Morbidity Meeting

By: Dr.Inayat Ullah

PGY-III Paeds

Shifa International Hospital Islamabad.

Case

l A Young 14 years old Girl with multifocal

Disseminated unresolving chronic

Osteomyelitis with underlying abscess.

Biodata

l Patient Name: A.B.C.

l MR# 17813514

l Age: 14 years

l Sex: Female

l Location: Swabi

l Admitted via : ER

l D.O.A: 01/05/2017 2300H

02/05/2017

l Fever..............25 days

l Backache.......25 days

l Bilateral hip pain....25 days.

HOPI

• Patient was in her usual state of health 25

days back when she developed high grade

fever, undocumented, intermittent and was

associated with back pain of mild to

moderate intensity with radiation into hip

right joint area.

• She is also bed ridden for the last 20 days

due to above symptoms.

Past History

• Had jaundiced 2 week agoand diagnosed

to be having Hep A for which she

remained admitted at local hospital and

was given supportive symptomatic

treatment.

On examiantion

l Vitals:

l HR:140/min

l RR: 23/min

l Temp: 38.5C

l Pain Score 6/10

l B.P: 100/60mmHg

On Examiantion

l Sick looking dehydrated, jaundiced, malnourished girl, febrile to touch and pale looking not in obvious distress

l CVS: S1+S2+0

l CNS: Intact no focal deficit, no SOMI.

l RESP: good air entry no added sounds, NVB.

l GIT: Abd soft non tender mild tenderness in RIF.

l MSS: Tenderness in right hip area and decreased range of motions.

1)Osteomyelitis of hip bone with

associated abscess

2)Septic arthritis of hip joint

3)Traumatic arthritis of hip

Admission plan

CBC CRP, RFT, ELECTROLYTES, ESR, LFT'S, BLOOD

C/S, URINE R/E, C/S, CT ABDOMEN AND PELVIS AND

CXR Were done.

Inj Ceftriaxone 1.5 g BD

Inj Vancomycin 700 mg q8H

Inj Ketorolac 15 mg iv q8 hourly

D/Saline @ 100 ml/hr.

LABS

HB 9.5 CL 94 Alk Phosp 311

HCT 30.2 HCO3 23 Gamma

GT

107

WBC 14700 N82

L18

BUN/Urea 10/21 ABO Group O-Positive

PLT 380000 Creat 0.46

CRP 147.72 BSR 130

ESR 90 ALT 46

PT/INR 12.3/1.2 AST 47

Na 131 T,Bili 1,68

K 3.4 D.Billi 0.911

Ultrasound report 02/05/17

• Echomixed area in right psaos muscle likely represent abscess

• Bilateral minimal pleural effusion.

• CT Abd/Pelvis:

• Large loculated thick walled partially enhancing hypodense area containing air loculi in R illiacus muscle with edema around consistent with abscess. Subtle reaction along R illiac bone tiny air loculiwithin illiacbone, extending and involving lower ribs.

• Findings are suggestive of infective process

Morning round plan

Interventional Radiology to Drain pus

Antibiotics Vancomycin and Meropenum

(instead of ceftriaxone) to continue.

Nutritional rehabilitation

PCM Protocol

02/05/2017

65 ml pus aspirated under ultrasound

guide successfully

Specimens were sent for Routine c/s,

fungal c/s, Gram stain, AFB Stain, AFB

C/S

Gene Xpert and anaerobic culture.

GRAM STAIN AND AFB STAIN

Gene Xpert 02/05/2017

Treatment Plan

Antibiotics continued

Clindamycin started 450 mg q8H

Amikacin 175 mg q8 hourly started

Vancomycin discontinued

High protein and high calorie diet started

and TPN weaned down.

Labs on 05/05/2017

HB 8.8 ESR 138

HCT 28.4 CRP 113.61

WBC 12600 Craet 0.47

Neutrophil 86 Vancomycin 6,54

Lymphos 11

Plateletes 424000

07/05/2017

Had persistent spiking fever

Backache

OE

Nontoxic with abdominal distension and RIF tenderness

Plan:

Pediatric surgery consult/Ortho consult.

