What Would Pediatric Infectious Disease Consultants Recommend for Management of Culture-Negative Acute Hematogenous Osteomyelitis?

Objective: To assess the opinion of pediatric infectious disease (PID) specialists regarding the management of culture-negative acute hematogenous osteomyelitis. Methods: A questionnaire that included a hypothetical case scenario of a 4-year-old boy with culture-negative osteomyelitis was distributed via a Web-based system to PID specialists across the United States. Results: Of 481 eligible participants surveyed, 147 (31%) responded. For initial therapy of osteomyelitis, 37% of respondents chose a beta-lactam, 24% chose clindamycin, 10% chose vancomycin as the sole therapy, and 29% chose a combination of these. The initial choice of antibiotics was correlated with the reported incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in the institution (P < 0.01). In areas where the prevalence of CA-MRSA was intermediate (between 25% and 50%), the choice of antibiotics was more heterogeneous. For change from intravenous to oral therapy, approximately 70% of respondents would change to oral therapy sooner than 3 weeks depending on clinical, laboratory, and social factors. After significant clinical and laboratory (sedimentation rate and C-reactive protein) improvements, most respondents (69%) chose to treat for a total duration (intravenous and oral) of 3 to 4 weeks. Conclusions: This study illustrates that the empiric choice of antibiotics for treatment of acute hematogenous osteomyelitis was driven by the local prevalence of CA-MRSA. When the prevalence of CA-MRSA was intermediate, the recommendations for management of bone infections were more heterogeneous. Clinical trials are needed to compare the effect of different management strategies on outcome, side effects, and costs.