sporins as well as macrolides have intracellular
activity, which is where non-typhoid
salmonella species are located. Azithromycin
reaches significantly higher concentrations
in phagocytes, up to 200-fold higher,
when compared to plasma. Macrolides have
not been studied extensively to determine
concentrations obtained in the bone; however,
there are a few studies evaluating azithromycin
concentration in alveolar bone.
Those studies found that azithromycin, on
average, has about a 4.4-fold higher concentration
in the alveolar bone compared to
plasma 12 hours after the third dose of azithromycin.
Ultimately, it is unclear exactly
what improved our patient’s condition – the
CT-guided drainage or the addition of the
azithromycin.
This case represents some pertinent
points to successful treatment of pediatric
osteomyelitis including considerations for
less common organisms, the importance of
maximizing dosing based on PK/PD for the
age of the patient, location of the infection,
and understanding bone physiology. This, in
addition to understanding the ability of antimicrobials
to penetrate the different types
of bone, is beneficial in the overall treatment
of osteomyelitis.
References
1. Dartnell J, Ramachandran M, Katchburian
M. Haematogenous acute and subacute
paediatric osteomyelitis: a systematic
review of the literature. J Bone Joint
Surg Br 2012; 94:584-95.
2. Burnett MW, Bass JW, Cook BA. Etiology
of Osteomyelitis Complicating Sickle
Cell Disease. Pediatrics Vol 101, No 2, Feb
1998.
3. American Academy of Pediatrics. Salmonella
Infections. In: Kimberlin DW, Brady
MT, Jackson MA, Long SS, eds. Red Book:
2018 Report of the Committee on Infectious
Diseases. American Academy of Pediatrics;
2018; 711-718
4. Kearns GL, Abdel-Rahman SM, Alander
SW, Blowey DL, Leeder JS, Kauffman
RE. Developmental pharmacology-drug
disposition, action, and therapy
in infants and children. N Engl J Med
2003;349(12):1157-67.
5. Funk SS, Copley LA. Acute hematogenous
osteomyelitis in children, pathogenesis,
diagnosis, and treatment. Orthop Clin N
Am 2017;48(2):199-208.
6. Garazzino S, Aprato A, Baietto L, et al.
Ceftriaxone bone penetration in patients
with septic non-union of the tibia. Int J of
Infect Dis 2011;15:e415-21.
7. Abdelgawad AA, et al. Treatment of acute
salmonella epiphyseal osteomyelitis using
computed tomography-guided drainage
in a child without sickle cell disease. J
of Pediatr Orthop B. 16:415-418.
8. Wen SC, Best E, Nourse C. Non-typhoidal
Salmonella infections in children: Review
of literature and recommendations for
management. Journal of Paediatrics and
Child Health. 2017. 53: 936-941.
9. Malizia T, Batoni G, Ghelardi E, et al. Interaction
between piroxicam and azithromycin
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periodontal tissues. J Periodontol 2001
Sep;72(9):1151-6.
PEOPLE + EVENTS
OBITUARY
Robert “Ray” Hull, MD, passed away
June 7, 2020.
He is survived by his wife, Kathyrn
Hull; two sons, Keith Hull and Wayne
Hull (Susan); two daughters, Cheryl Hull
(Don) and Pamela Nickel (Jay); and ten grandchildren.
He served his country in the United
States Armed Forces and received honorable
discharge as a major from the Army on Oct.
1, 1979. After high school graduation, Dr. Hull
received his license to be a lab and x-ray technician,
working seven nights a week on emergency
call to put himself through college and
earn his college degree. He excelled at many
sports – basketball, baseball, football, bowling,
billiards – and played collegiate golf. He
received a bachelor's degree at Tennessee
Tech in business management, and he then
completed medical school at the University
of Tennessee in Memphis. His internship was
at St. John’s Hospital in Tulsa, Oklahoma. After
moving to Rogers in 1972, Dr. Hull and his
wife raised their children in Rogers, and later,
Gentry. Dr. Hull opened his practice in Rogers,
Arkansas, in 1972, where he continued to
practice until his death from COVID-19.
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