings can assist clinicians in early recognition and management of coexisting infections, especially in situations where MRI is not readily available or when its findings are inconclusive. Timely identification of these factors is crucial for appropriate treatment planning and improved patient outcomes.

Blood cultures are routinely performed for microbiological diagnostic purposes in acute hematogenous osteomyelitis (AHO); however, the blood culture positivity rate is less than 50%. This retrospective study aimed to identify indicators to distinguish blood culture outcomes in children with AHO from July 2017 to 2024. Patients were stratified based on the results of blood cultures. The age, sex, duration of symptoms, duration of antibiotic therapy before blood culture, location of the lesion, maximum temperature, and inflammatory indexes from admission were reviewed. The efficacy of each index in diagnosing negative blood cultures was also determined according to the receiver operator curves. Logistic regression analysis was used to determine the independent risk factors for blood culture negativity. Among 75 patients, 47 had negative and 28 had positive cultures. No significant differences were found in age, sex, symptom duration, or leukocyte count. However, maximum temperature, duration of antibiotic therapy before culture, neutrophil count, C-reactive protein, and erythrocyte sedimentation rate (ESR) showed significant differences. Logistic regression identified antibiotic therapy duration >2.5 days (OR = 6.383, 95% CI: 1.720-23.680) and ESR <41.5 mm/h (OR = 12.377, 95% CI: 2.042-75.015) as independent risk factors for negative cultures. AHO patients with either of these factors are more likely to have negative blood cultures. For such children, early invasive procedures to obtain pus or tissue for culture should be considered.

ObjectiveThis study aims to explore the correlation between Acute Hematogenous Osteomyelitis (AHO) and Deep Venous Thrombosis (DVT) in children. It seeks to identify independent risk factors for DVT secondary to AHO, enhance understanding of the disease, and establish a predictive model to guide clinical practice.MethodsA retrospective analysis of clinical data from AHO patients treated at our hospital (January 2017 to December 2023) was conducted. Patients were divided into thrombosis and non-thrombosis groups based on DVT occurrence.Univariate analysis used independent samples t-tests, Mann–Whitney U tests, and chi-square tests to screen DVT-associated variables (P < 0.1). Significant variables were included in a binary logistic regression model to identify independent risk factors for DVT secondary to AHO. Model fit was assessed using the Hosmer–Lemeshow test, and Cox-Snell R2 was calculated through linear regression of P-values with the dependent variable. ROC curves were plotted, and AUC was recorded to evaluate model validity and reliability.ResultsUnivariate analysis revealed significant correlations between DVT and several factors, including age, peak levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), and D-dimer. Additionally, the time for CRP to normalize, concurrent pneumonia, intensive care use, the severity of osteomyelitis (Lawson score), and femoral involvement in osteomyelitis were also significantly associated with DVT (P < 0.05).Binary logistic regression identified age (OR = 1.248), D-dimer (OR = 1.600), and concurrent pneumonia (OR = 4.921) as significantly positively associated with secondary DVT (P < 0.05).The model demonstrated good goodness-of-fit (P > 0.05), accurately explained the data (R2 = 0.449, Cox-Snell R2 = 0.413), and had strong predictive performance (AUC = 0.895).ConclusionAge, peak levels of CRP/ESR/PCT/D-dimer, osteomyelitis severity (Lawson score), femoral involvement in osteomyelitis, and concurrent pneumonia were significantly associated with secondary deep vein thrombosis (DVT) in pediatric acute hematogenous osteomyelitis (AHO). Among these, age, peak D-dimer levels, and concurrent pneumonia were identified as independent risk factors for DVT in children with AHO.The current predictive model demonstrated good performance in this cohort, providing early warning for potential DVT risk in pediatric AHO patients. However, multicenter studies are needed to further validate its generalizability.Pediatricians may use this model to assess the necessity of DVT screening, reduce missed diagnoses, and initiate timely antithrombotic therapy to prevent adverse outcomes.