Ultrasound abd/pelvis

08/05/2017

Ortho planned for biopsy of multiple cystic

lesions from illiac crest

Pediatric surgery planned after discussing

with ortho laparoscopic abscess drainage

08/05/2017

Patient underwent incision and drainage of

pelvic collection and biopsy of illiac crest

the same day by pediatric surgeon and

orthopedic surgeon.

Specimen were sent for c/s, gram stain,

AFB C/S, Histopathology and gene Xpert

Post-op patient remained stable

Drain was inserted in wound.

Pus swab C/S report

Chem 7 08/05/2017

08/05/2017

PUS AFB Smear 08/05/2017

10/05/2017

Patient had spiking fever

Otherwise good oral intake

Temp: 103F

Face flushed and rash on upper abdomen

Plan:

Follow cultures and biopsy

Send CBC,. CRP, LDH, ANA and Blood c/s in am.

10/05/2017

Blood C/S 11/05/2017

12/05/2017

She was clinically improved

Tolerating orally well and was a bit

mobilized.

Discharged home with OPD follow-up after

5 days on

Drain still in situ.

Inj Ceftriaxone 2 gram IV OD for 5 days.

Tab Metronidazol 400 mg TID

OPD Follow-up 15/05/2017

• Clinically improved

• Fever spikes improved

• Ambulatory at the moment

• Vitals: Spo2: 98, HR:134, Temp: 38.4C

• Plan: Tab Metronidazole 400 mg TID 1 week

• Tab Ciprofloxacin 250 mg BD 1 week

• Drain removed and advised follow-up after 1

week.

OPD Follow-up 23/05/17

• Fever still persits low grade

• Oral intake improved

• On/off abdominal pain and backache

• On exam: systemic exam normal

• Oral ulceration

• Warm and red local area

• Advised CBC, CRP Bone Scan and Blood C/S

• But they didn’t comply and lost to follow-up.

14/06/2017 IPD

• Fever………………15 days.

• Wound dehiscence/discharge……5 days.

• Pain in right lower limb……..5 days

• On exam

• BP 11O/67, HR 134bpm, RR 25/min Temp;38C

• Wound in right iliac region with pus discharge

• Seen by pediatric surgery advised MRI and Orthopedic opinion

14/06/2017 IPD

• Antibiotics were started and orthopedic

consulted

• Inj Cefazolin 300 mg q6 hourly

• Inj Gentamicin 70 mg q8 hourly

• Inj Metronidazole 300 mg q8 hourly

• Analgesic paracetamol and ketorolac.

14/06/17

• Pus sent for Gram Stain and culture

• Gram stain and culture came out to be

negative

• Immunoglobulin level were in normal

range

14/06/17

14/06/2017

Labs on 14/06/2017

Na 137 ALT 14

K 4.5

CL 101

HCO3 19 15/06/2017

Creat 1.17

BUN/Urea 20/42 Creat 0.97

BSR 61 Gentacin 3.7

CRP 273.44

CT Pelvis 15/05/2017

CT Pelvis 15/05/2017

CT Report

16/06/2017

• Still C/O Pain

• Had been afebrile and range of motion at

local joint is decreased.

• CT Scan Pelvis done

• Seen by orthopedics and done

• Right hip Incision and drainage, wound

wash out, advised to continue antibiotics

18/06/2017

• Remained afebrile

• Not in distress or pain, drain in place

• Gram stain showed numerous pus cells

otherwise no growth of organism

• Advised to repeat CBC, CRP, Creat, ESR,

HIV and IgE levels.

Labs 19/06/2017

ESR 60

HIV Ab Non-Reactive

CRP 54.43

IgE 262

Creat 0.75

CBC Differential

Hb 9.4

HCT 31.2

WBC 19400

Neutrophils 84

Lymphocytes 12

Platelets 413000

Current status of patient

• Still admitted with on/off fever spikes and severe pain in local area still fluid draining from drains inserted after orthopedic surgery

• Antibiotics

• Cefazolin 750 mg q8 hourly IV

• Metronidazole 300 mg IV q8 hourly

• Gentamicin 70 mg q8 hourly IV

• Co-Trimoxazole 160 mg q12 hourly orally

• Nalbuphine and gravinate for IV analgesia Q6h

• Paracetamol 500 mg IV q8H

Questions

What may have contributed to this patient’s morbidity?

