Evaluation of the current use of imaging modalities and pathogen detection in children with acute osteomyelitis and septic arthritis

[Arthritis and osteomyelitis in childhood and adolescence-Bacterial and nonbacterial]

Bacterial arthritis and osteomyelitis are usually acute diseases, which in this way differ from the often insidious course of nonbacterial osteomyelitis; however, there is often an overlap both in less acute courses of bacterial illnesses and also in nonbacterial osteitis. The overlapping clinical phenomena can be explained by similar pathophysiological processes. In bacteria-related illnesses the identification of the pathogen and empirical or targeted anti-infectious treatment are prioritized, whereas no triggering agent is known for nonbacterial diseases. The diagnostics are based on the exclusion of differential diagnoses, clinical scores and magnetic resonance imaging (MRI). An activity-adapted anti-inflammatory treatment is indicated.

Diagnosis and Management of Acute Osteoarticular Infections: Summary of New Guidelines

Acute hematogenous osteomyelitis (AHO) and acute bacterial arthritis (ABA) are among the most common invasive bacterial infections in otherwise healthy children. The diagnosis of AHO and ABA requires a high index of suspicion in children presenting with fever and musculoskeletal pain and judiciously chosen laboratory and imaging studies. Choosing the appropriate empirical antibiotic requires familiarity with local susceptibility patterns, especially for Staphylococcus aureus. Typical antibiotic duration for osteoarticular infection is 2-4 weeks depending on the type of infection, response to therapy, and presence of complications. Transitioning from parenteral to oral antibiotics is guided by clinical and laboratory evidence of resolving infection. This review will provide an overview of the recommendations contained in the 2 recently published guidelines for the management of AHO and ABA.

Osteomyelitis and Septic Arthritis of the Upper Extremity in Pediatric Patients

PURPOSE OF REVIEW

For pediatric osteomyelitis and septic arthritis, 10-24% of cases occur in the upper extremity (UE). Due to delays in presentation and diagnosis, UE infections are often more complex and severe than infections of the lower extremity (LE). This review evaluates the literature from the past 6 years related to pediatric osteomyelitis and septic arthritis of the UE and provides a guide for professionals managing these conditions in children.

RECENT FINDINGS

The shoulder and elbow are the most commonly affected joints, and the humerus is the most commonly affected bone. As with the LE, diagnosis of UE osteoarticular infections is based on clinical evidence, laboratory data, and diagnostic imaging. While Staphylococcus aureus is the primary bacteria identified in UE infections, there is an underappreciation of the burden from Kingella kingae as a causative organism in culture-negative patients where PCR is not performed. Septic joints should be treated with irrigation and debridement urgently, with subsequent antibiotic therapy for a minimum of 2-4 weeks. For acute osteomyelitis without abscess or concomitant septic joints, antibiotic therapy is standard of care. Methicillin-resistant Staphylococcus aureus is associated with more severe infection requiring more surgeries. Various strategies exist for managing segmental bone loss in chronic osteoarticular infections. Osteomyelitis and septic arthritis tend to occur less frequently in the UE than the LE but have a devastating impact on the health and quality of life of children around the world. Complete resolution of disease can be achieved through an individualized approach to antibiotic and operative management. Further study is needed to assess the efficacy of aspiration as a primary treatment strategy in UE joints.

Microbiological Spectrum of Osteoarticular Infections and Their Management in Mongolian Children

Introduction. Osteoarticular infections (OI) in children cause considerable morbidity with associated long-lasting sequelae. Comprehensive clinical and microbiological data in Mongolian children are missing. Objectives. To generate epidemiological, clinical and microbiological data on osteoarticular infections (OI) in Mongolian children after the introduction of a standardized management protocol. Methods. A prospective study was done between 2019 and 2022 at the only tertiary pediatric hospital in Mongolia. Results. Forty-two children presented with septic arthritis (SA), 6 with osteomyelitis (OM) and 23 with combined SA and OM. Newborns and young infants (≤3 months) comprised 38.%. A causative organism was identified in 38 children: Staphylococcus aureus (n = 31), Klebsiella spp (n = 3), Enterobacter spp (n = 2), Enterobacter spp + Klebsiella spp (n = 1) and Candida albicans (n = 1). Five children (7%) had sequelae. Mongolian children with OI were younger compared to other cohorts. Conclusion. A standardized protocol for the management of OI in children was taken up well by the patients and treating staff leading to improved pathogen detection, facilitating antimicrobial stewardship in the future.

