Acute osteomyelitis/Septic arthritis/Acute discitis

Antimicrobial prescribing: NHS Grampian, Orkney & Shetland
NHS Grampian

Micro Organisms

Less than 5 years – Staphylococcus aureus, Kingella kingae, Group A Streptococcus, Streptococcus pneumoniae. Streptococcus agalactiae (GBS) and Escherichia coli in neonates.

Rare causes – Haemophilus influenza type b (unvaccinated individuals) & Salmonella spp (sickle cell disease).

5-18 years – Staphylococcus aureus, Group A Streptococcus and Streptococcus pneumoniae

Duration

For duration and oral switch seek specialist advice from paediatric infectious diseases consultant or microbiology.

Age less than 3 months

Therapy

IV Ceftriaxone*

*Contraindications to ceftriaxone:

  • Concomitant treatment with intravenous calcium (including total parenteral nutrition containing calcium) in premature and full-term neonates
  • Full-term neonates with jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia (bilirubin greater than or equal to 200 umol/L), or impaired bilirubin binding
  • 41 weeks or less corrected gestational age

Notes:

If Ceftriaxone is contra-indicated give IV Cefotaxime.

Review antibiotics in conjunction with paediatric infectious diseases consultant or microbiology once sensitivities are available.

Minimum 14 days IV therapy recommended – discuss ALL cases with paediatric infectious diseases consultant or microbiology before oral switch.

Age 3 months - 5 years

Therapy

IV Ceftriaxone*

*Contraindications to ceftriaxone:

  • Concomitant treatment with intravenous calcium (including total parenteral nutrition containing calcium) in premature and full-term neonates
  • Full-term neonates with jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia (bilirubin greater than or equal to 200 umol/L), or impaired bilirubin binding
  • 41 weeks or less corrected gestational age

Notes:

If Ceftriaxone is contra-indicated give IV Cefotaxime

Review antibiotics in conjunction with paediatric infectious diseases consultant or microbiology once sensitivities are available.

IV to oral switch if: afebrile, pain free for over 24 hours, CRP less than 20mg/L or reduced by 2/3 of highest value.

Age 6 years or above

Therapy

IV Flucloxacillin*

* Dose as per Osteomyelitis in BNFC.

Notes:

Review antibiotics in conjunction with paediatric infectious diseases consultant or microbiology once sensitivities are available.

IV to oral switch if: afebrile, pain free for over 24 hours, CRP less than 20mg/L or reduced by 2/3 of highest value.

Penicillin allergy Age less than 3 months

Therapy

Non-anaphylactic reaction to penicillin:

IV Ceftriaxone*

*Contraindications to ceftriaxone:

  • Concomitant treatment with intravenous calcium (including total parenteral nutrition containing calcium) in premature and full-term neonates
  • Full-term neonates with jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia (bilirubin greater than or equal to 200 umol/L), or impaired bilirubin binding
  • 41 weeks or less corrected gestational age

If Ceftriaxone is contra-indicated give IV Cefotaxime.

Review antibiotics in conjunction with paediatric infectious diseases consultant or microbiology once sensitivities are available.

Minimum 14 days IV therapy recommended – discuss ALL cases with paediatric infectious diseases consultant or microbiology before oral switch.

Anaphylactic reaction to penicillin:

If age less than 6 weeks seek immediate advice.

If age greater than 6 weeks IV Co-trimoxazole but seek early advice from paediatric infectious diseases consultant or microbiology.

Notes:

Minimum 14 days IV therapy recommended – discuss ALL cases with paediatric infectious diseases consultant or microbiology before oral switch.

Penicillin allergy Age 3 months - 5 years

Therapy

Non-anaphylactic reaction to penicillin:

IV Ceftriaxone*

*Contraindications to ceftriaxone:

  • Concomitant treatment with intravenous calcium (including total parenteral nutrition containing calcium) in premature and full-term neonates
  • Full-term neonates with jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia (bilirubin greater than or equal to 200 umol/L), or impaired bilirubin binding
  • 41 weeks or less corrected gestational age

If Ceftriaxone is contra-indicated give IV Cefotaxime.

Review antibiotics in conjunction with paediatric infectious diseases consultant or microbiology once sensitivities are available.

Anaphylactic reaction to penicillin:

IV Co-trimoxazole but seek early advice from paediatric infectious diseases consultant or microbiology.

Notes:

IV to oral switch if: afebrile, pain free for over 24 hours, CRP less than 20mg/L or reduced by 2/3 of highest value.

Penicillin allergy Age 6 years or above

Therapy

IV Vancomycin

Notes:

IV to oral switch if: afebrile, pain free for over 24 hours, CRP less than 20mg/L or reduced by 2/3 of highest value.

Review antibiotics in conjunction with paediatric infectious diseases consultant or microbiology once sensitivities are available.

If MRSA likely

Therapy

Add IV Vancomycin

Notes:

Review antibiotics in conjunction with paediatric infectious diseases consultant or microbiology once sensitivities are available.

In sickle cell disease

Therapy

IV Ceftriaxone*

*Contraindications to ceftriaxone:

  • Concomitant treatment with intravenous calcium (including total parenteral nutrition containing calcium) in premature and full-term neonates
  • Full-term neonates with jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia (bilirubin greater than or equal to 200 umol/L), or impaired bilirubin binding
  • 41 weeks or less corrected gestational age

Notes:

Review antibiotics in conjunction with paediatric infectious diseases consultant or microbiology once sensitivities are available.

Notes

Immediate consultation by Orthopaedic Surgeons is essential. Contact orthopaedic team prior to starting antibiotics unless patient is clinically septic.

Take blood cultures prior to administering antibiotics.

For patients with metal work seek specialist advice.

For further management information consult BSAC paediatric pathway for Bone and Joint Infection for Children Presenting to Hospital.

Editorial Information

Last reviewed: 27/06/2024

Next review date: 27/06/2027

Author(s): Specialist Antimicrobial Pharmacists.

Version: 1

Author email(s): gram.antibioticpharmacists@nhs.scot.

Approved By: Antimicrobial Management Team

Document Id: AMT_Emp_Hosp_Paed_Osteo_1