Osteomyelitis in children: comparison of hematogenous and secondary osteomyelitis Robert H. Fitzgerald, jr., md; D. G. Landells, md; J. D. E. Cowan,
md
Summary:
Dr. Charles A.
at the Dr. Charles A.
pattern of osteomyelitis, in which the disease was refractory to the customary therapeutic regimens, has been observed.
A review of osteomyelitis in 54 patients treated Janeway Child Health Centre over a 4-year period revealed equal frequencies of secondary and hematogenous osteomyelitis. Although the clinical picture in patients with hematogenous osteomyelitis was classic, patients with secondary osteomyelitis presented with an altered clinical response. Patients with secondary osteomyelitis have a history of an antecedent puncture wound or an inadequately treated contiguous focus of infection; antistaphylococcal antimicrobial therapy was ineffective for most because gram-negative bacilli were isolated in this group of patients. In contrast to patients with hematogenous osteomyelitis, who frequently respond to intensive antimicrobial therapy, those with secondary osteomyelitis will frequently require surgical intervention to eradicate the infection.
Resume: L'ostEomyElite chez I'enfant: comparaison entre la forme hEmatogene et la forme secondaire Apres avoir passe en revue 54 cas d'osteomyelite traites a The Dr. Charles A. Janeway Child Health Centre durant une periode de 4 ans, on a constate des frequences egales des formes d'osteomyelite secondaire et hematogene. Bien que le tableau clinique chez les malades souffrant d'osteomyelite hematogene ait 6te classique, les malades souffrant d'osteomyelite secondaire presentaient une reaction clinique modifie. Chez ces derniers malades on notait un antecedent d'une plaie penetrante anterieure ou un
foyer d'infection contigu insuffisamment traite;
le traitement antistaphylococcique antimicrobiale avait echoue parce qu'on a isole des bacilles gram-negatifs chez ce groupe de malades. Par corttraste avec les malades
souffrant d'osteomyelite hematogene, qui reagissaient
frequemment a une antibiotherapie energique, il fallait souvent operer ceux qui etaient atteints pour eliminer I'infection.
d'osteomyelite secondaire
Reports of osteomyelitis in children have been limited to discussion of hematogenous osteomyelitis, which is pre¬ dominantly staphylococcal in origin.1"6 Changing patterns of clinical presentation and bacterial etiology in adult patients have been documented in the literature.7,8 At the From the Mayo Clinic,
Rochester, Minnesota and the Dr. Charles A.
Janeway Child Health Centre, St. John's, Nfld. Reprint requests to: Dr. R. H. Fitzgerald, Mayo Clinic, Rochester, MN 55901, USA 166 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
Janeway Child Health Centre
a
changing
This occurred when osteomyelitis was secondary to an treated contiguous focus of infection or to a puncture wound. The natural history of such secondary osteomyelitis and comparison of it with hematogenous osteomyelitis have not been emphasized. This report is a retrospective review of osteomyelitis treated at the Dr. Charles A. Janeway Child Health Centre over a 4-year period, with emphasis on the type of osteomyelitis, clinical and laboratory findings, bacterial etiology and treatment.
inadequately
Methods A retrospective review was made of patients treated for osteomyelitis between January 1, 1970 and December 31, 1973. All patients included in the study had histories and physical and radiologic findings compatible with osteo¬ myelitis. In the majority, culture from the wound, blood, urine or tissue was positive. (Ideally, all patients included in a study of osteomyelitis should have a positive culture.) The administration of antimicrobial agents to patients be¬ fore their presentation, and to seriously ill patients after specimens had been obtained for blood and urine cultures, precluded the isolation of microorganisms in 12 patients. Those patients without a positive culture who were included in this study had characteristic radiologic or histologic changes of acute osteomyelitis. It is difficult to be certain of the diagnosis in patients with clinical features of osteomyelitis and a positive blood culture who respond to systemic antimicrobial agents but fail to develop characteristic radiographic changes. Eight such patients, seen and treated early in their disease process, were excluded from this study.