A transformer-based deep learning model for identifying the occurrence of acute hematogenous osteomyelitis and predicting blood culture results

Background

Acute hematogenous osteomyelitis is the most common form of osteomyelitis in children. In recent years, the incidence of osteomyelitis has been steadily increasing. For pediatric patients, clearly describing their symptoms can be quite challenging, which often necessitates the use of complex diagnostic methods, such as radiology. For those who have been diagnosed, the ability to culture the pathogenic bacteria significantly affects their treatment plan.

Method

A total of 634 patients under the age of 18 were included, and the correlation between laboratory indicators and osteomyelitis, as well as several diagnoses often confused with osteomyelitis, was analyzed. Based on this, a Transformer-based deep learning model was developed to identify osteomyelitis patients. Subsequently, the correlation between laboratory indicators and the length of hospital stay for osteomyelitis patients was examined. Finally, the correlation between the successful cultivation of pathogenic bacteria and laboratory indicators in osteomyelitis patients was analyzed, and a deep learning model was established for prediction.

Result

The laboratory indicators of patients are correlated with the presence of acute hematogenous osteomyelitis, and the deep learning model developed based on this correlation can effectively identify patients with acute hematogenous osteomyelitis. The laboratory indicators of patients with acute hematogenous osteomyelitis can partially reflect their length of hospital stay. Although most laboratory indicators lack a direct correlation with the ability to culture pathogenic bacteria in patients with acute hematogenous osteomyelitis, our model can still predict whether the bacteria can be successfully cultured.

Conclusion

Laboratory indicators, as easily accessible medical information, can identify osteomyelitis in pediatric patients. They can also predict whether pathogenic bacteria can be successfully cultured, regardless of whether the patient has received antibiotics beforehand. This not only simplifies the diagnostic process for pediatricians but also provides a basis for deciding whether to use empirical antibiotic therapy or discontinue treatment for blood cultures.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Investigation and Management of Lower Limb Septic Arthritis in Children: An Update Using the Latest British Orthopaedic Association Standard for Trauma (BOAST) Guidelines

Septic arthritis is a serious condition in children, with the hip and knee joints most typically affected. Patients typically present with pain, joint swelling, fever, and an inability to bear weight. Early recognition and treatment are crucial, as untreated septic arthritis can lead to serious complications, including sepsis, irreversible joint damage, growth problems, and early-onset arthritis. Clinical signs, inflammatory markers, and imaging are used for the diagnosis of septic arthritis. The mainstay of management includes antibiotic therapy and surgical washout. Long-term follow-up is essential to monitor for complications.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics

This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Ten-year Review of Acute Pediatric Hematogenous Osteomyelitis at a New Zealand Tertiary Referral Center

BACKGROUND

Acute hematogenous osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Recent research has highlighted an unusually high burden of disease in the New Zealand population compared with other Western regions. We have sought to identify trends in presentation, diagnosis, and management of AHO, with added focus on ethnicity and access to health care.

METHODS

A 10-year retrospective review of all patients <16 years with presumed AHO presenting to a tertiary referral center between 2008 and 2018 was performed.

RESULTS

One hundred fifty-one cases met inclusion criteria. The median age was 8 years with a male predominance (69.5%). Staphylococcus aureus was the most common pathogen using traditional laboratory culture method (84%). The number of cases per year decreased from 2008 to 2018. Assessment using New Zealand deprivation scores showed Māori children were most likely to experience socioeconomic hardship ( P ≤0.01). Median distance traveled by families to first hospital consult was 26 km (range 1 to 178 km). Delayed presentation was associated with need for prolonged antibiotic therapy. Incidence of disease varied by ethnicity with 1:9000 cases per year for New Zealand European, 1:6500 for Pacific, and 1:4000 for Māori. Overall recurrence rate was 11%.

