Impact of guidelines implementation on empiric antibiotic treatment for pediatric uncomplicated osteomyelitis and septic arthritis over a ten-year period: Results of the ELECTRIC study (ostEomyeLitis and sEptiC arThritis tReatment in children)

Abstract

BackgroundDue to the growing evidence of the efficacy of intravenous (IV) cefazolin with an early switch to oral cefalexin in uncomplicated pediatric osteomyelitis (OM) and septic arthritis (SA) in children, we changed our guidelines for empiric antibiotic therapy in these conditions. This study aims at evaluating the impact of the guidelines' implementation in reducing broad-spectrum antibiotic prescriptions, duration of IV antibiotic treatment and hospital stay, treatment failure and recurrence.Materials and methodsThis is a retrospective, observational, quasi-experimental study. The four years pre-intervention were compared to the six years, ten months post-intervention (January 2012, through December 2015; January 2016, through October 31st, 2022). All patients aged 3 months to 18 years with OM or SA were evaluated for inclusion. Each population was divided into three groups: pre-intervention, post-intervention not following the guidelines, and post-intervention following the guidelines. Differences in antibiotic prescriptions such as Days of Therapy (DOT), activity spectrum and Length of Therapy (LOT), length of hospital stay (LOS), broad-spectrum antibiotics duration (bsDOT), treatment failure and relapse at six months were analyzed as outcomes.ResultsOf 87 included patients, 48 were diagnosed with OM (8 pre-intervention, 9 post-intervention not following the guidelines and 31 post-intervention following the guidelines) and 39 with SA (9 pre-intervention, 12 post-intervention not following the guidelines and 18 post-intervention following the guidelines). In OM patients, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group, with also the lowest proportion of patients discharged on IV treatment. Notably, significantly fewer cases required surgery in the post-intervention groups. Considering SA, LOS, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group. The treatment failure rate was comparable among all groups for both OM and SA. There were no relapse cases. The overall adherence was between 72 and 100%.ConclusionsThe implementation of guidelines was effective in decreasing the extensive use of broad-spectrum antibiotics and combination therapy for both OM and SA. Our results show the applicability, safety, and efficacy of a narrow-spectrum IV empirical antibiotic regimen with cefazolin, followed by oral monotherapy with first/second-generation cephalosporins, which was non-inferior to broad-spectrum regimens.

Methods to Reduce Cost of Treatment in Childhood Bone and Joint Infection

“…Of note, studies that report hospitalization cost based on administrative data sets are considered at risk of selection bias because of inaccurate classification of diseases in hospital coding systems. Loss of follow-up and missing data were common issues, and only 9 studies explicitly mention guideline adherence 30,31,36,37,39,40,42,44,51 .…”

“…Sixteen publications were identified that met criteria by introducing a clinical care innovation and reporting its impact on LOS 12,13,[29][30][31][32][33][34][35][36][37][38][39][40][41][42] (Table III). Studies that only explored the efficacy of shorter antibiotic treatment have not been included as this is previously established information.…”

“…It should be noted that studies that demonstrate the greatest difference in preprotocol and postprotocol LOS generally started with a longer average hospital stay. For example, 5 studies had an initial LOS of more than 10 days 12,29,31,36,42 . Importantly, these studies generally did not exclude complex cases of BJI, which are prone to longer inpatient treatment.…”

Respuesta al caso clínico: abordaje de lesión ósea en adolescente previamente sano 1

“…La incidencia se estima en 1.2 a 13 casos por 100,000 niños por año. 2 Staphylococcus aureus (S. aureus) es el principal agente etiológico en 60 a 75% de las OM. Con una recurrencia y persistencia de la infección en 40% de los casos.…”

“…Siempre se debe obtener un hemocultivo en el caso de osteomielitis aguda antes de iniciar el tratamiento antibiótico, a pesar de las bajas tasas de positividad (10-40%). 2 Aunque las alteraciones óseas radiológicas se presentan después de siete días de evolución, la radiografía simple es un método útil de primera línea para evaluar la infección ósea donde no se cuenta con otros estudios de imagen. Las alteraciones radiográficas son detectadas en 35% de los casos y la alteración más frecuente es la reacción perióstica.…”