Transitioning antimicrobials from intravenous to oral in pediatric acute uncomplicated osteomyelitis

Osteomyelitis is a bone infection that requires prolonged antibiotic treatment and potential surgical intervention.If left untreated,acute osteomyelitis can lead to chronic osteomyelitis and overwhelming sepsis.Early treatment is necessary to prevent complications,and the standard of care is progressing to a shorter duration of intravenous(Ⅳ) antibiotics and transitioning to oral therapy for the rest of the treatment course.We systematically reviewed the current literature on pediatric patients with acute osteomyelitis to determine when and how to transition to oral antibiotics from a short Ⅳ course.Studies have shown that switching to oral after a short course(i.e.,3-7 d) of Ⅳ therapy has similar cure rates to continuing long-term Ⅳ therapy.Prolonged Ⅳ use is also associated with increased risk of complications.Parameters that help guide clinicians on making the switch include a downward trend in fever,improvement in local tenderness,and a normalization in C-reactive protein concentration.Based on the available literature,we recommend transitioning antibiotics to oral after 3-7 d of Ⅳ therapy for pediatric patients(except neonates) with acute uncomplicated osteomyelitis if there are signs of clinical improvement,and such regimen should be continued for a total antibiotic duration of four to six weeks.

Tramadol use in pediatric sickle cell disease patients with vaso-occlusive crisis

AIM: To evaluate whether the addition of scheduled oral tramadol to intravenous morphine and intravenous ketorolac reduces morphine requirements.METHODS: This single-centered, Institutional Review Board-approved, retrospective study at Moses Cone Memorial Hospital included pediatric patients who were ≥ 2 years old with vaso-occlusive crisis(VOC) caused by sickle cell disease(SCD), were on morphine patientcontrolled analgesia(PCA), and had scheduled oral tramadol added to their standard pain regimen. The study population was admitted between March 2008 and March 2011. The data was collected from electronic records and included age, weight, morphine use, tramadol use, hemoglobin, pain scores, number of days on PCA, length of hospital stay, respiratory rate, and polyethylene glycol use. Thirty patients were analyzed as independent admissions and seven patients as paired admissions. RESULTS: Eighteen pediatric SCD patients with VOC received morphine PCA and intravenous ketorolac and twelve patients received morphine PCA and intravenous ketorolac and scheduled oral tramadol. Baseline characteristics were similar between both groups with the exception of the average weight, which was greater in the tramadol group than in the morphine group. The average morphine requirements in patients with and without the use of tramadol were similar, both for the independent admissions [0.58 mg/kg per day vs 0.65 mg/kg per day(P = 0.31)] and the paired admissions [0.71 mg/kg per day vs 0.77 mg/kg per day(P = 0.5)]. The daily polyethylene glycol requirement was less in the tramadol group for both the independent [0.5 g/kg per day vs 0.6 g/kg per day(P = 0.64)] and paired admissions analyses [and 0.41 g/kg per day vs 0.55 g/kg per day(P = 0.67)].CONCLUSION: The addition of scheduled tramadol in patients receiving concomitant morphine and ketorolac demonstrates a trend toward decreased morphine and polyethylene glycol use.