Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics
- Comment: Serum CRP has a low accuracy to establish the diagnosis of AHO, but in situations where AHO is confirmed, the serum CRP performed on initial evaluation can serve as the baseline value for sequential monitoring.
- Infection of adjacent soft tissues (myositis and pyomyositis) or noninfectious inflammatory conditions such as transient (or toxic) synovitis, discitis, rheumatic fever, polymyositis, juvenile idiopathic arthritis, and post-infectious arthralgias or arthritis may mimic osteomyelitis.
- Congenital syphilis can involve bones and mimic other etiologies of osteomyelitis in young infants.
- Bone tumors such as osteosarcoma, Ewing sarcoma, metastases from neuroblastoma, Langerhans cell histiocytosis, and benign osteochondromas or osteoid osteomas may have clinical presentations that overlap with osteomyelitis.
- Bone pain may occur from leukemia, bone infarction associated with sickle cell disease, or metabolic defects such as Gaucher disease.
- Legg-Calve-Perthes disease and slipped capital femoral epiphysis can mimic AHO of the proximal femur.
- Complex regional pain syndromes and bacterial sepsis may also cause limb pain suggestive of bone infection.
- Bone fractures sometimes cause fever and, when nondisplaced, may mimic osteomyelitis.
- Chronic nonbacterial osteomyelitis, an auto-inflammatory disease, is often indistinguishable during the initial presentation from culture-negative AHO.
- In children with suspected AHO, we suggest performing invasive diagnostic procedures to collect aspirates and/or biopsy specimens of bone and/or associated purulent fluid collections for routine microbiological studies (aerobic bacteriologic culture and Gram stain) rather than performing only noninvasive diagnostic tests.
- Comment: This recommendation places a high value on confirming the microbiological diagnosis to allow optimization of the spectrum and duration of antimicrobial therapy. The decision to implement this recommendation and its timing may be influenced by factors such as local feasibility of obtaining invasive diagnostic procedures (by interventional radiology [IR] or in the operating room), individual clinical situations (e.g., need for therapeutic surgical intervention and concerns regarding procedural risks or sedation), positive results of prior noninvasive diagnostic tests (e.g., blood culture), and duration of any prior antimicrobial therapy.
- Comment: Despite the low sensitivity of plain radiography for detecting AHO on initial presentation, other important diagnoses may be ruled out by this simple, quick, safe, and relatively inexpensive imaging test.
- Comment: For children suspected to have uncomplicated AHO, imaging may not be required to establish or confirm the diagnosis. However, if a child does not respond to medical therapy within 24 to 48 hours or signs and symptoms suggest a potential role for surgical debridement, MRI may be performed to better define the location and extent of infection or to evaluate for an alternative diagnosis such as a malignancy. In children with suspected AHO who have associated joint effusion or other concern for the spread of infection into an adjacent joint (or soft tissues), US evaluation may provide valuable diagnostic guidance for further management. See IDSA/PIDS guideline for the management of bacterial arthritis in children.
Empiric Antimicrobial Therapy
- Comment: The yield of positive cultures from specimens collected by invasive diagnostic procedures (bone biopsy and aspirate), when obtained within 24 to 48 hours after initiation of antibiotic therapy, is similar to the yield when these cultures are obtained prior to the administration of antibiotics.
- Comment: The decision to implement this recommendation incorporating a reasonable delay may be influenced by local accessibility to experts and resources to perform invasive diagnostic procedures or the time required for transport to a higher level of care if appropriate. For children likely to have AHO, it is advisable that children remain hospitalized for observation while withholding antibiotics until cultures can be obtained.
- Comment: Antimicrobials with activity against community-acquired methicillin-resistant S. aureus (CA-MRSA) should be considered based on local susceptibility data and patient history with regard to previous CA-MRSA infections and/or colonization. In the presence of a clinical presentation, physical examination, exposure history, or other risk factors that either are inconsistent with S. aureus infection or suggest need for coverage for other organisms, additional empiric antimicrobial coverage for pathogens other than S. aureus may be warranted (such as younger age for Kingella kingae or children with underlying hemoglobinopathies who have increased risk for Salmonella spp. infection).
Definitive Parenteral and Oral Therapy
- Comment: This recommendation places a high value on avoiding unnecessary harm and cost associated with this intervention.
Invasive Therapeutic Procedures
Assess the Response
- Comment: Serial clinical examinations that assess the febrile response, pain, and musculoskeletal function are important clinical parameters to monitor response to treatment.
- Comment: This recommendation places a high value on avoidance of harms and costs as well as on the improvement of acceptability, feasibility, and equity.
- Comment: This recommendation places a high value on avoiding harms and costs associated with unnecessary and prolonged hospital stay. The decision to implement this recommendation and the selection of the type of OPAT (home, intermediate care facility, and clinic) may be influenced by the availability of local resources.
Duration of Antibiotics
- Comment: Although the optimal duration of therapy is best described for uncomplicated courses of AHO due to methicillin-susceptible S. aureus (MSSA), longer duration may be necessary for other pathogens, including more virulent strains of S. aureus (such as USA 300 and Panton Valentine leucocidin + [PVL+], whether CA-MRSA or MSSA), and for complicated courses.
- we recommend against obtaining end-of-therapy MRI and
- suggest against routine end-of-therapy plain radiographs.
Nonresponse or Relapse
- Clinicians should assess the adequacy of the antimicrobial regimen (spectrum of activity, dosage and penetration to the site of infection, and adherence) before deciding on the need to broaden the spectrum or to restart antimicrobials.
- Comment: The accuracy of the diagnosis of AHO may need to be reconsidered, especially in culture-negative cases.
Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics
August 5, 2021
Last Updated Month/Year
July 14, 2023
Supplemental Implementation Tools
External Publication Status
Country of Publication
Male, Female, Adolescent, Child, Infant
Health Care Settings
Epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant
Diagnosis, Assessment and screening, Treatment, Management
D010019 - Osteomyelitis
osteomyelitis, Acute Hematogenous Osteomyelitis, AHO
Woods CR, Bradley JS, Chatterjee A, Copley LA, Robinson J, Kronman MP, Arrieta A, Fowler SL, Harrison C, Carrillo-Marquez MA, Arnold SR, Eppes SC, Stadler LP, Allen CH, Mazur LJ, Creech CB, Shah SS, Zaoutis T, Feldman DS, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics. J Pediatric Infect Dis Soc. 2021 Sep 23;10(8):801-844. doi: 10.1093/jpids/piab027. PMID: 34350458.