Background Children with acute hematogenous osteomyelitis (AHO) and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are often treated with vancomycin (vanc) with risk of nephrotoxicity. This study evaluates resources used, and outcomes, of children with or without acute kidney injury (AKI) when vanc is used in this setting. Methods Children with AHO and MRSA bacteremia treated with vanc from 2009 to 2019 were retrospectively studied. AKI was assessed by chart review, for clinical diagnosis and by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Cohorts of children with or without KDIGO AKI were compared for differences of illness severity, treatment, resource utilization, and outcomes. Multivariate logistic regression analysis was accomplished to identify factors associated with risk for AKI. Cost analysis was performed using Pediatric Health Information System (PHIS) and Healthcare Cost and Utilization Project (HCUP) databases. Results Among 631 children with AHO, 85 children with MRSA bacteremia were treated with vanc for a sufficient duration to allow trough measurements. Of these, 14 (16.5%) had chart-diagnosed AKI, whereas 24 (28.2%) children met KDIGO criteria. Children with AKI had more febrile days and higher rates of thrombosis. They had longer duration of vanc treatment (8 vs 5 d) and higher troughs (27.8 vs 17.5 mg/L). The AKI group had more blood cultures, vanc troughs, creatinine levels, and longer length of stay (LOS; 19.9 vs 11.1 days). Multivariate analysis revealed that maximum vanc trough level (odds ratio 1.05) with a cutoff of 21.7 mg/L was a significant predictor of AKI. PHIS data of 3,133 children with AHO treated with vanc identified 75 (2.4%) with AKI who had significantly longer LOS (13 vs 7 d) and higher billed charges ($117K vs $51K) than children without AKI. HCUP data of 13,223 children with AHO identified 384 (2.9%) with AKI who had longer LOS (27 vs 6 d) and higher billed charges ($317K vs $37K) than those without. Conclusion Clinical diagnosis of AKI (16.5%) grossly underestimated the KDIGO occurrence (28.2%) in our population. This study showed vanc associated AKI results in significant increases in resource utilization and healthcare costs. A high vanc trough &amp;gt;21.7 mg/dL is a significant contributing factor to AKI. Disclosures All Authors: No reported disclosures.

Acute osteomyelitis in children shoud be divided into anepiphyseal type and a diaphyseal type according to the material that we obtained through following up 85 cases with acute osteomyelitis.Both of types have an obvious difference in affected age,region,clinical features,incidence of chronic osteomyelitis and residual deformities,The classification is based on whether the epiphysis was affected or not.The pathological development of two types are stated depending on the anatomical characteristics before and after maturing ration of epiphysis,It is very important that the epiphyseal csteomyelitis be early diagn osed.It can prevent severe residual deformities caused by the epiphysis being destroyed.

A correlation was found between the incidence of acute haematogenous osteomyelitis (AHO) and ABO blood groups but not between AHO and the secretory function of the saliva. AHO is more common among children of blood group O and, to a lesser extent, group A. Although it was found to occur more commonly among secretors than non-secretors, the difference from a control group was not statistically significant. At present this possibility can only be taken as a tentative suggestion for further research in this field.

Acute haematogenous osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Previous research on sequelae from AHO rarely considers outcomes more than 2 years following treatment. This study aims to establish the quality of life of patients diagnosed with AHO in childhood up to 13 years after diagnosis, evaluating the impact on social, emotional, physical, and school function. Children treated for AHO between 2008 and 2018 at a tertiary referral centre in New Zealand were identified. Paediatric Quality of Life Inventory (PedsQL) questionnaires were conducted via phone with either the child or primary caregiver and responses analysed. Forty patients met inclusion criteria, were contactable by phone, and consented to participate. The mean age was 7 years (range 0-15) and most were female (60%). Health-related quality of life (HRQOL) was scored as a percentage with most participants scoring >80% ( n = 27). Those who do experience reduced quality of life following treatment for AHO were likely to complain of pain, stiffness, or anxiety. The impact of significant childhood illness on mental health was not adequately captured by the PedsQL but was highlighted in qualitative feedback. The majority of children treated for AHO reported excellent HRQOL up to 13 years following treatment although a negative impact on mental health was reported using qualitative analysis. A refined scoring system is needed to assess the long-term impact of musculoskeletal infection. Patient case series, Level IV.