CONCLUSIONS

The incidence of AHO in New Zealand is concerningly high within Māori and Pacific populations. Future health interventions should consider environmental, socioeconomic, and microbiological trends in the burden of disease.

LEVEL OF EVIDENCE

Retrospective study, Level III.

Diagnosing acute bone and joint infection in children

Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.

Radiometal chelators for infection diagnostics

Infection of native tissues or implanted devices is common, but clinical diagnosis is frequently difficult and currently available noninvasive tests perform poorly. Immunocompromised individuals (for example transplant recipients, or those with cancer) are at increased risk. No imaging test in clinical use can specifically identify infection, or accurately differentiate bacterial from fungal infections. Commonly used [18F]fluorodeoxyglucose (18FDG) positron emission computed tomography (PET/CT) is sensitive for infection, but limited by poor specificity because increased glucose uptake may also indicate inflammation or malignancy. Furthermore, this tracer provides no indication of the type of infective agent (bacterial, fungal, or parasitic). Imaging tools that directly and specifically target microbial pathogens are highly desirable to improve noninvasive infection diagnosis and localization. A growing field of research is exploring the utility of radiometals and their chelators (siderophores), which are small molecules that bind radiometals and form a stable complex allowing sequestration by microbes. This radiometal-chelator complex can be directed to a specific microbial target in vivo, facilitating anatomical localization by PET or single photon emission computed tomography. Additionally, bifunctional chelators can further conjugate therapeutic molecules (e.g., peptides, antibiotics, antibodies) while still bound to desired radiometals, combining specific imaging with highly targeted antimicrobial therapy. These novel therapeutics may prove a useful complement to the armamentarium in the global fight against antimicrobial resistance. This review will highlight current state of infection imaging diagnostics and their limitations, strategies to develop infection-specific diagnostics, recent advances in radiometal-based chelators for microbial infection imaging, challenges, and future directions to improve targeted diagnostics and/or therapeutics.

Role of ultrasound in the treatment of pediatric infectious diseases: case series and narrative review

BACKGROUND

Infectious diseases are common in pediatric patients. In these patients, ultrasound is a useful imaging modality that involves no irradiation or sedation and can be performed repeatedly at the patient's bedside. The purpose of this review was to show pediatric cases with infectious disease that used ultrasound to decide the methods of treatment.

DATA SOURCES

Literature review was performed using Pubmed as the medical database source. No year-of-publication restriction was placed. The mesh terms used were: "ultrasound", "sonography", "infectious disease", "treatment", "antibiotics", "surgical intervention", "pediatric", "children", "deep neck abscess", "pyothorax", "empyema", "pneumonia", "urinary tract infection", "intra-abdominal abscess", "soft tissue infection", "septic arthritis", "osteomyelitis", and "surgical site infection".

RESULTS

We presented pediatric case series with infectious diseases, including deep neck abscess, pyothorax and empyema, pneumonia, urinary tract infection, intra-abdominal abscess, soft tissue infection, septic arthritis and osteomyelitis, and surgical-site infection. Ultrasound was useful for evaluating the extent and location of inflammation and abscess and for decision-making concerning surgical intervention.

CONCLUSION

Knowledge of these sonographic findings is important for sonographers during examinations and for physicians when determining the treatment plan and period of antibiotic therapy for infected lesions.

A systematic review of the optimal drainage technique for septic hip arthritis in children

INTRODUCTION

The hip is one of the most commonly affected joints in paediatric septic arthritis. Drainage can be performed using arthrocentesis (articular needle aspiration), arthroscopy or arthrotomy. The objective of this systematic review was to identify the most effective drainage technique for septic hip arthritis in the paediatric population.

MATERIALS AND METHODS

The electronic MEDLINE, EMBASE and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the paediatric hip. Outcome parameters were additional drainage procedures, clinical outcomes and radiological sequelae. The quality of each of the included studies was assessed with the Methodological Index for Non-randomized Studies (MINORS) score.

