Pneumococcal infection is common in children with HIV infection, but osteomyelits is unusual. The best treatment for bone and joint infection due to antibiotic resistant pneumococci is not known, especially in immunocompromised children.
A 6 month old girl, infected with HIV by mother to child transmission, had recently started combination antiretroviral therapy (cART). She presented with osteomyelitis of the left radius confirmed on bone scan. Blood cultures grew Streptococcus pneumoniae 9S resistant to penicillin, with reduced susceptibility to ceftriaxone.
Osteomyelitis was treated with parenteral teicoplanin, oral rifampicin and azithromycin. After two weeks of treatment she developed rash and fever. These were thought to be a drug eruption and resolved when teicoplanin was stopped. She completed a 3 month course of rifampicin and azithromycin and continued on cART. She has normal function of her left wrist 18 months after treatment. She remains on her original cART regimen with an undetectable viral load and normal CD4 count (34%; 1398 × 106/l).
The combination of rifampicin and azithromycin was well tolerated, simple to administer and effective. This combination deserves further study in bone and joint infection caused by antibiotic resistant Gram positive bacteria.