Streptococcus Pneumoniae Arthritis

Treatment of patients with osteomyelitis or arthritisshould be undertaken by a paediatrician and orthopaedic surgeon in collaboration. When osteomyelitis or arthritis is considered in the differential diagnosis, one should consider these conditions as a working-diagnosis and treat in conformity. The risk that retrospectively the working-diagnosis appeared to be incorrect does not compensate for the disadvantages of delayed treatment, especially in the case of septic arthritis. Before starting antimicrobial therapy microbiological diagnostics should be performed. Positive results are helpful in adjusting antimicrobial therapy during the switch from intravenous to oral therapy. Bone biopsies have a higher probability of positive culture than bloodculture (Karwowska et al., 1998). However, in the case of osteomyelitis, many physicians have the opinion that without a bone biopsy antimicrobial therapy may be started. In their opinion bone biopsies should only be performed when no adequate response to antimicrobial therapy is observed (Steer and Carapetis, 2004).

In the case of septic arthritis, surgical treatment is preferred since the affected joint can be considered as a cavity filled with pus. Opening or draining of the joint is diagnostic as well as therapeutic. Antimicrobial therapy is still a necessary adjuvant to the surgical procedure.

Joints that are easily reached usually are drained by an arthroscopic procedure, while more deeply situated joints, like the hip joint, are approached by arthrot-omy. Specimens of the synovial fluid or biopsies of synovial membrane for culture and pathology can be taken when the joint is flushed with saline solution. Aspiration of synovial fluid alone is insufficient treatment (Dabney and Bowen, 1995) and may lead to irreversible damage to the affected joint. Morbidity following arthroscopy is considered low while the time to cure the inflammatory response is reduced by the procedure leading to reduced costs with respect to the hospital stay (Smith, 1986). Drainage procedures using silastic drains that will stay in for some time, are not used anymore. When relapse occurs a second arthroscopic drainage may be performed.

Septic arthritis and osteomyelitis are frequently associated (Perlman et al., 2000). When one has doubts about the presence of concurrent osteomyelitis, a bone biopsy of the metaphyseal area can be performed during the drainage procedure of the joint.

Surgical drainage of osteomyelitis is indicated when abscesses or sequestra are demonstrated by radiological techniques.

Empirical antimicrobial therapy (Table 16.1) is based on the most likely micro-organism, with respect to the age of the patient, the clinical presentation and, when available, the results of the Gram-stain and the culture of the biopsy material (Hartwig et al., 2005).

In older children with the clinical presentation of acute haematogenous osteomyelitis without spread to a joint, empirical treatment can be restricted to flucloxa-cillin or a second generation cephalosporin, since almost always S. aureus is found as the causative micro-organism. When there is P-lactam hypersensitivity, clindamycin is a good alternative. Vancomycin is a large molecule and does not penetrate well into bone tissue. It is therefore less suitable for treating osteomyelitis. However in some instances, when S epidermidis is isolated, it is the only treatment option.

For young children or children with haemoglobinopathies (e.g., Sickle cell disease) empirical treatment should include cover for Gram-negative microorganisms. Therefore 3rd generation cephalosporins are more suitable. When children appear toxic, an aminoglycoside can be added to the treatment. This will lead to faster sterilisation of the bloodstream. Based on cultures and sensitivity testing, it may be possible to switch to antibiotics with a narrower spectrum of activity (Table 16.2) (Hartwig et al., 2005).

The intravenous route is preferred for initial therapy. A switch to oral therapy may be considered if the patient responds well, the CRP has fallen to approximately 1/3 of the value at presentation, and the micro-organism and sensitivity testing is available (see Table 16.3). The optimal duration of treatment for osteomyelitis and arthritis is not well defined. Previously, the total treatment duration wase 6 weeks or more. However, shorter treatment-courses seem to be equally effective. The risk

Table 16.1. Empirical antibiotic therapy in osteomyelitis/arthritis

Host factors

Medication*

Daily doses

Acute haematogenous

1.

Amoxicillin/clavulanic acid

150/15 mg/kg in 3x

osteomyelitis/arthritis

2.

Cefuroxime (+ AMG optional)

150 mg/kg in 3x

age <6 months or

(5 mg/kg in 1x)

insufficient Hib vaccination

Acute haematogenous

1.

Flucloxacillin

150 mg/kg in 3x

osteomyelitis/arthritis

2.

Cefuroxime

150 mg/kg in 3x

age >6 months

Acute haematogenous

1.

Cefotaxime

150 mg/kg in 3x

osteomyelitis/arthritis

2.

Ceftriaxone

100 mg/kg in 1x

haemoglobinopathy

Subacute/focal osteomyelitis

1.

Ceftazidime + AMG

150 mg/kg in 3x

(tobramycin or gentamicin)

5 mg/kg in 1 x

Chronic osteomyelitis

1.

Flucloxacillin

150 mg/kg in 3x

2.

Cefuroxime

150 mg/kg in 3x

Post-operative osteomyelitis/

1.

Flucloxacillin + AMG

150 mg/kg in 4x

arthritis

(tobramycin or gentamicin)

5 mg/kg in 1 x

Neonatal osteomyelitis/arthritis

1.