Until recently, only findings of local status and laboratory diagnostics were used as objective tests which defined terms and volume of therapeutic and preventive measures for clinical examination of patients who survived acute hematogenous osteomyelitis. The prescribed complex treatment does not take into account the following indexes: patient’s co-morbidity which is characterized by the autonomic reactivity; presence of stigmas of the connective tissue dysplasia, trophic status as well as psychological characteristics of patients. During the present study, connective tissue dysplasia was revealed in 70% of patients who had acute hematogenous osteomyelitis what was confirmed by the revealed phenotypic signs and biochemical blood markers. While assessing trophic status, a disharmonious body type and insufficient physical development were seen in patients who survived septic-pyemic form of the disease. Patients who had acute hematogenous osteomyelitis, even in the absence of markers of active inflammatory process, demonstrated signs of impaired adaptation-compensatory mechanisms involving the humoral regulation and a wide range of psychological problems which reflect tension of systems and play an important role in self-development and self-maintenance of the pathological process - the so-called principle of pathoautokinesis. Patients who survived hematogenous osteomyelitis, especially in the septic form, should continue their rehabilitation, have follow-up examinations and anti-relapse treatment. In this group of patients, multidisciplinary approach is needed for developing their rehabilitation program. Terms of this program should be individualized and defined by the normalizing of objective indicators (local status and comorbid conditions).

Studies of pediatric osteoarticular infections (OAIs) mostly focus on acute hematogenous osteomyelitis (AHO) and acute bacterial arthritis (ABA). A comprehensive descriptive analysis of pediatric OAIs, including subacute, chronic, and non-hematogenous types, is lacking. A detailed analysis of all pediatric OAIs was undertaken at 2 academic centers, Hasbro Children's Hospital, Providence, RI, and Nationwide Children's Hospital, Columbus, OH. Infections were classified as AHO (with or without suppurative arthritis), isolated ABA, subacute or chronic hematogenous osteomyelitis (SCHO), non-hematogenous osteoarticular infection (NHI), or hardware-associated osteoarticular infection (HOI). Clinical, radiological, and laboratory characteristics were compared. A total of 582 consecutive cases of OAIs were included: 295 AHO (51%), 88 ABA (15%), 76 NHI (13%), 73 HOI (13%), and 50 SCHO (9%). Median age was significantly higher for HOI (14.5 years), NHI (11.8), and SCHO (10.4) than for AHO (9) and ABA (5) (P < .001). Patients with AHO or ABA were more likely (P < .001) to be febrile (each 84%) compared with other groups (45%-56%) and had higher biomarkers of inflammation (white blood cell, erythrocyte sedimentation rate, C-reactive protein). A causative organism was identified in 74% of cases, mostly from tissue specimens (78%). Staphylococcus aureus was the most common organism across infection types (34%-55% of cases), while polymicrobial infection was common in NHI (22%) and HOI (21%). Chronic morbidity complicated infections in 89 (15%) patients, the majority of whom (66%) had SCHO, NHI, or HOI. SCHO, NHI, and HOI accounted for a significant proportion of pediatric OAIs and contributed disproportionately to chronic morbidity.

Haematogenous multifocal osteomyelitis in children represents a dangerous form of osteomyelitis in which sepsis can develop quickly if it is not treated early. A retrospective analysis of 26 children with acute multifocal haematogenous osteomyelitis over a period of 5years was undertaken in order to assess the clinical presentation, infective organism, laboratory investigations and risk factors involved. Children more than 1year of age with two or more bones involvement presenting within one week from the onset of symptoms were included in this study. All of the children were evaluated by clinical examination, blood tests and local ultrasound. The average age at presentation was 4.9years and girls were affected more than boys, with a female to male ratio of 1.4. Lower limbs were affected in 92% of cases, and, specifically, the tibia in 73.1% of the patients. Blood culture was positive in 38.5% of our cases. The predominant microorganism isolated from surgical samples was Staphylococcus aureus, among which methicillin-resistant S. aureus (MRSA) was found in 50% of the patients. Surgical drainage of the pus was done in 24 cases, followed by appropriate antibiotics, and two cases were treated by conservative means. All of the children were successfully treated except for four, who developed chronic osteomyelitis and sequelae. We conclude that acute multifocal haematogenous osteomyelitis in children needs early diagnosis by a high index of clinical suspicion and adequate treatment with timely intervention. The predominance of MRSA in our study shows the changing trend in its association with multiple bone involvement.

