Intravenous vs. oral antibiotics: Intravenous antibiotics were believed more likely to lead to rapid resolution of symptoms over 2–4 days without recurrence than were oral antibiotics or no antibiotic therapy (5). Boston et al. (2) recommended antibiotics for any patient with pain, compensatory scoliosis, or persistently elevated ESR. Scoles and Quinn (3) recommended 7–10 days of intravenous antibiotics for all patients with high fever, extreme pain, or positive blood, sputum, throat, or urine cultures. In most recently published reports, intravenous antibiotics are recommended as initial management (4). Ring et al. (5) analyzed a series of 47 patients. Of the 38 non-immobilized patients, 22 were treated with intravenous antibiotics, 10 received oral antibiotics, and 6 received no antibiotics. Prolonged or recurrent symptoms occurred in 9 of the 16 patients who did not receive intravenous antibiotics but in only 4 of the 22 patients treated with intravenous antibiotics. Seven patients were treated with immobilization. Only one of five patients treated with immobilization and intravenous antibiotics had a recurrence. Both patients treated with immobilization alone developed recurrent symptoms after immobilization was removed.
Hematogenous vertebral osteomyelitis: Antibiotic regimen should be guided by Gram stain after biopsy has been performed. Total parenteral antibiotic therapy in acute hematogenous vertebral osteomyelitis is indicated when physiological changes are not ideal for oral absorption, there is abscess formation, or compliance cannot be assured (83). Initially, a CBC and a CRP as well as a biopsy are obtained, and IV antibiotics (e.g., clindamycin) are begun. By day 4 conversion to high-dose (2–3 times normal) oral antibiotics (e.g., linezolid) can be considered if the CBC and CRP are trending toward normal. On day 21, the ESR can be checked. If it is <30 mm/hour, then one can consider stopping the antibiotics. If the ESR remains above 30 mm/hour, MRI can be considered to check the site of infection. Surgical debridement is recommended if inflammation and destruction are noted. The antibiotic treatment is extended to 6 weeks.
Spinal Epidural Abscesses in Children
Primary treatment surgical: The standard management for spinal epidural abscesses is surgical drainage and antibiotic therapy. However, sporadic cases of medically treated spinal abscesses have prompted studies reviewing the efficacy of conservative management (18, 57).
Considered for neurologically stable or patients with high surgical risks: Candidates for conservative medical management without surgical intervention include patients without neurological deficit or with complete deficit for more than 3 days, patients with extensive abscesses, or patients who are high surgical risks. However, it has been argued that delaying surgical treatment even in these patients may significantly increase morbidity (16, 58).
Spinal Subdural Abscesses in Children
Primary treatment surgical: The treatment of asymptomatic children with antibiotics alone has never been studied (126).
Intramedullary Spinal Cord Abscesses in Children
Primary treatment surgical: A limited laminectomy and myelotomy followed by copious drainage of the area with normal saline is favored by many authors as the surgical procedure of choice for children harboring intramedullary spinal cord abscesses (88, 101, 103). In a review of the literature, Kurita et al. found only three cases between 1997 and 2007 in which patients with intramedullary spinal cord abscesses were treated with antibiotics alone (102).