RESULTS

Out of 2428 articles, 19 studies with a total of 406 hip joints were included in the systematic review. Additional arthroscopy or arthrotomy was performed in 15% of the hips treated with arthrocentesis, in 14% after arthroscopy and in 3% after arthrotomy. Inferior clinical outcomes and more radiological sequelae were seen in patients treated with an arthrotomy. A meta-analysis could not be performed due to the diversity and low quality of the studies (MINORS median 4 [range 2-15]).

CONCLUSIONS

This systematic review gives a comprehensive overview of the available literature on treatment for septic hip arthritis in children. Arthrocentesis and arthroscopic procedures may have a higher risk of additional drainage procedures in comparison with arthrotomy. However, arthrotomy might be associated with inferior outcomes in the longer term. The included studies are diverse and the scientific quality is generally low.

Identifying predictors for source culture positivity in children with acute musculoskeletal infections

OBJECTIVES

Identifying the causative bacterial pathogen for children with acute hematogenous musculoskeletal infections (MSKIs) allows for improved care. The purpose of our study was to determine if clinical markers could predict which patients will have a causative pathogen found on source culture alone, thus being highest yield to undergo operative diagnostic procedures.

METHODS

A single-center, retrospective cohort study was performed. Medical records for patients between 6 months and 18 years of age admitted between July 2014 and September 2018 with a discharge diagnosis of acute osteomyelitis, septic arthritis, or pyomyositis were reviewed. Patients were stratified based on results of blood and source cultures. Predictors of interest were screened on a univariable basis with significant predictors retained in a multivariate analysis.

RESULTS

There were 170 patients included. No predictors were significantly associated with increased odds of having a causative pathogen found on source culture alone. Degree of C-reactive protein elevation and history of fever were associated with decreased odds of being source culture positive, OR (95% CI); 0.92 (0.87, 0.98) and 0.39 (0.19, 0.81), respectively.

CONCLUSIONS

Predictive modeling failed to identify children with MSKIs whose causative pathogen was found by source culture alone. It is difficult to predict which MSKI patients will be highest yield for operative diagnostic procedures.

ACR Appropriateness Criteria® Osteomyelitis or Septic Arthritis-Child (Excluding Axial Skeleton)

Imaging plays an integral role in the evaluation of suspected musculoskeletal infections in children, not only in the accurate identification of infection such as osteomyelitis or septic arthritis, but also in guiding management. Various diagnostic modalities serve different purposes in the assessment of suspected pediatric musculoskeletal infections. The purpose of this document is to provide imaging guidance in the most frequently encountered clinical scenarios in which osteomyelitis and/or septic arthritis are suspected, outside of the axial skeleton. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion.

Predictive Algorithms in the Diagnosis and Management of Pediatric Hip and Periarticular Infection

➤ Although the criteria of Kocher et al. were an important advancement in our ability to diagnose septic arthritis of the hip early, the changing microbial landscape and availability of advanced imaging have rendered it insufficient for contemporary clinical use.➤ Routine use of magnetic resonance imaging and recognition of disseminated disease have prompted the development of algorithms to predict concurrent osteoarticular infection in cases of septic arthritis and osteomyelitis that were previously assumed to be "isolated."➤ Recent research has attempted to stratify childhood bone and joint infection (BJI) by severity to guide treatment planning. This is valuable, as patients with multifocal disease, more virulent pathogens, and immunocompromise can have longer hospital stays and require multiple surgeries.➤ The increasing prevalence of clinical prediction algorithms in childhood BJI is not completely matched by quality in methodology. Clinicians need to be wary of adopting predictive algorithms prior to robust external validation.

Paediatric Osteomyelitis and Septic Arthritis Pathogen Distribution and Antimicrobial Resistance in a Single Centre: A 15-Year Retrospective Analysis

BACKGROUND

The epidemiological characteristics of the common pathogens underlying acute haematogenous osteoarticular infection (AHOI) and their resistance to drugs have temporal and regional differences.

AIMS

To determine the antimicrobial treatment most effective for culture-negative AHOI patients and those without bacterial cultures.

