Oral Versus Parenteral Antibiotics for Osteoarticular Infections: You PICC

A previously healthy 8-year-old girl presented to the emergency department with right hip pain and inability to bear weight on the right lower extremity. She had been afebrile at home, although was receiving ibuprofen for pain. Inflammatory markers were elevated, including a C-reactive protein (CRP) of 76.4 mg/L and an erythrocyte sedimentation rate of 40 mm per hour. A radiograph of the pelvis did not show any obvious joint effusion. Given the concern for septic hip, orthopedics was consulted and she was taken to the operating room for aspiration of her right hip joint. Aspiration showed cloudy yellow fluid with a white blood cell count >85 000. Orthopedics proceeded with incision and drainage and she was admitted for parenteral antibiotics. She was empirically started on cefazolin. The broth from her hip culture grew coagulase-negative Staphylococcus species, but the fluid culture was negative, and this was presumed to be a contaminant. The orthopedic and infectious disease teams made a joint decision to treat empirically with cefazolin for a total of 4 weeks for presumed septic hip. A peripherally inserted central catheter (PICC) was placed on hospital day 3 and she was discharged on hospital day 4. At the time of discharge, the patient had no hip pain, was afebrile, able to bear weight, and had a CRP of 8.8 mg/L.

Four days after discharge, the patient presented to the emergency department with pain, erythema, and swelling above the site of her PICC line. A duplex ultrasound of the arm showed a deep vein thrombus. Her PICC line was removed and she was started on enoxaparin for 3 months. She was discharged on oral high-dose cephalexin. Total duration of treatment was 16 days; antibiotics were then discontinued based on a normal clinical examination and inflammatory markers.

This case illustrates the harm that can …