Acute Osteoarticular Infections in Children: A Long-Awaited Guide(lines) Out of the Woods Free

Chances are, if you have practiced pediatrics for even a few years, you have struggled with management questions for a child with an osteoarticular infection. How long should I treat? Do I need an X-ray at the end of therapy?  Should I advocate for a bone biopsy? Which inflammatory markers should I follow? Evidence and formal guidance were lacking, leading providers to feel they were wandering the proverbial woods without a map. A historical review of recommendations for acute osteoarticular infections over the years (though not intended to cast dispersions upon the authors, who were limited by data available at the time), helps us appreciate the evidence (and guidelines) we currently possess. 

Back in 1970, a review in the New England Journal of Medicine advocated for a minimum of 4 weeks of parenteral antibiotic therapy for osteomyelitis.¹ Ten years later, in 1980, an article in the same journal stressed “the necessity of prolonged parenteral therapy for at least 4 to 6 weeks to achieve a 70 to 80 per cent cure rate.”² By 1987, prominent authors lamented that “the appropriate length of therapy has been the subject of debate for many years,” though a movement for shorter courses of parenteral therapy was gaining traction.³ In 1990, prominent infectious disease specialists noted “the minimum or optimum duration of antimicrobial therapy for acute osteomyelitis infections is unknown,” and advocated for completion of large dosage oral antibiotic therapy in the hospital.⁴ Pediatrics in Review highlighted this uncertainty, noting in 1995 that 5 to 7 days of parenteral antibiotics followed by 3 to 4 weeks of oral therapy was often sufficient for treatment of acute hematogenous osteomyelitis (AHO), though 4 to 6 weeks of parenteral therapy was also an option, as was treatment until the ESR normalized.⁵ Recommendations for treatment of acute bacterial arthritis (ABA) in the late 1990s could reference minimum courses of parenteral therapy (eg, one week) prior to transition to oral therapy, with suggestions to document appropriate serum bactericidal titers before using oral antibiotics.⁶ Many textbooks and review articles were silent on other key management aspects of AHO and ABA, such as the need for plain films at the end of therapy.

In 2008, one could still see an article with the provocative title, “Acute haematogenous osteomyelitis in children:  Is there any evidence for how long we should treat?”⁷ Nonetheless, references to shorter courses of parenteral and overall therapy for AHO and ABA became more frequent.^8,9 Between 2002 and 2010, however, publications from 9 countries still reflected ongoing uncertainty, with reported treatment durations for AHO ranging from 3 to 8 weeks.⁹

Thankfully, we are now out of the woods. In 2021, the first North American guidelines addressing management of AHO in children were published, followed in 2024 by guidelines addressing ABA (the lead author on both, interestingly, being Charles Woods).^10,11 Among many recommendations (which are concisely and expertly summarized for your review by Drs. Shapiro, Carillo-Marquez and Arnold in Pediatrics in Review), is a recommendation that uncomplicated courses of Staphylococcus aureus AHO responding to initial therapy require only a 3–4-week course of antibiotics. CRP is also the suggested inflammatory marker to follow, and recommendations are made against end-of-therapy radiographs in uncomplicated courses of osteomyelitis not involving the physes. For ABA, the guidelines suggest withholding empiric antibiotics in stable appearing children until a joint aspirate is obtained for culture and recommend 10-14 days of antibiotics for uncomplicated infections. 

Though many questions remain, these guidelines (and the review in Pediatrics in Review) finally provide long-awaited answers.  

References

1. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic aspects and unusual aspects (first of 3 parts).  New Eng J Med. 1970;282(4):198–206
2. Waldvogel FA, Vasey H. Osteomyelitis: the past decade.  New Eng J Med. 1980;303(7):360–370
3. Green NE, Edwards K. Bone and joint infections in children. Orthop Clin North Am. 1987;18(4):555–576
4. Nelson JD. Acute osteomyelitis in children. Infect Dis Clin North Am. 1990;4(3):513-522
5. Roy DR. Ped Rev. 1995;16(10):380–384
6. Matan AJ, Smith JT. Pediatric septic arthritis. Orthopedics. 1997;20(7):630–635
7. Weichart S, Sharland M, Clarke NMP, Faust SN. Acute haematogenous osteomyelitis in children: is there any evidence for how long we should treat? Curr Opin Infect Dis. 2008;21:258–262
8. Dodwell ER. Osteomyelitis and septic arthritis in children: current concepts. Curr Opin Pediatr. 2013;25:58–63
9. Pääkkönen M, Peltola H. Antibiotic treatment for acute haematogenous osteomyelitis of childhood: moving towards shorter courses and oral administration. Int J Antimicrob Agent. 2011;38:273–80
10. Woods CR, Bradley JS, Chatterjee A, et al. Clinical practice guideline by the Pediatric Infectious Disease Society and the Infectious Disease Society of America: 2021 guideline on diagnosis and management of acute hematogenous osteomyelitis in Pediatrics. J Pediatr Infect Dis Soc. 2021;10:801–844
11. Woods CR, Bradley JS, Chatterjee A, et al. Clinical practice guideline by the Pediatrics Infectious Disease Society (PIDS) and the Infectious Disease Society of America (IDSA): 2023 guideline on diagnosis and management of acute bacterial arthritis in pediatrics. J Pediatr Infect Dis Soc. 2024;13(1):1–59