Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics
Publication Date: August 4, 2021
Last Updated: September 2, 2022
Diagnosis
Laboratory Tests
In children with suspected AHO, we recommend performing blood culture prior to the administration of antimicrobial therapy. ( S , M)
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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.
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In children with suspected AHO, we suggest against using serum procalcitonin (PCT). ( W , L)
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Treatment
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.
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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.
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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).
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Overview
Title
Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics
Authoring Organizations
Infectious Diseases Society of America
Pediatric Infectious Diseases Society