[SEIP-SERPE-SEOP Consensus document on the treatment of uncomplicated acute osteomyelitis and septic arthritis]

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.

Diagnostic and therapeutic approach to spondylodiscitis in Spanish children through the RIOPed network: evaluation before and after the publication of the national consensus document

OBJECTIVE

Pediatric spondylodiscitis (PSD) is an uncommon condition, for which there are no specific international clinical guidelines. Factors related to complications have not been stablished. Our aim was to describe clinical and epidemiological characteristics of PSD, to analyze factors associated with complications and to evaluate adherence to the recommendations of the Spanish National Consensus Document (NCD) for the diagnostic and therapeutic approach to acute osteoarticular infections.

MATERIAL AND METHODS

Ambispective, multicenter, national study of two PSD cohorts: historical (2008-2012) and prospective (2015-2020, after publication of NCD). Patients with diagnosis of PSD were included. Demographic, clinical, microbiological and radiological data were recorded. Factors related to the development of complications were analized by logistic regression. Comparisons between both cohorts were performed.

RESULTS

Ninety-eight PSD were included. In 84.7%, diagnosis was confirmed by magnetic resonance imaging. Microbiological isolation was obtained in 6.1%, with methicillin-sensitive S. aureus as the main etiologic agent. Complications occurred in 18.9%, the most frequent being soft tissue abscess. Of the 8.6% of patients with sequelae, persistent pain was the most common. Comparing cohorts, there was better adherence to NCD treatment recommendations in the prospective one (57.6% vs. 12.9%, p < 0.01), including a reduction in the length of intravenous antibiotic therapy (10 vs. 14 days, p < 0.01).

CONCLUSIONS

The evolution of PSD in our series was favorable, with low frequency of complications and sequelae. The adherence to the recommendations of the NCD was high. Studies with larger sample size are needed to establish new recommendations to optimize the approach to these infections.

Hospital at Home Program for the Treatment of Pediatric Osteoarticular Infections

OBJECTIVES

Hospital at home (HAH) replaces acute inpatient hospital care for selected patients by providing care in their homes. We sought to describe the characteristics, management, and complications of patients with osteoarticular infections (OAIs) treated in an HAH program and its economic impact.

METHODS

We conducted a retrospective observational study evaluating an HAH program in a pediatric hospital in Spain, describing the characteristics of patients with confirmed OAIs requiring intravenous antibiotic therapy admitted to this program between January 2019 and December 2022. The program operates as a virtual ward with possible daily visits by physicians and nurses and 24/7 telephone contact.

RESULTS

A total of 88 patients (median age, 4.1 years; interquartile range [IQR], 1.7-10.6) with OIAs were admitted to the HAH program. Osteomyelitis (57%) and septic arthritis (29%) were the most frequent infections. Cefuroxime (42%) and cefazolin (39%) were the most frequently prescribed antibiotics. Caregiver self-administration was performed in 99%, allowing multiple daily doses of antimicrobial therapy, 80% by peripheral line. Thirteen patients (15%) had drug-related adverse events, only 3 requiring drug modification. Two patients (2%) were readmitted during HAH, and 1 was readmitted within 30 days of HAH discharge. The median HAH stay was 7 days (IQR, 4-8.75). For osteomyelitis, hospital days lowered from 8.5 days (IQR, 4.5-12) to 4 days (IQR, 3-7) after HAH implementation (P = .005) with 68% per-patient estimated cost savings.

CONCLUSIONS

HAH treatment of OAIs is effective and cost-efficient. Patient support by medical and nursing staff, adequate family training, and regular communication are essential to ensure safe home admission.

The use of the ratio of C-reactive protein to albumin for the diagnosis of pediatric septic arthritis

Purpose

This study aimed to investigate the relationship between the ratio of c-reactive protein to albumin (CAR) and pediatric septic arthritis (PSA).

Methods

Clinical and laboratory data were collected. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive ability of CAR in identifying PSA. Multivariable logistic regression analyses was performed to calculate adjusted odds ratio (OR) with 95% confidence interval (CI).

Results

We included 305 patients with PSA (CAR ≤ 0.447, 182 patients; CAR > 0.447, 123 patients) between September 2013 and November 2022. ROC analysis showed that CAR performed best in diagnosing PSA, with an area under curve (AUC) value of 0.828. After adjusted for potential confounders, we found that high CAR was associated with PSA (OR = 6.85, 95% CI: 2.30-20.40, p = 0.001). In sensitivity analyses, subgroups analyses, and propensity score matching, the results remain stable.

Conclusions

The CAR (>0.447) at admission was an independent risk factor for PSA. It is worthy to further investigate this association.

