1369 - The Spectrum of Chronic Osteomyelitis in Children

Background: While the majority of pediatric osteomyelitis cases are acute in nature, a significant subset present with prolonged symptoms often associated with substantial morbidity. Little data exist to guide clinicians in the management of these infections. We sought to describe the epidemiology, clinical features and management of chronic osteomyelitis in children.

Methods: We reviewed hospital admissions with an ICD10 code for chronic osteomyelitis from 2011-2018 at Texas Children’s Hospital. Cases were included if symptoms lasted >28 days on presentation. Patients diagnosed with chronic recurrent multifocal osteomyelitis were excluded. Cases were classified as those 1) associated with a contiguous focus (CoF), 2) penetrating or open trauma, 3) orthopedic hardware (OH), 4) post-acute chronic osteomyelitis (PACO, those occurring after >28 days of therapy for acute osteomyelitis) and 5) primary hematogenous chronic osteomyelitis (PHCO, those with 28 days of symptoms without other clear risk factors).

Results: 114 cases met inclusion criteria.  The median patient age is 11.8 years and 35.9% patients had underlying comorbidities. 83% of patients underwent a surgical procedure.  Cases were diverse in terms of pathogenesis (Figure 1).  A microbiologic etiology was identified in 72.8% of cases and was polymicrobial in 20.2% of cases; Staphylococcus aureus was the single most common etiology (Figure 2).  CoF infection was more often associated with polymicrobial etiology with or without Pseudomonas (P< 0.001) and disease of the foot.  PACO was caused by S. aureus in 95% of cases (p< 0.001, Figure 3).  The overall median duration of total therapy was 210 days.  41% were discharged from hospital on OPAT with or without later transition to oral antibiotics.  26.3% of patients had persistent functional limitations at time of last follow-up of which 46% experienced repeat hospital admission/surgery.  There was no association between duration of intravenous therapy and persistent functional limitations. Figure 1. Categories of Chronic Osteomyelitis
Figure 2. Microbiology of Pediatric Chronic Osteomyelitis
Figure 3. Clinical Features of Pediatric Chronic Osteomyelitis


Conclusion: Children with chronic osteomyelitis are diverse both in terms of pathogenesis and microbiology.  Pathogenesis and clinical presentation can provide clues to microbiologic etiology.  Prolonged intravenous therapy does not appear to improve functional outcomes in chronic osteomyelitis