Results There were 54 patients in the study. The number treated in each of the 4 years did not change appreciably (Fig. 1). The patients ranged in age from 6 weeks to 15 years (mean, 8.5 years); five patients were less than 1 year old (Fig. 2). There were 40 boys and 14 girls. In 27 patients the osteomyelitis was the sequel of exogenous contamination or of an antecedent contiguous focus of infection that had been inadequately treated: in
17 patients there was a history of a puncture wound at the site of the osteomyelitis, and in 10 patients there was soft tissue abscess in 6 and septic an adjacent infection arthritis in 4 (3 in the hip and 1 in the elbow). In the other 27 patients there was no history of infection or significant trauma, and they appeared to have pure hematogenous osteomyelitis. Thirty-five patients had received antimicrobial agents prior to admission (23 of the 27 patients with secondary osteomyelitis and 12 of the 27 patients with
hematogenous osteomyelitis). Clinical
presentation Thirty-three patients (16 with hematogenous and 17 with secondary osteomyelitis) had only a limp or a painful extremity. Thirty (56%) of the 54 patients were afebrile (temperature < 38°C) at the time of admission; 18 of the 30 (equally divided between the two groups) had received antimicrobial therapy prior to admission. The erythrocyte sedimentation rate (ESR) ranged from 10 to 90 mm/h (mean, 46 mm). In the 27 patients with secondary osteomyelitis the mean ESR was 40 mm/h (38 mm/h in patients with puncture wounds, 51 mm/h in pa¬ tients with contiguous soft tissue abscess, and 47 mm/h in patients with adjacent septic arthritis). In the 27 patients with hematogenous osteomyelitis the mean ESR was 47
mm/h.
Microbiologic findings one positive culture was obtained in each of patients. In 24 of the 27 patients with secondary osteo¬ myelitis, culture was positive: 21 cultures were from surgical specimens alone, 1 was from multiple blood specimens, 1 was from blood and surgical specimens (the same organism) and 1 was from urine (with negative cultures of blood and surgical specimens). In 18 of the 27 patients with hema¬ togenous osteomyelitis, culture was positive: two cultures were from blood only, nine were from surgical specimens, one was from a specimen obtained from a lytic lesion by needle aspiration, and six were from both blood and surgical specimens. In spite of vigorous attempts to identify the etiologie agent by cultures of throat secretions, stool, urine, blood and, when possible, surgical specimens, a positive culture was not obtained in 12 patients (3 with secondary and 9 with hematogenous osteomyelitis), 6 of whom had received anti¬ microbial agents prior to presentation. In all 12 patients the clinical picture was that of sepsis, and radiologic examination demonstrated lytic destruction with reactive 20 n
At least
42
16
patients (three with secondary and hematogenous osteomyelitis) incision, drainage and debridement were performed; all had histopathologic findings characteristic of osteomyelitis. In two patients with hema¬ togenous osteomyelitis, specimens obtained by aspiration of destructive bony lesions yielded no microorganisms on culture. In five patients with hematogenous osteomyelitis, multiple blood and urine cultures were negative. Gram-positive organisms (Micrococcaceae family) ac¬ counted for 54% of the isolates; 21 (88%) were Staphylo¬ coccus aureus, 15 being penicillin-resistant (at 1 \xg/m\) and none being resistant to the penicillinase-resistant penicillins. Forty-six percent of the organisms isolated were gramnegative bacilli Pseudomonas species in 13 cases, Escheri¬ chia coli in 3 and Klebsiella species in 3. The organisms isolated from patients with secondary osteomyelitis were primarily gram-negative: 19 patients had gram-negative bacilli alone, 1 had a gram-negative bacillus and a gram-positive coccus, and 4 had gram-positive cocci alone. In 17 of the patients with hematogenous osteomyelitis, gram-positive cocci were isolated; in only 1 patient was a gram-negative bacillus isolated. Treatment Until the results of microbiologic studies were available, patients with no abscess formation were initially treated by immobilization of the involved extremity and parenteral administration of a semisynthetic penicillinase-resistant peni¬ cillin and ampicillin. If a patient failed to respond clinically to this therapy within 48 to 72 hours, the extremity was examined and further radiographs were taken. If the in¬ fection could be localized, surgical debridement was per¬ formed. In 25 of the 27 patients with secondary osteomyelitis and 16 of the 27 patients with hematogenous osteomyelitis there was evidence of abscess formation or failure to demonstrate clinical improvement in 48 to 96 hours after intravenous administration of antimicrobial agents, and all 41 patients had surgical debridement. Four of the 54 patients returned with evidence of recurrence; 1 required additional surgical debridement and 3 required only further intravenous antimicrobial therapy. These failures resulted from inadequate surgical treatment in one patient and inadequate antimicrobial therapy in three patients, all of whom received antimicrobial agents intravenously for only 1 week. Complications resulting from the osteomyelitis occurred in six patients. Physeal destruction in three patients (two with hematogenous and one with secondary osteomyelitis) resulted in growth disturbance. Partial loss of motion of adjacent joints occurred in two patients. Soft tissue extension
H
10 n
Range; 6 weeks to 15 years Mean: 8.5 years
12 4
No. of
bone formation. In five
two with
i 6H
patients 8H
3
I 1970 1971 1972 1973
Year FIG. 1.Number of children with
osteomyelitis, by
H 2H ,
md
Summary:
Dr. Charles A.
at the Dr. Charles A.
pattern of osteomyelitis, in which the disease was refractory to the customary therapeutic regimens, has been observed.
