SAN DIEGO – Early focal cultures and strategic use of polymerase chain reaction (PCR) testing helped a hospital detect Kingella kingae seven times more often in a study of young children with acute non-complex hematogenous osteomyelitis, Rachel Quick, MSN, CNS, said at an annual meeting on infectious diseases.

Kingella kingae turned out to be the leading culprit in these cases, although the new approach also enhanced detection of Staphylococcus aureus and other bacteria, said Ms. Quick of Seton Healthcare Family in Austin, Texas. Children also transitioned to oral antibiotics a median of 22 days sooner and needed peripherally inserted central catheters (PICC) two-thirds less often after the guideline was implemented, she said during her oral presentation.

K. kingae, a leading cause of septic osteomyelitis in young children, is important to identify quickly because it is resistant to antibiotics used to empirically treat MRSA infection, Ms. Quick noted. Additionally, case reports and clinical experience support PCR testing when cultures of suspected pediatric bone and joint infections are negative. After implementing several other guidelines to improve and standardize care for acutely ill children, the hospital created this one, which emphasizes early imaging to identify sites of infection, early focal and blood cultures, and PCR of culture-negative samples. Importantly, PCR was nearly always performed on samples collected before children started antibiotics, she said.

After implementing the guideline, Ms. Quick and her associates compared 25 children treated beforehand with 24 children treated afterward. Patients were 6 months to 5 years old, had physical signs and symptoms of acute hematogenous osteomyelitis or septic joint, and had been symptomatic for less than 14 days. The study was conducted between 2009 and 2016.

Kingella kingae was identified in one patient (4%) from the baseline cohort and in seven patients (29%) after the guideline was rolled out (P = .02), Ms. Quick said. Kingella was cultured from focal samples only, not from blood. Detection of methicillin-sensitive Staphylococcus aureus (MSSA) jumped from 8% to 17%, while cases with no detectable pathogen dropped from 80% to 46%. Lengths of stay and readmission rates did not change significantly.

Taken together, the findings show how early focal cultures and PCR can facilitate targeted therapy in acute pediatric bone and joint infections, prevent unnecessary antibiotic use, and expedite a targeted transition to oral antibiotics, said Ms. Quick. “We recognize that we have a small sample and that these are not complicated cases,” she said. “Our findings do not suggest it’s more important to look for Kingella than Staphylococcus aureus, but that Kingella should be up there in the ranks of what we’re looking for.”

The investigators reported having no conflicts of interest.

Michael J. Ackerman, MD, PhD

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