Duration of intravenous antibiotic therapy for children with acute osteomyelitis or septic arthritis: a feasibility study.

BACKGROUND: There is little current consensus regarding the route or duration of antibiotic treatment for acute osteomyelitis (OM) and septic arthritis (SA) in children. OBJECTIVE: To assess the overall feasibility and inform the design of a future randomised controlled trial (RCT) to reduce the duration of intravenous (i.v.) antibiotic use in paediatric OM and SA. DESIGN: (1) A prospective service evaluation (cohort study) to determine the current disease spectrum and UK clinical practice in paediatric OM/SA; (2) a prospective cohort substudy to assess the use of targeted polymerase chain reaction (PCR) in diagnosing paediatric OM/SA; (3) a qualitative study to explore families' views and experiences of OM/SA; and (4) the development of a core outcome set via a systematic review of literature, Delphi clinician survey and stakeholder consensus meeting. SETTING: Forty-four UK secondary and tertiary UK centres (service evaluation). PARTICIPANTS: Children with OM/SA. INTERVENTIONS: PCR diagnostics were compared with culture as standard of care. Semistructured interviews were used in the qualitative study. RESULTS: Data were obtained on 313 cases of OM/SA, of which 218 (61.2%) were defined as simple disease and 95 (26.7%) were defined as complex disease. The epidemiology of paediatric OM/SA in this study was consistent with existing European data. Children who met oral switch criteria less than 7 days from starting i.v. antibiotics were less likely to experience treatment failure (9.6%) than children who met oral switch criteria after 7 days of i.v. therapy (16.1% when switch was between 1 and 2 weeks; 18.2% when switch was > 2 weeks). In 24 out of 32 simple cases (75%) and 8 out of 12 complex cases (67%) in which the targeted PCR was used, a pathogen was detected. The qualitative study demonstrated the importance to parents and children of consideration of short- and long-term outcomes meaningful to families themselves. The consensus meeting agreed on the following outcomes: rehospitalisation or recurrence of symptoms while on oral antibiotics, recurrence of infection, disability at follow-up, symptom free at 1 year, limb shortening or deformity, chronic OM or arthritis, amputation or fasciotomy, death, need for paediatric intensive care, and line infection. Oral switch criteria were identified, including resolution of fever for ≥ 48 hours, tolerating oral food and medicines, and pain improvement. LIMITATIONS: Data were collected in a 6-month period, which might not have been representative, and follow-up data for long-term complications are limited. CONCLUSIONS: A future RCT would need to recruit from all tertiary and most secondary UK hospitals. Clinicians have implemented early oral switch for selected patients with simple disease without formal clinical trial evidence of safety. However, the current criteria by which decisions to make the oral switch are made are not clearly established or evidence based. FUTURE WORK: A RCT in simple OM and SA comparing shorter- or longer-course i.v. therapy is feasible in children randomised after oral switch criteria are met after 7 days of i.v. therapy, excluding children meeting oral switch criteria in the first week of i.v. therapy. This study design meets clinician preferences and addresses parental concerns not to randomise prior to oral switch criteria being met. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Clostridium difficile in children: a review of existing and recently uncovered evidence.

The clinical significance of the presence of Clostridium difficile in children's faeces remains uncertain using current diagnostic procedures. Clostridium difficile is a relatively common finding in infants with no symptoms of gastrointestinal disease, suggesting it may be an incidental finding and form part of the normal gut micro-flora in this age group. On the other hand, particularly in older children or those with significant co-morbidity, there are examples where C. difficile causes disease and exerts considerable morbidity and even mortality (C. difficile infection, CDI). Between these extremes lie a substantial group of children who have both diarrhoea and C. difficile in their stools but where the nature of the association is not clear: Clostridium difficile associated disease (CDAD). We review the significance of C. difficile in children presenting recently uncovered paediatric data from a large UK epidemiological study that informs some key unanswered questions.

Managing bone and joint infection in children.

There is little high quality evidence on which to base the management of bone and joint infections in children. This pragmatic practice note aims to provide a consensus framework of best current practice prior to the availability of data from large national randomised controlled trials. For straightforward infection in previously normal children, recent trends suggest that shorter length of intravenous therapy with switch to oral treatment is acceptable, although this is not the case for the management of complex infections including those with multifocal disease, significant bone destruction, resistant or unusual pathogens, sepsis or in immunosuppressed children. Flowsheets for management based on the evidence reviewed are presented.

Complicated urinary tract infections: practical solutions for the treatment of multiresistant Gram-negative bacteria.

Resistance in Gram-negative bacteria has been increasing, particularly over the last 6 years. This is mainly due to the spread of strains producing extended-spectrum ß-lactamases (ESBLs) such as CTX-M enzymes or AmpC ß-lactamases. Many of the isolates producing these enzymes are also resistant to trimethoprim, quinolones and aminoglycosides, often due to plasmid co-expression of other resistance mechanisms. CTX-M-producing Escherichia coli often occurs in the community and as E. coli is one of the commonest organisms causing urinary tract infections (UTIs) the choice of agents to treat these infections is diminishing. Novel combinations of antibiotics are being used in the community and broad-spectrum agents such as carbapenems are being used increasingly as empirical treatment for severe infections. Of particular concern therefore are reports in the UK of organisms that produce carbapenemases. As resistance is becoming more widespread, prudent use of antimicrobials is imperative and, as asymptomatic bacteriuria is typically benign in the elderly, antibiotics should not be prescribed without clinical signs of UTI. The use of antibiotics as suppressive therapy or long-term prophylaxis may no longer be defensible.

Have the organisms that cause breast abscess changed with time?--Implications for appropriate antibiotic usage in primary and secondary care.

Many patients with breast abscess are managed in primary care. Knowledge of current trends in the bacteriology is valuable in informing antibiotic choices. This study reviews bacterial cultures of a large series of breast abscesses to determine whether there has been a change in the causative organisms during the era of increasing methicillin-resistant Staphylococcus aureus (MRSA). Analysis was undertaken of all breast abscesses treated in a single unit over 2003 - 2006, including abscess type, bacterial culture, antibiotic sensitivity and resistance patterns. One hundred and ninety cultures were obtained (32.8% lactational abscess, 67.2% nonlactational). 83% yielded organisms. Staphylococcus aureus was the commonest organism isolated (51.3%). Of these, 8.6% were MRSA. Other common organisms included mixed anaerobes (13.7%), and anaerobic cocci (6.3%). Lactational abscesses were significantly more likely to be caused by S. aureus (p < 0.05). Methicillin-resistant Staphylococcus aureus rates were not statistically different between lactational and nonlactational abscess groups. Appropriate antibiotic choices are of great importance in the community management of breast abscess. Ideally, microbial cultures should be obtained to institute targeted therapy but we recommend the continued use of flucloxacillin with or without metronidazole (or amoxicillin-clavulanate as a single preparation) as initial empirical therapy.

Septic arthritis of the knee by Salmonella montevideo.

We describe a case of salmonella septic arthritis of the knee in a middle-aged woman with the following predisposing conditions: long-term corticosteroids and microscopic collagenous colitis. The patient presented with enteritis caused by the same strain 3 months before the arthritis. The first series of cultures were negative and the possibility of a chronic carriage of the disease was not suspected initially. The patient was treated with antibiotics and arthroscopic washouts; the corticosteroid treatment was maintained. There was a progressive clinical and microbiological improvement and the patient was discharged 3 weeks later. Salmonella montevideo is a rare form of salmonella and is known to be associated with tropical fishes, reptiles and imported species.