A review of osteomyelitis in 54 patients treated Janeway Child Health Centre over a 4-year period revealed equal frequencies of secondary and hematogenous osteomyelitis. Although the clinical picture in patients with hematogenous osteomyelitis was classic, patients with secondary osteomyelitis presented with an altered clinical response. Patients with secondary osteomyelitis have a history of an antecedent puncture wound or an inadequately treated contiguous focus of infection; antistaphylococcal antimicrobial therapy was ineffective for most because gram-negative bacilli were isolated in this group of patients. In contrast to patients with hematogenous osteomyelitis, who frequently respond to intensive antimicrobial therapy, those with secondary osteomyelitis will frequently require surgical intervention to eradicate the infection.
Resume: L'ostEomyElite chez I'enfant: comparaison entre la forme hEmatogene et la forme secondaire Apres avoir passe en revue 54 cas d'osteomyelite traites a The Dr. Charles A. Janeway Child Health Centre durant une periode de 4 ans, on a constate des frequences egales des formes d'osteomyelite secondaire et hematogene. Bien que le tableau clinique chez les malades souffrant d'osteomyelite hematogene ait 6te classique, les malades souffrant d'osteomyelite secondaire presentaient une reaction clinique modifie. Chez ces derniers malades on notait un antecedent d'une plaie penetrante anterieure ou un
foyer d'infection contigu insuffisamment traite;
le traitement antistaphylococcique antimicrobiale avait echoue parce qu'on a isole des bacilles gram-negatifs chez ce groupe de malades. Par corttraste avec les malades
souffrant d'osteomyelite hematogene, qui reagissaient
frequemment a une antibiotherapie energique, il fallait souvent operer ceux qui etaient atteints pour eliminer I'infection.
d'osteomyelite secondaire
Reports of osteomyelitis in children have been limited to discussion of hematogenous osteomyelitis, which is pre¬ dominantly staphylococcal in origin.1"6 Changing patterns of clinical presentation and bacterial etiology in adult patients have been documented in the literature.7,8 At the From the Mayo Clinic,
Rochester, Minnesota and the Dr. Charles A.
Janeway Child Health Centre, St. John's, Nfld. Reprint requests to: Dr. R. H. Fitzgerald, Mayo Clinic, Rochester, MN 55901, USA 166 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
Janeway Child Health Centre
a
changing
This occurred when osteomyelitis was secondary to an treated contiguous focus of infection or to a puncture wound. The natural history of such secondary osteomyelitis and comparison of it with hematogenous osteomyelitis have not been emphasized. This report is a retrospective review of osteomyelitis treated at the Dr. Charles A. Janeway Child Health Centre over a 4-year period, with emphasis on the type of osteomyelitis, clinical and laboratory findings, bacterial etiology and treatment.
inadequately
Methods A retrospective review was made of patients treated for osteomyelitis between January 1, 1970 and December 31, 1973. All patients included in the study had histories and physical and radiologic findings compatible with osteo¬ myelitis. In the majority, culture from the wound, blood, urine or tissue was positive. (Ideally, all patients included in a study of osteomyelitis should have a positive culture.) The administration of antimicrobial agents to patients be¬ fore their presentation, and to seriously ill patients after specimens had been obtained for blood and urine cultures, precluded the isolation of microorganisms in 12 patients. Those patients without a positive culture who were included in this study had characteristic radiologic or histologic changes of acute osteomyelitis. It is difficult to be certain of the diagnosis in patients with clinical features of osteomyelitis and a positive blood culture who respond to systemic antimicrobial agents but fail to develop characteristic radiographic changes. Eight such patients, seen and treated early in their disease process, were excluded from this study.
