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ARTICLES: Theoklis Zaoutis, A. Russell Localio, Kateri Leckerman, Stephanie Saddlemire, David Bertoch, and Ron Keren Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in Children Pediatrics 2009; 123: 636-642 [Abstract] [Full text] [PDF]

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Which parameters to decide timing of transition to oral therapy?

Angela De Cunto, Federico Minen   (12 February 2009)

High failure rate for osteomyelitis treatment

Charles Grose, Jill Amsberry   (13 March 2009)

Which parameters to decide timing of transition to oral therapy? 12 February 2009
Angela De Cunto, Dr IRCCS Burlo Garofolo University of Trieste Italy, Federico Minen Send letter to journal: Re: Which parameters to decide timing of transition to oral therapy? angela.decunto{at}libero.it Angela De Cunto, et al.	Dear Sir, we read with interest your article about Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in Children (1). The route for antibiotic treatment still represents an undefined issue and your paper provides important data about effectiveness of early transition to oral therapy in treatment of acute osteomyelitis. However, probably a more important issue is defining the laboratory and/or clinical parameters that would determine the decision to switch to oral therapy (and that would influence the outcome). You reported that transition to oral therapy occurred at time of discharge. However you did not specify laboratory and/or clinical parameters considered to decide time of discharge. Moreover, also length of therapy can affect osteomyelitis outcome. Although overall treatment for 4-6 weeks is considered standard therapy, it can be useful to know if the duration of therapy was the same for the different hospitals and if not how it influenced the outcome. 1. Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics. 2009;123(2):636-42 Conflict of Interest: None declared
High failure rate for osteomyelitis treatment 13 March 2009
Charles Grose, Physician/professor University of Iowa, Jill Amsberry Send letter to journal: Re: High failure rate for osteomyelitis treatment Charles-grose{at}uiowa.edu Charles Grose, et al.	To the Editor.- We have read the recent article about treatment of osteomyelitis with both interest and skepticism (1). We suggest that the conclusion that intravenous (IV) and oral treatment regimens have equal failure rates (5% vs. 4%) be reconsidered, because we consider the failure rate for IV treatment to be too high. One of us (CG) has been director of pediatric infectious diseases at the University of Iowa Children’s Hospital since January 1985. The hospital medical records were completely computerized as of Sept. 2003. Thus we know for certain that 49 cases of osteomyelitis in otherwise healthy children were seen through December 2008. Based on reliable patient census data back to January 1985, we estimate a total of 200 inpatient cases of osteomyelitis in otherwise healthy children over the past 23 years. There was one failure in the late 1980s. In that case, the private pediatrician switched to oral therapy after one week of IV therapy at our hospital. Because of prolonged litigation against the pediatrician, we have remained leery of oral therapy. Thus, over 95% of the 200 cases have been treated with IV antibiotics for at least 3 weeks. Therapy is stopped when the ESR falls below 20 mm/hr. IV therapy is continued for 1-2 more weeks if the ESR remains above 20 mm at 4 weeks. Oral therapy is usually substituted for IV therapy if the IV line fails around 3 weeks. Our protocol is essentially the same as that recently described in the Pediatric Infectious Disease Journal (2). We have knowledge of a second failure in the 1990s, when oral therapy was substituted during the second week. Thus our failure rate is around 1% for mainly IV therapy of osteomyelitis in otherwise healthy children between 1985-2008. The pediatric infectious diseases division is small (usually 3 physicians) but we are the only pediatric infectious disease specialists in the entire state of Iowa. Therefore, it is unlikely that many treatment failures would have been missed because they were treated elsewhere in the state. Obviously, an occasional patient may have obtained subsequent therapy in an adjacent state. Thus, our failure rate compares favorably with the best in the article (1.8%). Importantly, we find the highest failure rate of 12.5% among the surveyed hospitals in the article (1) to be unexpectedly high and question why the authors chose to include it in their calculations because it skews the range of failures. Furthermore, are the authors aware of any published osteomyelitis treatment protocol that cites a failure rate of 12.5% as the anticipated or accepted failure rate? References 1. Zaoutis T, Lacalio AR, Leckerman K, Saddlemire S, Bertoch D., Keren R. Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in Children. Pediatrics. 2009; 123(2):636- 642 2. Saphyakhajon P. Joshi AY, Huskins WC, Henry NK, Boyce TG. Empiric antibiotic therapy for acute osteoarticular infections with suspected methicillin-resistant Staphylococcus aureus or Kingella. Pediatr Infect Dis J. 2008;27(8):765-7. Conflict of Interest: None