Early Transition to Oral Antimicrobial Therapy Among Children With Staphylococcus aureus Bacteremia and Acute Hematogenous Osteomyelitis.

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is a frequent complication of acute hematogenous osteomyelitis (AHO) in children, but data on the optimal duration of parenteral antibiotics prior to transition to oral antibiotics remains sparse. We examined clinical outcomes associated with early transition to oral antimicrobial therapy among children admitted to our institution with AHO and SAB, and evaluated the utility of a severity of illness score (SIS) to guide treatment decisions in this setting. METHODS: Children with AHO and SAB admitted to our institution between January 1, 2009, and December 31, 2018, were retrospectively reviewed and stratified according to a previously validated SIS into mild (0-3), moderate (4-7) and severe (8-10) cohorts. Groups were assessed for differences in treatment (eg, parenteral and oral antibiotic durations, surgeries) and clinical response (eg, bacteremia duration, acute kidney injury, length of stay and treatment failure). RESULTS: Among 246 children identified with AHO and SAB, median parenteral antibiotic duration differed significantly between mild (n = 80), moderate (n = 98) and severe (n = 68) cohorts (3.6 vs. 6.5 vs. 14.3 days; P ≤ 0.001). SIS cohorts also differed with regard to number of surgeries (0.4 vs. 1.0 vs. 2.1; P ≤ 0.001), duration of bacteremia (1.0 vs. 2.0 vs. 4.0 days; P ≤ 0.001), acute kidney injury (0.0% vs. 3.0% vs. 20.5%; P ≤ 0.001), hospital length of stay (4.8 vs. 7.4 vs. 16.4 days; P ≤ 0.001) and total duration of antibiotics (34.5 vs. 44.7 vs. 60.7 days; P ≤ 0.001). Early transition to oral antimicrobial therapy among mild or moderate SIS cohorts was not associated with treatment failure despite SAB. CONCLUSIONS: SAB is associated with a wide range of illness among children with AHO, and classification of severity may be useful for guiding treatment decisions. Early transition to oral antimicrobial therapy appears safe in children with mild or moderate AHO despite the presence of SAB.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States.

OBJECTIVE: Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. STUDY DESIGN: Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. RESULTS: 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. CONCLUSION: At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Quality Improvement of Magnetic Resonance Imaging for Musculoskeletal Infection in Children Results in Decreased Scan Duration and Decreased Contrast Use.

BACKGROUND: Magnetic resonance imaging (MRI) is a heavily utilized resource to evaluate children suspected to have a musculoskeletal infection. Complex interdisciplinary workflows are involved with decision-making with regard to indications, anesthesia, contrast use, and procedural timing relative to the scan. This study assesses the impact of a quality improvement endeavor on MRI workflows at a tertiary pediatric medical center. METHODS: A registry of consecutively enrolled children for a multidisciplinary musculoskeletal infection program identified those evaluated with MRI from 2012 to 2018. Annual MRI process improvement feedback was provided to the key stakeholders. Demographic characteristics, laboratory parameters, MRI indications, anesthesia use, MRI findings, final diagnoses, scan duration, imaging protocol, surgical intervention following MRI, and length of stay were retrospectively compared between the 3 cohorts (initial, middle, and final) representing 2-year increments to assess the impact of the initiative. RESULTS: There were 526 original MRI scans performed to evaluate 1,845 children with suspected musculoskeletal infection. Anesthesia was used in 401 children (76.2%). When comparing the initial, middle, and final study period cohorts, significant improvement was demonstrated for the number of sequences per scan (7.5 sequences for the initial cohort, 5.8 sequences for the middle cohort, and 4.6 sequences for the final cohort; p < 0.00001), scan duration (73.6 minutes for the initial cohort, 52.1 minutes for the middle cohort, and 34.9 minutes for the final cohort; p < 0.00001), anesthesia duration (94.1 minutes for the initial cohort, 68.9 minutes for the middle cohort, and 53.2 minutes for the final cohort; p < 0.00001), and the rate of contrast use (87.6% for the initial cohort, 67.7% for the middle cohort, and 26.3% for the final cohort; p < 0.00001). There was also a trend toward a higher rate of procedures under continued anesthesia immediately following the MRI (70.2% in the initial cohort, 77.8% in the middle cohort, and 84.6% in the final cohort). During the final 6-month period, the mean scan duration was 24.4 minutes, anesthesia duration was 40.9 minutes, and the rate of contrast administration was 8.5%. CONCLUSIONS: Progressive quality improvement through collaborative interdisciplinary communication and workflow redesign led to improved utilization of MRI and minimized contrast use for suspected musculoskeletal infection. There was a high rate of procedural intervention under continued anesthesia for children with confirmed musculoskeletal infection. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Validation and Modification of a Severity of Illness Score for Children With Acute Hematogenous Osteomyelitis.