METHODS

Retrospective analysis of clinical data of children with AHOI who were culture positive from January 2007 to December 2021. And the distribution of the main pathogens and the drug resistance Staphylococcus aureus were analysed in different time periods, age groups and infection types.

RESULTS

A total of 188 cases met the inclusion criteria, including 97 cases of acute haematogenous osteomyelitis (AHO), 75 cases of septic arthritis (SA) and 16 cases of AHO concomitant with SA. The commonest causative pathogen in local children was S. aureus of Gram-positive cocci, followed by Streptococcus, and occasionally Gram-negative bacilli. The distribution of S. aureus had no significant correlation with age or infection type. Staphylococcus aureus accounted for 81.82%, 90.91% and 96.15% of all pathogens, and methicillin-resistant S. aureus (MRSA) accounted for 24.22%, 53.33% and 76.00% of S. aureus in 2007-11, 2012-16 and 2017-21, respectively. The frequency of MRSA infection showed an increasing trend over time.

CONCLUSION

Staphylococcus aureus is still the main pathogen of AHOI in local children. The proportion of MRSA in S. aureus has also increased over time to 76% in the last 5 years, and the increased proportion of MRSA can affect the choice of initial empirical medication.

Developments in diagnosis and treatment of paediatric septic arthritis

Acute septic arthritis in children is an orthopaedic emergency. A delay in diagnosis and inappropriate treatment can result in devastating damage to the joint with lifelong disability as a consequence. The clinical presentation can be a diagnostic challenge, especially in young children. A recent systematic review showed that joint tenderness and fever are important signals of septic arthritis. Ultrasound is helpful in detecting the presence of a joint effusion. Plain radiographs may show bone changes but magnetic resonance imaging is the most reliable imaging study for detecting concomitant osteomyelitis. The diagnosis of acute septic arthritis is highly suggestive when pus is aspirated from the joint, in case of a positive culture or a positive gram stain of the joint fluid, or if there is a white blood-cell count in the joint fluid of more than 50000/mm3. Staphylococcus aureus is the most commonly cultured organism. Recent systematic reviews have identified the most effective drainage techniques, including needle aspiration, arthroscopy and arthrotomy, depending on the affected joint. After the drainage procedure it is important to monitor the clinical and laboratory outcomes. Additional drainage procedures may be necessary in select cases.

Primary Septic Arthritis in Children Demonstrates Presumed and Confirmed Varieties Which Require Age-specific Evaluation and Treatment Strategies

BACKGROUND

There is uncertainty involved in the evaluation and treatment of children suspected to have septic arthritis particularly when no causative pathogen is confirmed. This study evaluates children with primary septic arthritis to refine the processes of evaluation and treatment and improve the rate of pathogen confirmation.

METHODS

Children suspected to have septic arthritis from 2009 to 2019 were retrospectively studied. Diagnosis of primary septic arthritis, defined as hematogenous joint infection without associated osteomyelitis, was established by clinical evaluation, radiology and laboratory results, including joint fluid analysis. Excluded cases were categorized by etiology. Children with primary septic arthritis were divided into confirmed and presumed cohorts for statistical comparison.

RESULTS

A total of 355 children (average age 4.4 y, range 0.05 to 18 y) were initially treated as septic arthritis. Eighty-seven (24.5%) were excluded due to other conditions, including 34 (9.6%) with noninfectious conditions. Among 268 children with primary septic arthritis, 134 were confirmed and 134 were presumed. A higher rate of 16S polymerase chain reaction (PCR) acquisition (71.6% vs. 45.5%) occurred in the confirmed cohort. Overall yield for various methods of pathogen identification were 27 of 239 (11.3%) by blood culture, 83 of 268 (31.0%) by joint fluid culture and 85 of 157 (54.1%) by PCR. PCR identified a pathogen in 87.5% of children with confirmed septic arthritis. Antibiotic pretreatment was associated with a lower rate of joint fluid culture positivity. Pathogens aggregated within specific age groups. The 4 to 9-year-old age group displayed the widest spectrum of pathogens with limited predictability.

