SEIP–SERPE–SEOP Consensus document on the treatment of uncomplicated acute osteomyelitis and septic arthritis

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Saavedra-Lozano, C. Calvo, R. Huguet Carol, C. Rodrigo, E. Núñez, I. Obando, P. Rojo, R. Merino, C. Pérez, F.J. Downey, E. Colino, J.J. García, M.J. Cilleruelo, F. Torner, L. García" "autores" => array:15 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Saavedra-Lozano" "email" => array:1 [ 0 => "jesaave@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Calvo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Huguet Carol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "C." 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"apellidos" => "Downey" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 10 => array:3 [ "nombre" => "E." "apellidos" => "Colino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 11 => array:3 [ "nombre" => "J.J." "apellidos" => "García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 12 => array:3 [ "nombre" => "M.J." "apellidos" => "Cilleruelo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 13 => array:3 [ "nombre" => "F." "apellidos" => "Torner" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 14 => array:3 [ "nombre" => "L." "apellidos" => "García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Sociedad Española de Infectología Pediátrica (SEIP), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sociedad Española de Reumatología Pediátrica (SERPE), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sociedad Española de Ortopedia Pediátrica (SEOP), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso SEIP-SERPE-SEOP sobre el tratamiento de la osteomielitis aguda y artritis séptica no complicadas" ] ] "textoCompleto" => "IntroductionThis is the second part of an earlier document, which examined the aetiopathogenesis and diagnosis of osteoarticular infections (OAI). This part addresses treatment, where there have been numerous new contributions in recent years,<a class="elsevierStyleCrossRefs" href="#bib0205">1–10</a> as well as follow-up and prognosis. It includes both acute osteomyelitis (AOM) and septic arthritis (SA), and basically reviews haematogenous community-acquired infections with acute course (<14 days of symptoms).At the end of the document the main recommendations for each section are listed, together with the level of evidence and degree of recommendation, as defined in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRef" href="#bib0255">11</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Aetiology and resistances: major issues for treatmentThe aetiology was described in the previous document, although it is briefly set out in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Resistances and other important considerations for treatmentWithin Staphylococcus aureus a distinction can be drawn between strains sensitive to methicillin (MSSA) and those resistant to methicillin (MRSA) through modification of the penicillin-binding proteins, and among these, between community-acquired (CA-MRSA) and hospital-acquired strains. In Spain most infections in children are caused by MSSA (>90%); however, we need to take account of the high rate of CA-MRSA in other geographical areas, such as certain states in the United States, Latin America, North Africa and Eastern Europe,<a class="elsevierStyleCrossRef" href="#bib0260">12</a> which will have to be considered in children from these regions. Methicillin resistance is an indicator of resistance to the other β-lactam antibiotics, including cephalosporins (except ceftaroline) and carbapenems.CA-MRSA tends to have few associated antibiotic resistances and is normally sensitive to clindamycin, cotrimoxazole (TMP–SMX), glycopeptides (vancomycin and teicoplanin), rifampicin and linezolid.<a class="elsevierStyleCrossRef" href="#bib0260">12</a>Kingella kingae is usually sensitive to β-lactam antibiotics, including ampicillin and cephalosporins, and therefore does not tend to give rise to treatment problems, except when clindamycin or cloxacillin are used in monotherapy. Other bacteria, such as Streptococcus pyogenes or Streptococcus pneumoniae normally respond well to penicillin.TreatmentChildren with OAI should be hospitalised for initial assessment and intravenous (IV) antibiotic treatment. These infections call for a multidisciplinary approach involving orthopaedic surgeons, rheumatologists and paediatric infectious diseases specialists, according to each case.Surgical treatmentSeptic arthritisThe classic treatment for all kinds of SA involves performing an arthrotomy (surgical drainage) to evacuate the joint, washing out the purulent material, placing an external drain to avoid reaccumulation of fluid and immobilising the joint to avoid subluxations, especially in the hip.<a class="elsevierStyleCrossRef" href="#bib0265">13</a> Draining of the affected joint and lavage is universally accepted, but it is not so obvious which is the best way of achieving it (arthrotomy, arthroscopy or arthrocentesis), since there are no adequate studies endorsing any particular approach, though traditionally arthrotomy has been recommended in the shoulder, and especially the hip, given the greater risk of sequelae.<a class="elsevierStyleCrossRef" href="#bib0265">13</a> The need for surgical drainage is always more likely to arise in infections by high-virulence microorganisms, such as S. aureus producing toxins like Panton–Valentine leukocidin (PVL) (generally MSSA, sometimes MRSA), and when the evolution of the infection is more prolonged.<a class="elsevierStyleCrossRef" href="#bib0265">13</a>Arthrocentesis: joint puncture, needle aspiration and joint lavagePerforming an arthrocentesis on the affected joint is essential in order to obtain a microbiological diagnosis, achieve decompression of the joint space (avoiding vascular compromise in the shoulder and the hip) and facilitate the effectiveness of the antibiotic after the purulent material has been flushed out.<a class="elsevierStyleCrossRef" href="#bib0270">14</a> It must be undertaken in aseptic conditions, and is a simple procedure (more complex in the hip and the shoulder), with few risks, which can guide diagnosis.<a class="elsevierStyleCrossRef" href="#bib0275">15</a> There are no absolute contraindications, except local infection at the puncture site, severe sepsis or shock. It must be performed as soon as possible (preferably before starting the antibiotic), although it can be delayed for a few hours (6–12h, for example); early intervention is especially important in SA of the hip and shoulder.<a class="elsevierStyleCrossRefs" href="#bib0270">14,16</a> Most of the authors of this document are in favour of draining the joint and starting antibiotic therapy as soon as possible, but cannot give an exact recommendation of the time needed to avoid complications or sequelae.Ultrasound can be very helpful for locating the puncture site. The child must receive appropriate sedoanalgesia; inhaled nitrous oxide may be administered.Both arthrocentesis and arthrotomy enable the joint to be washed out with normal saline. Arthrocentesis has the advantage of being a less traumatic procedure and achieving more rapid patient recovery, and is associated with a faster decrease in C-reactive protein (CRP), which could reduce the duration of IV antibiotic and length of stay in hospital.Prompt performance of arthrocentesis, daily clinical assessment and repetition of the procedure when necessary with joint lavage are the keys to the success of this therapeutic approach.<a class="elsevierStyleCrossRef" href="#bib0285">17</a>Therapeutic arthrocentesis can be used for any joint, including the shoulder and the hip, as various studies show.<a class="elsevierStyleCrossRefs" href="#bib0205">1,4,5,17–20</a> In a randomised study of children with arthritis of the shoulder, for example, no differences were found in prognosis or length of stay in patients treated with aspiration versus arthrotomy.<a class="elsevierStyleCrossRef" href="#bib0205">1</a> As for the hip, there are also studies that support a favourable outcome in children treated with aspiration/irrigation.<a class="elsevierStyleCrossRef" href="#bib0225">5</a> The following are factors that the authors consider indicate a poor prognosis and thus a need for open surgery: symptoms lasting at least six days, CRP >10mg/dL, >15,000neutrophils/mm3 and erythrocyte sedimentation rate (ESR) >50mm/h.<a class="elsevierStyleCrossRef" href="#bib0225">5</a> Repeated aspiration of the hip joint has also been assessed, and more rapid recovery and resumption of walking were observed, without sequelae,<a class="elsevierStyleCrossRef" href="#bib0295">19</a> though some patients required open drainage.In conclusion, in most cases, except in newborns (NBs), where there is no adequate evidence of outcomes without surgical arthrotomy,<a class="elsevierStyleCrossRef" href="#bib0290">18</a> children with recent symptoms (<5–6 days) could be candidates for drainage via arthrocentesis and antibiotherapy.<a class="elsevierStyleCrossRefs" href="#bib0220">4,6,18</a> In SA of the shoulder and hip, the decision will depend on how early action is taken, on the analytical assessment and on the experience of the team responsible for the patient. In all these cases, the children should be admitted to a hospital with an experienced orthopaedic surgeon, to perform surgical treatment if necessary.ArthrotomyThis is the main advanced surgical procedure in the treatment of SA. In principle, it can be performed on any joint. There are authors who consider it essential for treating SA of the hip,<a class="elsevierStyleCrossRef" href="#bib0265">13</a> although some more recent studies note the possibility of nonsurgical approaches in these locations.<a class="elsevierStyleCrossRefs" href="#bib0220">4,19</a> Equally, other authors recommend surgical intervention if the joint fluid is not satisfactorily drained after 2 or 3 arthrocenteses.<a class="elsevierStyleCrossRef" href="#bib0285">17</a> Arthrotomy could be indicated, at the outset, in cases of longer evolution, given the greater difficulty of evacuating denser and more organised material,<a class="elsevierStyleCrossRefs" href="#bib0265">13,16</a> in cases of raised inflammatory markers or of highly virulent pathogens (MRSA) and in neonates and small infants.<a class="elsevierStyleCrossRefs" href="#bib0225">5,19</a> The object of the surgical procedure can be regarded as threefold<a class="elsevierStyleCrossRef" href="#bib0305">21</a>: drainage of the purulent content and necrotic material, reduction of the intra-articular pressure and direct assessment of the lesion, and also a collection of microbiological and anatomopathological samples. In addition, it enables an external drain to be placed to avoid further collections.<a class="elsevierStyleCrossRefs" href="#bib0265">13,22</a> Although no well-designed studies exist, many authors suggest leaving this type of drainage for irrigation/aspiration, especially in the hip; it must be removed promptly (<48–72h).Given that this procedure involves opening the joint, it may be necessary, in some cases, to stabilise the joint using cutaneous traction or ferrules to avoid dislocations in the post-operative period, although early mobilisation must be implemented to avoid problems later, such as rigidity or flexion.<a class="elsevierStyleCrossRef" href="#bib0265">13</a>Other authors propose arthroscopy as a less aggressive method than arthrotomy for treating SA in children.<a class="elsevierStyleCrossRefs" href="#bib0230">6,23,24</a> The main limitations are the age of the patients and the difficulty of the procedure.Surgical drainage in osteomyelitisIt has been found that over 90% of patients with AOM have favourable outcomes with antibiotic treatment if initiated early,<a class="elsevierStyleCrossRefs" href="#bib0235">7,18,25,26</a> performing surgical drainage when the presence of a collection or sequestrum in the bone or subperiosteal level is detected,<a class="elsevierStyleCrossRef" href="#bib0290">18</a> when no clinical improvement has occurred after 48–72h of antibiotherapy and in acute exogenous osteomyelitis (AEO). However, subperiosteal abscesses, even those greater than 3mm, may have favourable outcomes without surgical drainage.<a class="elsevierStyleCrossRef" href="#bib0290">18</a> As in the case of SA, microbiological samples must be taken, as well as anatomopathological samples when this is considered necessary, and it is essential to place an external drain to avoid post-surgical collections.It is worth emphasising that some experts have had very good results performing an initial bone puncture, which could improve aetiologic diagnosis and evolution.Medical treatmentIn the last few years a trend has been emerging towards simplifying antibiotic treatment in uncomplicated OAI, with the use of parenteral antibiotic treatment followed by a course of oral antibiotics, with high doses of antibiotherapy and shorter duration, both of IV treatment<a class="elsevierStyleCrossRefs" href="#bib0240">8–10</a> and overall.<a class="elsevierStyleCrossRefs" href="#bib0210">2,3</a> This trend is based on the pioneering experience of a controlled clinical trial published by Peltola et al.,<a class="elsevierStyleCrossRef" href="#bib0235">7</a> which has subsequently been confirmed in prospective cohort or randomised studies.<a class="elsevierStyleCrossRefs" href="#bib0210">2,3,7,8,10</a> Recently, guidelines from the United Kingdom incorporating some of these recommendations have been published.<a class="elsevierStyleCrossRef" href="#bib0270">14</a> These strategies may not be valid in cases of highly virulent microorganisms, such as PVL-producing S. aureus, given their greater severity and poorer prognosis,<a class="elsevierStyleCrossRefs" href="#bib0335">27,28</a> and longer duration of antibiotic treatment is recommended.<a class="elsevierStyleCrossRef" href="#bib0340">28</a>Initial empirical treatmentIf there is any suspicion of OAI in a child, IV antibiotic treatment should be initiated promptly (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), after collecting samples for microbiological testing, as appropriate.<a class="elsevierStyleCrossRef" href="#bib0325">25</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>An antibiotic with good activity against MSSA and S. pyogenes should be used, since these are the most common aetiological agents.<a class="elsevierStyleCrossRefs" href="#bib0210">2,10,27,30</a> In the case of AOM through puncture injury to the foot bone (through a training shoe), Pseudomonas aeruginosa should also be covered. In children aged >5 years of age it is advisable to use an antibiotic with good activity against K. kingae,<a class="elsevierStyleCrossRef" href="#bib0345">29</a> and in children with <3 doses of the H. influenzae type b or S. pneumoniae vaccine (especially in those <2 years old) these microorganisms should also be covered.