Serum C-reactive protein, erythrocyte sedimentation rate and white blood cell count in septic arthritis of children

D-dimer may aid in the diagnosis of pediatric musculoskeletal infections: a prospective study

Musculoskeletal infections, including septic arthritis, osteomyelitis, and soft tissue infections, are critical morbidity factors for children and adolescents. This study investigated the role of D-dimer levels for diagnosing childhood musculoskeletal infections. This single-center prospective study was initiated in April 2020 following approval from the local ethics committee. The study included 54 children, divided into the infection group ( n = 21), comprising patients who underwent surgical treatment for childhood musculoskeletal infections and had macroscopically visible purulent discharge during surgery, and the control group ( n = 33), comprising healthy children. In the infection group, the mean values of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), plasma D-dimer, and white blood cell (WBC) were 39.42 ± 27.00 mm/h, 101.50 ± 76.90 mg/l, 2.34 ± 2.59 mg/l, and 15.55 ± 6.86 × 10 9 /l, respectively. On comparison, the infection group showed higher levels of WBC, CRP, ESR, D-dimer, and neutrophil-to-lymphocyte ratio than the control group. When the D-dimer cutoff value of 0.43 mg/l was taken, it was observed that it had 95.2% sensitivity and 81.8% specificity. The area under curve (AUC) of the above-mentioned parameters calculated via receiver operating characteristic curves showed CRP levels as the optimum predictor of childhood musculoskeletal infections, followed by the ESR, plasma D-dimer, and WBC levels in descending order (AUC: 0.999, 0.997, 0.986, and 0.935, respectively). D-dimer is another test, which in combination with other conventional established tests (CRP and ESR) can be helpful in diagnosis of pediatric infection. We recommend the addition of D-Dimer to ESR, CRP, and WBC as a first-line investigation in cases with suspected pediatric musculoskeletal infections.

Clinical Presentation of Acute Osteomyelitis in the Pediatric Emergency Department

OBJECTIVES

Acute osteomyelitis is a challenging diagnosis to make in the pediatric emergency department (ED), in part because of variability in its presentation. There are limited data detailing the presenting features of pediatric osteomyelitis, factors that are essential to understand to inform diagnostic decision making. We sought to describe relevant clinical data that contributed to the diagnosis of acute osteomyelitis in children presenting to a pediatric ED.

METHODS

This was a 10-year retrospective cohort study of patients 18 years or younger diagnosed with acute osteomyelitis in the ED of a large tertiary care children's hospital. Collected data included demographics, clinical history, patient-reported symptoms, vital signs, physical examination findings, and results of basic laboratory, microbiologic, and imaging studies. Descriptive statistics were used to summarize key findings.

RESULTS

Two hundred eleven cases of acute osteomyelitis were identified during the study period. The median age was 8.4 years, with 61.1% male. One hundred twenty-seven patients (60.2%) presented to care more than once before being diagnosed. Common symptoms included pain (94.3%), functional limitation (83.9%), and fever (76.3%). Common examination findings included functional limitation (78.2%), focal tenderness (73.5%), and swelling (52.1%). One hundred seventeen patients (55.5%) were febrile during their ED evaluation. Elevated C-reactive protein (>0.8 mg/dL, 92.9%) and erythrocyte sedimentation rate (>10 mm/h, 94.3%) were the most sensitive laboratory markers.

CONCLUSIONS

Fever may be absent in up to a quarter of pediatric patients with acute osteomyelitis. Although highly sensitive, inflammatory marker elevations were more modest than those reported previously in cases of pediatric septic arthritis.

Predictors of failure after initial arthroscopic washout in septic arthritis of native knee joint- a retrospective analysis

Background

Acute septic arthritis of the knee is an orthopaedic emergency requiring prompt debridement and washout to reduce infection. However, more than one washout procedure may be required to eradicate infection. This study was performed to analyse the factors associated with the failure of a single arthroscopic washout.

Methods

This is a retrospective analysis of 78 patients with septic arthritis of the knee over 6 years from January 2015 from a single trauma centre. We analysed the variables like patient demographic factors, comorbidities, laboratory parameters and various operative and non-operative factors with regard to the outcome after a single arthroscopic washout. Statistical analysis using univariate and multivariate logistic regression analysis were performed to identify the variables associated.

Results

Out of the 78 patients who underwent arthroscopic washout for a diagnosis of septic arthritis, 31 patients (39.74%) had failure of a single arthroscopic washout, with six patients (7.69%) requiring two additional washouts and one patient (1.28%) requiring three additional washouts to eradicate infection. Statistical analysis identified high temperature at presentation (p value 0.084), BMI >45 (p value 0.025), high CRP (0.014), high neutrophil count (p value 0.113) and high creatinine (p value 0.111) as the predictors of failure of a single arthroscopic washout.

Conclusion

A high failure rate (39.74%) was seen with a single arthroscopic washout procedure. A high BMI, elevated CRP, higher temperature at presentation, elevated neutrophil count were identified as the predictors of failure of a single arthroscopic washout for septic arthritis of the knee in our study.

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In septic arthritis of the knee, more than one arthroscopic washout may be required to eradicate infection.

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Our study evaluated the repeated arthroscopic washout rates in hematogenous septic arthritis of native knee joint.

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High temperature at presentation, high CRP, high BMI and high creatinine were associated with repeated infection.

