Clinical Scorecard: Changes in the Incidence of Acute Hematogenous Osteomyelitis from Unidentified Pathogens Following Nonpharmaceutical Interventions: Insights from an Interrupted Time-Series Study on Seasonal Viral Impact

At a Glance

Key Highlights

• Osteoarticular infections have an estimated incidence of approximately 22 cases per 100,000 children in France, and AHO accounts for about 40% of osteoarticular infections in children younger than 5 years.

• In France, Israel, and Switzerland, K. kingae is considered to be involved in 50%-80% of AHO cases in young children and is probably the leading pathogen in UP-AHO.

• Blood cultures are positive in only approximately 20%-30% of AHO cases, making the underlying epidemiology difficult to establish.

• UP-AHO incidence decreased 57.6% immediately after COVID-19-related NPIs were implemented in March 2020 and increased 101.0% after school reopening in September 2020.

• Human rhinovirus accounted for an estimated 21.3% of UP-AHO incidence and varicella-zoster virus for 9.8%; no significant associations were found for the other viruses studied.

Guideline-Based Recommendations

The study was an observational interrupted time-series analysis rather than a clinical guideline. The following reflects diagnostic, management, and surveillance considerations described in the study and cited guidance.

Diagnosis

• The study identified UP-AHO using ICD-10 codes M860, M861, M862, and M869 while excluding cases associated with S. aureus, S. pyogenes, or S. pneumoniae, as well as sickle cell disease and prosthesis-related infections.

• Because microbiological confirmation is often limited, the authors note that K. kingae may be underrecognized, particularly in milder disease that does not require surgical intervention or deep sampling.

Management

• French guidance cited by the authors recommends intravenous antibiotic therapy for at least the first 3 days of osteomyelitis treatment, which is typically administered in hospitals.

• K. kingae should be considered an important potential pathogen in young children with UP-AHO because it is probably the leading cause in this age group in the study setting.

Monitoring & Follow-up

• Population-level monitoring of seasonal virus circulation may help clarify changes in UP-AHO incidence over time.

• The authors found the strongest temporal associations with human rhinovirus and, to a lesser extent, varicella-zoster virus.

Risks

• K. kingae can colonize the oropharynx and may enter the bloodstream; viral infections may compromise the mucosal barrier and facilitate bacterial translocation.

Patient & Prescribing Data

The study included 5,619 children aged 1 to <5 years hospitalized with UP-AHO from January 2015 through August 2023. The median age was 2 years, and 73.9% were aged 1 to <3 years.

Joint aspiration was performed in 4.1% of patients and bone biopsy in 8.0%. The authors note that K. kingae often causes mild AHO forms that rarely require surgical intervention or deep sampling.

Clinical Best Practices

• Use comprehensive hospital-based surveillance to monitor UP-AHO incidence and changes over time.

• Consider the possible contribution of seasonal viral circulation when evaluating epidemiological shifts in UP-AHO among young children.

• Interpret associations cautiously because viral circulation was assessed at the population level rather than through individual virologic testing in children with UP-AHO.

Related Resources & Content

• Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics — Woods CR, Bradley JS, Chatterjee A, et al; Journal of the Pediatric Infectious Diseases Society; 2021; 10:801-844.

• Kingella kingae and Viral Infections — Basmaci R, Bidet P, Bonacorsi S; Microorganisms; 2022; 10:230.

• Temporal Association Between Rhinovirus Activity and Kingella kingae Osteoarticular Infections — Droz N, Enouf V, Bidet P, et al; Journal of Pediatrics; 2018; 192:234-239.e2.

• High Respiratory Virus Oropharyngeal Carriage Rate During Kingella kingae Osteoarticular Infections in Children — Basmaci R, Bonacorsi S, Ilharreborde B, et al; Future Microbiology; 2015; 10:9-14.

• Antibiotic Therapy for Osteoarticular Infections in 2023: Proposals From the Pediatric Infectious Pathology Group (GPIP) — Lorrot M, Gillet Y, Basmaci R, et al; Infectious Diseases Now; 2023; 53:104789.