<a class="elsevierStyleCrossRef" href="#bib0350">30</a> In regions where the prevalence of MRSA infections is <10% of S. aureus infections, an antibiotic with good coverage for this bacterium should be used.The antibiotics, most widely used and with which there is most experienced in children are cefazolin, cloxacillin and clindamycin.<a class="elsevierStyleCrossRefs" href="#bib0325">25,30</a> This group of experts considers cefazolin the antibiotic of choice in properly vaccinated children aged >2 years in geographical areas where the prevalence of CA-MRSA infections is <10%. In children 2 years of age or older that have received <3 vaccine doses, treatment with cefuroxime is recommended, and as alternatives cloxacillin (with little activity against K. kingae)<a class="elsevierStyleCrossRef" href="#bib0355">31</a> combined with cefotaxime or amoxicillin/clavulanic acid. In children younger than 3 months the recommendation is to combine cloxacillin and cefotaxime; cefazolin and gentamicin is also a suitable combination. Cloxacillin combined with ceftazidime would be the most appropriate antibiotic regime in AOM of the bones of the foot due to a puncture wound. These recommendations are set out in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>In areas with a high prevalence of MRSA, this group of experts recommends using clindamycin, combined with a β-lactam antibiotic in children under 5 to cover K. kingae. In all cases, if MRSA infection is suspected or confirmed, rifampicin could be added to the treatment.<a class="elsevierStyleCrossRef" href="#bib0360">32</a> The most suitable options in the event of serious MRSA infection (severe sepsis, septic shock and/or septic pulmonary emboli) are listed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<a class="elsevierStyleCrossRefs" href="#bib0270">14,32–34</a> The antibiotics most commonly used for OAI in children, both orally and via IV, are set out in <a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3–5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>If a microbiological isolate is obtained, the treatment will be adjusted, choosing the antibiotic with the narrowest spectrum.Hospitalisation and duration of intravenous treatmentChildren with an OAI should remain in hospital for initial empirical IV treatment for a minimum of 2–5 days.<a class="elsevierStyleCrossRefs" href="#bib0210">2,3,10,14,35</a> Children younger than 3 months could need a longer duration of IV treatment and those <1 month of age should receive most of the antibiotic treatment by this route.<a class="elsevierStyleCrossRef" href="#bib0375">35</a>The duration of treatment, both IV and in total, should be more prolonged in the case of MRSA or PVL-producing MSSA infection, looking out for possible complications.<a class="elsevierStyleCrossRefs" href="#bib0335">27,28</a> This group of experts recommends a minimum of 10–14 days of IV treatment in these cases. The duration of treatment of complicated OAI should be determined on an individual basis.CRP is very useful for monitoring the response to treatment and evaluating when to switch antibiotic treatment to oral administration.<a class="elsevierStyleCrossRefs" href="#bib0210">2,18</a> If the patient progresses well, CRP normalises in 7–10 days and ESR in 3–4 weeks.<a class="elsevierStyleCrossRef" href="#bib0380">36</a> An increase, or lack of decrease, in CRP is a very specific marker for negative progression or complications. In order to switch to oral antibiotherapy and discharge the patient, a decrease of at least 30% in the CRP level, absence of fever for 24–48h and an improvement in the signs and symptoms of the infection should be observed.Outpatient treatment and follow-upThis group of experts recommends using oral cefadroxil whenever possible, with cefuroxime axetil as a suitable alternative (at the time of writing this consensus document, there is a shortage of cefadroxil oral suspension in Spain, as well as serious problems in the supply of all these antibiotics in oral solution – <a href="http://www.aeped.es/comite-medicamentos/noticias/retirada-mercado-antibiotico-cefadroxilo-no-todo-esta-perdido-informe-c">http://www.aeped.es/comite-medicamentos/noticias/retirada-mercado-antibiotico-cefadroxilo-no-todo-esta-perdido-informe-c</a> – and practically the only remaining option is to use amoxicillin/clavulanic acid or crushed adult tablets). In the case of S. pyogenes or penicillin-susceptible S. pneumoniae, the use of oral amoxicillin is recommended.For oral treatment of CA-MRSA, clindamycin<a class="elsevierStyleCrossRef" href="#bib0360">32</a> or TMP–SMX<a class="elsevierStyleCrossRef" href="#bib0385">37</a> are suggested, according to susceptibility, combined or not with rifampicin.<a class="elsevierStyleCrossRefs" href="#bib0270">14,32</a> There is more clinical experience with clindamycin, although its oral tolerability is poorer. A quinolone could be used as an alternative to these.If there is no microbiological isolate, treatment should be continued using an antibiotic with a similar spectrum to that used intravenously. In the case of cefazolin or cloxacillin, it would continue with cefadroxil or cefuroxime. <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> lists the oral antibiotics recommended in different situations.Following discharge from the hospital it is advisable to follow-up the patient closely, especially for adherence and adverse effects, with assessment at 5–7 days to confirm favourable clinical evolution and tolerability to the antibiotic.The total duration of antibiotic treatment should never be <10–14 days in the case of SA and 20 days in the case of AOM. In infections by MRSA or PVL-producing MSSA a minimum of 3–4 and 4–6 weeks is recommended for SA and AOM respectively.<a class="elsevierStyleCrossRef" href="#bib0360">32</a>Salmonella infection requires more prolonged treatment (4–6 weeks), especially in children with sickle-cell disease. AOM of the pelvis and spine also require minimum durations of 4 weeks.<a class="elsevierStyleCrossRef" href="#bib0280">16</a>While antibiotic treatment continues, this group of experts recommends performing at least a complete blood count and CRP every 10–14 days to monitor the infection and to check for potential adverse effects, although this should be determined on an individual basis. There was no total consensus on the use of ESR for follow-up. Some authors advocated performing an ESR test, especially before ending treatment; others, however, did not advocate it, given that it falls slowly and a prolonged elevated rate could unnecessarily lengthen treatment without signifying unfavourable evolution or complications.<a class="elsevierStyleCrossRef" href="#bib0380">36</a>Discontinuation of treatment should always be conditional on the disappearance of clinical symptoms and normalisation of CRP.<a class="elsevierStyleCrossRefs" href="#bib0210">2,3</a> A visit is recommended for finishing the antibiotic treatment and another a month after the end of treatment. Closer follow-up is advisable in complicated cases, when there is axial or pelvic involvement and in infants >3 months of age.Adjuvant treatmentNon-steroidal anti-inflammatory drugs are recommendable in the acute phase to relieve pain and fever. It has been demonstrated that early treatment of SA with corticosteroids (2–4 days), at the onset of symptoms, can reduce the symptoms and lead to earlier discharge. However, the only two randomised studies diverged over prevention of sequelae.<a class="elsevierStyleCrossRefs" href="#bib0390">38,39</a> Therefore, given the low frequency of sequelae in Spain and the possibility of interfering with the diagnosis of noninfectious arthritis or masking the evolution of the process, this group of experts recommends that corticosteroids should not be used routinely, but should be restricted to confirmed infections with a high degree of inflammation (dexamethasone, 0.2mg/kg/8h).<a class="elsevierStyleCrossRef" href="#bib0395">39</a>Complications and prognosisComplications and/or sequelae of acute OAI in children in Spain, with early diagnosis, range between 5% and 10%. They are more common in MRSA infections and/or in the presence of virulence factors such as PVL, infants <3 months old, SA of the hip and delayed diagnoses.<a class="elsevierStyleCrossRefs" href="#bib0225">5,13,16,19,40</a> In countries with scarce resources sequelae can be high (up to 30%).Acute complicationsComplications of OAI should be identified early.Local complicationsThe most frequent complication is spread from the primary focus to adjacent tissues, especially in younger children. AOM may develop a subperiosteal abscess, spread to the joint (osteoarthritis) or entail muscular involvement (pyomyositis), especially in pelvic locations, and this is relatively common in the case of MRSA.<a class="elsevierStyleCrossRef" href="#bib0280">16</a> These complications must be suspected in the presence of continued fever, persistently positive blood cultures or sustained high CRP.A much less frequent but serious complication is the appearance of a deep vein thrombosis (DVT), which is more common in adolescent males with osteomyelitis of the femur or tibia caused by S. aureus, especially by MRSA.<a class="elsevierStyleCrossRef" href="#bib0340">28</a>Systemic complicationsOn rare occasions OAI caused by S. aureus can give rise to severe sepsis, with hypotension and multiorgan involvement, which requires admission to an intensive care unit and can be fatal.<a class="elsevierStyleCrossRefs" href="#bib0335">27,28</a> Another uncommon complication associated with DVT in osteomyelites caused by S. aureus is septic pulmonary thromboembolism, with respiratory distress and chest pain, which shows up as nodular images and bilateral cavitations on X-rays.<a class="elsevierStyleCrossRef" href="#bib0340">28</a>SequelaeThe consequences of an inadequately treated OAI can be devastating. The most frequent complication is avascular necrosis of the epiphyses (hip and shoulder), followed by a length discrepancy or angular deformity of the extremities and pathological fractures.<a class="elsevierStyleCrossRef" href="#bib0280">16</a> Articular impingement may induce early degeneration of the joint (loss of mobility and pain).Some of the factors most commonly associated with sequelae are: delay in beginning antibiotherapy, hip involvement, MRSA infection and NB (61%). The treatment of sequelae must be tailored to the individual.<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a> sets out the most significant recommendations of this consensus document with the degree of evidence.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres502750" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec523908" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres502749" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec523907" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Aetiology and resistances: major issues for treatment" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Resistances and other important considerations for treatment" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Treatment" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0025" "titulo" => "Surgical treatment" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0030" "titulo" => "Septic arthritis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Arthrocentesis: joint puncture, needle aspiration and joint lavage" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Arthrotomy" ] ] ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Surgical drainage in osteomyelitis" ] ] ] 1 => array:3 [ "identificador" => "sec0050" "titulo" => "Medical treatment" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Initial empirical treatment" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Hospitalisation and duration of intravenous treatment" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Outpatient treatment and follow-up" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Adjuvant treatment" ] ] ] ] ] 7 => array:3 [ "identificador" => "sec0075" "titulo" => "Complications and prognosis" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0080" "titulo" => "Acute complications" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Local complications" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Systemic complications" ] ] ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Sequelae" ] ] ] 8 => array:2 [ "identificador" => "sec0100" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-08-20" "fechaAceptado" => "2014-10-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec523908" "palabras" => array:5 [ 0 => "Osteoarticular infection" 1 => "Acute osteomyelitis" 2 => "Septic arthritis" 3 => "Treatment" 4 => "Paediatrics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec523907" "palabras" => array:5 [ 0 => "Infección osteoarticular" 1 => "Osteomielitis aguda" 2 => "Artritis séptica" 3 => "Tratamiento" 4 => "Pediatría" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "This is a Consensus document of the Spanish Society of Paediatric Infectious Diseases (Sociedad Española de Infectología Pediatrica), the Spanish Society of Paediatric Rheumatology (Sociedad Española de Reumatología Pediátrica) and the Spanish Society of Paediatric Orthopaedics (Sociedad Española de Ortopedia Pediátrica), on the treatment of uncomplicated acute osteomyelitis and septic arthritis.A review is presented on the medical and surgical treatment of acute osteoarticular infection, defined as a process with <14 days of symptomatology, uncomplicated and community-acquired. The different possible options are evaluated based on the best available scientific knowledge, and a number of evidence-based recommendations for clinical practice are provided." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Presentamos el documento de Consenso sobre tratamiento de la osteomielitis aguda y la artritis séptica no complicadas, elaborado por la Sociedad Española de Infectología Pediátrica, la Sociedad Española de Reumatología Pediátrica y la Sociedad Española de Ortopedia Pediátrica.En este documento se revisa el abordaje y el tratamiento médico-quirúrgico de la infección osteoarticular aguda, considerada como aquella que presenta una evolución inferior a 14 días, no complicada, de origen comunitario en niños, basándonos en las mejores evidencias científicas disponibles y valorando las diversas opciones disponibles en la actualidad. En función de dichas evidencias, se aportan una serie de recomendaciones para la práctica clínica." