Osteomyelitis in Pediatric Patients, Isolation of Most Common Bacteria: Our Hospital Study

Najeeb ur Rehman¹, Raheel Akbar Baloch², Muhammad Faraz Jokhio³, Ajmal Khan Silro⁴, Niaz Hussain Keerio^5*, Mohsin Aijaz Soomro⁶ and Syed Shahid Noor⁷

^*Correspondence: Niaz Hussain Keerio, Muhammad Medical College and Hospital Mirpurkhas, Pakistan, Email:

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Introduction

Osteomyelitis is a wide term for a set of illnesses characterized by bone and/or bone marrow inflammation or infection. In 1852, Chassaignac published the first description of osteomyelitis [1]. The terms osteon (meaning bone) and muelinos are combined to form the term "osteomyelitis" (meaning marrow).

The inoculation of metaphyseal arteries at the transition point between arteriolar and venous sinusoids slows blood flow and increases vascular turbulence, which is the pathophysiology underlying this [2]. Acute, subacute, and chronic osteomyelitis are the primary forms of osteomyelitis [3]. Acute osteomyelitis lasts for less than two weeks, subacute osteomyelitis lasts for two to three months, and chronic osteomyelitis lasts for more than three months [4,5].

The causes of osteomyelitis can be secondary to a contiguous focus of infection following trauma, surgery, or the insertion of a prosthetic joint; or secondary to a contiguous focus of infection associated with vascular insufficiency, primarily occurring in patients with diabetes mellitus and/or peripheral vascular disease, and following hematogenous spread of infection, which is a major mechanism for vertebrate infection [6,7].

S. aureus, Enterobacter spp., Streptococcus (groups A and B), and Hemophilus influenzae are the most often involved causal agents in pediatric osteomyelitis, according to the literature. Bacteria such as Mycobacterium, Bartonella, Coxiella, and fungus such as Histoplasma, Cryptococcus, and Blastomyces, as well as Candida, are among the uncommon causes of osteomyelitis that are observed in immunocompromised individuals or those who have been to an endemic area [8].

Fever, discomfort at the infection site, reluctance, and trouble using the afflicted extremity are all frequent clinical symptoms [9]. Anorexia, malaise, and vomiting are less common clinical symptoms. On examination, there is generally focal edema, pain, warmth, and erythema [10].

Drainage of purulent material may take place with fistula. Early diagnosis and prompt treatment leads to very less mortality (around zero) and the complication rate around 5%. The aim of the study is to study type of osteomyelitis and the bacterial profile associated with osteomyelitis.

Materials and Methods

The present study was conducted from January 2019 to January 2020 at Orthopedic department of Peoples University of health and Sciences for Women Nawabshah Pakistan.

Institutional Ethics Committee approval was obtained. Pediatric patients coming with the complaints of fever, bone pain with clinical diagnosis of osteomyelitis were included in the study.

Study was performed only with informed consent from the patient’s legal guardian. Patients were examined for signs like tenderness, oedema or warmth. X ray or computerized tomography (CT) scan of the patients was done, and data was collected. Specimens like, discharge from that site or fluid by aspiration were collected depending on the case presentation.

Blood culture was done in all the patients. Samples were sent for Gram staining and culture. Culture was done on blood agar and MacConkey agar. Conventional methods (biochemical tests) were used for bacterial identification.

Antibiotic Susceptibility testing was performed using disk diffusion method. Treatment was decided and started based on the reports of Antibiotic susceptibility tests.

Results

In our 1-year duration, there were 35 cases presenting with signs and symptoms of osteomyelitis i.e. clinical osteomyelitis. We could isolate bacteria in all the cases. Maximum number of cases (45.73%) were seen in 6-10 years’ age group. Males were affected 3 times more as compared to females.

Overall incidence was found to be 1.67%. Acute osteomyelitis was the most common type in our study (85.75%). Tibia was the most commonly affected (56.25%) site followed by femur (18.75%). Thus, 65.71% cases were positive by blood culture while 34.28% cases were negative. MSSA was the most commonly isolated, in about 56.25% cases. MRSA was isolated in 12.5% cases, Acinetobacter in 9.38%, CONS, S. pyogens and E. coli were isolated in 6.25% each. Pseudomonas was isolated in 3.12% (Tables 1 to Table 4).

Table 1: Age distribution in cases of osteomyelitis.

Table 2: Sex distribution in patients presenting with osteomyelitis.

Table 3:Type of osteomyelitis.

Table 4: Samples on blood culture.

Discussion

In our study 6-10 years age group was the most affected (45.73%), as seen in table 1. This finding correlates well with the study of Puccini et al who found maximum number of cases in 6-14 years’ age group (61.9%) cases [11]. This finding also correlates with Zaoutis et al, who studied children aged 2 months to 17 years and found detection rate of 42% in < 5 years and 58% for 6-17 years. As per results seen in table 2, males were more affected (75%) as compared to females (25%). Similar findings were seen in other studies and reviews [12]. Our study reports an overall incidence of 0.812% pediatric osteomyelitis. Cases of acute osteomyelitis (Table 3) were much more (85.75%) as compared to subacute (11.4%) and chronic osteomyelitis (2.85%). This may be due to the fact that in our study, 28.13% cases were of < 5 years and in this age group it is difficult to elicit pain as compared to older age group. This brings the older pediatric age group (>5 years) more quickly to hospital as compared to younger group [13].

A western study mentioned that acute osteomyelitis is seen more commonly among children. We found tibia (56.25%), femur (18.75%) and humerus (12.5%) were more involved as compared to other bones. The reason for such a finding could be due the possibility of these bones being more prone to injury as compared to other bones. This finding correlates well with a similar study by Puccini et al. Two cases of foot osteomyelitis found in our study had a history of trauma.

Blood culture was found to be positive in 65.71% cases (Table 4), which as per literature is able to detect around 50% cases. Discharge from the site has more detection rate. Like other studies also, S. aureus was most common isolate (68.75%) amongst cases. S. aureus attaches to bone by expressing receptors (adhesins) for components of the bone matrix (fibronectin, laminin, collagen, and bone sialo glycoprotein); the pathogen's attachment to cartilage is enabled by the expression of the collagenbinding adhesion. Gram-Negative bacteria such as Acinetobacter, E. coli, and Pseudomonas were isolated.

Conclusion

Osteomyelitis is a sort of infection of the bone. Even if the most prevalent cause is bacteria, fungus can also play a part. The forecast that treatment beginning osteomyelitis is ignored or delayed is typically bad and leads to severe consequences. S. aureus was the most prevalent cause of acute and primarily impacted child bacterial osteomyelitis in school age groups. Very few incidences of osteomyelitis in Pakistan have been recorded compared with other infectious diseases.

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