Download PaedCh 11_Musculoskeletal RN_4C_March 2017

PAEDIATRIC HOSPITAL LEVEL ESSENTIAL MEDICINES LIST
CHAPTER 11: MUSCULOSKELETAL SYSTEM
NEMLC 2 MARCH 2017
GENERAL COMMENT
The Paediatric Committee recommended that the Musculoskeletal System Chapter be incorporated into
the Infective/Infectious Diseases Chapter. It was proposed that it be incorporated after external
comment has been received.
MEDICINE AMENDMENTS
SECTION
MEDICINE
ADDED/DELETED/NOT ADDED
11.1 Arthritis, Septic (Pyogenic)
Medicine Treatment
Vancomycin
Corticosteroids Dexamethasone
Ibuprofen
Therapeutic Drug Monitoring added
Added
Removed - Referral to Pain Chapter
added
11.3 Osteitis/Osteomyelitis, Acute
General and supportive
measures
Medicine Treatment
Surgical Drainage
Vancomycin
Gentamicin
Removed - refer to specialist for
consideration of drainage
Therapeutic Drug Monitoring added
Therapeutic Drug Monitoring added
11.1 Arthritis, Septic (Pyogenic)
Medicine Treatment
Antibiotic Therapy
Intravenous (IV) to oral switch outlined
The Paediatric Committee recommended that IV to oral switch could occur once there was clinical
improvement and the patient's inflammatory markers were normalising.
The text was amended as follows:
Adjust antibiotic therapy based on culture results or if response to antibiotic treatment is unsatisfactory.
Where a single agent has been found to be sensitive, continue treatment on that single agent.
Continue with IV antibiotics until there is evidence of good clinical response and laboratory markers of
infection improve. Once clinical improvement and inflammatory markers are normalising, patients can
be switched to Continue antibiotic therapy orally.
Vancomycin: Therapeutic Drug Monitoring added
Since long durations of antibiotic therapy is indicated for septic arthritis and osteomyelitis, the
Paediatric Expert Review Committee recommended that therapeutic drug monitoring be recommended
with vancomycin where available.
PaedCh11_Musculoskeletal System_ 4N-March 2017
The text was amended as follows:
If MRSA is suspected, replace cloxacillin with vancomycin.
 Vancomycin IV, 15 mg/kg/dose administered over 1 hour given 6 hourly.
Where available, vancomycin doses should be adjusted on the basis of therapeutic drug levels.
o Trough levels (taken immediately prior to next dose), target plasma level 15-20 mcg/mL.
Level of evidence: III SAMF1, NHLS2
Corticosteroid - Dexamethasone: added
Short course intravenous dexamethasone in conjunction with antibiotic therapy has been shown to lead
to significant clinical and laboratory improvements, accelerated recovery and reduced long-term
sequelae.3
A double-blind, placebo-controlled study evaluated 123 children with haematogenous arthritis, assigned
to receive either antibiotic therapy alone or antibiotic therapy with intravenous dexamethasone (0.2
mg/kg/dose 8 hourly for 4 days). The primary outcome was a reduction of the number of patients with
sequelae or dysfunction of the affected joint. After 12 months, 2% of the dexamethasone group had
residual dysfunction compared to 26% in the control group. Additionally those in the dexamethasone
groups had a normal C-reactive protein (CRP) and resolution of symptoms at 2.04 ± 1.25 days and 2.34 ±
5.06 respectively, compared to 4.68 ± 6.23 days and 7.81 ± 2.04 days in the control group (p=0.01 and
0.001 respectively).4
Another double-blind, placebo-controlled trial, evaluating 49 children with septic arthritis randomised to
receive intravenous dexamethasone (0.15 mg/kg/dose 6 hourly for 4 days) also found a positive effect
with the use of dexamethasone. The primary outcome was time to clinical and laboratory normalisation
and duration of hospitalisation. Statistically significant differences were noted in the dexamethasone
group for duration of fever (p=0.021), local inflammatory signs (p=0.021), levels of acute phase reactants
(p=0.003) and duration of intravenous antibiotic treatment (0.007).5
The Paediatric Committee recommended that short-course corticosteroid therapy in septic arthritis
should be included, and sent out for external comment.
The following text was added.
PLUS
Corticosteroids
 Dexamethasone, IV, 0.15 mg/kg 6 hourly for 4 days.