Clinical and Radiographic Outcomes and Treatment Algorithm for Septic Arthritis in Children

BACKGROUND

Septic arthritis (SA) in children is an acute inflammatory disease of the joints. If not treated promptly, it could become a surgical emergency. The incidence of the disease in children in Europe is approximately 2-7 per 100,000 children. The aim of this systematic review was to investigate which of these treatments-arthrocentesis, arthrotomy, and arthroscopy-provides better results in children and when to use them.

METHODS

Three independent authors conducted a systematic review of PubMed, ScienceDirect, and MEDLINE databases to assess studies with any level of evidence that reported the surgical outcome of SA. Two senior investigators evaluated and approved each stage's findings.

RESULTS

A total of 488 articles were found. After screening, we chose 24 articles that were suitable for full-text reading based on the inclusion and exclusion criteria. The results of our analysis showed that there are no numerically significant differences reported in the literature on clinical and radiographic outcomes by surgical technique.

CONCLUSIONS

We developed an algorithm that could be used if septic arthritis is suspected. Based on our results, the surgical technique to be used will depend on the operator who will perform it.

Surgical treatment of septic arthritis of the hip in children: arthrotomy compared with repeated aspiration-lavage

PURPOSE

To review two cohorts of children treated by two different protocols (repeated needle aspiration-lavage vs. arthrotomy) for surgical treatment of septic arthritis of the hip (SAH).

METHODS

In order to compare between the two methods, the following parameters were checked: (a) Scar cosmesis was assessed by the Patient and Observer Scar Assessment Scale (POSAS). We considered satisfactory results (no scar discomfort) when POSAS was within 10% of the ideal score; (b) 24-h post-operative pain was evaluated by visual analog scale (VAS); (c) Complication rates of incomplete drainage (re-arthrotomy/therapy modification from aspiration-lavage to arthrotomy). The results were evaluated by the Student t-test or by the chi-square test.

RESULTS

Seventy-nine children (aged 2-14 years) admitted during 2009-2018 and available for at least two years of follow-up were enrolled. The POSAS score (range 12-120 points) at the latest follow-up was higher in the arthrotomy group compared with the aspiration-lavage group (18.10 ± 6.22 versus 12.27 ± 1.40, p < 0.001); 77.4% of patients treated by arthrotomy had no scar discomfort. The 24-h post-intervention VAS (range 1-10) was 5.06 ± 1.29 after arthrotomy and 4.03 ± 1.13 after aspiration-lavage, p < 0.04. Complications were three times more frequent in the aspiration-lavage group (8.8% in the arthrotomy group and 26.7% in the aspiration-lavage group, p = 0.045).

CONCLUSIONS

We conclude that the lower complication rate observed in the arthrotomy group outweighs by far scar cosmesis and post-operative pain advantages in the aspiration-lavage group. Arthrotomy as a drainage method is safer than aspiration-lavage.

Impact of guidelines implementation on empiric antibiotic treatment for pediatric uncomplicated osteomyelitis and septic arthritis over a ten-year period: Results of the ELECTRIC study (ostEomyeLitis and sEptiC arThritis tReatment in children)

Background

Due to the growing evidence of the efficacy of intravenous (IV) cefazolin with an early switch to oral cefalexin in uncomplicated pediatric osteomyelitis (OM) and septic arthritis (SA) in children, we changed our guidelines for empiric antibiotic therapy in these conditions. This study aims at evaluating the impact of the guidelines' implementation in reducing broad-spectrum antibiotic prescriptions, duration of IV antibiotic treatment and hospital stay, treatment failure and recurrence.

Materials and methods

This is a retrospective, observational, quasi-experimental study. The four years pre-intervention were compared to the six years, ten months post-intervention (January 2012, through December 2015; January 2016, through October 31st, 2022). All patients aged 3 months to 18 years with OM or SA were evaluated for inclusion. Each population was divided into three groups: pre-intervention, post-intervention not following the guidelines, and post-intervention following the guidelines. Differences in antibiotic prescriptions such as Days of Therapy (DOT), activity spectrum and Length of Therapy (LOT), length of hospital stay (LOS), broad-spectrum antibiotics duration (bsDOT), treatment failure and relapse at six months were analyzed as outcomes.

Results

Of 87 included patients, 48 were diagnosed with OM (8 pre-intervention, 9 post-intervention not following the guidelines and 31 post-intervention following the guidelines) and 39 with SA (9 pre-intervention, 12 post-intervention not following the guidelines and 18 post-intervention following the guidelines). In OM patients, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group, with also the lowest proportion of patients discharged on IV treatment. Notably, significantly fewer cases required surgery in the post-intervention groups. Considering SA, LOS, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group. The treatment failure rate was comparable among all groups for both OM and SA. There were no relapse cases. The overall adherence was between 72 and 100%.