Diagnostic test accuracy of serum procalcitonin compared with C-reactive protein for bone and joint infection in children and adolescents: a systematic review and meta-analysis

OBJECTIVE

The objective of this review was to synthesize the best available evidence for the diagnostic test accuracy of serum procalcitonin compared with serum C-reactive protein for suspected osteomyelitis and septic arthritis in hospitalized children and adolescents.

INTRODUCTION

Measurement of serum C-reactive protein remains a routine investigation for the diagnosis of osteoarticular infection in children and adolescents. Measurement of serum procalcitonin has been shown to outperform C-reactive protein in adults with osteomyelitis and septic arthritis. Before procalcitonin can be considered as a potential replacement or add-on test in children and adolescents, a systematic review and meta-analysis targeting this population should be conducted.

INCLUSION CRITERIA

Original studies reporting the diagnostic accuracy of procalcitonin and/or C-reactive protein in children and adolescents between one month and 18 years of age admitted to hospital with suspected osteoarticular infection were included. Studies must have compared the index test to at least one reference test. Reference test was defined as positive culture or polymerase chain reaction confirmation of a pathogen from blood, bone biopsy, or joint fluid aspirate in combination with at least two of the following: i) purulent material from sterile site, ii) positive radiological findings consistent with osteoarticular infection, and ii) symptoms and signs consistent with osteomyelitis and/or septic arthritis.

METHODS

The JBI methodology for systematic reviews of diagnostic test accuracy was followed. Information was sourced from four databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science) and four gray literature sources (MedNar, OpenGrey, Google Scholar, and ProQuest Dissertations and Theses). Only studies published in English were considered. The methodological quality of selected studies was formally evaluated, sensitivity and specificity data were extracted, and 95% confidence intervals determined. Meta-analysis was performed to estimate summary points using a bivariate model and to generate a hierarchical summary receiver operating characteristic (HSROC) curve with global measures of test accuracy performance, such as likelihood ratio and diagnostic odds ratio. A narrative was provided where meta-analysis was not appropriate.

RESULTS

Eight studies were included in the review. Four of these studies used a common C-reactive protein test threshold of 20 mg/L. At this threshold, the estimated pooled sensitivity of C-reactive protein was 0.86 (0.68-0.96) and the pooled specificity was 0.9 (0.83-0.94). Using a hierarchical summary receiver operating characteristic model from six studies, the diagnostic odds ratio for C-reactive protein was estimated to be 39.4 (14.8-104.9) with a positive likelihood ratio 5.3 (2.3-11.9) and a negative likelihood ratio 0.1 (0.07-0.2). There were insufficient studies from this review to statistically evaluate the diagnostic accuracy of procalcitonin.

CONCLUSION

Clinicians should continue to measure serum C-reactive protein as the preferred inflammatory marker in hospitalized children and adolescents with suspected osteomyelitis or septic arthritis. More evidence is needed before incorporating procalcitonin routinely into clinicians' diagnostic test strategy. Improvements with the design, quality, and reporting of procalcitonin diagnostic test assays in children and adolescents with osteoarticular infection is needed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019140276.

Acute Arthritis in Children: How to Discern between Septic and Non-Septic Arthritis?

The term septic arthritis refers to an infection of the synovial space. This is an infrequent condition in healthy children, but it should be considered a medical emergency potentially leading to irreversible articular damage. Therefore, prompt diagnosis and antimicrobial treatment play a crucial role in improving the prognosis. Although septic arthritis is the most common cause of acute arthritis, many other diseases may mimic a similar clinical picture, constituting a diagnostic challenge for the clinician who first approaches the patient. Herein we analyze the main features of septic arthritis, offering an overview of the main conditions involved in the differential diagnosis and suggesting a diagnostic workup plan.

Septic Arthritis of the Knee in Children: A Critical Analysis Review

» Septic arthritis of the knee is the most common type of septic arthritis in children, and it may result in irreversible joint damage. » Staphylococcus aureus is the most common pathogen associated with septic arthritis, but other causative pathogens are possible in children with certain risk factors. » The diagnosis of septic arthritis of the knee is based on history and physical examination, blood tests, and arthrocentesis. » Empiric treatment with anti-staphylococcal penicillin or a first-generation cephalosporin is usually recommended but may be tailored according to local resistance patterns and clinical culture data. » Open or arthroscopic surgical debridement including extensive lavage is effective in eradicating infection, and most patients do not require additional surgical intervention.

Thiol/disulfide homeostasis as a novel indicator of oxidative stress during the treatment process of patients with septic arthritis

Objectives

This study aims to investigate dynamic thiol/disulfide homeostasis as a novel indicator of oxidative stress and to find out its association with standard inflammatory markers during the treatment of patients with septic arthritis (SA).

Patients and methods

In this prospective study, a new colorimetric method for measuring thiol/disulfide homeostasis was assessed between May 2013 and October 2014 in 24 patients with SA (14 males, 10 females; mean age 14.5±19.1 years; range, 1 to 80 years) at baseline and the end of the third week of the treatment, and in 24 healthy controls (14 males, 10 females; mean age 12.5±18.7 years; range, 1 to 85 years). Also, standard inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate, and white blood cell count were evaluated.