Pain and inflammation
Ibuprofen: removed
1
South African Medicine Formulary (SAMF) 12th Edition, University of Cape Town, and Health and Medical
Publishing Group. 2016
2
National Health Laboratory Services (NHLS) Reference ranges.
3
Macchiaiolo M, et al. Should steroids be used in the treatment of septic arthritis? Arch Dis Child. 2014;0:1-2.
4
Odio CM, et al. Double blind, randomized, placebo-controlled study of dexamethasone therapy for
hematogenous septic arthritis in children. Pediatr Infect Dis J. 2003, 22:883-886.
5
Harel L, et al. Dexamethasone therapy for septic arthritis in children. J Pediatr Orthop. 2011; 31:211-215.
PaedCh11_Musculoskeletal System_ 4N-March 2017
The Paediatric Committee outlined that ibuprofen may not be sufficient to manage the pain associated
with septic arthritis, and recommended that a referral to the pain control chapter would be beneficial
and outline the appropriate measures.
The text was amended as follows:
For pain and inflammation:
 Ibuprofen, oral, 5–10 mg/kg/dose, 6 hourly.
Refer to Chapter 20: Pain control and palliative care
11.3 Osteitis/Osteomyelitis, Acute
Surgical Drainage: Removed
The Paediatric Committee was of the opinion that there appeared to be a reluctance to intervene
surgically, and recommended that patients be referred for the confirmation of diagnosis and
consideration of surgical drainage.
The text was amended as follows:
» GENERAL AND SUPPORTIVE MEASURES
» Surgical drainage if:
>
frank pus is aspirated from bone,
>
clear evidence of progression to soft tissues,
>
when a marked improvement has not occurred within 24–36 hours on adequate IV antibiotic
treatment,
» coexisting septic arthritis,
» Immobilise affected limb in position of function.
» Supportive and symptomatic care.
.
.
REFERRAL
» Refer to specialist for confirmation of diagnosis, and consideration of surgical drainage.
» Multi-organ involvement.
» Failure to achieve progressive improvement on treatment.
Medicine Treatment
Antibiotic Therapy
Intravenous (IV) to oral switch outlined
The Paediatric Committee recommended that IV to oral switch could occur once there was clinical
improvement and the patient's inflammatory markers were normalising.
The text was amended as follows:
Adjust antibiotic therapy based on culture results or if response to antibiotic treatment is unsatisfactory.
Where a single agent has been found to be sensitive, continue treatment on that single agent.
Continue with IV antibiotics until there is evidence of good clinical response and laboratory markers of
PaedCh11_Musculoskeletal System_ 4N-March 2017
infection improve (usually about 2 weeks). Once clinical improvement and inflammatory markers are
normalising, patients can be switched to oral antibiotic therapy. Oral antibiotics may then be
considered.
Special circumstances
Vancomycin: Therapeutic Drug Monitoring added
Gentamicin: Therapeutic Drug Monitoring added
Since long durations of antibiotic therapy is indicated for septic arthritis and osteomyelitis, the
Paediatric Expert Review Committee recommended that therapeutic drug monitoring be recommended
with vancomycin and gentamicin where available.
The text was amended as follows:
Special Circumstances
If MRSA, replace cloxacillin with vancomycin.
 Vancomycin IV, 15 mg/kg/dose administered over 1 hour given 6 hourly.
Where available, vancomycin doses should be adjusted on the basis of therapeutic drug levels.
o Trough levels (taken immediately prior to next dose), target plasma level 15-20 mcg/mL.
Penetrating foot bone injuries: replace cefotaxime with ceftazidime plus aminoglycoside:
 Ceftazidime, IV, 50 mg/kg/dose 6 hourly.
PLUS
 Gentamicin, IV, 6 mg/kg once daily.
Where available, gentamicin doses should be adjusted on the basis of therapeutic drug levels.
o Trough levels (taken immediately prior to next dose), target plasma level < 1 mg/L.
o Peak levels (measured 1 hour after commencement of IV infusion or IM/IV bolus dose), target
plasma level > 8 mg/L.
Pain and inflammation
Ibuprofen: removed
The Paediatric Committee outlined that ibuprofen may not be sufficient to manage the pain associated
with septic arthritis, and recommended that a referral to the pain control chapter would be beneficial
and outline the appropriate measures.
The text was amended as follows:
For pain and inflammation:
 Ibuprofen, oral, 5–10 mg/kg/dose, 6 hourly.
Refer to Chapter 20: Pain control and palliative care
PaedCh11_Musculoskeletal System_ 4N-March 2017