BACKGROUND: Children with osteomyelitis demonstrate a wide spectrum of illness. Objective measurement of severity is important to guide resource allocation and treatment decisions, particularly for children with advanced illness. The purpose of this study is to validate and improve a previously published severity of illness scoring system for children with acute hematogenous osteomyelitis (AHO). METHODS: Children with AHO were prospectively studied during evaluation and treatment by a multidisciplinary team who provided care according to evidence-based guidelines to reduce variation. A severity of illness score was calculated for each child and correlated with surrogate measures of severity. Univariate analysis was used to assess the significance of each parameter within the scoring model along with new parameters, which were evaluated to improve the model. The scoring system was then modified by the addition of band count to replace respiratory rate. The modified score was calculated and applied to the prospective cohort followed by correlation with the surrogate measures of severity. RESULTS: One hundred forty-eight children with AHO were consecutively studied. The original severity of illness score correlated well with length of stay and other established measures of severity. Band percent of the white blood cell differential ≥1.5% was found to be significantly associated with severity and chosen to replace respiratory rate in the model. The modified calculated severity scores correlated well with the chosen surrogate measures and significantly differentiated children with osteomyelitis on the basis of causative organism, length of stay, intensive care, surgeries, bacteremia, and disseminated or multifocal disease. CONCLUSIONS: The findings of this study validate the previously published severity of illness scoring tool in large cohort of children who were prospectively evaluated. The replacement of respiratory rate with band count improved the scoring system.

Severity Adjusted Risk of Long-term Adverse Sequelae Among Children With Osteomyelitis.

BACKGROUND: The purpose of this investigation was to evaluate the risk for long-term, adverse outcomes among children with osteomyelitis. METHODS: Children with osteomyelitis were prospectively enrolled from 2012 to 2014. Care was accomplished by a multidisciplinary team according to an institutional algorithm. Data were collected to define the severity of illness during the initial hospitalization and assess short, intermediate and long-term outcomes. Clinical examination, radiographic assessment and functional outcome survey administration were performed at a minimum of 2 year follow-up. A comparison cohort analysis was performed according to initial severity of illness score of mild (0-2), moderate (3-6) and severe (7-10). RESULTS: Of 195 children enrolled, 139 (71.3%) returned for follow-up at an average of 2.4 years (range, 2.0-5.0 years). Children with severe illness were less likely to have normal radiographs (severe, 4.0%; moderate, 38.2%; mild, 53.2%, P < 0.0001), and more likely to have osteonecrosis, chondrolysis, or deformity (severe, 32.0%; moderate, 5.9%; mild, 1.3%, P < 0.0001). Functional outcome measures did not significantly differ between severity categories. By regression analysis severity of illness score, plus age less than 3 years and Methicillin-resistant Staphylococcus aureus predicted severe sequelae with an area under the curve of 0.8617 and an increasing odds ratio of 1.34 per point of increase in severity score. CONCLUSION: Long-term severe adverse outcomes among children with osteomyelitis occurred in 11 of 139 (7.9%) children and were predicted by initial severity of illness. Other risks that diminished the likelihood of complete resolution or increased the risk of severe sequelae included Methicillin-resistant Staphylcoccus aureus etiology and young age. The majority of children with osteomyelitis do not require long-term follow-up beyond the initial treatment period.

Differentiation of Deep Venous Thrombosis Among Children With or Without Osteomyelitis.

BACKGROUND: Children with osteomyelitis are at risk for deep venous thrombosis (DVT). This study evaluates the characteristics of DVT among children to differentiate between those with and without osteomyelitis. METHODS: Children with DVT of any cause were studied between 2008 and 2016. Children with DVT and osteomyelitis were compared with those with DVT without osteomyelitis. Another comparison cohort included children with osteomyelitis but without DVT. Comorbidities, severity of illness (SOI), and clinical course were compared between cohorts. RESULTS: DVT was identified in 224 children, a prevalence of 2.5 per 10,000 children. Among those with DVT, 28 (12.1%) had osteomyelitis. The DVT rate among 466 children with osteomyelitis was 6.0%. Children with osteomyelitis and DVT had greater SOI (9.1 vs. 2.7), bacteremia rate (82.1% vs. 38.4%), methicillin-resistant Staphylococcus aureus rate (89.3% vs. 21.2%), surgeries per child (2.1 vs. 0.7), and intensive care unit admission rate (67.9% vs. 5.9%) than that of children without DVT (P<0.00001). Of 196 children who had DVT without osteomyelitis, 166 (84.7%) had comorbidities including defined hypercoagulability (27 or 13.8%). Children with DVT due to osteomyelitis were without comorbidities or hypercoagulability (P<0.00001). The rate of pulmonary embolism was similar for children with DVT with or without osteomyelitis (3/28, or 10.7% vs. 18/196, or 9.2%). CONCLUSIONS: Children with DVT and osteomyelitis differ substantially from other children with DVT by the absence of comorbidities or post-thrombotic syndrome. They also differ from children with osteomyelitis without DVT by higher SOI, methicillin-resistant S. aureus rate, and occurrence of intensive care. Awareness of for the characteristics of DVT among children with osteomyelitis will reduce delay to diagnostic ultrasound and improve anticoagulation management which must be carefully coordinated given the high rate of surgery of these children. LEVEL OF EVIDENCE: Level II-prognostic, retrospective cohort comparison.

