Medicolegal Issues

Oral Trimethoprim-Sulfamethoxazole a Consideration for Acute Osteomyelitis


Clinical question: Is oral trimethoprim-sulfamethoxazole (TMP-SMX) a therapeutic option for the treatment of acute osteomyelitis in children?

Background: With the recent increase in methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis in children, both clindamycin and vancomycin have become common first-line options for treatment. MRSA’s resistance to clindamycin and the potential for the development of resistance to vancomycin are significant concerns with both of these approaches. The efficacy of TMP-SMX in acute osteomyelitis is unknown, despite almost uniform susceptibility of MRSA to TMP-SMX and excellent oral bioavailability.

Study design: Retrospective chart review.

Setting: Tertiary-care children’s hospital.

Synopsis: Twenty patients with acute osteomyelitis who had received TMP-SMX and had documented follow-up were identified from 1998 to 2009. All patients were presumed to have staphylococcal disease either confirmed via positive culture (eight patients) or history and/or initial response to antistaphylococcal antibiotics. Fifteen of the patients initially received vancomycin or clindamycin for a median of 4.5 days before then receiving TMP-SMX. Nineteen patients received TMP-SMX primarily via the oral route. The median duration of total antibiotic therapy was 40 days. At the end of therapy, all patients were effectively treated with complete resolution of symptoms. Eight patients did experience mild adverse events to TMP-SMX and were switched to an alternative antibiotic.

The study demonstrates that oral TMP-SMX is a potential therapeutic option for staphylococcal acute osteomyelitis in children. Although theoretical concerns regarding efficacy have limited its use in severe staphylococcal infections, resistance patterns will increasingly necessitate consideration of palatable alternatives to vancomycin and clindamycin. This retrospective nature of this report, the lack of long-term follow-up beyond the completion of therapy, and the high rate of antibiotic-switching due to adverse events are limitations that preclude immediate and widespread uptake of this antibiotic regimen.

Bottom line: Oral TMP-SMX is a potentially effective option for acute staphylococcal osteomyelitis.

Citation: Messina AF, Namtu K, Guild M, Dumois JA, Berman DM. Trimethoprim-sulfamethoxazole therapy for children with acute osteomyelitis. Pediatr Infect Dis J. 2011;30:1019-1021.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

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