Results

At baseline, serum disulfide was higher in SA group compared to the control group, whereas native thiol was lower (p<0.05 for all). At the end of the third week of the treatment, serum disulfide level was lower, whereas the native thiol was higher compared to baseline (p<0.05 for all). In addition, serum disulfide level was positively correlated with CRP (r=0.736, p<0.001) and disulfide/native thiol ratio (r=0.779, p<0.001). Furthermore, in multiple regression analyses, the disulfide level was independently associated with CRP (β=0.226, p=0.005).

Conclusion

Our results suggest that the elevated levels of serum disulfide and standard inflammatory markers at baseline in patients with SA and decreased levels of these parameters are related with oxidative stress. This homeostasis shifted towards disulfide formation due to thiol oxidation. Therefore, thiol/ disulfide homeostasis may be a helpful biomarker for the follow- up in patients with SA.

Risk factors for failure of eradicating infection in a single arthroscopic surgical procedure for septic arthritis of the adult native shoulder with a focus on the volume of irrigation

BACKGROUND

Septic arthritis of a native joint is relatively rare but is still a challenging and important orthopedic emergency. Most previous reports have focused on the clinical outcomes rather than the risk factors for failure in arthroscopic surgery.

METHODS

We retrospectively reviewed the records of patients with septic monoarthritis of the shoulder who underwent arthroscopic irrigation and débridement between January 2007 and January 2019. All patients were divided into 2 groups according to recurrence after a single arthroscopic surgical procedure: eradicated group or recurred group. To identify risk factors affecting the recurrence of septic arthritis of the shoulder after arthroscopic surgery, the following parameters were considered: age; sex; involved side; presentation of rotator cuff tear; volume of irrigation; bacterial organism involved; preoperative erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count in blood and joint fluid; diabetes mellitus; and hypertension. We compared the eradicated and recurred groups regarding the presence of potential risk factors.

RESULTS

The study included 97 patients with a mean age of 61 years. Septic arthritis of the shoulder was eradicated completely with a single arthroscopic surgical procedure in 85 patients. However, a second arthroscopic surgical procedure was necessary in 12 patients (12.4%) because of infection recurrence. No significant differences were found between groups except in the volume of irrigation (P < .001).

CONCLUSIONS

Most patients with septic arthritis (87.6%) of native shoulders were effectively treated with a single arthroscopic irrigation and débridement. The amount of irrigation may be the most important factor for preventing the need for additional surgical management.

C-Reactive Protein Level at Time of Discharge Is Not Predictive of Risk of Reoperation or Readmission in Children With Septic Arthritis

Purpose: C-reactive protein (CRP) level is used at our tertiary pediatric hospital in the diagnosis, management, and discharge evaluation of patients with septic arthritis. The purpose of this study was to evaluate the efficacy of a discharge criterion of CRP < 2.0 mg/dL for patients with septic arthritis in preventing reoperation and readmission. We also aimed to identify other risk factors of treatment failure.

Methods: Patients diagnosed with septic arthritis between January 1, 2007 and December 31, 2017 were identified with ICD 9/10 and related CPT codes. Systematic chart reviews were performed to obtain demographic data, infection characteristics, and treatment details. Bivariate tests of associations between potential risk factors and readmission and reoperation were performed. Quantitative variables were analyzed using Mann-Whitney tests and categorical variables were analyzed using Chi-square tests.

Results: One hundred and eighty-three children with septic arthritis were included in the study. Seven (3.8%) were readmitted after hospital discharge for further management, including six who required reoperation. Mean CRP at discharge for single-admission patients was 1.71 mg/dL (± 1.07) and 1.96 mg/dL (± 1.19) for the readmission group (p = 0.664). Forty-eight children (25.9%) had CRP values greater than the recommended 2.0 mg/dL at discharge. Only three of these patients (6.2%) were later readmitted. The only common variable of the readmitted children was an antibiotic-resistant or atypical causative bacteria.

Conclusions: CRP levels are useful in monitoring treatment efficacy of septic arthritis in children but are not reliable as a discharge criterion to prevent readmission or reoperation. We recommend determining discharge readiness on the basis of clinical improvement and down-trending CRP values. There was a higher risk of readmission in children with an antibiotic-resistant or atypical causative bacteria. Close monitoring of these patients and those with negative cultures at time of discharge is suggested to identify signs of persistent infection.

Level of evidence: III, retrospective cohort study.

Corticosteroids as adjunctive therapy with antibiotics in the treatment of children with septic arthritis: a meta-analysis

Purpose

We performed a meta-analysis to systematically assess the effect of adjunctive administration of dexamethasone with antibiotic therapy in the clinical course of septic arthritis (SA) in children.

Method

Potential academic articles were identified from the Cochrane Library, Medline, PubMed, Embase, ScienceDirect, and other databases. The time range we retrieved from was from the inception of electronic databases to January 2018. The reference lists of identified studies were manually checked to identify other potentially eligible trials. The STATA version 11.0 (Stata Corporation, College Station, TX, USA) was used to analyze the pooled data.

Results

Three randomized controlled trials, and one retrospective cohort study were included in the meta-analysis. There were significant differences in the days of hospitalization (mean difference [MD] = -4.226, 95% CI: -4.785 to -3.667, P=0.001), the days of intravenous antibiotics treatment (MD = -3.593, 95% CI: -4.825 to -2.361, P=0.001), the days of oral antibiotics treatment (MD = -1.658, 95% CI: -2.539 to -0.777, P=0.001), and the days to normalization of C-reactive protein (MD = -3.075, 95% CI: -3.362 to -2.788, P=0.001).

