Why carry out this study? |
Blood samples from newborns in neonatal units are often collected by puncturing the baby’s heel. |
Although this procedure is generally harmless, it can sometimes lead to neonatal osteomyelitis of the calcaneus. This study summarizes clinical experience with heel puncture-related osteomyelitis of the calcaneus (HP-CO) in newborns. |
What was learned from this study? |
The most common surgical interventions to treat this condition involve incision and drainage. |
Methicillin, gentamicin, nafcillin, and cloxacillin are the most frequently used antibiotics to treat the infection. |
However, the clinical efficacy of these treatments is still unsatisfactory, with an overall incidence of complications of 47%. |
Digital Features
Introduction
Methods
Study Design and Identification
Inclusion and Exclusion Criteria
Data Collection
Study | Country | Patients | Sex/age (days) | BW (g) | GA (weeks) | MOD | Side | HP | Symptoms | SD (days) | Organism | FU (months) | Intervention |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Lilien, 1976 [5] | USA | 2 | B/5 | 2040 | 36 | VB | L | 6 | Swelling, tenderness, purulent discharge | 18 | S. aureus | 1.84 | PO oxacillin Debridement + methicillin IV |
B/10 | 1710 | 34 | VB | L | 12 | Swelling, erythema, fever, tenderness, purulent discharge | 21 | S. aureus | 1.84 | Methicilin IV + kanamycin IM | |||
Canale, 1981 [6] | USA | 3 | B/1 | NA | 29 | VB | R | 30 | Swelling (fluctuant mass) | 21 | P. aerugenosa | 30 | Debridement + sequestrectomy + carbenicillin + gentamycin IV |
B/1 | NA | 28 | CS | R | 16 | Swelling and cellulitis | 16 | S. aureus | 48 | Nafcillin + gentamycin Debridement + nafcillin | |||
B/1 | 2080 | 36 | VB | R | 16 | Swelling and cellulitis | 17 | S. aureus | 48 | Nafcillin + gentamycin + debridement | |||
Goldberg, 1981 [12] | Israel | 1 | G/6 | 3100 | 36 | VB | R | 3 | Swelling and erythema | 10 | Negative culture | 1.38 | Cephalothin IV + gentamycin IV + PO cephalexin |
Borris, 1986 [8] | Denmark | 2 | G/22 | 1180 | 32 | CS | R&L | 10 | Purulent discharge (right heel), swelling and redness (both heels) | 122 | S. aureus | 84 | Incision + drainage + methicillin + kanamycin + lincomycin |
G/9 | 1200 | Preterm | VB | R | +a | Tenderness | 122 | S. aureus | 84 | Erythromycin IM | |||
Gjurić, 1992 [9] | Croatia | 2 | G/10 | 2520 | Full term | VB | R | 1 | Purulent discharge, swelling and redness | 35 | S. aureus | 1.15 | Drainage + methicillin IV |
G/10 | 3910 | Full term | VB | L | 1 | Purulent discharge, swelling and redness | 35 | S. aureus | 1.15 | Drainage + methicillin IV | |||
Abril, 1999 [7] | Spain | 3 | G/7 | NA | NA | NA | L | NA | Pain, swelling, fever edema, erythema | NA | S. aureus | 96 | Drainage + cloxacillin IV |
B/10 | 1600 | NA | NA | L | 17 | Tenderness, fever | NA | NA | 96 | Cloxacillin IV | |||
G/17 | 3100 | Full term | VB | L | 3 | Tenderness, swelling, fever | 4 | S. aureus | 96 | Drainage + cloxacillin IV | |||
Yüksel, 2007 [10] | Turkey | 1 | G/17 | NA | Full term | VB | L | 1 | Redness/erythema, swelling and tenderness | 10 | S. aureus | 1.5 | Drainage + cefazolin + gentamicin + bone curettage |
Tural, 2016 [11] | Turkey | 1 | G/7 | 3600 | Full term | VB | R | 1 | Redness/erythema, swelling, edema, fever | 3 | S. aureus | NA | Drainage + mupirocin ointment + sulbactam/ampicillin IV + PO Augmentin |
Study | Patients | Bacterial culture results | Biomarkers levels | Radiographic imaging | Summary points |
---|---|---|---|---|---|
Lilien, 1976 [5] | 2 | Cultured pus sample was found to have CoPS | NA | An X-ray showed erosion of the left calcaneus, indicating osteomyelitis | Neonates contracted infections from heel punctures. In case 2, positive blood culture may be due to manipulation of the infected area. Management involves antibiotics and abscess drainage |
