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The Influence of the Route of Antibiotic Administration, Methicillin Susceptibility, Vancomycin Duration and Serum Trough Concentration on Outcomes of Pediatric Staphylococcus aureus Bacteremic Osteoarticular Infection

McNeil, J. Chase MD; Kaplan, Sheldon L. MD; Vallejo, Jesus G. MD

The Pediatric Infectious Disease Journal: June 2017 - Volume 36 - Issue 6 - p 572–577
doi: 10.1097/INF.0000000000001503
Antimicrobial Reports

Background: Bacteremia is often one factor used in deciding the need for prolonged intravenous antimicrobial therapy in osteoarticular infections (OAIs). We examined treatment practices and outcomes of Staphylococcus aureus bacteremic osteoarticular infections (BOAIs) evaluated at Texas Children’s Hospital.

Methods: Cases of acute hematogenous OAI in children with positive blood cultures for S. aureus at Texas Children’s Hospital between 2011 and 2014 were reviewed. Orthopedic complications included chronic osteomyelitis, growth arrest, pathologic fracture, avascular necrosis and chronic dislocation. Acute kidney injury was defined as a doubling of the baseline creatinine.

Results: One hundred and ninety-two cases of S. aureus OAI were identified with 102 cases of BOAI included [35 methicillin-resistant S. aureus (MRSA)]. Twenty-five patients were discharged home on oral antibiotics. Patients discharged on oral antibiotics had a shorter duration of fever, had a more rapid decline in C-reactive protein and were less likely to have MRSA. The frequency of orthopedic complications did not increase in patients who received early transition to oral antibiotics. For patients with MRSA bacteremia, the rates of complications between those who received ≥7 days versus <7 days of vancomycin did not differ. Vancomycin serum troughs >15 µg/mL were not associated with a decreased duration of fever, bacteremia or hospitalization, need for repeat operation or orthopedic complications but were associated with acute kidney injury.

Conclusions: S. aureus BOAIs are associated with substantial morbidity. Early transition to oral therapy may be a safe option for select patients with S. aureus BOAI, including those due to MRSA. Prolonged courses of vancomycin and vancomycin troughs >15 μg/mL were not associated with improved outcomes for MRSA OAI.

Supplemental Digital Content is available in the text.

From the Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas.

Accepted for publication November 17, 2016.

J.C.M. is PI on NIAID K23AI099159 and is a consultant for Becton Dickinson and Company. S.L.K. is PI on a single-center investigator-initiated phase 2 trial of ceftaroline in acute osteomyelitis sponsored by Allergan that started after the time period of this study and thus is not directly related to the presented work; J.C.M. and J.G.V. are coinvestigators on this trial. The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Address for correspondence: J. Chase McNeil, MD, 1102 Bates Street, Suite 1150, Houston, TX 77030. E-mail:

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