Reflections on so-called culture-negative osteoarticular infections in pediatric populations

Osteoarticular infections (OAIs) in children persist to be a major clinical concern due to their potential long-term impact on bone growth and joint function. Despite careful sampling, a significant proportion of OAIs remain culture-negative, historically obscuring the true epidemiology of these conditions. At the same time, subacute osteomyelitis is increasingly being detected and recognized as a distinct osteoarticular infection. Subacute hematogenous osteomyelitis (SAHO) is often under-recognized, as it is typically characterized by localized pain, mild or absent systemic manifestations, non-contributory laboratory tests and blood cultures, but positive radiological findings. This review focuses on the phenomenon of so-called culture-negative OAIs, exploring their microbiological basis, the role of fastidious and atypical microorganisms, parallels with subacute osteomyelitis, and the role of modern diagnostic technologies.