**7. Management**

It is a necessary antibiotic treatment, as soon as possible, in order to prevent the potentially adverse anatomic and functional consequences, preferably after obtaining blood and bone aspirates for culture. As cultures may be negative or difficult to obtain, empirical treatment is based on the local prevalence of organisms, resistance patterns taking account of the change over the years of the spectrum of organisms causing OM. The choice of an agent is generally either a penicillin‐ ase‐resistant penicillin (e.g. nafcillin, oxacillin, flucloxacillin), which will be effective against S. aureus but may be of limited value against other organisms, or a broad‐spectrum cephalosporin, which could have reduced the activity against *S. aureus.* Antibiotics against methicillin‐sensitive *S. aureus* (MRSA) and streptococci (a penicillinase‐resistant penicillin, first generation cephalo‐ sporin or clindamycin) must be incorporated into any empiric regimen for OM because *S. aureus*, *group A Streptococci* and group B streptococcus (GBS) and *S. pneuomoniae* together account for more than 90% of the cases of osteoarthritis in neonates [39]. Immunization rates worldwide have obviated the need to use antibiotics against Hib in many countries. Cefuroxime, a sec‐ ond‐generation cephalosporin can be used as a single agent against both methicillin‐sensitive *S. aureus* (MSSA) and Hib, if they are the suspected pathogens. The increasing incidence of peni‐ cillin‐resistant S pneumoniae warrants the use of a clindamycin and cefotaxime/ceftriaxone com‐ bination. When treating neonatal OM, consider nafcillin and tobramycin or vancomycin and gentamicin combinations to provide coverage of bacteria from the Enterobacteriaceae family, in addition to group B streptococci and *S. aureus*. Vancomycin is preferred for proven or suspected MRSA‐related septicaemia or known multi‐drug resistant MRSA infection. The suspicion of enteric organisms justify additional therapy with an aminoglycoside, such as gentamicin, tobra‐ mycin or amikacin or an extended‐spectrum, a Pseudomonas‐active agent, such as cefepime [40]. In the case of acquired MRSA infections should be started vancomycin, rather than a peni‐ cillin antibiotic [5]. Daptomycin, Linezolid, and Quinupristin‐dalfopristin have not been fully evaluated or approved for use in neonates and should be employed when the neonate cannot tolerate vancomycin [40]. If B streptococcical infection is confirmed, combination therapy with penicillin G (or ampicillin) and gentamicin should be given for 2–5 days, after which time penicil‐ lin G (or ampicillin) alone is adequate. Monitoring serum acute‐phase proteins, particularly the C‐reactive protein, has been proposed as a useful way to determine resolution of infection and duration of therapy [40]. Management of *C. albicans* OM requires prolonged antifungal therapy. Society of America practices guidelines, including surgical debridement in selected cases and fluconazole therapy for 6–12 months, intravenous initially and then orally [26]. Amphotericin B is the most commonly used antifungal therapy. They are not provided clear guidelines on the optimum duration of treatment to eradicate infection. Even if by many are advocated short‐ ened courses of antibiotic therapy because of morbidity and cost implications related to the prolonged therapy, the recommended entire duration of treatment still consists of at least 4–6 weeks until normalization of the C‐reactive protein level [41]. Moreover it is typically recom‐ mended that infants under 3 months are given the full course of antibiotics parentally due to concerns over absorption and efficacy of oral antibiotics and to ensure adequate serum levels of the antibiotic. Recently some studies reported about oral therapy after a few days of intravenous therapy. Jagodzinski et al. [42] treated 70 children with intravenous therapy, converted after 3 (59%) or 5 (86%) days and continued for three weeks using temperature and C‐reactive protein as parameters to response to therapy. The use of third‐generation cephalosporins alone to treat OM is not recommended because they are not optimal for treating serious *S. aureus* infections. An earlier study by Vinod et al. [43] suggested that a reduced course of antibiotic therapy could be effective in the treatment of acute OM. Ecury‐Goossen et al. [44] resolved clinical symptoms, microbiologic, and radiologic signs by using a short course of two weeks of intravenous anti‐ biotics followed by 4 weeks of oral clindamycin, in selected preterm neonates with OM. The signs of continuing infection are persisting pain, fever, and rising hematologic markers that need prolonged antibiotics and repeated surgical intervention. While in children >3 months an early transition from intravenous to oral therapy (3–4 days) is suggested and a total course of 3 weeks in the treatment of acute OM, there are insufficient data on neonates to alter the cur‐ rent recommendation that a full course of at least 4 weeks of antibiotics be given parentally for neonatal OM due to concerns over absorption and efficacy of oral antibiotics [5]. Intraarticular administration of antibiotic is unnecessary. Some authors reported about successful treatment of newborns with oral dicloxacillin [45–47] fluclocacillin, fusidic acid and penicillin V for an additional period ranging from 14 to 42 days after an initial course of intravenous therapy. Despite everything, large, randomized controlled trials are needed to clarify the best practice in treating acute OM in children. It is important underline that OM and septic arthritis have a potential for life‐long disability if treated insufficiently. Vertebral OM of the upper cervical spine requiring surgical treatment in children is rare. Glotzbecker et al. [48] described a surgery of stabilization of the upper cervical spine due to progressive instability caused by OM.

