Osteomyelitis
ICD-10 M86 · ICD-11 FB84

Osteomyelitis with Sepsis in Children: When Initial Empiric Antimicrobial Therapy Has Not Achieved Rapid Bacteremia Clearance

This protocol addresses children with presumed acute haematogenous osteomyelitis (AHO) who are ill-appearing, present with sepsis, or have a rapidly progressive bone infection, and in whom the initial empiric antimicrobial regimen has not achieved the expected early response.

Clinical Scenario

The target population is children with presumed AHO who are ill-appearing, present with sepsis, or have a rapidly progressive bone infection. These presentations require immediate, aggressive management, and any failure of initial therapy demands a structured reassessment.

Why This Protocol Is Triggered: Prior Line Did Not Achieve Its Goals

The preceding step was immediate empiric antimicrobial therapy (with surgical debridement of infected bone and associated abscesses as soon as possible after diagnosis). The goals of that initial line were rapid resolution of bacteremia — serial blood cultures becoming negative within 1 to 2 days of initiation of therapy — and resolution of fever within 3 to 5 days. When those targets are not met, this next-step protocol applies.

Next-Step Approach (Partial Overview)

The approach involves a structured reassessment of the antimicrobial regimen — including its spectrum, site penetration, and adherence — along with consideration of broadening antimicrobial coverage. Additional microbiological sampling and a surgical reassessment are also part of the structured response. The complete algorithm, including specific decision points and sequencing, is in the full protocol…

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/jpids/piab027

  1. In children with presumed AHO who are ill-appearing or have a rapidly progressive infection, we recommend starting empiric antimicrobial therapy immediately rather than withholding antibiotics until invasive diagnostic procedures are performed (strong recommendation and moderate certainty of evidence).
  2. In children with AHO who present with sepsis or have a rapidly progressive infection, we recommend debridement of the infected bone and any associated abscesses as soon as possible after diagnosis, rather than treating with medical therapy alone (strong recommendation and moderate certainty of evidence).
  3. Clinicians should assess the adequacy of the antimicrobial regimen (spectrum of activity, dosage and penetration to the site of infection, and adherence) before deciding on the need to broaden the spectrum or to restart antimicrobials (Good practice statement).
  4. Clinicians should reassess the need for surgical intervention for therapeutic and/or diagnostic purposes (Good practice statement).
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