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Age and CRP Associated With Improved Tissue Pathogen Identification in Children With Blood Culture Negative
Jessica D Burns1, Vidyadhar V Upasani2, Tracey P Bastrom2
1Phoenix Children's Hospital, Phoenix, AZ.
Insights
In children with acute hematogenous osteomyelitis (AHO), age over 3.1 years and C-reactive protein (CRP) above 4.1 mg/dL predict positive tissue cultures when blood cultures are negative. These factors help guide the utility of tissue biopsy in pediatric AHO cases.
Area of Science:
- Pediatric Infectious Diseases
- Orthopedic Surgery
- Clinical Microbiology
Background:
- Acute hematogenous osteomyelitis (AHO) is a common pediatric condition requiring accurate diagnosis for effective management.
- Blood and tissue cultures are crucial for pathogen identification in AHO, guiding treatment and reducing failure rates.
- Current guidelines recommend tissue cultures, especially when blood cultures are negative.
Purpose of the Study:
- To identify predictors of positive tissue cultures in pediatric patients with AHO when blood cultures yield negative results.
- To establish criteria for optimizing the diagnostic yield of tissue biopsies in AHO.
- To inform clinical decision-making regarding the necessity of tissue sampling in pediatric osteomyelitis.
Main Methods:
- Retrospective comparative study involving 1003 children with AHO across 18 US pediatric medical centers.
- Analysis of predictors for positive tissue cultures in patients with negative blood cultures.
- Determination of optimal cutoffs for predictors using sensitivity and specificity analysis.
Main Results:
- In children with negative blood cultures (n=385), tissue cultures were positive in 69.4%.
- Multivariate analysis identified age (P <0.001) and C-reactive protein (CRP) (P =0.004) as independent predictors of positive tissue cultures.
- Age >3.1 years and CRP >4.1 mg/dL demonstrated 87.3% sensitivity for predicting positive tissue cultures in blood culture-negative cases.
Conclusions:
- Tissue biopsy may offer limited clinical value for AHO patients under 3.1 years with CRP ≤ 4.1 mg/dL, considering procedural morbidity.
- For AHO patients over 3.1 years with CRP > 4.1 mg/dL, tissue biopsy may be beneficial, though empiric antibiotic coverage can impact results.
- These findings help refine the indications for tissue biopsy in pediatric AHO, balancing diagnostic utility against invasiveness.
Background:
Acute hematogenous osteomyelitis (AHO) is a relatively common condition in children, and identifying the offending pathogen with blood or tissue cultures aids in diagnosis and medical management while reducing treatment failure. Recent 2021 AHO clinical practice guidelines from the Pediatric Infectious Disease Society recommend obtaining routine tissue cultures, particularly in cases with negative blood cultures. The purpose of this study was to identify variables associated with positive tissue cultures when blood cultures are negative.
Methods:
Children with AHO from 18 pediatric medical centers throughout the United States through the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study were evaluated for predictors of positive tissue cultures when blood cultures were negative. Cutoffs of predictors were determined with associated sensitivity and specificity.
Results:
One thousand three children with AHO were included, and in 688/1003 (68.6%) patients, both blood cultures and tissue cultures were obtained. In patients with negative blood cultures (n=385), tissue was positive in 267/385 (69.4%). In multivariate analysis, age ( P <0.001) and C-reactive protein (CRP) ( P =0.004) were independent predictors. With age >3.1 years and CRP >4.1 mg/dL as factors, the sensitivity of obtaining a positive tissue culture when blood cultures were negative was 87.3% (80.9-92.2%) compared with 7.1% (4.4-10.9%) if neither of these factors was present. There was a lower ratio of methicillin-resistant Staphylococcus aureus in blood culture-negative patients who had a positive tissue culture 48/188 (25.5%), compared with patients who had both positive blood and tissue cultures 108/220 (49.1%).
Conclusion:
AHO patients with CRP ≤ 4.1 mg/dL and age under 3.1 years are unlikely to have clinical value from tissue biopsy that exceeds the morbidity associated with this intervention. In patients with CRP > 4.1 mg/dL and age over 3.1 years, obtaining a tissue specimen may add value; however, it is important to note that effective empiric antibiotic coverage may limit the utility of positive tissue cultures in AHO.
Level Of Evidence:
Level III-Retrospective comparative study.
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