Canale, 1981 [6] | 3 | Pus was found during aspiration. Case 1 had P. aeruginosa, case 2 had S. aureus in blood cultures, and case 3 had S. aureus growth during surgery | Case 1&2: NA Case 3: WBC ↑ | X-ray results: Case 1: Osteomyelitis in right os calcis. Case 2: Soft-tissue swelling and periosteal elevation in os calcis, distal, and proximal tibia. Case 3: Periosteal elevation in proximal femur on repeat X-ray | Swollen lower limbs in newborns may indicate heel infection. Antibiotics may be prescribed, but surgery may be necessary if there is no improvement within 48 h. Repeated heel pricks can cause bone infections, so orthopedic surgeons must advise caution |
Goldberg, 1981 [12] | 1 | No organisms were identified from blood cultures or the heel puncture site | WBC ↑ ESR ↑ | A bone scan showed exaggerated uptake in the right calcaneus and distal tibia. X-ray 10 days later revealed an osteolytic lesion in the posterior portion of the right calcaneus, indicative of osteomyelitis | Antibiotic therapy, when given immediately, is successful. Routine X-rays of the healed os calcis are seen in 2–3 months. Prophylactic treatment is strongly advised |
Borris, 1986 [8] | 2 | Pus was discharged from the right heel, and culture revealed growth of S. aureus, which was coagulase-negative in case 1. In case 2, a culture grew S. aureus | NA | X-ray of the calcaneus revealed osteomyelitis in the right heel in case 1, while in case 2, the bone was unaffected | Neonatal infection caused growth issues in both patients. Early radiographic examination missed bone involvement in case 2. Children under 4 years with calcaneus osteomyelitis should be monitored for hind foot growth problems |
Gjurić, 1992 [9] | 2 | Case 1: S. aureus from heel abscess culture on day 9. Case 2: S. aureus from pus and sterile blood culture on day 7 | Case 1: WBC ↑ Case 2: WBC ↑ | Case 1: X-ray findings of right calcaneal osteomyelitis on day 9 of illness Case 2: X-ray signs of osteomyelitis of left calcaneus and talus on day 7 of illness | Two newborns got infected during neonatal screening due to a heel puncture that penetrated the bone. To prevent this, follow guidelines for heel puncture sites in infants |
Abril, 1999 [7] | 3 | S. aureus was found to be growing in the drainage cultures | Case 1: WBC ↑, ESR ↑ Case 2: NA Case 3: WBC ↑, ESR ↑ | Initial X-rays for these patients were normal. Follow-up technetium scans for cases 2 and 3 showed increased uptake in the calcaneus | Deformity of the calcaneus can lead to flatfoot despite treatment. To avoid this complication, a strict aseptic technique is required for neonatal heel puncture |
Yüksel, 2007 [10] | 1 | S. aureus grew in the pus culture, while the blood culture was negative | WBC ↑, ESR ↑, CRP – | An osteolytic lesion on the posterior part of the left calcaneus was found on an X-ray of the heel, suggesting osteomyelitis. An MRI later confirmed this diagnosis | Improper sterile technique during the first heel puncture in healthy neonates may lead to calcaneal osteomyelitis. To prevent this, use lateral parts of the heel and avoid central and posterior areas |
Tural, 2016 [11] | 1 | S. aureus was detected in nasal swab culture of the patient and her mother | WBC ↑, ESR ↑, CRP↑ | The X-ray revealed a bone lesion on the calcaneus that suggests the presence of osteomyelitis Ultrasound found a 24 × 11 mm fluid sac with heavy content on the back of the right foot MRI showed tissue defect, edema, inflammation, and contrast enhancement in the same foot | Calcaneal osteomyelitis should be considered as a probable diagnosis in neonates with heel swelling after undergoing invasive procedures such as the Guthrie test |