Conclusion

The present meta-analysis base points strongly toward a beneficial effect for corticosteroids in SA. Corticosteroids as adjunctive therapy with antibiotics in the treatment of children with SA could shorten the number of days of hospitalization, the days of intravenous antibiotics treatment, the days of oral antibiotics treatment, and the days to normalization of C-reactive protein. We recommend corticosteroids as adjunctive therapy with antibiotics in the treatment of children with SA.

Arthritis in children: comparison of clinical and biological characteristics of septic arthritis and juvenile idiopathic arthritis

AIM

Childhood arthritis arises from several causes. The aim of this observational study is to compare the clinical and biological features and short-term outcome of different types of arthritis because they have different treatment and prognoses.

METHODS

Children <16 years of age hospitalised in a French tertiary care centre for a first episode of arthritis lasting for less than 6 weeks who underwent joint aspiration were retrospectively included. We performed non-parametrical tests to compare groups (septic arthritis (SA), juvenile idiopathic arthritis (JIA) and arthritis with no definitive diagnosis). The time before apyrexia or C reactive protein (CRP) <10 mg/L was analysed using the Kaplan-Meier method.

RESULTS

We studied 125 children with a sex ratio (M/F) of 1.1 and a median age of 2.2 years (range 0.3 to 14.6). SA was associated with a lower age at onset (1.5 years, IQR 1.2-3.0 vs 3.6 years, IQR 2.2-5.6), shorter duration of symptoms before diagnosis (2 days, IQR 1-4 vs 7 days, IQR 1-19) and higher synovial white blood cell count (147 cells ×10³/mm³, IQR 71-227, vs 51 cells ×10³/mm³, IQR 12-113), than JIA. Apyrexia occurred later in children with JIA (40% after 2 days, 95% CI 17% to 75%) than children with SA (82%, 95% CI 68% to 92%), as did CRP<10 mg/L (18% at 7 days, 95% CI 6.3% to 29.6% vs 82.1%, 95% CI 76.1% to 89.7%, p=0.01).

CONCLUSIONS

There were no sufficiently reliable predictors for differentiating between SA and JIA at onset. The outcomes were different; JIA should be considered in cases of poor disease evolution after antibiotic treatment and joint aspiration.

Current trends of microorganisms and their sensitivity pattern in paediatric septic arthritis: A prospective study from tertiary care level hospital

PURPOSE

Early treatment of septic arthritis is essential before irreversible damage to the articular cartilage occurs. Clinicians often start empirical antibiotic therapy for symptomatic relief while awaiting a definitive culture report. In present day parlance with variations in different centres in the private and public sector and rampant antibiotic abuse, a lot of resistance is being seen in the flora and their sensitivity patterns. Hence it is imperative to document and analyze these changing trends.

METHODS

The authors conducted a retrospective analysis of prospectively gathered data of 60 patients under 14 years of age. Joint arthrotomy was performed as a standard therapeutic protocol and the drained pus or synovial fluid was sent for gram stain and culture by 2 different methods: conventional agar plate method and BACTEC Peds Plus/F bottle method. Antibiotic susceptibility tests were done by the disc diffusion method of Clinical Laboratory Standards Institute (CLSI).

RESULTS

The commonest presenting age group was below 1 year (80% patients) including 24 neonates. There were 19 hospital and 41 community acquired cases of septic arthritis. The hip (56%) was the commonest affected joint followed by knee (28%), shoulder joint (11%) and elbow (5%). Microorganism was isolated in 53% isolates of joint fluid only (36 culture positive patients). Conventional agar methods of culture showed positive report in only 42% patients (15/36 patients) while with the BACTEC method the yield was 71%. In the Community acquired septic arthritis, methicillin sensitive Staphylococcus aureus was isolated as commonest microbe while resistant variety of gram negative bacilli including E. coli and Klebsiella were found as predominant organism causing hospital acquired nosocomial infection of joints. The results strikingly differ in terms of response to treatment as most patients (11/19 patients) showed significant resistance to the most commonly practiced empirical antibiotic regimen of ampicillin-cloxacillin group in routine practice. When cefazolin was used as empirical antibiotic, it has shown good response and better sensitivity in 82% patients (27/33 patients).

CONCLUSION

S. aureus is still the most common organism in septic arthritis. The BACTEC system was found to improve the yield of clinically significant isolates. Though a significant resistance to common antibiotic regimen is noticed, the strain is susceptible to cephalosporin group of antibiotics. We recommend the use of cephalosporine antibiotics as an empirical therapy till culture and sensitivity report are available.

Risk factors for failure of a single surgical debridement in adults with acute septic arthritis

BACKGROUND

Acute septic arthritis in a native joint may require more than one surgical debridement to eradicate the infection. Our objectives were to determine the prevalence of failure of a single surgical debridement for acute septic arthritis, to identify risk factors for failure of a single debridement, and to develop a prognostic probability algorithm to predict failure of a single surgical debridement for acute septic arthritis in adults.

METHODS

We collected initial laboratory and medical comorbidity data of 128 adults (132 native joints) with acute septic arthritis who underwent at least one surgical debridement at our institution between 2000 and 2011. Univariate and logistic regression analyses were used to identify potential risk factors for failure of a single surgical debridement. Stepwise variable selection was used to develop a prediction model and identify probabilities of failure of a single surgical debridement.