Conclusions

The implementation of guidelines was effective in decreasing the extensive use of broad-spectrum antibiotics and combination therapy for both OM and SA. Our results show the applicability, safety, and efficacy of a narrow-spectrum IV empirical antibiotic regimen with cefazolin, followed by oral monotherapy with first/second-generation cephalosporins, which was non-inferior to broad-spectrum regimens.

Surveillance of osteoarticular infections caused by Staphylococcus aureus in a paediatric hospital in Mexico City

Staphylococcus aureus is the main aetiologic agent of osteoarticular infections (OAIs) in paediatric patients. The aim of this prospective unicenter study was to describe the phenotypic and genotypic characteristics of S. aureus isolates obtained from OAIs in paediatric patients admitted to tertiary care hospital. Through a surveillance program called OsteoCode, a multidisciplinary team was created and we identified 27 patients with OAIs caused by S. aureus from 2019 to 2021. The susceptibility profile, virulence factors, biofilm formation, pulsed-field gel electrophoresis (PFGE), clonal complex (CC) and sequence type (ST) were determined. In addition, the clinical characteristics and evolution of the patients presented six months after the diagnosis of OAIs were described. Ninety-two percent of the isolates were methicillin-sensitive S. aureus (MSSA). In methicillin-resistant S. aureus (MRSA), SCCmec-II and SCCmec-V were detected. The pvl gene was only observed in MSSA (18.5%) and was associated with highest fever (p=0.015), multiple localization (p=0.017), and soft tissue sites of infection beyond the bone (pyomyositis, pulmonary abscess) (p=0.017). Biofilm formation was detected in 55.6% of isolates. The most common CC were CC5 and CC30 which represent the most common linages for bone and joint infections worldwide. The isolates were distributed in different STs, and ST672 was predominant. MRSA were associated with a longer duration of intravenous treatment and a prolonged hospital stay (p=0.023). Recurrent infection occurred in five children and orthopaedic complications in 33.3% of patients. This is the first study that reflects the epidemiology of S. aureus in OAIs in paediatric patients in Mexico; a clear predominance of MSSA distributed in different STs was observed. Our findings highlight that a multidisciplinary team is required for the diagnosis and treatment of OAIs.

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.

[Evaluation of the impact of the Spanish consensus document on the approach to osteoarticular infections in Spain through the Paediatrics Osteoarticular Infections Network (RIOPED)]

INTRODUCTION

In 2014 the Consensus Document produced by the Spanish Paediatric Societies (SEIP-SERPE-SEOP) was published to help in the diagnosis and treatment of osteoarticular infections (OAI). In 2015 the RIOPed was considered as a multidisciplinary national network for the investigation into OAI. The aim of this study was to assess the level of adaption to the recommendations established in the Consensus during one year of follow-up.

MATERIAL AND METHODS

A prospective, national multicentre study was carried out in 37 hospitals between September 2015 and September 2016. The study included patients >16years-old with a diagnosis of OAI, confirmed by microbiological isolation, or probable: septic arthritis (SA) with >40,000 white cells in synovial fluid, or osteomyelitis (OM)/spondylodiscitis (SD) with a compatible imaging test. The results were compared with those obtained in a retrospective study conducted between 2008 and 2012.

RESULTS

A total of 235 cases were included, of which 131 were OM, 79 SA, 30 OA, and 15 SD. As regards the complementary tests that the Consensus considered mandatory to perform, radiography was carried out on 87.8% of the cases, a blood culture on 91.6%, and culture of the synovial fluid in 99% of SA. A magnetic resonance (MR) was performed on 71% of the OM cases. The choice of intravenous empirical antibiotic treatment was adapted to the recommendations in 65.1% of cases, and in 62.3% for the oral treatment. Surgery was performed in 36.8% of SA cases (85.7% arthrotomy), with a significant decrease compared to the retrospective study (P=.014). Only 58.5% of cases followed the recommendations on the duration of the treatment; however, a lower duration of intravenous treatment was observed.

CONCLUSIONS

In general, the level of adaptation to the recommendations that were set by the Expert Group, is good for the complementary tests, and acceptable as regards the choice of antibiotic treatment, although inadequate in almost 40% of cases. A decrease in hospital stay was achieved.

Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis

BACKGROUND AND OBJECTIVES

Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children. Quality improvement (QI) methods have been used to successfully improve care and decrease costs through standardization for numerous conditions, including pediatric AHO. We embarked on a QI initiative to standardize our approach to the inpatient management of AHO, with a global aim of reducing inpatient costs.

