Antibiotic pretreatment and culture yield in pediatric osteoarticular infection: a systematic review and meta-analysis.

Abstract

Whether early antibiotic administration compromises microbiological tissue culture yield in children with suspected osteoarticular infection remains a common clinical concern, yet the underlying evidence has never been pooled. We performed a systematic review and meta-analysis to quantify the association between antibiotic pretreatment and tissue culture yield in pediatric osteomyelitis and septic arthritis. MEDLINE (PubMed) and Embase (Ovid) were searched from inception to December 2025 under a protocol prospectively registered with PROSPERO (CRD420251126960); the review is reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) 2020 statement. Eligible studies reported tissue culture yield in pediatric patients (0-18 years) with osteoarticular infection stratified by antibiotic exposure prior to culture; all included evidence was observational, and no randomized controlled trials were identified. Risk of bias was assessed using a modified Newcastle-Ottawa Scale, and a Der Simonian-Laird random-effects meta-analysis was performed for the primary outcome of tissue culture positivity from the infection site. Nine studies: 7 retrospective cohort studies and 2 case series, comprising 1,704 tissue culture specimens were included. Antibiotic pretreatment was not associated with reduced tissue culture yield (odds ratio, 1.60; 95% confidence interval, 1.23-2.08; P=0.0004; I²=8.9%), with culture positivity of 71.5% in pretreated versus 60.0% in not-pretreated specimens. Because an odds ratio greater than 1 could be misread as a benefit of antibiotics, we emphasize that this direction most plausibly reflects confounding by indication or disease severity rather than a true effect on yield. No evidence of publication bias was detected (Egger P=0.99). Pooled evidence does not support routinely withholding antibiotics solely to preserve tissue culture yield in pediatric osteoarticular infection. Because the included studies were observational and subject to confounding by indication, these findings should not be taken as a uniform recommendation on antibiotic timing; decisions should remain individualized, with appropriate specimens obtained before antibiotics whenever clinically feasible.