Practical Issues in Early Switching from Intravenous to Oral Antibiotic Therapy in Children with Uncomplicated Acute Hematogenous Osteomyelitis: Results from an Italian Survey

Background: The European Society of Pediatric Infectious Diseases (ESPID) guidelines for acute hematogenous osteomyelitis (AHOM) have been published recently. In uncomplicated cases, an early (2-4 days) switch to oral empirical therapy, preferentially with flucloxacillin, is recommended in low methicillin-resistant Staphylococcus aureus settings. We conducted a survey with the aim of evaluating the behaviors of Italian pediatricians at this regard. Methods: An open-ended questionnaire investigating the empiric therapy adopted in uncomplicated AHOM children according to age was sent by email to 31 Italian pediatric clinics taking care of children with infectious diseases, and results were analyzed. Results: The preferred intravenous (IV) regimen was a penicillin plus an aminoglycoside (n = 10; 32.3%) in children aged <3 months, and a combination of a third-generation cephalosporin plus oxacillin (n = 7; 22.6%), or oxacillin alone (n = 6; 19.4%) in those ≥3 months. In every age class, amoxicillin-clavulanate was the first-choice oral antibiotic. Other antibiotics largely used orally included clindamycin, rifampicin, and trimethoprim/sulfamethoxazole. Flucloxacillin was never prescribed. Only 3 centers switched to oral therapy within 7 days in children ≥3 months of age. The most commonly reported reason influencing the time to switch to oral therapy concerned caregivers' adherence to oral therapy. Conclusion: Adherence to guidelines was poor, and early transition to oral therapy in the clinical practice was rarely adopted. Given the large use of potentially effective, but poorly studied, oral antibiotics such as amoxicillin/clavulanate, trimethoprim/sulfamethoxazole, and rifampicin, our data may stimulate further studies of this regard.