Was it preventable or not?

What is the current acceptable morbidity and mortality

associated with this condition?

What are the current evidence based guidelines for the

treatment of this condition?

What are the lessons learned for future management?

Osteomyelitis

• Haematogenous infection is the most common, acute or subacute.

• Long bones are most often affected in children.

• Most unifocal, 5–20 % multifocal.

• In neonates, OM is often multifocal with associated SA.

• Chronic recurrent multifocal osteomyelitis

• Rare inflammatory condition.

• Recurrent, sterile, lytic lesions.

• Often in the clavicle, humerus, and tubular bones.

Etiology

• Neonates

• Group B streptococcus (GBS), Methicillin sensitive Staphylococcus

aureus, (MSSA), Escherichia coli

• Gram-negatives, Candida albicans

• <2 years

• MSSA, Kingella kingae, Streptococcus pneumoniae , non-typeable

Haemophilus spp., E. coli

, MSSA PVL (uncommon in the UK), MRSA PVL

• 2–5 years

• MSSA, K. kingae , group A streptococcus (GAS), S. pneumoniae,

non-typeable Haemophilus spp., MSSA PVL MRSA PVL, Coxeilla

burnettii.

Etiology cont’d

• >5 years

• MSSA, MSSA PVL (uncommon in the UK), MRSA PVL

• Other much rarer organisms (consider in immunosuppressed

children or other risk factors)

• H. influenzae type b (unimmunized), coagulase-negative

Staphylococcus (subacute), Pseudomonas spp., Neisseria

gonorrhoeae, Neisseria meningitidis

• Mycobacterium tuberculosis Salmonella spp. (sickle cell disease),

Bartonella henselae , non-tuberculous mycobacteria, Klebsiella

spp., Fusobacterium (often multifocal), Aspergillus Candida

albicans

Signs symptoms of osteomyelitis

Child

• Usually short history, with an ill child in pain.

• Fever frequent, but may be absent.

• Refusal to move the limb or to weight bear, limp, erythema, bone or

• limb swelling, local tenderness.

• In SA there is a unifocal hot, immobile, tender peripheral joint, with pain on passive joint movement.

• May have no focal signs.

Chronic/multifocal osteomyelitis.

• Subacute or chronic osteomyelitis

• Longer history, maybe weeks, with no systemic symptoms.

• Often no fever. Less acute local signs with limp, refusal to move the limb or weight bear, local bony swelling or tenderness.

• Chronic recurrent multifocal osteomyelitis

• Initially indistinguishable from acute/subacute OM.

• Histology non-specific.

• Pain may be severe, persistent and debilitating.

Risk factors and differentials

• Risk factors

• Trauma, sickle cell disease, immunodeficiency, penetrating wounds,

• bone fixators or plates, varicella infection (GAS).

• Differential diagnosis

• Trauma including non-accidental injury, malignancy (osteosarcoma, leukaemia, neuroblastoma), reactive arthritis, haemarthrosis,

• Henoch–Schönlein purpura, juvenile idiopathic arthritis, tuberculosis.

Investigations

• Blood tests

• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) more reliably increased than white cell count but normal values do not absolutely exclude OM or SA (although osteoarticularinfection is less likely if CRP and ESR are normal).

• Microbiological culture of blood (all cases), joint fluid (from aspiration), periosteal pus or bone biopsy.

• Difficult cases may require molecular diagnostic techniques (e.g. 16S rDNA polymerase chain reaction (PCR), targeted multiplex PCR)

Imaging

• Plain radiographs are often unhelpful in acute presentations as osteolytic changes/periosteal elevation occur 10–21 days after the onset of symptoms. They are important as a baseline assessment, to exclude trauma and in subacutepresentations.