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Saavedra-Lozano J, Calvo C, Huguet Carol R, Rodrigo C, Núñez E, Obando I, et al. Documento de consenso SEIP-SERPE-SEOP sobre el tratamiento de la osteomielitis aguda y artritis séptica no complicadas. An Pediatr (Barc). 2015;82:273.e1–273.e10." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Modified from Khan et al.<a class="elsevierStyleCrossRef" href="#bib0255">11</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Category \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Definition \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Strength of recommendation</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poor evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Quality of evidence</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Properly randomised clinical studies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Well designed but non-randomised clinical studiesCohort studiesCase and control studiesOthers: multiple series or consequence of convincing results of non-controlled experiments \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Opinion of experts based on clinical experienceDescriptive studiesRecommendations of committees of experts \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802057.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Level of evidence and strength of recommendation used in this consensus document." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteria \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><3 months<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureusS. agalactiaeEnterobacteria (especially Escherichia coli) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3 months–5 years<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureusK. kingaeS. pyogenes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>5 years<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureusS. pyogenes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802058.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk situation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteria \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Puncture wound in foot wearing training shoes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">P. aeruginosa \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chicken pox and wounds \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. pyogenes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sickle-cell disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Salmonella sp. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Complement deficiency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neisseria meningitidis<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Newborn with complex pathologies, immunodeficiencies, patients with prostheses or osteosynthesis material \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Plasmocoagulase-negative Staphylococcus; S. epidermidis, S. hominis, S. saprophyticus, S. haemolyticus, S. lugdunensis. Candida sp., as well as other gram-positive cocci and bacilli and gram-negative bacilli \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Agammaglobulinaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mycoplasma pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chronic granulomatous disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus, Serratia marcescens and Aspergillus fumigatus, among others \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patients from countries highly endemic for tuberculosis, immunodeficiencies that affect the interferon-gamma/interleukin-12 axis and treatments with biologic immunomodulators that interfere with interferon production \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mycobacterium tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802062.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Other microorganisms occasionally associated with osteoarticular infection in newborns are Neisseria gonorrhoeae, coagulase-negative Staphylococcus and Candida." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Kingella kingae can produce osteoarticular infection in children <5 years, but much more commonly in those <2 years. In addition, in children <2 years Streptococcus pneumoniae should be considered, and in inadequately vaccinated children <5 years, Haemophilus influenzae." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Neisseria gonorrhoeae must be considered in sexually active adolescents." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "Neisseria meningitidis can produce reactive arthritis or arthritis by direct invasion in systemic infections." ] ] ] "descripcion" => array:1 [ "en" => "Most common aetiology of osteoarticular infection by age and associated risk factors." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "A/C, amoxicillin/clavulanic acid; d, day; GAS, S. pyogenes; GBS, S. agalactiae; h, hours; IM, intramuscular; IV, intravenous; MRSA, methicillin-resistant S. aureus; p.o., by mouth." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose (mg/kg/d) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum daily dose<a class="elsevierStyleCrossRef" href="#tblfn0025">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interval \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Observations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Amoxicillin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80–100 (p.o.)<a class="elsevierStyleCrossRef" href="#tblfn0065">i</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6g<a class="elsevierStyleCrossRef" href="#tblfn0065">i</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q6–8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Susceptible bacteria such as GAS, GBS or S. pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">A/C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80–100<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> (p.o.)100<a class="elsevierStyleCrossRef" href="#tblfn0035">c</a> (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–6g of amoxicillin<a class="elsevierStyleCrossRef" href="#tblfn0040">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q6–8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">p.o.: q8h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefadroxil<a class="elsevierStyleCrossRef" href="#tblfn0045">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60–90 (p.o.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefazolin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100<a class="elsevierStyleCrossRef" href="#tblfn0065">i</a> (150) (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q6–8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefotaxime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150–200 (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q6–8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ceftazidime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150 (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">If Pseudomonas infection suspected \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ceftriaxone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75–100 (IV/IM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q12–24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefuroxime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150–200 (IV)60–90 (p.o.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV 6gp.o.: 3g<a class="elsevierStyleCrossRef" href="#tblfn0065">i</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ciprofloxacin<a class="elsevierStyleCrossRef" href="#tblfn0050">f</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30mg/kg/d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV: 400mg/dosep.o.: 750mg/dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV: q8–12h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clindamycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30–40 (p.o./IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV: 2.7gp.o.: 1350mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q6–8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In severe infections up to 4.8gr/d (IV) has been used \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cloxacillin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150 (up to 200) (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q4–6h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not recommended p.o. as it does not have optimal bioavailability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Daptomycin<a class="elsevierStyleCrossRef" href="#tblfn0055">g</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–10 (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–6mg/kg(350 and 500mg vials) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infants and small children could need larger doses:>12 years: 4–6mg/kg6–12 years: 7mg/kg2–6 years: 8–10mg/kg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Levofloxacin<a class="elsevierStyleCrossRef" href="#tblfn0050">f</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (p.o./IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">p.o.: 75mg IV: 500mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤5 years: 10mg/kg/12h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Linezolid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (p.o./IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">600mg/dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥12 years: 600mg/12h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Rifampicin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15–20 (p.o./IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">600mg/24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q12–24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not in monotherapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Teicoplanin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">400mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q24h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First 3 doses: 10mg/kg/12hDoses of up to 15–20mg/kg/d have been used in patients with hematopoietic stem cell transplantationSevere infections: trough levels >10μg/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">TMP–SMX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–15 (p.o./IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">160mg of TMP/6–12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">p.o.: q12hIV: q6–12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe infections, up to 320mg of TMP/6h IV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Vancomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45–60 (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2–4g \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">q6–8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Important to measure trough levels and adjust accordingly (for MRSA it should be 15–20μg/mL)<a class="elsevierStyleCrossRef" href="#tblfn0060">h</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802063.png" ] ] ] "notaPie" => array:9 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "a" "nota" => "Maximum recommended quantity of drug per day." ] 1 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "b" "nota" => "Of amoxicillin." ] 2 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "c" "nota" => "Increasing the dose of amoxicillin IV to 120–150mg/kg/day could be considered, using formulations with a lesser quantity of clavulanic acid (amoxicillin:clavulanic concentration 10:1; 2g/200mg or 500mg/50mg vials)." ] 3 => array:3 [ "identificador" => "tblfn0040" "etiqueta" => "d" "nota" => "Avoid administering >125mg of clavulanic acid per dose (by adding amoxicillin alone, if necessary). Consider administering a probiotic, especially if gastrointestinal side effects occur." ] 4 => array:3 [ "identificador" => "tblfn0045" "etiqueta" => "e" "nota" => "At the time of writing these guidelines the marketing of cefadroxil 250mg/5mL suspension had been suspended in Spain." ] 5 => array:3 [ "identificador" => "tblfn0050" "etiqueta" => "f" "nota" => "According to the data sheet, in patients <18 years ciprofloxacin for this indication and levofloxacin for any indication would be off-label, although there is ample experience in children." ] 6 => array:3 [ "identificador" => "tblfn0055" "etiqueta" => "g" "nota" => "Daptomycin is not approved for patients <18 years (compassionate treatment) and is not recommendable if pulmonary involvement due to septic emboli is suspected, as it is rendered inactive by the pulmonary surfactant. The youngest children could require 6mg/kg/12h." ] 7 => array:3 [ "identificador" => "tblfn0060" "etiqueta" => "h" "nota" => "Although some guides recommend these levels, some authors have recently suggested lower trough levels." ] 8 => array:3 [ "identificador" => "tblfn0065" "etiqueta" => "i" "nota" => "Higher doses could be considered, in view of its good tolerability." ] ] ] "descripcion" => array:1 [ "en" => "Antibiotics most commonly used in OAI in children (listed in alphabetical order)." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "A/C, amoxicillin/clavulanic acid; IM, intramuscular; IV, intravenous; MRSA, methicillin-resistant S. aureus; TMP–SMX, trimethoprim–sulfamethoxazole." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Empirical antibiotics<a class="elsevierStyleCrossRef" href="#tblfn0070">a</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><3 months(including newborns) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cloxacillin+cefotaxime/gentamicin<a class="elsevierStyleCrossRef" href="#tblfn0070">a</a>Alternative: consult paediatric infectious diseases specialist \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3 months–5 years<a class="elsevierStyleCrossRef" href="#tblfn0075">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cefuroxime in monotherapy or cloxacillin+cefotaxime<a class="elsevierStyleCrossRef" href="#tblfn0080">c</a>Alternative: A/CAlternatives in children >2 years with no suspicion of S. pneumoniae:Cefazolin or cloxacillin<a class="elsevierStyleCrossRef" href="#tblfn0085">d</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">5 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cefazolin or cloxacillin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Adolescents<a class="elsevierStyleCrossRef" href="#tblfn0090">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Penicillin G (25,000U/kg/6h) IV or ceftriaxone IV/IM \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802061.