METHODS

We used existing literature and local consensus to develop a care algorithm for the inpatient management of AHO. We used the Model for Improvement as the framework for the project, which included process mapping, failure mode analysis, and key driver identification. We engaged with institutional providers to achieve at least 80% consensus regarding specific key drivers and tested various interventions to support uptake of the care algorithm.

RESULTS

Fifty-seven patients were included. There were 31 patients in the preintervention cohort and 26 in the postintervention cohort, of whom 19 were managed per the algorithm. Mean inpatient charges decreased from $45 718 in the preintervention cohort to $32 895 in the postintervention cohort; length of stay did not change. Adherence to recommended empirical antimicrobial agents trended upward.

CONCLUSIONS

A simple and low-cost QI project was used to safely decrease the cost of inpatient care for pediatric AHO at a tertiary care children's hospital. A robust local consensus process proved to be a key component in the uptake of standardization.

Outpatients with acute osteoarticular infections had favourable outcomes when they received just oral antibiotics without intravenous antibiotics

AIM

The traditional approach for acute paediatric osteoarticular infections (OAI) has comprised initial intravenous antibiotics followed by prompt oral antibiotics. We assessed how providing just oral antibiotics compared to the traditional two-step approach.

METHODS

This prospective study was performed at the Hospital La Paz, Madrid, Spain, from September 2015 to September 2016. We compared 25 outpatients, with good general health and a mean age of 25 months who received just oral antibiotics, with 228 hospitalised children of a similar age who received intravenous and oral antibiotics from other hospitals in the Spanish Network of Osteoarticular Infections.

RESULTS

The groups were comparable in terms of age, sex, fever, erythrocyte sedimentation rate value, C-reactive protein and diagnosis. The oral group comprised 15 with osteomyelitis, seven with septic arthritis, two with osteoarthritis and one with spondylodiscitis. This group had a lower percentage of Staphylococcus aureus (8% vs 26%, p = 0.06) and higher proportion of Kingella kingae (24% vs 9%, p = 0.017) than the intravenous group. There were complications (24%) and follow-up sequelae (6%) in the intravenous group, but none in the oral group.

CONCLUSION

Outpatients with OAI who were in good general health had favourable outcomes when they received oral antibiotics without intravenous antibiotics.

Epidemiology and Management of Acute, Uncomplicated Septic Arthritis and Osteomyelitis: Spanish Multicenter Study

BACKGROUND

Acute osteoarticular infection (OAI) is a potentially severe disease. The aim of this study was to evaluate the etiology, clinical characteristics and therapeutic approach of OAI in children in Spain.

METHODS

Medical records from children <14 years with OAI from 25 hospitals between 2008 and 2012 were reviewed. Confirmed osteomyelitis (OM) and septic arthritis (SA) required a positive bacterial isolate; otherwise, they were considered probable. Probable SA with <40,000 cells/mm in joint fluid was not included.

RESULTS

A total of 641 children were evaluated. Two hundred and ninety-nine cases (46%) were OM, 232 (36%) SA, 77 (12%) osteoarthritis and 33 (5%) spondylodiscitis. Children with OM were older (63 vs. 43 months for SA; P < 0.001). Magnetic resonance imaging and bone scintigraphy had the highest yield for OM diagnosis (94%). Arthrocentesis was performed in 96% of SA. A microorganism was isolated in 246 patients (38%: 33% OM vs. 55% SA; P < 0.001): Staphylococcus aureus was the most common (63%), followed by Kingella kingae (15%) and Streptococcus pyogenes (9%). Ninety-five percent of children initially received IV antibiotics, mostly cefotaxime + cloxacillin (60%) or cloxacillin (40%). Total treatment duration was 38 (±31) days for OM and 28 (±16) days for SA (P < 0.0001). Twenty percent of children with OM (46% because of complications) and 53% with SA (95% initial arthrotomy) underwent surgery. Patients with SA were compared according to initial arthrotomy (n = 123) versus arthrocentesis (n = 109), and no clinical differences were observed, except for higher rate of hip SA in the former (50% vs. 9%; P < 0.001). Children with arthrocentesis had less sequelae [6.6% vs. 1%; P = 0.03, odds ratio = 0.58 (95% confidence interval: 0.45-0.76)], but not in the multivariate analysis.

CONCLUSIONS

This is the largest pediatric cohort of OAI in Spain. S. aureus was the most common isolate, although K. kingae was recovered in a high proportion of cases. Conservative management was applied in half of the patients. There was a low rate of sequelae, even with nonsurgical approaches.