Amoxicillin/clavulanic acid

150/15 mg/kg in 4x

2.

Cefotaxime + Flucloxacillin

150 mg/kg in 3x

150 mg/kg in 4x

3.

Ceftriaxone + Flucloxacillin

100 mg/kg in 1x

150 mg/kg in 4x

Spondylodiscitis

1.

Flucloxacillin

150 mg/kg in 3x

Septic arthritis

1.

Cefotaxime

150 mg/kg in 3x

Sexual activity

2.

Ceftriaxone

100 mg/kg in 1x

*In the column "Medication" the given choices are equal alternatives.

*In the column "Medication" the given choices are equal alternatives.

of relapse is increased when treatment duration falls below 3 weeks (Dich et al., 1975). When the patient responds quickly to treatment and no complications are present, duration of treatment is generally advised to be 3 to 4 weeks.

When osteomyelitis is due to puncture-wounds, P. aeruginosa and S. aureus are the most frequently encountered micro-organisms. In the literature several combinations of antibiotics are proposed in these situations. In case of Pseudomonas infections surgical exploration and cleansing of the wound is part of the treatment, followed by 1 to 2 weeks of antibiotic treatment (Jacobs et al., 1989). Quinolones are not often used for this indication in children due to concerns about the safety of their use. Although quinolones penetrate well into bone tissue, P. aeruginosa may become resistant during treatment.

Osteomyelitis after bites or in relation to odontogenous infections should include cover for against S. aureus and anaerobes. Empirical treatment with amoxi-cillin/clavulanic acid or clindamycin is preferred.

Empirical antimicrobial treatment for neonatal osteomyelitis should cover Group B streptococci, E.coli and S. aureus (Jacobs et al., 1989). Treatment with amoxicillin/clavulanic acid (in combination with an aminoglycosid) or a third

Table 16.2. Antibiotic treatment based on isolated micro-organism and antibiotic sensitivity testing advice for children >4 weeks of age

Duration of

Pathogen Medication* Daily doses treatment**

Group A streptococci

Benzylpenicillin

200.000 U/kg in 6x

3-4 weeks

Group B streptococci

Benzylpenicillin

200.000 U/kg in 6x

4-6 weeks

E. coli

Cefotaxime + AMG

150 mg/kg in 3x

4-6 weeks

(tobramycin or

5 mg/kg in 1x

gentamicin)

H. influenzae b

Amoxicillin

150 mg/kg in 4x

4 weeks

(ß lactamase neg.)

H. influenzae b

Amoxicillin/clavulanic

150/15 mg/kg in 4x

4 weeks

(ß lactamase pos.)

acid

K. kingae

Benzylpenicillin

200.000 E/kg in 6x

3-4 weeks

+ AMG (tobramycin

5 mg/kg in 1x

or gentamycin)

N gonorrhoeae

Benzylpenicillin

200.000 E/kg in 6x

3 weeks

S aureus

Flucloxacillin

150 mg/kg in 4x

3-4 weeks

S pneumoniae

Benzylpenicillin

200.000 E/kg in 6x

3-4 weeks

Salmonella sp.

Cefotaxime

150 mg/kg in 4x

4 weeks

P aeruginosa

Ceftazidime + AMG

150 mg/kg in 3x

4-6 weeks

(tobramycine of

5 mg/kg in 1x

gentamicine)

Candida albicans

Fluconazole

15-20 mg/kg in 1x

6 weeks

*Choice of medications is preference although dependent on the sensitivity testing. **Duration is dependant on clinical response and fall in infectious parameters.

*Choice of medications is preference although dependent on the sensitivity testing. **Duration is dependant on clinical response and fall in infectious parameters.

Table 16.3. Options for switch to oral therapy when pathogen is sensitive

Maximum

Medication

Daily dose

daily dose

Remarks

Amoxicillin

50 mg/kg in 3x

4000 mg

Bactericidal, resorption app. 70-90% T1/2: 1-2 hours

Amoxicillin/

50/12.5 mg/kg in 3x

4000/1000 mg

Bactericidal, resorption amoxicillin

clavulanic acid

70-90%, clavulanic acid 60% T1/2: 1-2 hours

Clindamycin

25 mg/kg in 4x

1800 mg

Bacteriostatic, resorption >90% T1/2: 2-3 hours

Co-trimoxazole

36 mg/kg in 2x

1600/320 mg

Bactericidal, resorption >90% T1/2: 8-17 hours

Flucloxacillin

50 mg/kg in 4x

4000 mg

Bactericidal, resorption app. 50% T1/2: 1 hour

Fucidin acid

50 mg/kg in 3x

1500 mg

Resorption app. 90% T1/2: 9 hours

Linezolid

30 mg/kg in 3x

1200 mg

Resorption >90%

generation cephalosporin in combination with fluxcloxacillin is the preferred treatment. No information is present on switch-therapy in neonates. Because of the multifocal presentation and the severity of the disease a treatment duration of 4 to 6 weeks of intravenous antibiotics is usually prescribed.

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