diagnostic workup, and improved adherence to recommendations. An orthopedic and an intervention radiologist would be very helpful in determining the surgery for diagnosis and treatment and to obtain a bone biopsy under fluoroscopic guidance. The involvement of physiotherapists allows individualized rehabilitation programs, designed to improve the anatomical and functional characteristics of the affected bones. A prompt approach to obtain‐ ing tissue and blood specimens for the culture led to a higher rate of organism identification. Additionally a multidisciplinary team led to a shorter total length of hospital stay and a lower

Neonatal Osteomyelitis

103

http://dx.doi.org/10.5772/intechopen.69675

Considerable morbidity may be associated with neonatal OM. Joint effusion may lead to sub‐ luxation or dislocation of the affected joint, accumulation of inflammatory exudate within the joint causes vascular compression and may result in avascular necrosis of the affected epiphy‐ sis. Vein thrombosis and fractures are recently reported. Osteomyelitis may become respon‐ sible for permanent sequelae in 6–50% like joint disabilities, change in bone growth due to the damage of the cartilaginous growth plate, limb length discrepancies, arthritis, pathologic fractures, and rarely complete destruction of joints. Multiple risk factors are associated with bad outcomes in the long run. A delay in diagnosis and treatment can result in complications that include: damage to the growth plate with premature and/or asymmetrical closure of the growth plate; avascular necrosis of the femoral head with or without complete dissolution of the femoral head and neck; pseudoarthrosis; limb length discrepancies, angular deformities at joints; joint dislocations; joint arthrodesis; vertebra magna (with narrowing of the spinal canal); and block vertebrae. Other factors are: late in surgical drainage and appropriate antibiotic cov‐ erage, involvement of hip or shoulder, culture positivity and *S. aureus* isolation [3]. It has been documented that as many as 40% of children with septic arthritis of the hip will develop a seri‐ ous complication, and a long‐term follow‐up is mandatory. Especially for concomitant septic arthritis and OM, the final outcome may be not evident until 9–10 years of age. Copley et al. [49] proposed criteria for discharge based on having a CRP < 2 mg/dL prior to discharge along with clinical improvement, resolution of fever, and having two sets of negative blood cultures for at least 48 h following any initial findings of bacteremia. Given the reported peripheral inserted central catheter complications (adverse drug reaction, a return emergency department visit or rehospitalization for adverse outcome), it should be considered the practice of oral antibiotic

therapy instead of prolonged intravenous antibiotics after hospital discharge [50].

Acute OM, although rare in neonates, is a condition associated with morbidity and possible functional sequelae that need a prompt diagnosis and treatment. The implementation of evi‐ dence‐based, clinical practice guidelines, a lower rate of initial bone scans, a faster change to oral antibiotics, a lower rate of presumptive drainage, and a shorter length of hospital stay are

hospital readmission rate [3].

**9. Prognosis and outcome**

**10. Conclusions**

challenging objectives [51].

#### **8. Consultations**

The involvement of a multidisciplinary team of pediatricians, orthopaedists, and infec‐ tious disease specialists is helpful in the management of OM and results in a more efficient diagnostic workup, and improved adherence to recommendations. An orthopedic and an intervention radiologist would be very helpful in determining the surgery for diagnosis and treatment and to obtain a bone biopsy under fluoroscopic guidance. The involvement of physiotherapists allows individualized rehabilitation programs, designed to improve the anatomical and functional characteristics of the affected bones. A prompt approach to obtain‐ ing tissue and blood specimens for the culture led to a higher rate of organism identification. Additionally a multidisciplinary team led to a shorter total length of hospital stay and a lower hospital readmission rate [3].