• Ultrasonography is useful for identifying deep effusions in SA and

• subperiosteal collections in OM.

• Magnetic resonance imaging MRI with enhancement has best diagnostic sensitivity and specificity.

• Technetium radionuclide bone scan ( 99mTc)

• High sensitivity and specificity but used less often due to the radiation burden

• May give false-negative results in infancy

Management

• Multidisciplinary including paediatricians,

orthopaedic surgeons, radiologists and

microbiologists.

• Little high quality evidence to guide

therapy, but established, consistent

practice.

Surgical management

• Often not required in OM with early radiographic signs.

• Surgical drainage in acute OM is indicated if no response to antibiotics

• after 48–72 hours or if radiological evidence of a substantial pus collection.

• Urgent wash-out and drainage of SA in hip, aspiration and irrigation in other joints, to reduce pressure on growth plate.

• More aggressive surgical management if PVL MSSA or MRSA suspected or confirmed.

• Immobilize any surgically treated limb or focus of infection.

Medical management

• Start empirical intravenous antibiotics on clinical

diagnosis of acute OM or SA.

• Use high doses:

• Neonates to <3 months: intravenous cefotaxime

amoxicillin as in suspected sepsis/meningitis

• ≥ 3 months to ≤ 5 years:

• intravenous cefuroxime monotherapy

• ≥ 6 years:

• intravenous flucloxacillin or clindamycin monotherapy.

• Optimize antimicrobial treatment if organism is identified.

Medical management

• In simple unifocal disease

• a rapid switch to oral therapy may be appropriate:

• Neonates to <3 months:

• consider intravenous to oral switch after 14–21 days if:

• Afebrile+ pain-free for at least 24 hours

• And CRP <20 mg/L or CRP decreased by ≥ 2/3 of highest value.

• Child ≥3 months:

• consider intravenous to oral switch after 48–72 hours if :

• Afebrile + pain-free for at least 24 hours

• andCRP <20 mg/L or CRP decreased by ≥ 2/3 of highest value.

Medical managementWhen switching to oral antibiotics, dose, administration frequency, and

• palatability must be considered.

• Suggested pragmatic empirical oral antibiotic choices where organism

• remains unknown. Use high doses:

• Neonatal- 1–2 months-2 month – 2 years-2–5 years

• : Co-amoxiclav suspension three times daily

• 6–8 years

• : Co-amoxiclav suspension three times daily or

• flucloxacillin four times daily (only if child can take tablets)

• 9–18 years

• : Flucloxacillin four times daily or clindamycin four times daily

• Antibiotic therapy is continued for a total of 3–4 weeks in SA and 4–6 weeks

in OM

Complex disease

• Complex disease (multifocal significant bone destruction,

resistant/unusual pathogen immunosuppressed, sepsis, or

shock) requires prolonged intravenous antibiotic therapy and

the total length of antibiotic course may need to exceed 6

weeks.

• Treatment of complex disease should be managed in

conjunction with experts in bone and joint infection.

• Prolonged intravenous therapy can be given in the community

in some cases

• Chronic recurrent multifocal osteomyelitis: Use simple

analgesia and non-steroidal anti-inflammatory drugs (NSAIDs);

refer to paediatric rheumatologist if alternative or experimental

therapies are considered necessary

Prognosis

• Outcome

• Most children with simple disease are discharged without long-term care or further assessment of growth or function.

• Significant risk of deep venous thrombosis and thromboembolism in children with OM.

• In severe diseases, risk of joint stiffness, limb shortening, dislocation (acutely neonates), and avascular necrosis of affected epiphysis.

• Delay in starting antibiotics for 7-10 days leads to permanent loss of bone structure and future growth abnormality.

• Future research

• The optimal duration of therapy is unknown and shorter treatment courses should be studied in randomized clinical trials.

• The safety of early oral switching in OM and SA should be further investigated in randomized clinical trials.

References

• Manual of Childhood infections by Mike

Sharland 3rd edition (Blue Book) by Royal

College Of Paediatrics and Child Health

(RCPCH)