Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics

Publication Date: August 5, 2021
Last Updated: September 2, 2022


Laboratory Tests

In children with suspected AHO, we recommend performing blood culture prior to the administration of antimicrobial therapy. ( S , M)
In children with suspected AHO, we suggest performing a serum C-reactive protein (CRP) on initial evaluation. ( W , VL)
  • 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.
In children with suspected AHO, we suggest against using serum procalcitonin (PCT). ( W , L)

Differential Diagnosis

  • 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.

Invasive Procedures

  • 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.
( W , M)
  • 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.


In children with suspected AHO, we recommend obtaining plain radiography of the potentially infected bone(s) rather than not performing plain radiographs. ( S , M)
  • 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.
In children with suspected AHO requiring further imaging studies to confirm the diagnosis, we suggest magnetic resonance imaging (MRI) rather than scintigraphy (bone scan), computerized tomographic (CT) scan, or ultrasound (US). ( W , VL)
  • 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

In children with presumed AHO who are ill-appearing or have rapidly progressive infection, we recommend starting empiric antimicrobial therapy immediately rather than withholding antibiotics until invasive diagnostic procedures are performed. ( S , M)
  • 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.
In children with presumed AHO who are not clinically ill and for whom an aspirate or biopsy by invasive diagnostic procedure is being planned prior to initiating antibiotics, we suggest withholding antibiotics for no more than 48 to 72 hours. ( W , VL)
  • 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.
In children with suspected AHO, we recommend using empiric antimicrobial therapy active against Staphylococcus aureus. ( S , M)
  • 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

In children with confirmed AHO, selection of a definitive antibiotic regimen should be based on the principles of selecting an effective agent against the identified pathogen, with the narrowest spectrum, lowest adverse effect profile, and most favorable host tolerance. (G, )
In children with suspected AHO without an identified bacterial cause, selection of a definitive antibiotic regimen should be based on the principles of selecting an effective agent based on the most likely causative organism(s), with a spectrum comparable to that on which the patient demonstrated clinical and laboratory improvement, and with the lowest adverse effect profile and most favorable host tolerance. (G, )

In children with AHO requiring a surgical procedure, we recommend against routine use of surgical-site (i.e., instilled or implanted) antimicrobial agents. ( S , VL)
  • Comment: This recommendation places a high value on avoiding unnecessary harm and cost associated with this intervention.

Invasive Therapeutic Procedures

In children with AHO who present with sepsis or have a rapidly progressive infection, we recommend debridement of the infected bone and any associated abscesses as soon as possible after diagnosis, rather than treating with medical therapy alone. ( S , M)
In a child with AHO who is clinically stable but is documented to have a substantial abscess (greater than 2 cm), we suggest debridement rather than treating with medical therapy alone. ( W , VL)

Assess the Response

In children with suspected or confirmed AHO receiving antimicrobial therapy, we suggest performing sequential monitoring of CRP in addition to serial clinical evaluation to assess response to therapy, rather than relying solely on clinical evaluation. ( W , L)
  • Comment: Serial clinical examinations that assess the febrile response, pain, and musculoskeletal function are important clinical parameters to monitor response to treatment.

Discharge Planning

For children with suspected or documented AHO who respond to initial intravenous antibiotic therapy, we recommend transition to an oral antibiotic regimen rather than outpatient parenteral antimicrobial therapy (OPAT) when an appropriate (active against the confirmed or presumed pathogen(s)) and well-tolerated oral antibiotic option is available. ( S , L)
  • Comment: This recommendation places a high value on avoidance of harms and costs as well as on the improvement of acceptability, feasibility, and equity.
For children with suspected or documented AHO who respond to initial parenteral antibiotic therapy but for whom oral antimicrobial therapy is not feasible, we suggest transition to OPAT, rather than remaining in an acute-care hospital for the total duration of therapy. ( W , VL)
  • 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

In children with AHO presumed or proven to be caused by S. aureus who have had an uncomplicated course and responded to initial therapy, we suggest a 3- to 4-week duration of antibiotics rather than a longer course. ( W , VL)
  • 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.

End-of-Therapy Imaging

  • we recommend against obtaining end-of-therapy MRI and
( S , L)
  • suggest against routine end-of-therapy plain radiographs.
( W , VL)
In children with complicated AHO or with involvement of the physis, we suggest end-of-therapy imaging studies (plain radiographs and/or MRI). ( W , VL)

Nonresponse or Relapse

For children either experiencing primary treatment failure or early or late recurrence of AHO:
  • 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.
(G, )
Clinicians should reassess the need for surgical intervention for therapeutic and/or diagnostic purposes. (G, )
  • Comment: The accuracy of the diagnosis of AHO may need to be reconsidered, especially in culture-negative cases.

Long-Term Follow-up

In children with AHO who are determined to be at risk of long-term adverse outcomes, we suggest a follow-up period of at least 1 year by specialists with experience treating children with AHO. ( W , L)

Recommendation Grading




Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics

Authoring Organizations

Publication Month/Year

August 5, 2021

Last Updated Month/Year

July 14, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Male, Female, Adolescent, Child, Infant

Health Care Settings

Ambulatory, Hospital

Intended Users

Epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant


Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D010019 - Osteomyelitis


osteomyelitis, Acute Hematogenous Osteomyelitis, AHO

Source Citation

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.


Number of Source Documents
Literature Search Start Date
August 1, 2017
Literature Search End Date
May 1, 2019