Department of Orthopedics, Children's Medical Center of Dallas, Dallas, TX 75235, USA.
J Bone Joint Surg Am. 2013 Apr 17;95(8):686-93. doi: 10.2106/JBJS.L.00037.
Care of children with osteomyelitis requires multidisciplinary collaboration. This study evaluates the impact of evidence-based guidelines for the treatment of pediatric osteomyelitis when utilized by a multidisciplinary team.
Guidelines for pediatric osteomyelitis were developed and were implemented by a multidisciplinary team comprised of individuals from several hospital services, including orthopaedics, pediatrics, infectious disease, nursing, and social work, who met daily to conduct rounds and make treatment decisions. With use of retrospective review and statistical analysis, we compared children with osteomyelitis who had been managed at our institution from 2002 to 2004 (prior to the implementation of the guidelines), referred to as Group I in this study, with those who were managed in 2009 according to the guidelines, referred to as Group II.
Two hundred and ten children in Group I were compared with sixty-one children in Group II. No significant differences between the two cohorts were noted for age, sex, incidence of methicillin-resistant Staphylococcus aureus infection (18.1% in Group I compared with 26.2% in Group II), incidence of methicillin-sensitive Staphylococcus aureus infection (23.8% in Group I compared with 27.9% in Group II), bacteremia, or surgical procedures. Significant differences (p < 0.05) between cohorts were noted for each of the following: the delay in magnetic resonance imaging after admission (2.5 days in Group I compared with one day in Group II), the percentage of patients who had received clindamycin as the initial antibiotic (12.9% in Group I compared with 85.2% in Group II), the percentage of patients who had had a blood culture before antibiotic administration (79.5% in Group I compared with 91.8% in Group II), the percentage of patients who had had a culture of tissue from the infection site (62.9% in Group I compared with 78.7% in Group II), the percentage of patients in whom the infecting organism was identified on tissue or blood culture (60.0% in Group I compared with 73.8% in Group II), the number of antibiotic changes (2.0 changes in Group I compared with 1.4 changes in Group II), and the mean duration of oral antibiotic use (27.7 days in Group I compared with 43.7 days in Group II). When compared with Group I, Group II had clinically important trends of a shorter total length of hospital stay (12.8 days in Group I compared with 9.7 days in Group II; p = 0.054) and a lower hospital readmission rate (11.4% in Group I compared with 6.6% in Group II; p = 0.34).
Evidence-based treatment guidelines applied by a multidisciplinary team resulted in a more efficient diagnostic workup, a higher rate of identifying the causative organism, and improved adherence to initial antibiotic recommendations with fewer antibiotic changes during treatment. Additionally, there were trends toward lower hospital readmission rates and a shorter length of hospitalization.
儿童骨髓炎的治疗需要多学科协作。本研究评估了多学科团队使用循证医学治疗儿童骨髓炎指南的效果。
制定了儿童骨髓炎指南，并由来自多个医院科室的人员组成的多学科团队实施，包括骨科、儿科、传染病科、护理和社会工作，他们每天开会进行查房并做出治疗决策。通过回顾性研究和统计学分析，我们比较了在我院接受治疗的两组儿童骨髓炎患者，一组为 2002 年至 2004 年（指南实施前）的 I 组，另一组为 2009 年按指南治疗的 II 组。
I 组有 210 例患儿，II 组有 61 例患儿。两组患儿在年龄、性别、耐甲氧西林金黄色葡萄球菌感染发生率（I 组 18.1%，II 组 26.2%）、甲氧西林敏感金黄色葡萄球菌感染发生率（I 组 23.8%，II 组 27.9%）、菌血症或手术方面无显著差异。但在以下方面两组间存在显著差异（p < 0.05）：入院后磁共振成像的延迟时间（I 组 2.5 天，II 组 1 天）、初始使用克林霉素作为抗生素的患者比例（I 组 12.9%，II 组 85.2%）、接受抗生素治疗前进行血培养的患者比例（I 组 79.5%，II 组 91.8%）、从感染部位采集组织培养的患者比例（I 组 62.9%，II 组 78.7%）、在组织或血培养中鉴定出感染病原体的患者比例（I 组 60.0%，II 组 73.8%）、抗生素更换次数（I 组 2.0 次，II 组 1.4 次）以及口服抗生素使用时间的平均值（I 组 27.7 天，II 组 43.7 天）。与 I 组相比，II 组具有更短的总住院时间（I 组 12.8 天，II 组 9.7 天；p = 0.054）和更低的住院再入院率（I 组 11.4%，II 组 6.6%；p = 0.34）的临床重要趋势。
多学科团队应用循证治疗指南可提高诊断效率，提高确定病原体的比例，并提高初始抗生素建议的依从性，减少治疗期间抗生素的更换次数。此外，还存在降低住院再入院率和缩短住院时间的趋势。