Results There were 54 patients in the study. The number treated in each of the 4 years did not change appreciably (Fig. 1). The patients ranged in age from 6 weeks to 15 years (mean, 8.5 years); five patients were less than 1 year old (Fig. 2). There were 40 boys and 14 girls. In 27 patients the osteomyelitis was the sequel of exogenous contamination or of an antecedent contiguous focus of infection that had been inadequately treated: in
17 patients there was a history of a puncture wound at the site of the osteomyelitis, and in 10 patients there was soft tissue abscess in 6 and septic an adjacent infection arthritis in 4 (3 in the hip and 1 in the elbow). In the other 27 patients there was no history of infection or significant trauma, and they appeared to have pure hematogenous osteomyelitis. Thirty-five patients had received antimicrobial agents prior to admission (23 of the 27 patients with secondary osteomyelitis and 12 of the 27 patients with
hematogenous osteomyelitis). Clinical
presentation Thirty-three patients (16 with hematogenous and 17 with secondary osteomyelitis) had only a limp or a painful extremity. Thirty (56%) of the 54 patients were afebrile (temperature < 38°C) at the time of admission; 18 of the 30 (equally divided between the two groups) had received antimicrobial therapy prior to admission. The erythrocyte sedimentation rate (ESR) ranged from 10 to 90 mm/h (mean, 46 mm). In the 27 patients with secondary osteomyelitis the mean ESR was 40 mm/h (38 mm/h in patients with puncture wounds, 51 mm/h in pa¬ tients with contiguous soft tissue abscess, and 47 mm/h in patients with adjacent septic arthritis). In the 27 patients with hematogenous osteomyelitis the mean ESR was 47
mm/h.
Microbiologic findings one positive culture was obtained in each of patients. In 24 of the 27 patients with secondary osteo¬ myelitis, culture was positive: 21 cultures were from surgical specimens alone, 1 was from multiple blood specimens, 1 was from blood and surgical specimens (the same organism) and 1 was from urine (with negative cultures of blood and surgical specimens). In 18 of the 27 patients with hema¬ togenous osteomyelitis, culture was positive: two cultures were from blood only, nine were from surgical specimens, one was from a specimen obtained from a lytic lesion by needle aspiration, and six were from both blood and surgical specimens. In spite of vigorous attempts to identify the etiologie agent by cultures of throat secretions, stool, urine, blood and, when possible, surgical specimens, a positive culture was not obtained in 12 patients (3 with secondary and 9 with hematogenous osteomyelitis), 6 of whom had received anti¬ microbial agents prior to presentation. In all 12 patients the clinical picture was that of sepsis, and radiologic examination demonstrated lytic destruction with reactive 20 n
At least
42
16
patients (three with secondary and hematogenous osteomyelitis) incision, drainage and debridement were performed; all had histopathologic findings characteristic of osteomyelitis. In two patients with hema¬ togenous osteomyelitis, specimens obtained by aspiration of destructive bony lesions yielded no microorganisms on culture. In five patients with hematogenous osteomyelitis, multiple blood and urine cultures were negative. Gram-positive organisms (Micrococcaceae family) ac¬ counted for 54% of the isolates; 21 (88%) were Staphylo¬ coccus aureus, 15 being penicillin-resistant (at 1 \xg/m\) and none being resistant to the penicillinase-resistant penicillins. Forty-six percent of the organisms isolated were gramnegative bacilli Pseudomonas species in 13 cases, Escheri¬ chia coli in 3 and Klebsiella species in 3. The organisms isolated from patients with secondary osteomyelitis were primarily gram-negative: 19 patients had gram-negative bacilli alone, 1 had a gram-negative bacillus and a gram-positive coccus, and 4 had gram-positive cocci alone. In 17 of the patients with hematogenous osteomyelitis, gram-positive cocci were isolated; in only 1 patient was a gram-negative bacillus isolated. Treatment Until the results of microbiologic studies were available, patients with no abscess formation were initially treated by immobilization of the involved extremity and parenteral administration of a semisynthetic penicillinase-resistant peni¬ cillin and ampicillin. If a patient failed to respond clinically to this therapy within 48 to 72 hours, the extremity was examined and further radiographs were taken. If the in¬ fection could be localized, surgical debridement was per¬ formed. In 25 of the 27 patients with secondary osteomyelitis and 16 of the 27 patients with hematogenous osteomyelitis there was evidence of abscess formation or failure to demonstrate clinical improvement in 48 to 96 hours after intravenous administration of antimicrobial agents, and all 41 patients had surgical debridement. Four of the 54 patients returned with evidence of recurrence; 1 required additional surgical debridement and 3 required only further intravenous antimicrobial therapy. These failures resulted from inadequate surgical treatment in one patient and inadequate antimicrobial therapy in three patients, all of whom received antimicrobial agents intravenously for only 1 week. Complications resulting from the osteomyelitis occurred in six patients. Physeal destruction in three patients (two with hematogenous and one with secondary osteomyelitis) resulted in growth disturbance. Partial loss of motion of adjacent joints occurred in two patients. Soft tissue extension
H
10 n
Range; 6 weeks to 15 years Mean: 8.5 years
12 4
No. of
bone formation. In five
two with
i 6H
patients 8H
3
I 1970 1971 1972 1973
Year FIG. 1.Number of children with
osteomyelitis, by
H 2H ,