RESULTS

Of the 128 patients (132 affected joints) who underwent surgical debridement for acute septic arthritis, forty-nine (38%) of the patients (fifty joints) experienced failure of a single debridement and required at least two debridements (range, two to four debridements). Staphylococcus aureus was the most common bacterial isolate (in sixty, or 45%, of the 132 joints). Logistic regression analysis identified five independent clinical predictors for failure of a single surgical debridement: a history of inflammatory arthropathy (odds ratio [OR], 7.3; 95% confidence interval [CI], 2.4 to 22.6; p < 0.001), the involvement of a large joint (knee, shoulder, or hip) (OR, 7.0; 95% CI, 1.2 to 37.5; p = 0.02), a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L (OR, 4.7; 95% CI, 1.8 to 17.7; p = 0.002), S. aureus as the bacterial isolate (OR, 4.6; 95% CI, 1.8 to 11.9; p = 0.002), and a history of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; p = 0.04).

CONCLUSIONS

Most (62%) of the septic joints were managed effectively with a single surgical debridement. Adults with a history of inflammatory arthropathy, involvement of a large joint, a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L, an infection with S. aureus, or a history of diabetes had a higher risk of failure of a single surgical debridement for acute septic arthritis and requiring additional surgical debridement(s).

Septic arthritis of the elbow with Streptococcus pneumoniae in a 9-month-old girl

A 9-month-old girl presented with a swollen, erythematous and hot left elbow, which was tender on palpation. Physical examination was unremarkable except temperature of 38.4°C and restriction of elbow movement. Blood tests showed an elevated C reactive protein of 116 mg/L. Plain radiograph and ultrasound of the elbow showed no pathological findings. MRI revealed an intra-articular effusion and associated myositis, but did not demonstrate intra-articular synovitis. Arthroscopic lavage of the joint yielded purulent fluid and gross synovitis involving the entire joint. Streptococcus pneumoniae was isolated from the synovial fluid, although the patient had been immunised with Prevenar (pneumococcal vaccine). Postoperative empiric treatment with antibiotics for 6 weeks was started. Follow-up of 2 years revealed a healthy girl with a full range of motion of her elbow and no signs of complications. This case of septic arthritis emphasises the importance of the clinical presentation to determine the correct diagnosis and treatment modalities.

Transient synovitis of the hip as a complication of chickenpox in infant: Case study

Chickenpox has many rare complications; transient synovitis is one of the very painful and self-limiting rare complications. This patient suffered from transient synovitis associated with chickenpox. After being diagnosed, it was managed by diclofenac sodium suppositories. Physicians must be able to correlate all of the possible complications of chickenpox in order to avoid misdiagnoses.

Microorganisms and their sensitivity pattern in septic arthritis of north Indian children: a prospective study from tertiary care level hospital

Background. Septic arthritis is a true orthopaedic emergency. Important factors determining outcome are rapid diagnosis and timely intervention. Changing trends in microbiological spectrum and emerging drug resistance poses big challenge. Present study evaluates bacterial strains and their sensitivity pattern in septic arthritis of North Indian children. Methods. Fifty children with septic arthritis of any joint were evaluated. Joint was aspirated and 2 cc of aspirated fluid was sent for gram stain and culture. Blood cultures were also sent for bacteriological evaluation. Results. Fifty percent cases had definite radiological evidence of septic arthritis whereas ultrasound revealed fluid in 98% cases. Aspirated fluid showed isolates in 72% cases. The most common organism was Staphylococcus aureus (62%) followed by Streptococcus pneumoniae and Gr. B Streptococcus. Blood culture could grow the organism in 34% cases only. The bacterial strain showed significant resistance to common antibiotic cocktail in routine practice. Resistance to cloxacillin and ceftriaxone was 62% and 14% respectively. No organisms were resistant to vancomycin and linezolid. Conclusion. S. aureus is still the most common organism in septic arthritis. Though a significant resistance to common antibiotic cocktail is noticed, the strain is susceptible to higher antibiotics. We recommend using these antibiotics as an empirical therapy till culture and sensitivity report is available.

Impact of C-reactive protein test results on evidence-based decision-making in cases of bacterial infection

Background

C-reactive protein (CRP) is widely used to detect bacterial infection in children. We investigated the impact of CRP test results on decision-making and summarized the evidence base (EB) of CRP testing.

Methods

We collected information from the hospital records of 91 neonates with suspected sepsis and of 152 febrile children with suspected infection on the number of ordered CRP tests, the number of EB-CRP tests, and the impact of the test results on decision-making. CRP diagnostic accuracy studies focusing on pediatric infections were reviewed critically. The main outcomes were the proportion of CRP tests that were EB and the proportion of tests that affected decision-making. A secondary outcome was the overall one-year expenditure on CRP testing.

Results

The current EB for CRP testing in pediatric infections is weak and suggests that CRP is of low diagnostic value. Approximately 54.8% of tests performed for suspected neonatal sepsis and 28% of tests performed for other infections were EB; however, the results of only 12.9% of neonatal sepsis tests and of 29.9% of tests on children with other infections informed decision-making. The one-year overall cost for CRP testing and related health care was $26,715.9.

