EBM Review: Comparative effectiveness of intravenous vs. oral antibiotics for postdischarge treatment of acute osteomyelitis in children.

Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs. oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015 Feb;169(2):120-8.

Reviewed by:

Damon Jones, MD Damon Jones, MD PGY-3

Jane Stremming, MD Jane Stremming, MD PGY-3

Background:

  • Osteomyelitis is a relatively uncommon infection in pediatrics
    • Incidence of about 2 – 13/100,000 in developed countries, higher in developing countries
  • Mean age of diagnosis is 6.6 years
    • 40% occur in pre-school aged children
  • Male: Female 1.82:1
  • Risk factors include blunt trauma (30%) and recent systemic infection (37%)
    • No identified risk factors in nearly half of all cases (47%)
  • Presenting symptoms include pain (81%), localized signs symptoms (70%), fever (62%), reduced ROM (50%), and reduced weight bearing (50%)
  • ESR and CRP usually elevated on presentation (91 and 81%, respectively)
    • WBC elevated in only 36% of cases

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Oral administration of albuterol and myasthenic syndromes

Finlayson S, Spillane J, Kullmann DM, Howard R, Webster R, Palace J, Beeson D.
Slow channel congenital myasthenic syndrome responsive to a combination of
fluoxetine and salbutamol. Muscle Nerve. 2013 Feb;47(2):279-82.

We report an unusual case due to heteroallelic mutations in CHRNE. The slow channel mutation, p.εS278del, is accompanied by a severe low-expression mutation, p.εR217L, on the second allele. Expression studies and cosegregation of p.εS278del with the disorder in the patient’s offspring demonstrate robust expression of the p.εS278del mutation. The patient showed modest benefits from standard treatment with fluoxetine, but there was dramatic improvement when salbutamol was combined with fluoxetine. This case suggests that salbutamol, which is beneficial in some other congenital myasthenic syndromes, might also be considered in addition to fluoxetine in slow channel syndrome.

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Burke G, Hiscock A, Klein A, Niks EH, Main M, Manzur AY, Ng J, de Vile C,
Muntoni F, Beeson D, Robb S. Salbutamol benefits children with congenital
myasthenic syndrome due to DOK7 mutations. Neuromuscul Disord. 2013
Feb;23(2):170-5.

Congenital myasthenic syndromes due to DOK7 mutations cause fatigable limb girdle weakness. Treatment with ephedrine improves muscle strength. Salbutamol, a β(2)-adrenergic receptor agonist with fewer side effects and more readily available, has been effective in adult and anecdotal childhood cases. This study reports the effects of salbutamol on motor function in childhood DOK7 congenital myasthenic syndrome. Nine children (age range 5.9-15.1years) were treated with oral salbutamol, 2-4mg TDS. The effect on timed tests of motor function, pre- and up to 28months post-treatment, was audited retrospectively. All 9 reported functional benefit within 1month, with progressive improvement to a plateau at 12-18months. Within the first month, all 3 non-ambulant children resumed walking with assistance. Although improvements were seen in some timed tests (timed 10m, arm raise time, 6min walk time) this did not fully reflect the observed functional benefits in daily living activities. No major side effects were reported. We conclude that oral salbutamol treatment significantly improves strength in children with DOK7 congenital myasthenic syndrome and is well tolerated. Outcome measures need to be refined further, both to accurately reflect functional abilities in children and to document progress and treatment response.

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Sadeh M, Shen XM, Engel AG. Beneficial effect of albuterol in congenital
myasthenic syndrome with epsilon-subunit mutations. Muscle Nerve. 2011
Aug;44(2):289-91.

Mutations in the epsilon subunit of the acetylcholine receptor (AChR) are a common cause of congenital myasthenic syndrome (CMS). Patients are usually treated with acetylcholinesterase inhibitors and 3,4-diaminopyridine with modest clinical benefit. We report 2 patients with CMS due to mutations in the AChR epsilon subunit. The first patient carries two heterozygous frameshift mutations, ε127ins5 and ε1293insG. The second patient is homozygous for the εC142Y mutation that curtails AChR expression to 22% of wild-type in HEK cells. Treatment with pyridostigmine and 3,4-diaminopyridine had a limited beneficial effect in the first patient, and the second patient became wheelchair-bound during therapy. The additional use of albuterol produced dramatic improvement in strength and in activities of daily living in both patients. The efficacy and safety of albuterol in patients who harbor identified low-expressor or null mutations in the epsilon or other subunits of AChR merits a well-designed clinical trial.

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Schreuder LT, Nijhuis-van der Sanden MW, de Hair A, Peters G, Wortmann S, Bok
LA, Morava E. Successful use of albuterol in a patient with central core disease
and mitochondrial dysfunction. J Inherit Metab Dis. 2010 Dec;33 Suppl 3:S205-9.

Albuterol, a selective beta-adrenergic agonist, has been used experimentally in combination with exercise therapy in a few inherited neuromuscular disorders to increase muscle strength and muscle volume . We report on a 9-year-old boy with central core disease and mitochondrial dysfunction due to compound heterozygous RYR1 mutations receiving albuterol treatment for 1 year. Throughout the period of albuterol administration, the patient underwent an aerobic exercise regime of training sessions three times a week that lasted 20 min each. No side effects of albuterol use were seen. Significant clinical progress, including self care, sitting up, raising arms above the shoulders, independent feeding, and better speech and writing were observed compared with minimal development of these abilities in the previous years on physiotherapy. Improved forced expiratory volume in 1 s (FEV1) score was detected and increased muscle strength was noted: progress was measured using various functional tests and assessment scales. The only complication observed was a mild progression of the joint contractures, possibly due to an unbalance between the flexor and extensor musculature. In general, in this pilot study in a complex case of metabolic myopathy our patient has shown promising results following albuterol treatment and aerobic exercise therapy.

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