The impact of Staphylococcus aureus genomic variation on clinical phenotype of children with acute hematogenous osteomyelitis

The etiology of acute hematogenous osteomyelitis (AHO) remains unknown, and the disease has no laboratory model. We describe an AHO model in the rabbit which resembles the human disease. The model was developed on the premise that previous attempts had omitted an essential etiologic factor other than the bacteria. Six-week-old white New Zealand rabbits were divided into three different groups. Group I received an injury to the proximal tibial physeal plate, group II received a standardized bacteremia with Staphylococcus aureus, and group III received both the fracture and the bacteremia. The physeal plate injuries healed within 7 days. The animals with bacteremia only had occasional small foci of osteomyelitis identified histologically. The animals with fracture and bacteremia developed significant osteomyelitis in almost all cases.

Introduction. Currently, there is a limited number of works devoted to the comprehensive study of specific features of surgical treatment of patients with acute hematogenous osteomyelitis (AHO) which includes histological and immune histochemical (IHC) tests of the bone marrow at different periods of the disease. In this regard, the purpose of our work was to make the morphological analyses of bone tissue and bone marrow fragments in children with hematogenous osteomyelitis. Material and methods. In 2013- 2016, in the department of purulent surgery of the city hospital in Stavropol, there were 64 children with AHO of long tubular bones aged from 3 to 17. 47 boys (73.4%), 17 girls (26.6%). The lesion was located in : femur - 25 (39.1%) children; tibia - 24 (37.5%); fibula - 6 (9.4%); humerus - 5 (7.8%); ulna - 3 (4.7%); radius - 1 (1.5%). All children had urgent osteoperforation of the affected bone. Bone slices were taken for histological examination and bone marrow fragments for IHC examination. Tissue sections were stained with hematoxylin and eosin, pikrofuksin by Van Gieson, aniline blue by Mallory, trichrome by Masson. IHC examination was done using a standard protocol with anti-CD3, CD4, CD8 monoclonal antibodies. Results. In AHO, the histological examination has revealed fragments of spongy bone tissue, elements of yellow and red bone marrow with diffuse abundant leukocyte infiltration, hemorrhages in bone marrow spaces, microcore fractures and necrotic foci in the trabeculae, vast areas of pronounced autolytic resorption of the bone tissue. Accumulation of CD3+cells (2-4) is seen in the inflammation infiltrate areas located along the fistula passage. The expression of T-lymphocyte-helper markers, or CD4 +, is moderate in chronic osteomyelitis (2 points). The expression of T-lymphocyte suppressor marker, or CD8 +, is moderate in chronic osteomyelitis (2 points). Immunoreactive material - coarse granular, cytoplasmic, disseminated (3 points). CD8 + lymphocytes are seen in clusters of cells in the amount from 4-6 to 20-30. In addition, to our mind, the picture of structural location of lymphocytes, is not completed, since cells are moving to the zone of interaction of CD8 + lymphocytes. Conclusions. Thus, minor subpopulations of lymphocytes, in particular double-positive T cells, or CD3 + / CD4 + / CD8 + lymphocytes, or highly differentiated memory cells are registered in the red bone marrow of patients with AHO. It characterizes the immunoregulatory index of the organism and may indicate the presence of autoimmune component in the immune response. If even separate CD8 + lymphocytes are revealed in the bone marrow of children with hematogenous osteomyelitis at IHC, it may indicate a risk of complications.

Hemophilus influenzae may account for 10% or more of cases of acute hematogenous osteomyelitis in infants. H. influenzae osteomyelitis is more often seen in the upper extremities. Two patients with H. influenzae acute osteomyelitis seen at a community hospital are described. The second patient is the first known case of osteomyelitis secondary to ampicillin-resistant H. influenzae. A review of 22 additional cases revealed that meningitis accompanied osteomyelitis in 10% (2/22).