Conclusions

The routine ordering of CRP for children with infections is based on weak evidence. The impact of the CRP test results on decision-making is rather small, and CRP ordering may contribute to unnecessary health care expenditures. Better quality research is needed to definitively determine the diagnostic accuracy of CRP levels in children with infections.

The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children

Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm.

The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient.

A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.

Differentiating osteoarticular infections caused by Kingella kingae from those due to typical pathogens in young children

Osteoarticular infections caused by Kingella kingae are characterized by mild-to-moderate clinical and biologic inflammatory signs that are different from those caused by Gram-positive cocci. A combined score was built to find the best model to predict K. kingae osteoarticular infections by using the following 4 variables: body temperature <38°C, serum C-reactive protein <55 mg/L, white blood cell count <14,000/mm, and band forms <150/mm.

Pediatric septic hip with or without arthrotomy: retrospective analysis of 62 consecutive nonneonatal culture-positive cases

In our multicenter treatment study on pediatric nonneonatal osteoarticular infections we had 62 septic hip arthritides. All had confirmed joint effusion, were culture-positive, and Staphylococcus aureus was isolated in 71% of the cases. Sixty-one of the 62 had a diagnostic joint aspiration. Following protocol, arthrotomy was to be performed only if the response to antimicrobial treatment was slow. The course of illness was monitored by preset criteria. Analysis of 95% of the patients who attended the last checkup >/=1 year posthospitalization showed that invasive surgery had been avoided in 81% of the patients. All patients recovered completely. Routine arthrotomy in nonneonatal hip arthritis warrants reconsideration.

Sensitivity of erythrocyte sedimentation rate and C-reactive protein in childhood bone and joint infections

In addition to the examination of clinical signs, several laboratory markers have been measured for diagnostics and monitoring of pediatric septic bone and joint infections. Traditionally erythrocyte sedimentation rate (ESR) and leukocyte cell count have been used, whereas C-reactive protein (CRP) has gained in popularity. We monitored 265 children at ages 3 months to 15 years with culture-positive osteoarticular infections with a predetermined series of ESR, CRP, and leukocyte count measurements. On admission, ESR exceeded 20 mm/hour in 94% and CRP exceeded 20 mg/L in 95% of the cases, the mean (+/- standard error of the mean) being 51 +/- 2 mm/hour and 87 +/- 4 mg/L, respectively. ESR normalized in 24 days and CRP in 10 days. Elevated CRP gave a slightly better sensitivity in diagnostics than ESR, but best sensitivity was gained with the combined use of ESR and CRP (98%). Elevated ESR or CRP was seen in all cases during the first 3 days. Measuring ESR and CRP on admission can help the clinician rule out an acute osteoarticular infection. CRP normalizes faster than ESR, providing a clear advantage in monitoring recovery.

LEVEL OF EVIDENCE

Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Acute septic arthritis in children

BACKGROUND

Acute septic arthritis is a health-care problem in growing children. The aim of the present study was to determine the demographic features, clinical presentation, diagnostic evaluation, treatment and outcome of children suffering from acute septic arthritis.

METHODS

Retrospective review of consecutive admissions of children < or =14 years of age with a bacteriologically and/or radiologically confirmed diagnosis of septic arthritis during the 10 year period, January 1997-December 2006 at King Fahad Hospital, King Abdulaziz Medical City was undertaken.

RESULTS

Sixty-five patients (male : female, 2.4:1), 10 days-14 years of age (mean +/- SD: 3.3 +/- 3.2 years), met the inclusion criteria. More than half of the patients were under 2 years. The most frequent clinical features were pain (92%), fever (77%), limitation of joint movement (77%) and joint swelling (72%). Joint involvement was monoarticular in 97% of knees, and hips were affected in 75% of patients. Bacteria were isolated from joint aspirate or blood in 28 patients (43%), and Staphylococcus aureus was the most common organism, comprising 39% of the total bacterial isolates. Radiological diagnostic findings were observed in 19 (32%) of 60 patients with plain radiographs, nine (69%) of 16 patients with sonograms of the hip, 36 (80%) of 45 patients with Tc-labeled bone scan and nine (100%) of nine patients with magnetic resonance imaging. The joint infection resolved with no sequelae in 46 patients who were followed up for 6-36 months, but two had bone deformity and 17 were lost to follow up.

CONCLUSION

According to the present series, septic arthritis is most common in young infants, mainly monoarticular, and is frequently localized in the knee and hip joints. Early diagnosis and appropriate treatment are associated with excellent outcome.

Evaluation of conservative treatment of non specific spondylodiscitis

The objective of this study was to analyse the presentation, aetiology, conservative management, and outcome of non-tuberculous pyogenic spinal infection in adults. We performed a retrospective review of 56 patients (35 women and 21 men) of pyogenic spinal infection presenting over a 7-year period (1999-2006) to the Department of Spinal Surgery of Hesperia Hospital. The medical records, radiologic imaging, bacteriology results, treatment, and complications of all patients were reviewed. The mean age at presentation was 47.8 years (age range 35-72 years), the mean follow-up duration was 12.5 months. The most common site of infection was lumbar spine (n: 48), followed by the thoracic spine (n: 8). Most patients were symptomatic for between 4 and 10 weeks before presenting to hospital. The frequently isolated pathogen was Staphylococcus aureus in 31 of 56 cases (57.6%). Percutaneous biopsies were diagnostic in 57% of patients; the open biopsy was indicated if closed biopsy failed and when the infection was not accessible by percutaneous technique. The patients were managed by conservative measures alone, including antibiotic therapy and spinal bracing. The mean period of antibiotic therapy was 8.5 weeks (range 6-9 weeks), followed by oral antibiotics for 6 weeks. All patients had a supportive spinal brace for mean 8 weeks (range 6-10 weeks). The duration of the administration of oral antibiotics was dependent on clinical and laboratory evidence (white cell count, erythrocyte sedimentation rate, C-reactive protein) that the infection was resolved. The follow-up MR gadolinium scans were essential to monitor the response to medical treatment. The diagnosis of pyogenic spinal infection should be considered in any patient presenting with severe localised unremitting back and neck pain, especially when accompanied with systemic features, such as fever and weight loss and in the presence of elevated inflammatory markers. The conservative management of infection with antibiotic therapy and spinal bracing was very successful.