CONCLUSIONS

This study emphasizes the need for systematic processes of evaluation and treatment for children suspected to have primary septic arthritis, including minimization of antibiotic pretreatment, age-based empiric antibiotic selection, and sufficient follow-up to ensure noninfectious conditions are distinguished in culture-negative cases. Extended observation, before intervention, may be appropriate for some children.

LEVEL OF EVIDENCE

Level III-retrospective control study.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

External Validation of an Algorithm to Predict Adjacent Musculoskeletal Infection in Pediatric Patients With Septic Arthritis

BACKGROUND

Septic arthritis (SA) remains a potentially morbid disease in the pediatric population. Magnetic resonance imaging (MRI) is the most sensitive tool for recognizing associated osteomyelitis and intramuscular abscess, but is a limited resource. The aim of this study is to externally validate a previously developed algorithm (Rosenfeld and colleagues) to predict adjacent infection in pediatric patients diagnosed with SA.

METHODS

We identified 120 children under 16 with presumed SA presenting to a tertiary referral center between 2008 and 2018. Patients without confirmed SA, those with insufficient data, and patients who did not receive perioperative MRI were excluded, leaving 53 patients. The previous algorithm suggests that patient age (above 4 y), C-reactive protein (>8.9 mg/L), platelet count (<310×10cells/µL), duration of symptoms (>3 d), and absolute neutrophil count (>7.2×10cells/µL) are risk factors for adjacent infection, with 3 or more variables signifying a "positive" result. Comparing against the gold standard of MRI, the accuracy of the algorithm was validated in terms of sensitivity, specificity, likelihood ratio (LR), and positive and negative predictive value. Discrimination and calibration of this algorithm have been assessed using receiver operating curve analysis and calibration plots.

RESULTS

The sensitivity and specificity of criteria from Rosenfeld algorithm were 73% and 44%, respectively. Receiver operating curve showed poor discrimination [area under the curve=0.54, confidence interval (CI): 0.26-0.83]. The positive predictive value was 55.9% and the negative predictive value was 63.1% with LR +1.23 (CI: 0.87-1.98) and LR -0.61 (CI 0.28-1.30). Only 53% of patients with 4 or more criteria had an adjacent infection on MRI. Examining our cohort, children with a positive MRI finding had higher mean C-reactive protein (77 vs. 122 mg/L, P=0.04) and were more likely to have waited >72 hours days between symptom onset and hospital presentation (P=0.03).

CONCLUSION

Although treatment algorithms are an attractive tool to guide clinicians and resource allocation, they need to take into account the local population characteristics before routine implementation.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Pediatric Septic Arthritis of the Knee Due to a Multi-Sensitive Streptococcus pyogenes Strain Responsive to Clindamycin-A Case Report

Septic arthritis is an inflammatory process usually generated by a bacterial infection. The knee is one of the most frequently involved joints. The etiology varies depending on age, and hematogenous spread remains the primary cause in children. Herein, we report a case of a previously healthy three-year-old female who was referred to our institution for acute swelling of her right knee. After a clinical and radiological diagnosis of septic arthritis, an empirical treatment with a combination of cefotaxime and clindamycin was initiated. The isolation of a multi-sensitive Streptococcus pyogenes strain from the joint’s effusion prompted the discontinuation of clindamycin and the usage of cefotaxime alone. One week later, an ultrasound was executed due to worsening in the patient’s clinical conditions, and an organized corpuscular intra-articular effusion with diffuse synovial thickening was revealed. Cefotaxime was therefore replaced with clindamycin, which improved the symptoms. Despite the antibiotic sensitivity test having revealed a microorganism with sensitivity to both cephalosporin and clindamycin, clinical resistance to cefotaxime was encountered and a shift in the antimicrobial treatment was necessary to ensure a full recovery. This case study confirms that an antibiotic regimen based solely on a susceptibility test may be ineffective for such cases.

