Osteomyelitis Clinical Pathway — Emergency Department and Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Patient Education

Provider Resources

Child with Suspected Bone Infection

History/Physical Examination

Consider Differential Diagnosis

Low Suspicion for Osteomyelitis

Continued Suspicion for Osteomyelitis

Investigate and treat as clinically indicated
Review Differential Diagnosis

Initial labs and imaging
- CBC with Diff, CRP, Blood Culture
- Consider CK if myositis possible
- Plain X-ray of affected area

Osteomyelitis Less Likely

Osteomyelitis Suspected

Labs within normal limits
If joint effusion on X-ray
- Septic Arthritis Pathway
If fracture on X-ray
- Fracture Pathway
Consider Orthopedic Consult

Order MRI with Contrast
- Order while in ED
- Admission should not be delayed for MRI
- Consult sedation/anesthesia as appropriate
Review MRI Osteomyelitis Protocol
Admit to general pediatrics
Pain control as appropriate
After obtaining blood culture
- Ill appearing, initiate Sepsis Pathway
Anticipated delay in obtaining MRI over 24 hrs
- Consider starting empiric antibiotics

MRI not consistent
with osteomyelitis

MRI consistent
with osteomyelitis

Start empiric antibiotics unless plan for OR intervention in next 24 hours
Infectious Diseases consultation
Consider Orthopedic Consultation
Review Considerations for Biopsy or
Surgical Intervention
Repeat CRP in 48-72 hours

Alternative Diagnosis

Treat, admit as clinically appropriate
Primary medical doctor follow up if symptoms do not improve

Good Treatment Response

Inadequate Treatment Response after 48-72 hours of antibiotics

Improving CRP
Improving fever curve
Reduction in pain
Conversion to Oral Antibiotics

Continued fever, pain
No improvement in CRP
Repeatedly positive blood cultures
Discuss changing empiric antibiotics with infectious diseases
Orthopedic Consultation

Discharge

Inadequate Treatment Response

Discuss utility of repeat imaging and biopsy/surgical intervention with infectious diseases and orthopedics

Posted: October 2020
Revised: November 2023

Authors:
- M. Dunn, MD;
- T. Joerger, MD;
- J. Nguyen, MD;
- J. Burns, MD;
- B. Coburn, MD;
- K. Downes, MD;
- J. Anari, MD;
- A. Arkader, MD;
- R. Rempell, MD;
- D. Spiegel, MD;
- A. S. Srinivasan, MD;
- S. K. Swami, MD;
- S. Vatsky, MD;
- K. Smith, PhD;
- K. Pough, PharmD

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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Emergency Department and Inpatient Clinical Pathway for Evaluation/Treatment of Osteomyelitis

Evidence