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Special situations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sickle-cell anaemia: cloxacillin+cefotaxime or A/C in monotherapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Anaerobes: clindamycin (alternatives: A/C or metronidazole)<a class="elsevierStyleCrossRef" href="#tblfn0095">f</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">History of puncture wound: cloxacillin+ceftazidime \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Prosthesis-related superinfection: vancomycin/linezolid/ciprofloxacin/levofloxacin with or without rifampicin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">β-Lactam allergy: clindamycin, and as alternatives, TMP–SMX or quinolones. Combining rifampicin with either of them could be considered. For other options it would be advisable to consult a paediatric infectious diseases specialist. In such cases one should remember the possibility of K. kingae in children aged <2–5 years and enterobacteria in those <3 months, who might not be adequately covered with these antibiotics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Serious conditions<a class="elsevierStyleCrossRef" href="#tblfn0100">g</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Glycopeptide (or linezolid)±rifampicin±clindamycin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Alternative: daptomycin (not approved in children) when glycopeptides or linezolid cannot be used, if there is no pulmonary involvement. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802060.png" ] ] ] "notaPie" => array:7 [ 0 => array:3 [ "identificador" => "tblfn0070" "etiqueta" => "a" "nota" => "If there are high rates of MRSA (>10%), use of clindamycin or vancomycin is recommended." ] 1 => array:3 [ "identificador" => "tblfn0075" "etiqueta" => "b" "nota" => "In children >2 years the same regimen could be used as in those >5 years, provided they are properly vaccinated, given that both Kingella and S. pneumoniae are uncommon." ] 2 => array:3 [ "identificador" => "tblfn0080" "etiqueta" => "c" "nota" => "If cefuroxime IV is not available or a resistant bacterium is suspected." ] 3 => array:3 [ "identificador" => "tblfn0085" "etiqueta" => "d" "nota" => "If Kingella is suspected, combining another β-lactam antibiotic should be considered (as when clindamycin is used in monotherapy)." ] 4 => array:3 [ "identificador" => "tblfn0090" "etiqueta" => "e" "nota" => "The empirical treatment would be the same as for children >5 years and this option would only be for suspected N. gonorrhoeae." ] 5 => array:3 [ "identificador" => "tblfn0095" "etiqueta" => "f" "nota" => "Always consider anaerobes in the event of torpid progression. For example, Fusobacterium necrophorum has sometimes been implicated." ] 6 => array:3 [ "identificador" => "tblfn0100" "etiqueta" => "g" "nota" => "Children with involvement of several locations, with associated sepsis or with pulmonary thromboembolisms. As long as there is no diagnostic confirmation of an MRSA, the possibility of adding a β-lactam antibiotic should be assessed, given that they have greater activity against methicillin-susceptible S. aureus. h These two combinations would cover most microorganisms, including Streptococcus agalactiae. Gentamicin (or amikacin, in certain cases) could be better for hospital-acquired gram-negative bacteria." ] ] ] "descripcion" => array:1 [ "en" => "Initial empirical treatment of osteoarticular infections by age and certain underlying conditions of the patient." ] ] 4 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "A/C, amoxicillin/clavulanic acid; GAS, S. pyogenes; GBS, S. agalactiae; Hib, Haemophilus influenzae type b; TMP–SMX, trimethoprim–sulfamethoxazole." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Empirical oral treatment (without microbiological isolate)</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Newborns<a class="elsevierStyleCrossRef" href="#tblfn0105">a</a> and <3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cefuroxime axetilAlternative: A/C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3 months–5 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cefuroxime axetil; cefadroxil<a class="elsevierStyleCrossRef" href="#tblfn0110">b</a> in children >2 yearsAlternative: A/C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>5 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cefadroxil<a class="elsevierStyleCrossRef" href="#tblfn0110">b</a> or cefuroxime axetil \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802055.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Specific treatment according to microbiological isolate<a class="elsevierStyleCrossRef" href="#tblfn0120">d</a></th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganism \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Methicillin-susceptible S. aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cefadroxil<a class="elsevierStyleCrossRef" href="#tblfn0110">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Methicillin-resistant S. aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clindamycin/ciprofloxacin/TMP–SMX<a class="elsevierStyleCrossRef" href="#tblfn0115">c</a>±rifampicinAlternative: linezolid \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hib \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cefuroxime axetilAlternative: A/C \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">GBS, GAS, S. pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicillin \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802059.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0105" "etiqueta" => "a" "nota" => "Most of the treatment should be administered intravenously." ] 1 => array:3 [ "identificador" => "tblfn0110" "etiqueta" => "b" "nota" => "At the time of writing this consensus document cefadroxil suspension had ceased to be marketed in Spain; cefuroxime axetil is a suitable alternative, but also suffers from supply problems, leaving amoxicillin/clavulanic acid in solution or preparation from tablets as the only options (see text). In the event of allergy the oral alternatives of the antibiotics commented on in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> could be considered." ] 2 => array:3 [ "identificador" => "tblfn0115" "etiqueta" => "c" "nota" => "Always adjust according to susceptibility." ] 3 => array:3 [ "identificador" => "tblfn0120" "etiqueta" => "d" "nota" => "According to susceptibility; TMP–SMX has the advantage of convenience of use, tolerability and flavour, but less experience." ] ] ] "descripcion" => array:1 [ "en" => "Oral antibiotic treatment." ] ] 5 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• In most cases of SA, children with recent symptoms will be candidates for drainage via arthrocentesis and antibiotherapy, and it is not essential to perform an arthrotomy (BII), which should be considered after 48–72h or 2–3 punctures and aspirations if the response is not satisfactory (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• In arthritis of the shoulder and hip, the decision to perform surgical drainage will depend on how early action is taken, on the laboratory analyses and on the experience of the team responsible for the patient. In many cases it may be sufficient to drain and lavage the joint by arthrocentesis, which may need to be repeated (BII). These patients must be treated where there is a team with expertise in this type of childhood infection. Surgical drainage is always more likely to be necessary in infections by high-virulence microorganisms such as PVL-producing S. aureus (AII). In the case of NB and small infants, given the paucity of evidence, a surgical arthrotomy should be performed in most situations (AIII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• If an arthrotomy is performed, placement of a surgical drain should be considered, especially in the hip and the shoulder, and in the youngest infants, for a maximum of 48–72h (BIII), as well as immobilisation of the joint after surgery to avoid complications, implementing early passive mobilisation (CIII). On this point the group of experts did not reach total consensus, and some members do not recommend placement of a drain or immobilisation in most cases (CC, RM) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• If OAI is suspected in a child, IV antibiotic treatment should be initiated as soon as possible (AII), after appropriate collection of microbiological samples, which should always include samples for blood culture (AI). The start of antibiotic treatment should not be delayed beyond 6–12h and the minimum duration of IV administration should be 2–5 days (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Children aged <3 months, and especially those of less than a month, should receive a major part of the antibiotic treatment via IV (AII). The duration of treatment, both IV and in total, should be more prolonged and individualised in the case of MRSA or PVL-producing MSSA infection, with a minimum of 10–14 days IV (AII). Equally, the duration of treatment in the case of complicated OAI may need to be prolonged and should be determined on an individual basis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• In all cases, an empirical antibiotic with good activity against MSSA and S. pyogenes should be used (AI). In children aged <5 years it is advisable to use an antibiotic with good activity against K. kingae (AI) and in those children aged <5 years with <3 doses of H. influenzae type b or S. pneumoniae vaccine (especially in those under 2 years old) an antibiotic with good coverage against these microorganisms should be used (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Cefazolin is the initial antibiotic of choice in children aged >2 years. Other options are cloxacillin and clindamycin (the latter especially if the prevalence of MRSA is over 10%) (AII). If clindamycin or cloxacillin is used in patients ≤2–5 years it is advisable to combine it with another antibiotic with good activity against Kingella, normally a β-lactam antibiotic (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• In children aged <2 years or with <3 doses of vaccine, treatment with cefuroxime is recommended, and as an alternative, amoxicillin/clavulanic acid. Another option would include cloxacillin combined with cefotaxime (BII). This last alternative would be the one indicated for children aged <3 months (AI) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• In the event of serious infection, defined as severe sepsis or septic shock, and/or suspicion of septic pulmonary emboli, the most suitable antibiotic would be vancomycin with or without rifampicin (AII), preferably combined with a β-lactam antibiotic with adequate coverage for MSSA until the microbiological isolate is available. If MRSA is identified there are other alternatives, which could include clindamycin, linezolid or daptomycin, in various combinations, with or without rifampicin (BIII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• The duration of IV treatment should never be <2–5 days (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Non-steroidal anti-inflammatory drugs are recommendable in the acute phase for relief of pain and fever in OAI (AII). The use of corticosteroids is confined to situations with a high degree of inflammation, especially if the infectious aetiology is confirmed or is very probable (BII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• A decrease of at least 30% in CRP levels with absence of fever for ≥24–48h and improvement in the signs and symptoms of the infection allow oral antibiotic treatment to be initiated and discharge from hospital to be considered (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• Evolution of OAI with antibiotic treatment should be positive. A lack of response to antibiotic treatment indicates a resistant pathogen, a developing complication or a non-infectious diagnosis (BII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• This panel recommends the use of oral cefadroxil in Spain, whenever possible, in view of its good tolerability, narrow spectrum and substantial clinical experience (AII). Cefuroxime axetil or amoxicillin/clavulanic acid are alternatives, if there is a shortage. In the case of S. pyogenes or S. pneumoniae with good susceptibility to penicillin, oral amoxicillin is recommended (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• For oral treatment of community-acquired MRSA, this group of experts recommends the use of clindamycin (AII), TMP–SMX (BII) or ciprofloxacin (BII), combined or not with rifampicin (CIII). Treatment with quinolones in monotherapy should be avoided. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• If no microbe is isolated, treatment should be continued using an antibiotic with a similar spectrum to that used intravenously (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• It is advisable to give the patient an appointment at the outpatient clinic in 5–7 days (BIII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• The total duration of antibiotic treatment should never be <10–14 days in the case of SA (AII) and 20 days in the case of AOM (AII). Discontinuation of treatment should always be conditional on the disappearance of clinical symptoms and normalisation of CRP (AII) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">• More prolonged follow-up of NB and small infants, hip involvement and complicated OAI should be undertaken by orthopaedics and/or rheumatology (AIII) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab802056.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of recommendations and evidence." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Septic arthritis of the shoulder in children in Malawi. A randomised, prospective study of aspiration versus arthrotomy and washout" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.P. Smith" 1 => "M. Thyoka" 2 => "C.B. Lavy" 3 => "A. Pitani" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Bone Joint Surg Br" "fecha" => "2002" "volumen" => "84" "paginaInicial" => "1167" "paginaFinal" => "1172" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12463664" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0210" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prospective, randomized trial of 10 days versus 30 days of antimicrobial treatment, including a short-term course of parenteral therapy, for childhood septic arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Peltola" 1 => "M. Paakkonen" 2 => "P. 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Spanish Association of Paediatrics

SEIP–SERPE–SEOP Consensus document on the treatment of uncomplicated acute osteomyelitis and septic arthritis

Documento de consenso SEIP-SERPE-SEOP sobre el tratamiento de la osteomielitis aguda y artritis séptica no complicadas

J. Saavedra-Lozanoa,

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jesaave@yahoo.es

Corresponding author.

