Emergency Department and Inpatient Clinical Pathway for Evaluation/Treatment of Osteomyelitis
- Related Pathways
Exclusion Criteria
- Age ≤ 56 days—see Febrile Infant Pathway
- Immunocompromised state
- Sickle cell disease
- Risk for Subacute Bacterial Endocarditis (SBE)
- Recent orthopedic procedure
- Orthopedic hardware or prosthesis
- Penetrating trauma
- Suspected bone involvement associated with wounds
- Symptoms ≥ 2 wks
Analgesia as indicated
Team Assessment
- History and Physical
- Differential Diagnosis
- Concern for Finger or Toe Osteomyelitis
- Initial labs and imaging
- CBC with Diff, CRP, Blood Culture
- CK as indicated
- Plain X-ray of affected area
- Consider ultrasound for suspected joint involvement,
Infectious Arthritis Pathway
Sepsis Pathway, as indicated
Osteomyelitis Less Likely
Osteomyelitis Suspected
- Start empiric antibiotics
- Order MRI with contrast
- Order while in ED
- Admission should not be delayed for MRI
- Consult sedation/anesthesia as appropriate
- Admit to general pediatrics
MRI not consistent with osteomyelitis
MRI consistent with osteomyelitis
Consider discontinuing empiric antibiotics
- Continue antibiotics
- Consult ID
- Consider Orthopedic Consult
- Considerations for Biopsy or Surgical Intervention
- Repeat CRP in 48–72 hrs
Review Differential Diagnosis
- Treat, admit as clinically appropriate
- Primary care follow-up if symptoms do not improve
Adequate treatment response
Inadequate treatment response after 48–72 hrs 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
- Consult ID and Orthopedics if not already done
- Consider changing empiric antibiotics
- Consider repeat imaging and biopsy/surgical intervention
Follow-up with ID for repeat labs and antibiotic duration
Evidence
- PIDS/IDSA Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics
- Impact of Antibiotic Pretreatment on Bone Biopsy Yield for Children with Acute Hematogenous Osteomyelitis
- CRP and ESR Sensitivity in Osteomyelitis
- Discharge on Oral vs. IV Antibiotics in Osteomyelitis
- Acute Hematogenous Osteomyelitis
- Osteoarticular Infections
- American College of Radiology ACR Appropriateness Criteria
