The etiologic agents for complicated pneumonias and osteomyelitis have changed recently, according to presenters Drs. William and Creech, who assisted pediatric hospitalists in updated diagnosis and intervention strategies.
The increase in complicated pneumonias and empyemas is mostly due to the increase in Streptococcus pneumoniae serotype 19a. After introduction of the PCV-7 vaccine, incidence of serotype 19a infections increased to 98% of infections. Serotype 19a is now included in the PCV-13 vaccine, approved by the FDA in 2011. There are multiple interventions available for empyemas including chest tube alone, chest tube with fibrinolysis, and VATS. Current research is being done to assess efficacy for these measures.
Osteomyelitis may be caused by direct inoculation, spread from local infection, or hematogenous spread. S. Aureus is causative agent in 80-90% of patients. MRSA infection has a more complicated course. Based on patient response and inflammatory markers, a short course of intravenous antibiotics followed by oral antibiotics may be appropriate.
1. Surgical intervention for empyemas is patient specific and depends on clinical status, effusion, status, presence of loculations, and expertise of consultants.
2. Hematogenous spread is the most common cause of osteomyelitis in children.
3. MRI is diagnostic modality of choice for osteomyelitis.
4. Bone aspiration and blood cultures are very helpful in treatment of osteomyelitis.
5. Clindamycin can be considered for first line osteomyelitis treatment if it is not a life threatening infection, a limb threatening infection, or a high likelihood of bacteremia. Beta lactam coverage should be considered in toddlers due to Kingella.
Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts Medical Center in Boston.