, C. Calvoa,b, R. Huguet Carolc, C. Rodrigoa, E. Núñeza,b, I. Obandoa, P. Rojoa, R. Merinob, C. Péreza, F.J. Downeyc, E. Colinoa, J.J. Garcíaa, M.J. Cillerueloa, F. Tornerc, L. Garcíaa

a Sociedad Española de Infectología Pediátrica (SEIP), Spain

b Sociedad Española de Reumatología Pediátrica (SERPE), Spain

c Sociedad Española de Ortopedia Pediátrica (SEOP), Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">This is the second part of an earlier document&#44; which examined the aetiopathogenesis and diagnosis of osteoarticular infections &#40;OAI&#41;&#46; This part addresses treatment&#44; where there have been numerous new contributions in recent years&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#8211;10</span></a> as well as follow-up and prognosis&#46; It includes both acute osteomyelitis &#40;AOM&#41; and septic arthritis &#40;SA&#41;&#44; and basically reviews haematogenous community-acquired infections with acute course &#40;&#60;14 days of symptoms&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">At the end of the document the main recommendations for each section are listed&#44; together with the level of evidence and degree of recommendation&#44; as defined in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Aetiology and resistances&#58; major issues for treatment</span><p id="par0015" class="elsevierStylePara elsevierViewall">The aetiology was described in the previous document&#44; although it is briefly set out in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resistances and other important considerations for treatment</span><p id="par0020" class="elsevierStylePara elsevierViewall">Within <span class="elsevierStyleItalic">Staphylococcus aureus</span> a distinction can be drawn between strains sensitive to methicillin &#40;MSSA&#41; and those resistant to methicillin &#40;MRSA&#41; through modification of the penicillin-binding proteins&#44; and among these&#44; between community-acquired &#40;CA-MRSA&#41; and hospital-acquired strains&#46; In Spain most infections in children are caused by MSSA &#40;&#62;90&#37;&#41;&#59; however&#44; we need to take account of the high rate of CA-MRSA in other geographical areas&#44; such as certain states in the United States&#44; Latin America&#44; North Africa and Eastern Europe&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> which will have to be considered in children from these regions&#46; Methicillin resistance is an indicator of resistance to the other &#946;-lactam antibiotics&#44; including cephalosporins &#40;except ceftaroline&#41; and carbapenems&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">CA-MRSA tends to have few associated antibiotic resistances and is normally sensitive to clindamycin&#44; cotrimoxazole &#40;TMP&#8211;SMX&#41;&#44; glycopeptides &#40;vancomycin and teicoplanin&#41;&#44; rifampicin and linezolid&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleItalic">Kingella kingae</span> is usually sensitive to &#946;-lactam antibiotics&#44; including ampicillin and cephalosporins&#44; and therefore does not tend to give rise to treatment problems&#44; except when clindamycin or cloxacillin are used in monotherapy&#46; Other bacteria&#44; such as <span class="elsevierStyleItalic">Streptococcus pyogenes</span> or <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> normally respond well to penicillin&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Children with OAI should be hospitalised for initial assessment and intravenous &#40;IV&#41; antibiotic treatment&#46; These infections call for a multidisciplinary approach involving orthopaedic surgeons&#44; rheumatologists and paediatric infectious diseases specialists&#44; according to each case&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Surgical treatment</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Septic arthritis</span><p id="par0035" class="elsevierStylePara elsevierViewall">The classic treatment for all kinds of SA involves performing an arthrotomy &#40;surgical drainage&#41; to evacuate the joint&#44; washing out the purulent material&#44; placing an external drain to avoid reaccumulation of fluid and immobilising the joint to avoid subluxations&#44; especially in the hip&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a> Draining of the affected joint and lavage is universally accepted&#44; but it is not so obvious which is the best way of achieving it &#40;arthrotomy&#44; arthroscopy or arthrocentesis&#41;&#44; since there are no adequate studies endorsing any particular approach&#44; though traditionally arthrotomy has been recommended in the shoulder&#44; and especially the hip&#44; given the greater risk of sequelae&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a> The need for surgical drainage is always more likely to arise in infections by high-virulence microorganisms&#44; such as <span class="elsevierStyleItalic">S&#46; aureus</span> producing toxins like Panton&#8211;Valentine leukocidin &#40;PVL&#41; &#40;generally MSSA&#44; sometimes MRSA&#41;&#44; and when the evolution of the infection is more prolonged&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a></p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Arthrocentesis&#58; joint puncture&#44; needle aspiration and joint lavage</span><p id="par0040" class="elsevierStylePara elsevierViewall">Performing an arthrocentesis on the affected joint is essential in order to obtain a microbiological diagnosis&#44; achieve decompression of the joint space &#40;avoiding vascular compromise in the shoulder and the hip&#41; and facilitate the effectiveness of the antibiotic after the purulent material has been flushed out&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a> It must be undertaken in aseptic conditions&#44; and is a simple procedure &#40;more complex in the hip and the shoulder&#41;&#44; with few risks&#44; which can guide diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">15</span></a> There are no absolute contraindications&#44; except local infection at the puncture site&#44; severe sepsis or shock&#46; It must be performed as soon as possible &#40;preferably before starting the antibiotic&#41;&#44; although it can be delayed for a few hours &#40;6&#8211;12<span class="elsevierStyleHsp" style=""></span>h&#44; for example&#41;&#59; early intervention is especially important in SA of the hip and shoulder&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;16</span></a> Most of the authors of this document are in favour of draining the joint and starting antibiotic therapy as soon as possible&#44; but cannot give an exact recommendation of the time needed to avoid complications or sequelae&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Ultrasound can be very helpful for locating the puncture site&#46; The child must receive appropriate sedoanalgesia&#59; inhaled nitrous oxide may be administered&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Both arthrocentesis and arthrotomy enable the joint to be washed out with normal saline&#46; Arthrocentesis has the advantage of being a less traumatic procedure and achieving more rapid patient recovery&#44; and is associated with a faster decrease in C-reactive protein &#40;CRP&#41;&#44; which could reduce the duration of IV antibiotic and length of stay in hospital&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Prompt performance of arthrocentesis&#44; daily clinical assessment and repetition of the procedure when necessary with joint lavage are the keys to the success of this therapeutic approach&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">17</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Therapeutic arthrocentesis can be used for any joint&#44; including the shoulder and the hip&#44; as various studies show&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;4&#44;5&#44;17&#8211;20</span></a> In a randomised study of children with arthritis of the shoulder&#44; for example&#44; no differences were found in prognosis or length of stay in patients treated with aspiration versus arthrotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> As for the hip&#44; there are also studies that support a favourable outcome in children treated with aspiration&#47;irrigation&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> The following are factors that the authors consider indicate a poor prognosis and thus a need for open surgery&#58; symptoms lasting at least six days&#44; CRP &#62;10<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; &#62;15&#44;000<span class="elsevierStyleHsp" style=""></span>neutrophils&#47;mm<span class="elsevierStyleSup">3</span> and erythrocyte sedimentation rate &#40;ESR&#41; &#62;50<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> Repeated aspiration of the hip joint has also been assessed&#44; and more rapid recovery and resumption of walking were observed&#44; without sequelae&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> though some patients required open drainage&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; in most cases&#44; except in newborns &#40;NBs&#41;&#44; where there is no adequate evidence of outcomes without surgical arthrotomy&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> children with recent symptoms &#40;&#60;5&#8211;6 days&#41; could be candidates for drainage via arthrocentesis and antibiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;6&#44;18</span></a> In SA of the shoulder and hip&#44; the decision will depend on how early action is taken&#44; on the analytical assessment and on the experience of the team responsible for the patient&#46; In all these cases&#44; the children should be admitted to a hospital with an experienced orthopaedic surgeon&#44; to perform surgical treatment if necessary&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Arthrotomy</span><p id="par0070" class="elsevierStylePara elsevierViewall">This is the main advanced surgical procedure in the treatment of SA&#46; In principle&#44; it can be performed on any joint&#46; There are authors who consider it essential for treating SA of the hip&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a> although some more recent studies note the possibility of nonsurgical approaches in these locations&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">4&#44;19</span></a> Equally&#44; other authors recommend surgical intervention if the joint fluid is not satisfactorily drained after 2 or 3 arthrocenteses&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">17</span></a> Arthrotomy could be indicated&#44; at the outset&#44; in cases of longer evolution&#44; given the greater difficulty of evacuating denser and more organised material&#44;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;16</span></a> in cases of raised inflammatory markers or of highly virulent pathogens &#40;MRSA&#41; and in neonates and small infants&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;19</span></a> The object of the surgical procedure can be regarded as threefold<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">21</span></a>&#58; drainage of the purulent content and necrotic material&#44; reduction of the intra-articular pressure and direct assessment of the lesion&#44; and also a collection of microbiological and anatomopathological samples&#46; In addition&#44; it enables an external drain to be placed to avoid further collections&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;22</span></a> Although no well-designed studies exist&#44; many authors suggest leaving this type of drainage for irrigation&#47;aspiration&#44; especially in the hip&#59; it must be removed promptly &#40;&#60;48&#8211;72<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Given that this procedure involves opening the joint&#44; it may be necessary&#44; in some cases&#44; to stabilise the joint using cutaneous traction or ferrules to avoid dislocations in the post-operative period&#44; although early mobilisation must be implemented to avoid problems later&#44; such as rigidity or flexion&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Other authors propose arthroscopy as a less aggressive method than arthrotomy for treating SA in children&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;23&#44;24</span></a> The main limitations are the age of the patients and the difficulty of the procedure&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Surgical drainage in osteomyelitis</span><p id="par0085" class="elsevierStylePara elsevierViewall">It has been found that over 90&#37; of patients with AOM have favourable outcomes with antibiotic treatment if initiated early&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">7&#44;18&#44;25&#44;26</span></a> performing surgical drainage when the presence of a collection or sequestrum in the bone or subperiosteal level is detected&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> when no clinical improvement has occurred after 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h of antibiotherapy and in acute exogenous osteomyelitis &#40;AEO&#41;&#46; However&#44; subperiosteal abscesses&#44; even those greater than 3<span class="elsevierStyleHsp" style=""></span>mm&#44; may have favourable outcomes without surgical drainage&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> As in the case of SA&#44; microbiological samples must be taken&#44; as well as anatomopathological samples when this is considered necessary&#44; and it is essential to place an external drain to avoid post-surgical collections&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">It is worth emphasising that some experts have had very good results performing an initial bone puncture&#44; which could improve aetiologic diagnosis and evolution&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Medical treatment</span><p id="par0095" class="elsevierStylePara elsevierViewall">In the last few years a trend has been emerging towards simplifying antibiotic treatment in uncomplicated OAI&#44; with the use of parenteral antibiotic treatment followed by a course of oral antibiotics&#44; with high doses of antibiotherapy and shorter duration&#44; both of IV treatment<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">8&#8211;10</span></a> and overall&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#44;3</span></a> This trend is based on the pioneering experience of a controlled clinical trial published by Peltola et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> which has subsequently been confirmed in prospective cohort or randomised studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#44;3&#44;7&#44;8&#44;10</span></a> Recently&#44; guidelines from the United Kingdom incorporating some of these recommendations have been published&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a> These strategies may not be valid in cases of highly virulent microorganisms&#44; such as PVL-producing <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; given their greater severity and poorer prognosis&#44;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">27&#44;28</span></a> and longer duration of antibiotic treatment is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a></p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Initial empirical treatment</span><p id="par0100" class="elsevierStylePara elsevierViewall">If there is any suspicion of OAI in a child&#44; IV antibiotic treatment should be initiated promptly &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; after collecting samples for microbiological testing&#44; as appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">An antibiotic with good activity against MSSA and <span class="elsevierStyleItalic">S&#46; pyogenes</span> should be used&#44; since these are the most common aetiological agents&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#44;10&#44;27&#44;30</span></a> In the case of AOM through puncture injury to the foot bone &#40;through a training shoe&#41;&#44; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> should also be covered&#46; In children aged &#62;5 years of age it is advisable to use an antibiotic with good activity against <span class="elsevierStyleItalic">K&#46; kingae</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a> and in children with &#60;3 doses of the <span class="elsevierStyleItalic">H</span>&#46; <span class="elsevierStyleItalic">influenzae</span> type b or <span class="elsevierStyleItalic">S&#46; pneumoniae</span> vaccine &#40;especially in those &#60;2 years old&#41; these microorganisms should also be covered&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a> In regions where the prevalence of MRSA infections is &#60;10&#37; of <span class="elsevierStyleItalic">S&#46; aureus</span> infections&#44; an antibiotic with good coverage for this bacterium should be used&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The antibiotics&#44; most widely used and with which there is most experienced in children are cefazolin&#44; cloxacillin and clindamycin&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">25&#44;30</span></a> This group of experts considers cefazolin the antibiotic of choice in properly vaccinated children aged &#62;2 years in geographical areas where the prevalence of CA-MRSA infections is &#60;10&#37;&#46; In children 2 years of age or older that have received &#60;3 vaccine doses&#44; treatment with cefuroxime is recommended&#44; and as alternatives cloxacillin &#40;with little activity against <span class="elsevierStyleItalic">K&#46; kingae</span>&#41;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a> combined with cefotaxime or amoxicillin&#47;clavulanic acid&#46; In children younger than 3 months the recommendation is to combine cloxacillin and cefotaxime&#59; cefazolin and gentamicin is also a suitable combination&#46; Cloxacillin combined with ceftazidime would be the most appropriate antibiotic regime in AOM of the bones of the foot due to a puncture wound&#46; These recommendations are set out in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">In areas with a high prevalence of MRSA&#44; this group of experts recommends using clindamycin&#44; combined with a &#946;-lactam antibiotic in children under 5 to cover <span class="elsevierStyleItalic">K&#46; kingae</span>&#46; In all cases&#44; if MRSA infection is suspected or confirmed&#44; rifampicin could be added to the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> The most suitable options in the event of serious MRSA infection &#40;severe sepsis&#44; septic shock and&#47;or septic pulmonary emboli&#41; are listed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;32&#8211;34</span></a> The antibiotics most commonly used for OAI in children&#44; both orally and via IV&#44; are set out in <a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3&#8211;5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">If a microbiological isolate is obtained&#44; the treatment will be adjusted&#44; choosing the antibiotic with the narrowest spectrum&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Hospitalisation and duration of intravenous treatment</span><p id="par0125" class="elsevierStylePara elsevierViewall">Children with an OAI should remain in hospital for initial empirical IV treatment for a minimum of 2&#8211;5 days&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#44;3&#44;10&#44;14&#44;35</span></a> Children younger than 3 months could need a longer duration of IV treatment and those &#60;1 month of age should receive most of the antibiotic treatment by this route&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The duration of treatment&#44; both IV and in total&#44; should be more prolonged in the case of MRSA or PVL-producing MSSA infection&#44; looking out for possible complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">27&#44;28</span></a> This group of experts recommends a minimum of 10&#8211;14 days of IV treatment in these cases&#46; The duration of treatment of complicated OAI should be determined on an individual basis&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">CRP is very useful for monitoring the response to treatment and evaluating when to switch antibiotic treatment to oral administration&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#44;18</span></a> If the patient progresses well&#44; CRP normalises in 7&#8211;10 days and ESR in 3&#8211;4 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> An increase&#44; or lack of decrease&#44; in CRP is a very specific marker for negative progression or complications&#46; In order to switch to oral antibiotherapy and discharge the patient&#44; a decrease of at least 30&#37; in the CRP level&#44; absence of fever for 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h and an improvement in the signs and symptoms of the infection should be observed&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Outpatient treatment and follow-up</span><p id="par0140" class="elsevierStylePara elsevierViewall">This group of experts recommends using oral cefadroxil whenever possible&#44; with cefuroxime axetil as a suitable alternative &#40;at the time of writing this consensus document&#44; there is a shortage of cefadroxil oral suspension in Spain&#44; as well as serious problems in the supply of all these antibiotics in oral solution &#8211; <a href="http://www.aeped.es/comite-medicamentos/noticias/retirada-mercado-antibiotico-cefadroxilo-no-todo-esta-perdido-informe-c">http&#58;&#47;&#47;www&#46;aeped&#46;es&#47;comite-medicamentos&#47;noticias&#47;retirada-mercado-antibiotico-cefadroxilo-no-todo-esta-perdido-informe-c</a> &#8211; and practically the only remaining option is to use amoxicillin&#47;clavulanic acid or crushed adult tablets&#41;&#46; In the case of <span class="elsevierStyleItalic">S&#46; pyogenes</span> or penicillin-susceptible <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#44; the use of oral amoxicillin is recommended&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">For oral treatment of CA-MRSA&#44; clindamycin<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> or TMP&#8211;SMX<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">37</span></a> are suggested&#44; according to susceptibility&#44; combined or not with rifampicin&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;32</span></a> There is more clinical experience with clindamycin&#44; although its oral tolerability is poorer&#46; A quinolone could be used as an alternative to these&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">If there is no microbiological isolate&#44; treatment should be continued using an antibiotic with a similar spectrum to that used intravenously&#46; In the case of cefazolin or cloxacillin&#44; it would continue with cefadroxil or cefuroxime&#46; <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> lists the oral antibiotics recommended in different situations&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Following discharge from the hospital it is advisable to follow-up the patient closely&#44; especially for adherence and adverse effects&#44; with assessment at 5&#8211;7 days to confirm favourable clinical evolution and tolerability to the antibiotic&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The total duration of antibiotic treatment should never be &#60;10&#8211;14 days in the case of SA and 20 days in the case of AOM&#46; In infections by MRSA or PVL-producing MSSA a minimum of 3&#8211;4 and 4&#8211;6 weeks is recommended for SA and AOM respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a><span class="elsevierStyleItalic">Salmonella</span> infection requires more prolonged treatment &#40;4&#8211;6 weeks&#41;&#44; especially in children with sickle-cell disease&#46; AOM of the pelvis and spine also require minimum durations of 4 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">While antibiotic treatment continues&#44; this group of experts recommends performing at least a complete blood count and CRP every 10&#8211;14 days to monitor the infection and to check for potential adverse effects&#44; although this should be determined on an individual basis&#46; There was no total consensus on the use of ESR for follow-up&#46; Some authors advocated performing an ESR test&#44; especially before ending treatment&#59; others&#44; however&#44; did not advocate it&#44; given that it falls slowly and a prolonged elevated rate could unnecessarily lengthen treatment without signifying unfavourable evolution or complications&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Discontinuation of treatment should always be conditional on the disappearance of clinical symptoms and normalisation of CRP&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">2&#44;3</span></a> A visit is recommended for finishing the antibiotic treatment and another a month after the end of treatment&#46; Closer follow-up is advisable in complicated cases&#44; when there is axial or pelvic involvement and in infants &#62;3 months of age&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Adjuvant treatment</span><p id="par0175" class="elsevierStylePara elsevierViewall">Non-steroidal anti-inflammatory drugs are recommendable in the acute phase to relieve pain and fever&#46; It has been demonstrated that early treatment of SA with corticosteroids &#40;2&#8211;4 days&#41;&#44; at the onset of symptoms&#44; can reduce the symptoms and lead to earlier discharge&#46; However&#44; the only two randomised studies diverged over prevention of sequelae&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">38&#44;39</span></a> Therefore&#44; given the low frequency of sequelae in Spain and the possibility of interfering with the diagnosis of noninfectious arthritis or masking the evolution of the process&#44; this group of experts recommends that corticosteroids should not be used routinely&#44; but should be restricted to confirmed infections with a high degree of inflammation &#40;dexamethasone&#44; 0&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;8<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">39</span></a></p></span></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Complications and prognosis</span><p id="par0180" class="elsevierStylePara elsevierViewall">Complications and&#47;or sequelae of acute OAI in children in Spain&#44; with early diagnosis&#44; range between 5&#37; and 10&#37;&#46; They are more common in MRSA infections and&#47;or in the presence of virulence factors such as PVL&#44; infants &#60;3 months old&#44; SA of the hip and delayed diagnoses&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;13&#44;16&#44;19&#44;40</span></a> In countries with scarce resources sequelae can be high &#40;up to 30&#37;&#41;&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Acute complications</span><p id="par0185" class="elsevierStylePara elsevierViewall">Complications of OAI should be identified early&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Local complications</span><p id="par0190" class="elsevierStylePara elsevierViewall">The most frequent complication is spread from the primary focus to adjacent tissues&#44; especially in younger children&#46; AOM may develop a subperiosteal abscess&#44; spread to the joint &#40;osteoarthritis&#41; or entail muscular involvement &#40;pyomyositis&#41;&#44; especially in pelvic locations&#44; and this is relatively common in the case of MRSA&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a> These complications must be suspected in the presence of continued fever&#44; persistently positive blood cultures or sustained high CRP&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">A much less frequent but serious complication is the appearance of a deep vein thrombosis &#40;DVT&#41;&#44; which is more common in adolescent males with osteomyelitis of the femur or tibia caused by <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; especially by MRSA&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Systemic complications</span><p id="par0200" class="elsevierStylePara elsevierViewall">On rare occasions OAI caused by <span class="elsevierStyleItalic">S&#46; aureus</span> can give rise to severe sepsis&#44; with hypotension and multiorgan involvement&#44; which requires admission to an intensive care unit and can be fatal&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">27&#44;28</span></a> Another uncommon complication associated with DVT in osteomyelites caused by <span class="elsevierStyleItalic">S&#46; aureus</span> is septic pulmonary thromboembolism&#44; with respiratory distress and chest pain&#44; which shows up as nodular images and bilateral cavitations on X-rays&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a></p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Sequelae</span><p id="par0205" class="elsevierStylePara elsevierViewall">The consequences of an inadequately treated OAI can be devastating&#46; The most frequent complication is avascular necrosis of the epiphyses &#40;hip and shoulder&#41;&#44; followed by a length discrepancy or angular deformity of the extremities and pathological fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a> Articular impingement may induce early degeneration of the joint &#40;loss of mobility and pain&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Some of the factors most commonly associated with sequelae are&#58; delay in beginning antibiotherapy&#44; hip involvement&#44; MRSA infection and NB &#40;61&#37;&#41;&#46; The treatment of sequelae must be tailored to the individual&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a> sets out the most significant recommendations of this consensus document with the degree of evidence&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Aetiology and resistances&#58; major issues for treatment"
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              "titulo" => "Resistances and other important considerations for treatment"
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                  "titulo" => "Septic arthritis"
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                      "titulo" => "Arthrocentesis&#58; joint puncture&#44; needle aspiration and joint lavage"
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                      "titulo" => "Arthrotomy"
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                  "titulo" => "Surgical drainage in osteomyelitis"
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                  "identificador" => "sec0065"
                  "titulo" => "Outpatient treatment and follow-up"
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            0 => "Osteoarticular infection"
            1 => "Acute osteomyelitis"
            2 => "Septic arthritis"
            3 => "Treatment"
            4 => "Paediatrics"
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            0 => "Infecci&#243;n osteoarticular"
            1 => "Osteomielitis aguda"
            2 => "Artritis s&#233;ptica"
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            4 => "Pediatr&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This is a Consensus document of the Spanish Society of Paediatric Infectious Diseases &#40;Sociedad Espa&#241;ola de Infectolog&#237;a Pediatrica&#41;&#44; the Spanish Society of Paediatric Rheumatology &#40;Sociedad Espa&#241;ola de Reumatolog&#237;a Pedi&#225;trica&#41; and the Spanish Society of Paediatric Orthopaedics &#40;Sociedad Espa&#241;ola de Ortopedia Pedi&#225;trica&#41;&#44; on the treatment of uncomplicated acute osteomyelitis and septic arthritis&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A review is presented on the medical and surgical treatment of acute osteoarticular infection&#44; defined as a process with &#60;14 days of symptomatology&#44; uncomplicated and community-acquired&#46; The different possible options are evaluated based on the best available scientific knowledge&#44; and a number of evidence-based recommendations for clinical practice are provided&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presentamos el documento de Consenso sobre tratamiento de la osteomielitis aguda y la artritis s&#233;ptica no complicadas&#44; elaborado por la Sociedad Espa&#241;ola de Infectolog&#237;a Pedi&#225;trica&#44; la Sociedad Espa&#241;ola de Reumatolog&#237;a Pedi&#225;trica y la Sociedad Espa&#241;ola de Ortopedia Pedi&#225;trica&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En este documento se revisa el abordaje y el tratamiento m&#233;dico-quir&#250;rgico de la infecci&#243;n osteoarticular aguda&#44; considerada como aquella que presenta una evoluci&#243;n inferior a 14 d&#237;as&#44; no complicada&#44; de origen comunitario en ni&#241;os&#44; bas&#225;ndonos en las mejores evidencias cient&#237;ficas disponibles y valorando las diversas opciones disponibles en la actualidad&#46; En funci&#243;n de dichas evidencias&#44; se aportan una serie de recomendaciones para la pr&#225;ctica cl&#237;nica&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0130">Please cite this article as&#58; Saavedra-Lozano J&#44; Calvo C&#44; Huguet Carol R&#44; Rodrigo C&#44; N&#250;&#241;ez E&#44; Obando I&#44; et al&#46; Documento de consenso SEIP-SERPE-SEOP sobre el tratamiento de la osteomielitis aguda y artritis s&#233;ptica no complicadas&#46; An Pediatr &#40;Barc&#41;&#46; 2015&#59;82&#58;273&#46;e1&#8211;273&#46;e10&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Modified from Khan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Definition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Strength of recommendation</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Quality of evidence</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">I</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Properly randomised clinical studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Well designed but non-randomised clinical studiesCohort studiesCase and control studiesOthers&#58; multiple series or consequence of convincing results of non-controlled experiments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">III</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Opinion of experts based on clinical experienceDescriptive studiesRecommendations of committees of experts&nbsp;\t\t\t\t\t\t\n
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        ]