A Comparison of the Epidemiology, Clinical Features, and Treatment of Acute Osteomyelitis in Hospitalized Children in Latvia and Norway

Background and objectives: Paediatric acute osteomyelitis (AO) may result in major life-threatening and limb-threatening complications if not recognized and treated early. The management of AO may depend on local microbial prevalence and virulence factors. This study compares the approach to paediatric AO in hospitals in two countries—Latvia and Norway. Materials and Methods: The study includes patients with AO hospitalized in the paediatric department in the Norwegian hospital Sørlandet Sykehus Kristiansand (SSK), in the period between the 1st of January 2012 and the 31st of December 2019. The results from SSK are compared to the results of a published study of AO in patients hospitalized at the Children’s Clinical University Hospital (CCUH) in Riga, Latvia. Results: The most isolated pathogen from cultures in both hospitals was S. aureus (methicillin-sensitive). The lower extremity was the most affected body part (75% in CCUH, 95% in SSK), the main clinical symptom was pain (CCUH 92%, SSK 96.6%). Deep culture aspiration was most often taken intraoperatively in CCUH (76.6%) and percutaneously in SSK (44.8%). Oxacillin was the most applied antibiotic in CCUH (89.4%), and Cloxacillin in SSK (84.6%). Combined treatment with anti-Staphylococcal penicillins and Clindamycin was administered in 25.5% and 33.8% of CCUH and SSK patients, respectively. The median duration of the intravenous antibacterial treatment in CCUH and SSK was 15 and 10 days, respectively, and a switch to oral therapy was mainly made at discharge in both hospitals. The median total duration of antibiotic treatment was 25 days in CCUH and 35 days in SSK. 75% of CCUH and 10.3% of SSK patients were treated surgically. Complications were seen in 47% of patients in CCUH and in 38% in SSK. Conclusions: The transition to oral antibacterial treatment in both hospitals was delayed, which suggests a lack of criteria for discontinuation of intravenous therapy and could potentially contribute to longer hospitalization, higher cost of treatment and risk of complications. The use of more invasive techniques for deep culturing and significantly more common surgical interventions could possibly be linked to a higher complication rate in AO patients treated at the Latvian hospital.

Measuring complications of serious pediatric emergencies using ICD-10

OBJECTIVE

To create definitions for complications for 16 serious pediatric conditions using the International Classification of Diseases, 10th Revision, Clinical Modification or Procedure Coding System (ICD-10-CM/PCS), and to assess whether complication rates are similar to those measured with ICD-9-CM/PCS.

DATA SOURCES

The Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases from five states between 2014 and 2017 were used to identify cases and assess complication rates. Incidences were calculated using population counts from the 5-year American Community Survey.

DATA COLLECTION/EXTRACTION METHODS

Patients were identified by the presence of a diagnosis code for one of the 16 serious conditions. Only the first encounter for a given condition by a patient was included. Encounters resulting in transfer were excluded as the presence of complications was unknown.

STUDY DESIGN

We defined complications using data elements routinely available in administrative databases including ICD-10-CM/PCS codes. The definitions were adapted from ICD-9-CM/PCS using general equivalence mappings and refined using consensus opinion. We included 16 serious conditions: appendicitis, bacterial meningitis, compartment syndrome, new-onset diabetic ketoacidosis (DKA), ectopic pregnancy, empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. Using data from children under 18 years, we compared incidences and complication rates across the ICD-10-CM/PCS transition for each condition using interrupted time series.

PRINCIPAL FINDINGS

There were 61 314 ED visits for a serious condition; the most common was appendicitis (n = 37 493). Incidence rates for each condition were not significantly different across the ICD-10-CM/PCS transition for 13/16 conditions. Three differed: empyema (increased 42%), orbital cellulitis (increased 60%), and sepsis (increased 26%). Complication rates were not significantly different for each condition across the ICD-10-CM/PCS transition, except appendicitis (odds ratio 0.62, 95% CI 0.57-0.68), DKA (OR 3.79, 95% CI 1.92-7.50), and orbital cellulitis (OR 0.53, 95% CI 0.30-0.95).

CONCLUSIONS

For most conditions, incidences and complication rates were similar before and after the transition to ICD-10-CM/PCS codes, suggesting our system identifies complications of conditions in administrative data similarly using ICD-9-CM/PCS and ICD-10-CM/PCS codes. This system may be applied to screen for cases with complications and in health services research.

