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By Dean L. Winslow, MD, FACP, FIDSA
Dr. Winslow is Chairman, Department of Medicine, Santa Clara Valley Medical Center, Clinical Professor of Medicine and Pediatrics (Affiliated), Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine.
Dr. Winslow reports no financial relationships relevant to this field of study.
SYNOPSIS: Two hundred sixty-five children with culture-proven acute bone or joint infections were studied. All patients received 2-4 days of IV antibiotics followed by PO antibiotics. Clinical outcomes and resolution of inflammatory biomarkers were the same whether the patient had positive blood cultures or not on admission.
SOURCE: Pääkkönen M, et al. Does bacteremia associated with bone and joint infections necessitate prolonged parenteral antimicrobial therapy? J Pediatric Infect Dis Soc2015;4:174-177.
Two hundred sixty-five previously healthy children with culture-proven acute bone or joint infection (age range 3 months to 15 years) were studied. Cultures were obtained from the affected bone or joint and from blood. Clindamycin or a first-generation cephalosporin were given according to randomization for a total of 20 or 30 days in osteomyelitis and 10 or 30 days in septic arthritis. Patients with Haemophilus influenza type B arthritis were given IV ampicillin followed by PO amoxicillin. Treatment was always instituted IV and given for 2-4 days at the discretion of the treating clinicians.
The switch to PO was made once the patient was felt to be clinically responding and CRP began to decline. One hundred thirty-one patients had osteomyelitis with or without adjacent septic arthritis, and 134 had septic arthritis alone. Blood cultures were positive in 59% of cases. Staph. aureus (MSSA) was isolated in 199 cases, Haemophilus influenza type B in 26 cases, Streptococcus pyogenes in 25 cases, Streptococcus pneumonia in 12 cases, and other organisms in 3 cases. Mean duration of IV antibiotics was 4 days in both the no bacteremia and bacteremia groups; CRP normalized in 10 days in both groups; and ESR normalized in 23 days in patients with no bacteremia and in 24 days in the patients with bacteremia. There were no relapses or treatment failures in the entire series.
I found this to be a very interesting paper, which supports one of my biases regarding over-treatment of many infections, especially in adult infectious disease. While one needs to be careful about extrapolating treatment of a largely pediatric disease to adult infections, the take-home point still applies: There is nothing magical about IV antibiotics despite the common perception of patients, generalist physicians, and even infectious disease subspecialists that there is.
Despite the potential for even more adherence issues in children than in adults, the fact that serious bacteremic infections can be successfully treated with very short courses of IV antibiotics (followed by PO) should be reassuring to infectious disease specialists. Since the introduction of PICC lines in the 1980s, there has clearly been a “duration creep” in the lengths of IV treatment of many infections. In most cases, there is no justification for this but it is often done because of “fear of failure” by the treating physicians and there is often the attitude, “because we can” since PICCs are so easy to insert.
What is often forgotten is that PICC lines can be complicated by subclavian vein thrombosis and line sepsis, and the prolonged duration of IV antibiotics is likely driving both increased C. difficile infection rates and increased prevalence of antimicrobial-resistant bacteria, as well as dramatically increased costs.