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      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#60;3 months<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span><span class="elsevierStyleItalic">S&#46; agalactiae</span>Enterobacteria &#40;especially <span class="elsevierStyleItalic">Escherichia coli</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3 months&#8211;5 years<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span><span class="elsevierStyleItalic">K&#46; kingae</span><span class="elsevierStyleItalic">S&#46; pyogenes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#62;5 years<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span><span class="elsevierStyleItalic">S&#46; pyogenes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab802058.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk situation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Puncture wound in foot wearing training shoes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">P&#46; aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chicken pox and wounds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; pyogenes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sickle-cell disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Salmonella</span> sp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Complement deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Neisseria meningitidis</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Newborn with complex pathologies&#44; immunodeficiencies&#44; patients with prostheses or osteosynthesis material&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Plasmocoagulase-negative <span class="elsevierStyleItalic">Staphylococcus</span>&#59; <span class="elsevierStyleItalic">S&#46; epidermidis</span>&#44; <span class="elsevierStyleItalic">S&#46; hominis</span>&#44; <span class="elsevierStyleItalic">S&#46; saprophyticus</span>&#44; <span class="elsevierStyleItalic">S&#46; haemolyticus</span>&#44; <span class="elsevierStyleItalic">S&#46; lugdunensis&#46; Candida</span> sp&#46;&#44; as well as other gram-positive cocci and bacilli and gram-negative bacilli&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Agammaglobulinaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chronic granulomatous disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span>&#44; <span class="elsevierStyleItalic">Serratia marcescens</span> and <span class="elsevierStyleItalic">Aspergillus fumigatus</span>&#44; among others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Patients from countries highly endemic for tuberculosis&#44; immunodeficiencies that affect the interferon-gamma&#47;interleukin-12 axis and treatments with biologic immunomodulators that interfere with interferon production&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab802062.png"
              ]
            ]
          ]
          "notaPie" => array:4 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Other microorganisms occasionally associated with osteoarticular infection in newborns are <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span>&#44; coagulase-negative <span class="elsevierStyleItalic">Staphylococcus</span> and <span class="elsevierStyleItalic">Candida</span>&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleItalic">Kingella kingae</span> can produce osteoarticular infection in children &#60;5 years&#44; but much more commonly in those &#60;2 years&#46; In addition&#44; in children &#60;2 years <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> should be considered&#44; and in inadequately vaccinated children &#60;5 years&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015"><span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> must be considered in sexually active adolescents&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020"><span class="elsevierStyleItalic">Neisseria meningitidis</span> can produce reactive arthritis or arthritis by direct invasion in systemic infections&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Most common aetiology of osteoarticular infection by age and associated risk factors&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A&#47;C&#44; amoxicillin&#47;clavulanic acid&#59; d&#44; day&#59; GAS&#44; <span class="elsevierStyleItalic">S&#46; pyogenes</span>&#59; GBS&#44; <span class="elsevierStyleItalic">S&#46; agalactiae</span>&#59; h&#44; hours&#59; IM&#44; intramuscular&#59; IV&#44; intravenous&#59; MRSA&#44; methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span>&#59; p&#46;o&#46;&#44; by mouth&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose &#40;mg&#47;kg&#47;d&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum daily dose<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Observations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#8211;100 &#40;p&#46;o&#46;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0065"><span class="elsevierStyleSup">i</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>g<a class="elsevierStyleCrossRef" href="#tblfn0065"><span class="elsevierStyleSup">i</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q6&#8211;8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Susceptible bacteria such as GAS&#44; GBS or <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">A&#47;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#8211;100<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a> &#40;p&#46;o&#46;&#41;100<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a> &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#8211;6<span class="elsevierStyleHsp" style=""></span>g of amoxicillin<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q6&#8211;8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p&#46;o&#46;&#58; q8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefadroxil<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#8211;90 &#40;p&#46;o&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefazolin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100<a class="elsevierStyleCrossRef" href="#tblfn0065"><span class="elsevierStyleSup">i</span></a> &#40;150&#41; &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q6&#8211;8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefotaxime&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150&#8211;200 &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q6&#8211;8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ceftazidime&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150 &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">If <span class="elsevierStyleItalic">Pseudomonas</span> infection suspected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ceftriaxone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#8211;100 &#40;IV&#47;IM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q12&#8211;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefuroxime&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150&#8211;200 &#40;IV&#41;60&#8211;90 &#40;p&#46;o&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV 6<span class="elsevierStyleHsp" style=""></span>gp&#46;o&#46;&#58; 3<span class="elsevierStyleHsp" style=""></span>g<a class="elsevierStyleCrossRef" href="#tblfn0065"><span class="elsevierStyleSup">i</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ciprofloxacin<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#58; 400<span class="elsevierStyleHsp" style=""></span>mg&#47;dosep&#46;o&#46;&#58; 750<span class="elsevierStyleHsp" style=""></span>mg&#47;dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#58; q8&#8211;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clindamycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;40 &#40;p&#46;o&#46;&#47;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&#58; 2&#46;7<span class="elsevierStyleHsp" style=""></span>gp&#46;o&#46;&#58; 1350<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q6&#8211;8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In severe infections up to 4&#46;8<span class="elsevierStyleHsp" style=""></span>gr&#47;d &#40;IV&#41; has been used&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cloxacillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150 &#40;up to 200&#41; &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q4&#8211;6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not recommended p&#46;o&#46; as it does not have optimal bioavailability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Daptomycin<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">g</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#8211;10 &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#8211;6<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#40;350 and 500<span class="elsevierStyleHsp" style=""></span>mg vials&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infants and small children could need larger doses&#58;&#62;12 years&#58; 4&#8211;6<span class="elsevierStyleHsp" style=""></span>mg&#47;kg6&#8211;12 years&#58; 7<span class="elsevierStyleHsp" style=""></span>mg&#47;kg2&#8211;6 years&#58; 8&#8211;10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Levofloxacin<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;p&#46;o&#46;&#47;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p&#46;o&#46;&#58; 75<span class="elsevierStyleHsp" style=""></span>mg IV&#58; 500<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8804;5 years&#58; 10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Linezolid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;p&#46;o&#46;&#47;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">600<span class="elsevierStyleHsp" style=""></span>mg&#47;dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;12 years&#58; 600<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Rifampicin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#8211;20 &#40;p&#46;o&#46;&#47;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">600<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q12&#8211;24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not in monotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Teicoplanin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">400<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">First 3 doses&#58; 10<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>hDoses of up to 15&#8211;20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d have been used in patients with hematopoietic stem cell transplantationSevere infections&#58; trough levels &#62;10<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">TMP&#8211;SMX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;15 &#40;p&#46;o&#46;&#47;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">160<span class="elsevierStyleHsp" style=""></span>mg of TMP&#47;6&#8211;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p&#46;o&#46;&#58; q12<span class="elsevierStyleHsp" style=""></span>hIV&#58; q6&#8211;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe infections&#44; up to 320<span class="elsevierStyleHsp" style=""></span>mg of TMP&#47;6<span class="elsevierStyleHsp" style=""></span>h IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Vancomycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#8211;60 &#40;IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#8211;4<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">q6&#8211;8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Important to measure trough levels and adjust accordingly &#40;for MRSA it should be 15&#8211;20<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL&#41;<a class="elsevierStyleCrossRef" href="#tblfn0060"><span class="elsevierStyleSup">h</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab802063.png"
              ]
            ]
          ]
          "notaPie" => array:9 [
            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Maximum recommended quantity of drug per day&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Of amoxicillin&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0035"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Increasing the dose of amoxicillin IV to 120&#8211;150<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day could be considered&#44; using formulations with a lesser quantity of clavulanic acid &#40;amoxicillin&#58;clavulanic concentration 10&#58;1&#59; 2<span class="elsevierStyleHsp" style=""></span>g&#47;200<span class="elsevierStyleHsp" style=""></span>mg or 500<span class="elsevierStyleHsp" style=""></span>mg&#47;50<span class="elsevierStyleHsp" style=""></span>mg vials&#41;&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0040"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Avoid administering &#62;125<span class="elsevierStyleHsp" style=""></span>mg of clavulanic acid per dose &#40;by adding amoxicillin alone&#44; if necessary&#41;&#46; Consider administering a probiotic&#44; especially if gastrointestinal side effects occur&#46;</p>"
            ]
            4 => array:3 [
              "identificador" => "tblfn0045"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0045">At the time of writing these guidelines the marketing of cefadroxil 250<span class="elsevierStyleHsp" style=""></span>mg&#47;5<span class="elsevierStyleHsp" style=""></span>mL suspension had been suspended in Spain&#46;</p>"
            ]
            5 => array:3 [
              "identificador" => "tblfn0050"
              "etiqueta" => "f"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0050">According to the data sheet&#44; in patients &#60;18 years ciprofloxacin for this indication and levofloxacin for any indication would be off-label&#44; although there is ample experience in children&#46;</p>"
            ]
            6 => array:3 [
              "identificador" => "tblfn0055"
              "etiqueta" => "g"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0055">Daptomycin is not approved for patients &#60;18 years &#40;compassionate treatment&#41; and is not recommendable if pulmonary involvement due to septic emboli is suspected&#44; as it is rendered inactive by the pulmonary surfactant&#46; The youngest children could require 6<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#46;</p>"
            ]
            7 => array:3 [
              "identificador" => "tblfn0060"
              "etiqueta" => "h"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0060">Although some guides recommend these levels&#44; some authors have recently suggested lower trough levels&#46;</p>"
            ]
            8 => array:3 [
              "identificador" => "tblfn0065"
              "etiqueta" => "i"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0065">Higher doses could be considered&#44; in view of its good tolerability&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Antibiotics most commonly used in OAI in children &#40;listed in alphabetical order&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A&#47;C&#44; amoxicillin&#47;clavulanic acid&#59; IM&#44; intramuscular&#59; IV&#44; intravenous&#59; MRSA&#44; methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span>&#59; TMP&#8211;SMX&#44; trimethoprim&#8211;sulfamethoxazole&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Empirical antibiotics<a class="elsevierStyleCrossRef" href="#tblfn0070"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#60;3 months&#40;including newborns&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cloxacillin<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>cefotaxime&#47;gentamicin<a class="elsevierStyleCrossRef" href="#tblfn0070"><span class="elsevierStyleSup">a</span></a>Alternative&#58; consult paediatric infectious diseases specialist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3 months&#8211;5 years<a class="elsevierStyleCrossRef" href="#tblfn0075"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cefuroxime in monotherapy or cloxacillin<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>cefotaxime<a class="elsevierStyleCrossRef" href="#tblfn0080"><span class="elsevierStyleSup">c</span></a>Alternative&#58; A&#47;CAlternatives in children &#62;2 years with no suspicion of <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#58;Cefazolin or cloxacillin<a class="elsevierStyleCrossRef" href="#tblfn0085"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cefazolin or cloxacillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Adolescents<a class="elsevierStyleCrossRef" href="#tblfn0090"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Penicillin G &#40;25&#44;000<span class="elsevierStyleHsp" style=""></span>U&#47;kg&#47;6<span class="elsevierStyleHsp" style=""></span>h&#41; IV or ceftriaxone IV&#47;IM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab802061.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Special situations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Sickle-cell anaemia&#58; cloxacillin</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">cefotaxime or A&#47;C in monotherapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Anaerobes&#58; clindamycin &#40;alternatives&#58; A&#47;C or metronidazole&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0095"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">History of puncture wound&#58; cloxacillin</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ceftazidime</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Prosthesis-related superinfection&#58; vancomycin&#47;linezolid&#47;ciprofloxacin&#47;levofloxacin with or without rifampicin</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">&#946;-Lactam allergy&#58; clindamycin&#44; and as alternatives&#44; TMP&#8211;SMX or quinolones&#46; Combining rifampicin with either of them could be considered&#46; For other options it would be advisable to consult a paediatric infectious diseases specialist&#46; In such cases one should remember the possibility of K&#46; kingae in children aged &#60;2&#8211;5 years and enterobacteria in those &#60;3 months&#44; who might not be adequately covered with these antibiotics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Serious conditions</span><a class="elsevierStyleCrossRef" href="#tblfn0100"><span class="elsevierStyleSup">g</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Glycopeptide &#40;or linezolid&#41;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>rifampicin<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>clindamycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Alternative&#58; daptomycin &#40;not approved in children&#41; when glycopeptides or linezolid cannot be used&#44; if there is no pulmonary involvement&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab802060.png"