Long-Term Outcomes of Acute Osteoarticular Infections in Children

Background: Acute hematogenous osteomyelitis (OM) and septic arthritis require immediate diagnosis and treatment by an interdisciplinary team of pediatric infectious disease specialists and pediatric orthopedic surgeons. Adverse outcomes such as growth disturbance, bone deformity, and chronic infections have been described in older studies. However, there is only little known about long-term follow-up of patients of the last two decades. Therefore, we aimed to evaluate subjective and objective long-term outcomes of these children with osteoarticular infections treated in the millennial years. Methods: Cross-sectional study performed in two pediatric centers including patients admitted for OM and/or SA between 2005 and 2014 and follow-up consultations in 2019. Patients with symptoms of ≤2 weeks duration at initial presentation were contacted. Subjective outcomes were assessed by standardized interview, objective outcomes by clinical examination. Medical charts were used to extract data from the initial presentations. Statistical analysis was performed by non-parametric tests and Fisher's exact test. Results: Of 147 eligible patients 77 (52%) agreed to participate, of which 68 (88%) had an interview and physical examination and 9 (12%) an interview only. Thirty-three (39%) had OM, 26 (34%) SA, and 21 (27%) combined OM/SA. Median (IQR) age at follow-up was 13.3 (10.5-18.0) years with a median (IQR) follow-up of 7.1 (6.1-8.6) years. Persistent complaints including pain, functional differences and scar paresthesia, reported by 21 (28%) patients, were generally mild and only 3 (5%) required ongoing medical care. Objective sequelae including pain, limited range of motion, unilateral axis deformity or asymmetric gait were found in 8 (12%) participants. Older age, female sex, joint involvement, surgical intervention, persistent fever, and C-reactive protein elevation were associated with adverse clinical outcome. Conclusions: Adverse outcomes were observed in a considerable number of patients, most of which were minor, and only few required ongoing medical care. Long-term follow up is advisable for patients with risk factors identified during the initial presentation. This study was registered on ClinicalTrials.gov (NCT03827980).

Pediatric Septic Arthritis: An Update

Septic arthritis in children is a surgical emergency, and prompt diagnosis and treatment are mandatory. If diagnosed quickly and treated correctly, the outcomes can be good. With delay in diagnosis and without proper treatment, outcomes often are quite devastating, with growth disturbance and joint destruction.

Pyogenic sacroiliitis in children: don't forget the very young

Pyogenic sacroiliitis (PS) is rare with less than 100 pediatric cases reported in the medical literature. To better characterize PS in the pediatric population, we investigated a series of children presenting with PS. Retrospective data analysis was done at an academic tertiary center between the years of 2000 and 2017. All hospitalized children ≤ 16 years of age with PS were evaluated. Of the 894 children hospitalized with osteoarticular infections, 18 were diagnosed with PS (2%) and are included in the review. Two clinically distinct groups were identified. PS in infants (n = 13, 72.2%, mean age 1.1 years) had an indolent course and a faster recovery without any bacterial source identified. In contrast, the group of older children (n = 5, 27.8%, mean age 11.6 years) had a more complicated course and a higher rate of identified bacterial infections.Conclusion: We describe an under-recognized entity of PS in infants with a mild clinical course and fast recovery that differ from the "classical" septic sacroiliitis. Infants with PS did not suffer from invasive complications, and pathogen characteristics of older children were not identified. Infants with fever, irritability, decreased range of motion in the pelvic area, and pain during diapering should alert the clinician to this diagnosis. What is Known: • Pediatric pyogenic sacroiliitis is an extremely rare condition usually caused by Staphylococcus aureus with highest incidence in adolescents. • The diagnosis of PS is challenging due to its rarity and difficulty in assessing the sacroiliac joint. What is New: • We describe an under-recognized entity of PS in infants with a mild clinical course, without invasive complications and with fast recovery that differ from "classical" septic sacroiliitis. • Infants with fever, irritability, decreased range of motion in the pelvic area and pain during diapering should raise clinical suspicion of this diagnosis.