[Evaluation of a clinical pathway for septic arthritis]

INTRODUCTION

Clinical pathways are tools that coordinate clinical work, reducing interclinican variability and improving patient care and management. The use of clinical pathways in septic arthritis is appropriate, as this disease has a predictable course and there is considerable variation in its management. The aim of this study was to evaluate a septic arthritis clinical pathway 2 years after its introduction and to describe the characteristics of the patients included.

MATERIAL AND METHODS

Clinical pathway documents: pathway matrix sheet, variance form, parent information sheet, satisfaction survey and evaluation indicators sheet.

RESULTS

Thirty-five patients were included, seven with a definitive diagnosis of septic arthritis and 28 with probable septic arthritis. No differences were found between the two groups, with good outcomes in both. Laboratory analyses were performed at admission in all patients, at discharge in 51 %, and at the end of treatment in 97 %. The indicators that best met the standard were clinical pathway coverage, performance of arthrocentesis/arthrotomy, and satisfaction with dealings with staff and the information received. The indicators furthest from the standard were admission shorter than 7 days (77 % vs > 95 %) and obtaining articular fluid prior to antibiotic therapy (76 % vs > 90 %).

CONCLUSIONS

The clinical pathway is useful for standardizing the process of septic arthritis diagnosis and treatment. With adequate clinical support, application of this pathway allows decisions to be made on hospital discharge following the clinical criteria of improvement without worsening prognosis. Our immediate challenges are to reduce inpatient stay and to obtain synovial fluid before starting antibiotic therapy.

RESPONSE OF C-REACTIVE PROTEIN AFTER CRANIOTOMY FOR MICROSURGERY OF INTRACRANIAL TUMORS

OBJECTIVE

C-reactive protein (CRP) is used as an indicator of inflammatory processes. However, its expression is unspecific and will increase after surgery. Without normative data on its regular course after craniotomy, postoperative infection can barely be detected or excluded.

METHODS

CRP was measured for 10 days in 46 patients who underwent elective craniotomy for microsurgery of intracranial tumors.

RESULTS

After craniotomy, CRP rapidly increased to reach a peak mean value of 32.43 ± 38.02 mg/l (P &lt; 0.001) on the second postoperative day. In 39 patients (85%), CRP reached its maximum level within the first 2 days. From Days 3 to 5 after surgery, mean CRP values constantly and significantly declined (P &lt; 0.001) to arrive at a mean of 6.67 ± 10.80 mg/l) on the fifth postoperative day. On Day 4, the mean CRP level returned to below one-third of the peak value (10.63 ± 17.08 mg/l). On an individual basis, this was true for 34 patients (74%). During the period of initial increase of CRP until the second postoperative day, there was no significant correlation between CRP and erythrocyte sedimentation rate, body temperature, hemoglobin, hematocrit, red cell count, platelet count, and white cell count. CRP increase was more pronounced with intrinsic brain tumors and was not correlated to the degree of malignancy.

CONCLUSION

Because CRP can be considerably increased in patients for 4 days after regular intracranial surgery, its diagnostic value during this period is limited. Only prolonged elevation or a secondary increase may indicate an ongoing infection.

Diagnostic utility of laboratory tests in septic arthritis

BACKGROUND

Septic arthritis remains a challenging diagnosis in which the doctor often relies on laboratory tests.

OBJECTIVE

To examine the diagnostic utility of three ancillary tests--namely, white blood cells (WBC), erythrocyte sedimentation rate (ESR) and the WBC in the joint fluid (jWBC)--using likelihood ratios (LRs) and receiver operating characteristic (ROC) curves.

METHODS

This was a retrospective cohort study at the Jacobi Medical Center. Medical charts of patients who had undergone arthrocentesis were included. Patients who had "dry taps" were excluded from the study. Patients were considered to have septic arthritis if they had a positive arthrocentesis culture or operative findings. The primary outcomes of this study were the sensitivities, specificities, LR(+) and LR(-) values of the laboratory tests for septic arthritis. The performance characteristics of the laboratory tests were analysed using ROC curves.

RESULTS

156 patients were enrolled, 16 (10%) had septic arthritis. The sensitivities for WBC, ESR and jWBC were 0.75, 0.75 and 0.50, and the specificities were 0.55, 0.11 and 0.88, respectively. The LR(+) values were 1.7, 0.84 and 4.0, and the LR(-) values were 0.46, 2.4 and 0.57, respectively. In ROC curve analysis, jWBC was the best test (area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.58 to 0.92), followed by WBC (AUC 0.69, 95% CI 0.57 to 0.80) and ESR (AUC 0.55, 95% CI 0.37 to 0.74). A cut-off of jWBC = 17 500 maximised sensitivity and specificity on the ROC curve.

