In our opinion, the currently available data justify the following recommendations: in uncomplicated cases of OM, SA and OM+SA, the intravenous phase (if needed at all) can be short, 2–5 days. A total course of 20 days for OM and OM+SA, and 10–14 days in SA suffices in most cases.[3,9–11] Sometimes, even a shorter course may heal the patient, but no randomized study has assessed these 'ultra-short' treatments.
An interesting modality would be to use, instead of the traditional bolus administration, continuous infusion of a time-dependent antibiotic (such as β-lactam, clindamycin and vancomycin), at least in the beginning of treatment. The MIC would thus be exceeded for the maximum length of time which brings considerable advantages over the traditional bolus administration. We foresee that continuous infusion will gain more attention also in the treatment of osteoarticular infections. In the past many studies on slow β-lactam infusions have suffered from methodological flaws, but a large randomized trial on childhood bacterial meningitis strongly supports this method of drug administration. Clindamycin infusion has already been used in adult bone and joint infections.
MRSA is a threat to successful treatment of OM, SA and OM+SA. Some MRSA strains seem to be able to form subperiosteal abscesses more often than methicillin-sensitive S. aureus, regardless of prompt treatment. Recent Infectious Diseases Society of America guidelines recommend vancomycin as the primary antibiotic for MRSA, although clindamycin is also permitted if the patient stays stabile and the local MRSA resistance to clindamycin is <10%. Some authors prefer this limit to be up to 25%. We concur with this view, especially that most MRSA strains have remained susceptible to clindamycin. Among 45 children with SA, of whom 13 had disease caused by the feared USA300 strain, only two patients required vancomycin; 49% were treated with clindamycin. Occasionally, the very expensive linezolid is indicated,[19,53] but resistance of S. aureus has already been detected, though not yet reported in osteoarticular infections. There is great demand for new antibiotics against MRSA and other resistant pathogens.
Osteoarticular infections of childhood are rare in high-income countries, and generally speaking, the outcome is favorable.[9–11] This is not the case in resource-poor settings where OM, SA and OM+SA are rampant, patients seek medical advice late in the disease, only suboptimal treatment is feasible and complications are common.[55,56] Chronic osteomyelitis is not infrequent, and at least in one report, a previous use of β-lactams predisposing to onset of MRSA was a risk factor for osteomyelitis relapse, as was the onset of disease in the metaepiphyseal region. All this said, osteoarticular infections affect mostly youth and place them disproportionately high in the healthcare burden in countries with already scarce resources. In these parts of the world simplified treatment schemes adapted to take into consideration local circumstances are needed.
The authors thank Heini Pohjankoski who allowed them to use the photograph of clindamycin-associated rash (Figure 2).
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Expert Rev Anti Infect Ther. 2011;9(12):1125-1131. © 2011 Expert Reviews Ltd.