Seasonal Variation and Weather Changes Related to the Occurrence and Severity of Acute Hematogenous Osteomyelitis in Children.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) demonstrates regional variability in incidence and severity. In this study, we evaluated seasonal variations of AHO and assessed the effects of weather trends on the occurrence and severity of illness in affected children. METHODS: National Weather Service data from the dates of symptom onset and of admission of children with AHO were gathered. Seasonal occurrence rates and the weather patterns were studied according to severity-of-illness category. Statistical analysis was performed with Pearson and Spearman correlations and analysis of variance. RESULTS: A total of 209 children with AHO were admitted within 21 days of symptom onset (average, 5.0 ± 3.8 days). Severity-of-illness scores ranged from 0 to 10 (average, 3.2 ± 3.2). Symptom onset occurred most commonly in summer (73 [34.9%]) or spring (54 [25.8%]). We found a significant correlation between severity of illness and minimum temperature at symptom onset during the summer season (P = .020). A significant change in average humidity (21.6%) occurred during the winter between the date of symptom onset and the date of admission for children with severe illness (P = .020). DISCUSSION: This study identified seasonal variation in the occurrence of AHO in children; summer was the most common season for occurrence. To our knowledge, this is the first detailed evaluation of weather parameters and trends in weather changes from symptom onset to admission with consideration of the effects of weather on the occurrence of infection and severity of illness.

Sequential Parenteral to Oral Clindamycin Dosing in Pediatric Musculoskeletal Infection: A Retrospective Review of 30 mg/kg/d Versus 40 mg/kg/d.

BACKGROUND: Children with musculoskeletal infection in methicillin-resistant Staphylococcus aureus (MRSA) prevalent communities are often treated with oral clindamycin. Current guidelines recommend approximately 40 mg/kg/d for MRSA infections. This study investigates the clinical practice of using 30 mg/kg/d of clindamycin as an alternative for outpatient dosing. METHODS: Children with musculoskeletal infection treated with outpatient clindamycin from 2009 to 2014 were studied by retrospective review. The amount of clindamycin administered was determined from dose, interval and duration of outpatient treatment. Hospital readmission, surgeries and sequelae were assessed. Severity of illness was determined for children with osteomyelitis. The readmission rate of 25 children treated with 40 mg/kg/d was compared with that of 190 children treated with 30 mg/kg/d. The reason for readmission was evaluated to consider whether antibiotic dosing strategy was a potential factor. RESULTS: Among 215 children studied, the average outpatient duration of treatment was 32.8 days. There was no significant difference in the rate of readmission between dosing cohorts. Severity of illness scores (0-10 scale) was significantly higher among readmitted children with osteomyelitis (mean 9.8 ± 0.4) than among those with osteomyelitis who were not readmitted (mean 2.9 ± 3.2), P = 0.001. Sequelae were more common in the high-dose group and were noted in 3 children (12%) in that cohort compared with 6 children (3.2%) in the low-dose cohort (P > 0.05). CONCLUSION: Oral dosing of 30 mg/kg/d was effective for musculoskeletal infection in children in an MRSA prevalent community. Illness severity appeared to have greater impact on readmission and sequelae than did antibiotic dosing.

Improved Magnetic Resonance Imaging Utilization for Children with Musculoskeletal Infection.

BACKGROUND: Magnetic resonance imaging (MRI) with sedation is an important resource used to evaluate children with musculoskeletal infection. This study assesses the impact of multidisciplinary guidelines and continuous process improvement on MRI utilization at a tertiary pediatric medical center. METHODS: A multidisciplinary team developed a guideline for MRI with sedation, and it was implemented at our institution. Scan duration, anatomic regions imaged, sequences performed, timing of surgical intervention, length of hospital stay, and readmissions for these children were compared with these measures among a cohort of similar children who had been treated prior to guideline implementation. Comparative data were gathered for the subsequent cohort to determine any impact of the continued process improvement program on MRI utilization. Statistical comparison was performed to determine significant differences between groups. RESULTS: Children evaluated prior to the guideline implementation had 9.0 MRI sequences per scan, an MRI scan duration of 111.6 minutes, and a hospital stay of 7.5 days. In comparison, children in the initial MRI guideline cohort had 7.5 sequences per scan, a scan duration of 76.1 minutes, and a hospital stay of 5.4 days. Children in the subsequent guideline cohort had 6.5 sequences per scan, a scan duration of 56.3 minutes, and a hospital stay of 5.0 days. The rate of immediate surgical procedure under continued anesthesia was 16.7% prior to the guideline, 50.5% among children in the initial guideline cohort, and 64% among children in the subsequent guideline cohort. Differences between cohorts were significant (p < 0.0001). In aggregate, 264 hours of MRI scan time and 809 hospital bed-days were conserved for more than thirty months. CONCLUSIONS: This initiative promoted improvement in diagnostic efficiency, therapeutic consistency, and patient safety for children with musculoskeletal infection. CLINICAL RELEVANCE: The findings of this study illustrate the beneficial impact of interdisciplinary coordination of care on clinical outcomes for children with musculoskeletal infection. Tangible improvements occurred for both length of stay and resource utilization.