CONCLUSIONS

jWBC was the best diagnostic test for septic arthritis, WBC and ESR were poor tests. However, no test was diagnostic, and the clinician must be careful with patients with a potential septic joint.

Advances in the Management of Septic Arthritis

Septic arthritis still continues to be a common and serious problem at major urban medical centers and is one of the most rapidly destructive forms of acute arthritis. The yearly incidence of bacterial arthritis varies from 2 to 10 per 100,000 in the general population to 30 to 70 per 100,000 in patients with rheumatoid arthritis and in patients with joint prostheses. Irreversible loss of joint function may develop in up to 50% of the patients. Despite better antimicrobial agents and improved hospital care, the fatality rate for this medical problem has not changed substantially during the past 30 years. An understanding of the risk factors and the pathogenesis of nongonoccocal bacterial arthritis and other forms of infectious arthritis, primarily in the context of a differential diagnosis and treatment, are important to avoid the delay in making a correct diagnosis and to improve the prognosis.

Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study

BACKGROUND

Distinguishing septic arthritis from transient synovitis of the hip in children can be challenging. Authors of recent retrospective studies have used presenting factors to establish algorithms for predicting septic arthritis of the hip in children. This study differs from previous work in three ways: data were collected prospectively, C-reactive protein levels were recorded, and the focus was on children in whom the findings were so suspicious for septic arthritis that hip aspiration was performed.

METHODS

Over four years, we prospectively collected data on every child (a total of fifty-three) who underwent hip aspiration because of a suspicion of septic arthritis at our institution. Diagnoses of confirmed septic arthritis, presumed septic arthritis, and transient synovitis were determined on the basis of the results of Gram staining, culture, and a cell count of the hip aspirate. Presenting factors and laboratory values were recorded. To evaluate the strength of predictors, we performed univariate and multivariate analysis on data from forty-eight patients who met the inclusion criteria.

RESULTS

Univariate analysis showed that fever, the C-reactive protein level, and the erythrocyte sedimentation rate were strongly associated with the final diagnosis (p < 0.05). On multivariate analysis, the C-reactive protein level and erythrocyte sedimentation rate were found to be significant predictors. However, the erythrocyte sedimentation rate was not independent of the C-reactive protein level on backward elimination, and the C-reactive protein level was the only risk factor that was strongly associated with the outcome at a 5% significance level. Patients with five predictive factors had a 98% chance of having septic arthritis, those with four factors had a 93% chance, and those with three factors had an 83% chance.

CONCLUSIONS

This prospective study of children who presented with findings that were highly suspicious for septic arthritis of the hip builds on the work of previous authors. We found fever (an oral temperature >38.5 degrees C) was the best predictor of septic arthritis followed by an elevated C-reactive protein level, an elevated erythrocyte sedimentation rate, refusal to bear weight, and an elevated serum white blood-cell count. In our study group, a C-reactive protein level of >2.0 mg/dL (>20 mg/L) was a strong independent risk factor and a valuable tool for assessing and diagnosing children suspected of having septic arthritis of the hip.

Spinal infections: diagnostic tests and imaging studies

Clinical signs and symptoms caused by spinal infections often are subtle and insidious; therefore, clinical suspicion in patients with nonmechanical pain is important in making the correct diagnosis in the early stage of disease. Serologic tests such as erythrocyte sedimentation rate and C-reactive protein are quite sensitive, but specificity is relatively low. Imaging tests include plain radiographs, radionuclide studies, computed tomography scan, and magnetic resonance imaging. Changes on plain radiographs appear at least 3 to 4 weeks after the onset of disease. Bone scan is a sensitive but not a specific test. Computed tomography provides structural details in the bone and intervertebral disc but magnetic resonance imaging is a superior imaging test for diagnosing infections earlier and more accurately. In many patients, percutaneous or open biopsy is required to make the definitive diagnosis of discitis or osteomyelitis and the organism responsible for the infection. Early and accurate diagnosis of spinal infections will lead to less invasive treatment for the patient.

LEVEL OF EVIDENCE

Level V (Expert Opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

Abnormal gait in a child with fever: diagnosing septic arthritis of the hip

The diagnosis of septic arthritis should be considered in all children with hip pain. We review the evaluation of children who present with fever and hip pain, emphasizing features that may assist in distinguishing septic arthritis of the hip from transient synovitis. We also discuss the impact of the increased prevalence of methicillin-resistant Staphylococcus aureus on the management of septic arthritis of the hip.

Management of septic arthritis

Septic arthritis in children remains a serious disease with the potential for significant systemic and musculoskeletal morbidity. Staphlococcus aureus is the most common cause of bone and joint infections in all age groups. Microbial invasion of the synovial space occurs typically results from hematogenous seeding. Diagnosis in neonates and young infants can be difficult since the clinical signs are much less specific in these age groups. Early diagnosis by needle aspiration of the affected joint and prompt initiation of appropriate antimicrobial therapy in conjunction with drainage of the affected joint is critical to avoid destruction of the articular cartilage and prevent disability. Septic arthritis in infants and children should always be managed by a pediatrician in close consultation with an orthopedic surgeon. