Landmark Study on Osteomyelitis
In a rigorous retrospective analysis of 2090 patients admitted with acute osteomyelitis to 36 children’s hospitals from 2009 to 2012, treatment failure and adverse outcomes were compared between those receiving postdischarge peripherally inserted central catheter (PICC) versus oral antibiotic therapy. The authors used propensity scores and complex modeling to control for severity, organism, infection location, child age, and hospital, along with statistical techniques (stratified and marginal modeling) to approximate a randomized controlled trial. Cases culled from the Pediatric Health Information System database were validated with individual chart review and data enhanced.
The key findings
Treatment failure rates both across and within hospitals were similar for children with acute osteomyelitis discharged on PICC and oral antibiotics, irrespective of child age or organism. Odds of adverse outcomes, including drug reactions, emergency department visits, and complications, were significantly higher overall in the PICC-treated group compared with those treated with oral antibiotics (odds ratio 3.61, 95% confidence interval 2.6–4.9).
These authors have improved on a similar 2009 Pediatric Health Information System study comparing oral and PICC antibiotic therapy for osteomyelitis. Critics of the 2009 article pointed to a risk of misclassification of exposure and outcome from relying on administrative data and a lower rate of methicillin-resistant Staphylococcus aureus in the cohort compared with present rates. By combining administrative data analysis with chart review for more than 2000 patients and using a cohort with 16% culture-proven methicillin-resistant Staphylococcus aureus, the current study represents a more definitive argument that PICC lines for routine osteomyelitis are unwarranted and cause net harm to patients. It is unlikely that we will see a double-blind randomized controlled trial for osteomyelitis management: institutional preference for oral or PICC outpatient therapy is strong. Consider advocating for evidence-based use of oral rather than prolonged intravenous antibiotics for your patients with acute hematogenous osteomyelitis.
CITATION Keren R, Shah SS, Srivastava R, et al; Pediatric Research in Inpatient Settings Network. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120–128
Med School 101: Capillary Refill Revisited
The authors sought to answer existential questions about that old physical examination standby, capillary refill time (CRT): What is the most valid and reliable method of capillary refill to estimate hemodynamic stability? This combination systematic review and meta-analysis included 21 international studies to answer these vast questions between 2 groups: neonates <7 days of age and infants and children from 7 days to 18 years old. The authors reviewed diagnostic statistics as well as cutoff ranges for CRT associated with different techniques, body sites, and effects of ambient temperature.
The key findings
For young neonates (<7 days), there were insufficient data around validity or consistent CRT findings for any particular site or technique, although >95% confidence interval cutoff was >5 to 7 seconds at some body sites in healthy infants.
For children >7 days old, abnormal CRT predicted some hemodynamic changes but not blood pressure abnormalities. Meta-analysis of >95% confidence interval upper cutoffs for CRT was ≥2 seconds on the finger versus ≥4 seconds on the chest or foot, after application of 5 seconds of moderate pressure. Ambient temperature outside of 20 to 25°C affected CRT.
Intraobserver and interobserver reliability for all CRT measures was variable.
Revisiting age-old paradigms around physical examination findings is an important complement to evaluating new techniques and technologies. CRT is a key physical examination finding for resuscitation; yet, current guidelines and clinical lore are vague about body site and technique. Based on this study, hospitalists would do well to refine their own preferred perfusion assessment style. “Delayed cap refill” need not be in the eye of the beholder.
CITATION Fleming S, Gill P, Jones C, et al. Validity and reliability of measurement of capillary refill time in children: a systematic review. Arch Dis Child. 2015;100(3):239–249
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Copyright © 2015 by the American Academy of Pediatrics