Conference Coverage

How to identify DVT faster in pediatric osteomyelitis

Key clinical point: Osteomyelitis patients with deep vein thrombosis are much sicker than those without DVT.

Major finding: Seven risk factors are useful in raising suspicion that a child with osteomyelitis had DVT.

Study details: This was a retrospective study of the medical records of more than 900,000 Texas children.

Disclosures: Dr. Copley reported having no relevant financial conflicts.


 

REPORTING FROM ESPID 2018

– Early identification of deep vein thrombosis in children with acute hematogenous osteomyelitis is critical given the need to plan anticoagulation management around the high likelihood that such patients will undergo multiple surgeries, Lawson A.B. Copley, MD, said at the annual meeting of the European Society for Paediatric Infectious Diseases.

professor of orthopaedic surgery and pediatrics at the University of Dr. Lawson A.B. Copley Texas Southwestern Medical Center and Children’s Medical Center of Dallas. Bruce Jancin/MDedge News

Dr. Lawson A.B. Copley

He and his coinvestigators have identified a handful of risk factors helpful in expediting recognition of deep vein thrombosis (DVT) in children with suspected invasive infection of the musculoskeletal system.

“To improve the rate and timing of identification of DVT, we recommend performing early screening ultrasound on all children with these risk factors who are suspected of having acute hematogenous osteomyelitis,” declared Dr. Copley, professor of orthopaedic surgery and pediatrics at the University of Texas, Dallas.

Delayed diagnosis of DVT in the setting of acute hematogenous osteomyelitis (AHO) is common. Indeed, in a review of the experience at Children’s Medical Center Dallas during 2012-2014, the average time delay from ICU admission in patients suspected of having AHO to identification of DVT by ultrasound was 6.3 days.

“We’ve changed some things on the basis of that study in order to accelerate that timeline,” he explained.

Their major change was to identify actionable risk factors for DVT. This was accomplished by conducting a retrospective study of the EHR of nearly 902,000 Texas children during 2008-2016.

The study demonstrated that children with AHO complicated by DVT are, from the get-go, very different from AHO patients without DVT. They have higher illness severity of illness, are more likely to be admitted to the ICU, are prone to methicillin-resistant Staphylococcus aureus infection with prolonged bacteremia, and are much more likely to undergo multiple surgeries. Moreover, children with AHO and DVT differed substantially from other children with DVT: The dual diagnosis children lacked comorbid conditions, were prone to septic pulmonary emboli, didn’t develop postthrombotic syndrome marked by chronic venous stasis and ulcerations, and had invariably negative coagulopathy workups.

“There is no need, we feel, to perform a hypercoagulopathy workup in children with AHO complicated by DVT,” Dr. Copley said.

Drilling deeper into the data, he and his coinvestigators identified 224 new cases of DVT in the study population, for a prevalence of 2.5 per 10,000 children, along with 466 children with AHO. A total of 6% of children with AHO had DVT, and 12.1% of all children with DVT had AHO. The researchers then compared the demographics, laboratory parameters, and treatment in three cohorts: the 196 children with DVT without AHO, 28 with both AHO and DVT, and 438 with AHO without DVT.

Through this analysis, they came up with a list of risk factors warranting early screening ultrasound in children suspected of having AHO:

  • An initial C-reactive protein level above 8 mg/dL, which was present in all 28 dual diagnosis children.
  • ICU admission, which occurred in 19 of 28 (68%) children.
  • A severity of illness score of at least 7 on a 10-point scale during the first several days in the hospital, present in 27 of the 28 children. The severity of illness scale was developed and validated by Dr. Copley and coworkers (J Pediatr Orthop. 2016 Oct 12. doi: 10.1097/BPO.0000000000000879).
  • Bacteremia in the initial blood culture, present in 23 of 28 patients (82%).
  • Just under 90% of the children with AHO and DVT had methicillin-resistant S. aureus, compared with 20% of those with AHO without DVT.
  • Septic pulmonary emboli visualized on chest x-ray, a complication that occurred in 64% of the dual diagnosis group versus just 1% of patients with DVT without AHO.
  • A band percentage of white blood cells greater than 1.5%, present in 86% of children with AHO and DVT.

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