              ]
            ]
          ]
          "notaPie" => array:7 [
            0 => array:3 [
              "identificador" => "tblfn0070"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0070">If there are high rates of MRSA &#40;&#62;10&#37;&#41;&#44; use of clindamycin or vancomycin is recommended&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0075"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0075">In children &#62;2 years the same regimen could be used as in those &#62;5 years&#44; provided they are properly vaccinated&#44; given that both <span class="elsevierStyleItalic">Kingella</span> and <span class="elsevierStyleItalic">S&#46; pneumoniae</span> are uncommon&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0080"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0080">If cefuroxime IV is not available or a resistant bacterium is suspected&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0085"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0085">If <span class="elsevierStyleItalic">Kingella</span> is suspected&#44; combining another &#946;-lactam antibiotic should be considered &#40;as when clindamycin is used in monotherapy&#41;&#46;</p>"
            ]
            4 => array:3 [
              "identificador" => "tblfn0090"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0090">The empirical treatment would be the same as for children &#62;5 years and this option would only be for suspected <span class="elsevierStyleItalic">N&#46; gonorrhoeae&#46;</span></p>"
            ]
            5 => array:3 [
              "identificador" => "tblfn0095"
              "etiqueta" => "f"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0095">Always consider anaerobes in the event of torpid progression&#46; For example&#44; <span class="elsevierStyleItalic">Fusobacterium necrophorum</span> has sometimes been implicated&#46;</p>"
            ]
            6 => array:3 [
              "identificador" => "tblfn0100"
              "etiqueta" => "g"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0100">Children with involvement of several locations&#44; with associated sepsis or with pulmonary thromboembolisms&#46; As long as there is no diagnostic confirmation of an MRSA&#44; the possibility of adding a &#946;-lactam antibiotic should be assessed&#44; given that they have greater activity against methicillin-susceptible <span class="elsevierStyleItalic">S&#46; aureus</span>&#46;</p> <p class="elsevierStyleNotepara" id="npar0105"><span class="elsevierStyleSup">h</span> These two combinations would cover most microorganisms&#44; including <span class="elsevierStyleItalic">Streptococcus agalactiae</span>&#46; Gentamicin &#40;or amikacin&#44; in certain cases&#41; could be better for hospital-acquired gram-negative bacteria&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Initial empirical treatment of osteoarticular infections by age and certain underlying conditions of the patient&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">A&#47;C&#44; amoxicillin&#47;clavulanic acid&#59; GAS&#44; <span class="elsevierStyleItalic">S&#46; pyogenes</span>&#59; GBS&#44; <span class="elsevierStyleItalic">S&#46; agalactiae</span>&#59; Hib&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> type b&#59; TMP&#8211;SMX&#44; trimethoprim&#8211;sulfamethoxazole&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Empirical oral treatment &#40;without microbiological isolate&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Newborns<a class="elsevierStyleCrossRef" href="#tblfn0105"><span class="elsevierStyleSup">a</span></a> and &#60;3 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cefuroxime axetilAlternative&#58; A&#47;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">3 months&#8211;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cefuroxime axetil&#59; cefadroxil<a class="elsevierStyleCrossRef" href="#tblfn0110"><span class="elsevierStyleSup">b</span></a> in children &#62;2 yearsAlternative&#58; A&#47;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#62;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cefadroxil<a class="elsevierStyleCrossRef" href="#tblfn0110"><span class="elsevierStyleSup">b</span></a> or cefuroxime axetil&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Methicillin-susceptible <span class="elsevierStyleItalic">S&#46; aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cefadroxil<a class="elsevierStyleCrossRef" href="#tblfn0110"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clindamycin&#47;ciprofloxacin&#47;TMP&#8211;SMX<a class="elsevierStyleCrossRef" href="#tblfn0115"><span class="elsevierStyleSup">c</span></a><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>rifampicinAlternative&#58; linezolid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hib&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cefuroxime axetilAlternative&#58; A&#47;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">GBS&#44; GAS&#44; <span class="elsevierStyleItalic">S&#46; pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0110">Most of the treatment should be administered intravenously&#46;</p>"
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              "identificador" => "tblfn0110"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0115">At the time of writing this consensus document cefadroxil suspension had ceased to be marketed in Spain&#59; cefuroxime axetil is a suitable alternative&#44; but also suffers from supply problems&#44; leaving amoxicillin&#47;clavulanic acid in solution or preparation from tablets as the only options &#40;see text&#41;&#46; In the event of allergy the oral alternatives of the antibiotics commented on in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> could be considered&#46;</p>"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0125">According to susceptibility&#59; TMP&#8211;SMX has the advantage of convenience of use&#44; tolerability and flavour&#44; but less experience&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Oral antibiotic treatment&#46;</p>"
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        "etiqueta" => "Table 6"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; In most cases of SA&#44; children with recent symptoms will be candidates for drainage via arthrocentesis and antibiotherapy&#44; and it is not essential to perform an arthrotomy &#40;BII&#41;&#44; which should be considered after 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h or 2&#8211;3 punctures and aspirations if the response is not satisfactory &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; In arthritis of the shoulder and hip&#44; the decision to perform surgical drainage will depend on how early action is taken&#44; on the laboratory analyses and on the experience of the team responsible for the patient&#46; In many cases it may be sufficient to drain and lavage the joint by arthrocentesis&#44; which may need to be repeated &#40;BII&#41;&#46; These patients must be treated where there is a team with expertise in this type of childhood infection&#46; Surgical drainage is always more likely to be necessary in infections by high-virulence microorganisms such as PVL-producing <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;AII&#41;&#46; In the case of NB and small infants&#44; given the paucity of evidence&#44; a surgical arthrotomy should be performed in most situations &#40;AIII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; If an arthrotomy is performed&#44; placement of a surgical drain should be considered&#44; especially in the hip and the shoulder&#44; and in the youngest infants&#44; for a maximum of 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h &#40;BIII&#41;&#44; as well as immobilisation of the joint after surgery to avoid complications&#44; implementing early passive mobilisation &#40;CIII&#41;&#46; On this point the group of experts did not reach total consensus&#44; and some members do not recommend placement of a drain or immobilisation in most cases &#40;CC&#44; RM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; If OAI is suspected in a child&#44; IV antibiotic treatment should be initiated as soon as possible &#40;AII&#41;&#44; after appropriate collection of microbiological samples&#44; which should always include samples for blood culture &#40;AI&#41;&#46; The start of antibiotic treatment should not be delayed beyond 6&#8211;12<span class="elsevierStyleHsp" style=""></span>h and the minimum duration of IV administration should be 2&#8211;5 days &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Children aged &#60;3 months&#44; and especially those of less than a month&#44; should receive a major part of the antibiotic treatment via IV &#40;AII&#41;&#46; The duration of treatment&#44; both IV and in total&#44; should be more prolonged and individualised in the case of MRSA or PVL-producing MSSA infection&#44; with a minimum of 10&#8211;14 days IV &#40;AII&#41;&#46; Equally&#44; the duration of treatment in the case of complicated OAI may need to be prolonged and should be determined on an individual basis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; In all cases&#44; an empirical antibiotic with good activity against MSSA and <span class="elsevierStyleItalic">S&#46; pyogenes</span> should be used &#40;AI&#41;&#46; In children aged &#60;5 years it is advisable to use an antibiotic with good activity against <span class="elsevierStyleItalic">K&#46; kingae</span> &#40;AI&#41; and in those children aged &#60;5 years with &#60;3 doses of <span class="elsevierStyleItalic">H</span>&#46; <span class="elsevierStyleItalic">influenzae</span> type b or <span class="elsevierStyleItalic">S&#46; pneumoniae</span> vaccine &#40;especially in those under 2 years old&#41; an antibiotic with good coverage against these microorganisms should be used &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Cefazolin is the initial antibiotic of choice in children aged &#62;2 years&#46; Other options are cloxacillin and clindamycin &#40;the latter especially if the prevalence of MRSA is over 10&#37;&#41; &#40;AII&#41;&#46; If clindamycin or cloxacillin is used in patients &#8804;2&#8211;5 years it is advisable to combine it with another antibiotic with good activity against <span class="elsevierStyleItalic">Kingella</span>&#44; normally a &#946;-lactam antibiotic &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; In children aged &#60;2 years or with &#60;3 doses of vaccine&#44; treatment with cefuroxime is recommended&#44; and as an alternative&#44; amoxicillin&#47;clavulanic acid&#46; Another option would include cloxacillin combined with cefotaxime &#40;BII&#41;&#46; This last alternative would be the one indicated for children aged &#60;3 months &#40;AI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; In the event of serious infection&#44; defined as severe sepsis or septic shock&#44; and&#47;or suspicion of septic pulmonary emboli&#44; the most suitable antibiotic would be vancomycin with or without rifampicin &#40;AII&#41;&#44; preferably combined with a &#946;-lactam antibiotic with adequate coverage for MSSA until the microbiological isolate is available&#46; If MRSA is identified there are other alternatives&#44; which could include clindamycin&#44; linezolid or daptomycin&#44; in various combinations&#44; with or without rifampicin &#40;BIII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; The duration of IV treatment should never be &#60;2&#8211;5 days &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Non-steroidal anti-inflammatory drugs are recommendable in the acute phase for relief of pain and fever in OAI &#40;AII&#41;&#46; The use of corticosteroids is confined to situations with a high degree of inflammation&#44; especially if the infectious aetiology is confirmed or is very probable &#40;BII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; A decrease of at least 30&#37; in CRP levels with absence of fever for &#8805;24&#8211;48<span class="elsevierStyleHsp" style=""></span>h and improvement in the signs and symptoms of the infection allow oral antibiotic treatment to be initiated and discharge from hospital to be considered &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; Evolution of OAI with antibiotic treatment should be positive&#46; A lack of response to antibiotic treatment indicates a resistant pathogen&#44; a developing complication or a non-infectious diagnosis &#40;BII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; This panel recommends the use of oral cefadroxil in Spain&#44; whenever possible&#44; in view of its good tolerability&#44; narrow spectrum and substantial clinical experience &#40;AII&#41;&#46; Cefuroxime axetil or amoxicillin&#47;clavulanic acid are alternatives&#44; if there is a shortage&#46; In the case of <span class="elsevierStyleItalic">S&#46; pyogenes</span> or <span class="elsevierStyleItalic">S&#46; pneumoniae</span> with good susceptibility to penicillin&#44; oral amoxicillin is recommended &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; For oral treatment of community-acquired MRSA&#44; this group of experts recommends the use of clindamycin &#40;AII&#41;&#44; TMP&#8211;SMX &#40;BII&#41; or ciprofloxacin &#40;BII&#41;&#44; combined or not with rifampicin &#40;CIII&#41;&#46; Treatment with quinolones in monotherapy should be avoided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; If no microbe is isolated&#44; treatment should be continued using an antibiotic with a similar spectrum to that used intravenously &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; It is advisable to give the patient an appointment at the outpatient clinic in 5&#8211;7 days &#40;BIII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; The total duration of antibiotic treatment should never be &#60;10&#8211;14 days in the case of SA &#40;AII&#41; and 20 days in the case of AOM &#40;AII&#41;&#46; Discontinuation of treatment should always be conditional on the disappearance of clinical symptoms and normalisation of CRP &#40;AII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8226; More prolonged follow-up of NB and small infants&#44; hip involvement and complicated OAI should be undertaken by orthopaedics and&#47;or rheumatology &#40;AIII&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Summary of recommendations and evidence&#46;</p>"
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      "titulo" => "References"
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                            1 => "M&#46; Paakkonen"
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                            0 => "H&#46; Peltola"
                            1 => "M&#46; Paakkonen"
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                            1 => "M&#46;J&#46; Kallio"
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                          ]
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                      "doi" => "10.1097/BPB.0b013e32833822be"
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                        0 => array:2 [
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                            4 => "T&#46; Haumont"
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            ]
            5 => array:3 [
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2014.10.008

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Year/Month	Html	Pdf	Total

2024 November	15	12	27
2024 October	72	46	118
2024 September	97	37	134
2024 August	88	68	156
2024 July	75	39	114
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2018 October	201	32	233
2018 September	169	15	184
2018 August	2	0	2
2018 July	7	0	7
2018 June	1	0	1
2018 May	5	0	5
2018 April	21	0	21
2018 March	24	1	25
2018 February	20	0	20
2018 January	14	0	14
2017 December	11	0	11
2017 November	18	0	18
2017 October	14	0	14
2017 September	9	0	9
2017 August	20	0	20
2017 July	22	1	23
2017 June	23	12	35
2017 May	28	10	38
2017 April	26	13	39
2017 March	11	13	24
2017 February	9	13	22
2017 January	8	4	12
2016 December	29	11	40
2016 November	33	5	38
2016 October	44	12	56
2016 September	58	19	77
2016 August	44	12	56
2016 July	25	14	39
2016 March	2	0	2
2015 December	3	22	25
2015 November	2	20	22
2015 October	9	26	35
2015 September	1	26	27
2015 August	2	16	18

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