An Assessment of Severity of Illness of Pediatric Musculoskeletal Infections: 1994-2009

PURPOSE: Care of children with osteomyelitis requires multi-disciplinary collaboration. This study evaluates the impact of evidence-based guidelines for pediatric osteomyelitis when applied by a multi-disciplinary team. METHODS: Guidelines for pediatric osteomyelitis were developed and implemented by a multi-disciplinary team comprised of orthopedics, pediatrics, infectious disease, nursing, and social work who met daily to conduct rounds and make treatment decisions. Children who were treated according to the guidelines (g) were compared to those who had been treated prior to the guidelines (ng) by retrospective review and statistical analysis. RESULTS: 210 children of the 2002-2004 cohort (ng) were compared to 61 children of the 2009 cohort (g). No significant differences between the two cohorts were noted for age, race, gender, incidence of Methicillin-resistant Staphylococcus aureus (g=26.2%; ng=18.1%), incidence of Methicillin-sensitive Staphylococcus aureus (g=27.9%; ng=23.8%), bacteremia, or surgeries. Significant differences between cohorts were noted (p<0.05) for each of the following: timing of initial MRI (g=1.0 day; ng=2.5 days); clindamycin as initial antibiotic (g= 85.3%; ng=12.8%); blood cultures before antibiotic administration (g=91.8% ; ng=79.5%); tissue cultures from infection site (g=78.7%; ng=62.9%); identification of organism by tissue or blood culture (g=73.8%; ng=60.0%); antibiotic changes (g=1.4 changes; ng=2.0 changes); and mean oral antibiotic duration (g=43.7 days; ng=27.7 days). Children treated with guidelines had clinically important trends of a shorter total length of stay (g=9.7 days; ng=12.8 days; p=0.054), and lower readmission rate (g=6.6%; ng=11.4%; p=0.34). CONCLUSION: Evidence-based treatment guidelines applied by a multi-disciplinary team resulted in more efficient diagnostic work-up, higher rate of identifying the causative organism, improved adherence to initial antibiotic recommendations with fewer antibiotic changes during treatment. Additionally, there were trends toward lower readmission rate and lower length of hospitalization. The establishment of evidence-based treatment guidelines will allow for the standardization of evaluation and treatment of children with musculoskeletal infections for severity of illness comparisons between cohorts separated through time and geographic location.