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5.1. Make a diagnosis and thus know the natural history (continue)

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5.1.4. Treatment

The earliest possible exhibition of appropriate antibiotics is vital and may be life saving in the management of acute bone and joint infections. These should be bactericidal rather than bacteriostatic, and usually should be administered intravenously, certainly for the first 48 hours.

As the infecting organism is usually a Staphylococcus, a locally available appropriate antibiotic to which this bacteria is sensitive should be used. This can of course be combined with other antibiotics when this is indicated. If the blood (or pus) culture grows either a staph which is resistant to the prescribed drug, or indeed another organism then the antibiotic will have to be changed.

If this drug treatment can be started within the first seventy-two hours then there is a possibility that the infection will resolve without the formation of pus, and that the patient will recover without any surgical operation. However, very close clinical examination is essential, and reappearance of a fever which had settled is always an important sign. Similarly if tenderness, and/or reluctance to allow passive movement of a joint increase or reappear, then pus is probably forming and may well have to be released (see below).

If the general condition of the patient continues to improve with antibiotics, and general and local rest (plaster gutter or traction) two decisions will have to be made. Firstly, when can local immobilisation be removed, and secondly for how long should the antibiotic/s be continued. It is here that clinical experience and judgement are important. These severe acute infections also cause anaemia and this should be carefully monitored and appropriately treated.

The dangers with too early mobilisation are that the infection may recur, or that there will have been so much death of bone that a pathological fracture may occur and this can be difficult to treat. Serial radiographic examination with any plaster immobilisation temporarily removed is essential, for as well as revealing the quality of the affected bone this may also reveal early sequestrum formation.

Pathological fracture with massive sequestration and no involucrum formation.

Fracture just below a good involucrum - probably due to the severity of the original infection having destroyed the periosteum.

However, in small children these sequestrae can absorb ‘spontaneously’, and this is probably more likely to happen if the area has not needed to have been explored surgically. Care must continue to be taken, and regular clinical examination is vital.

While there is some evidence available about the necessary duration of antibiotic therapy, we do not believe that there should be any hard and fast rules. We prefer to start with six weeks of treatment, usually orally instead of intravenously once the child’s general condition allows, and fever remains settled.

Similarly there is no general agreement as to whether it is best to start with one or with two antibiotics. But at least one should be bactericidal. If and when the blood culture (and sensitivities) becomes available it may be wise to change the one or two antibiotics being given (if other suitable drugs are available) but again careful clinical monitoring is essential, and this is not a task which should be the responsibility of ‘junior’ doctors.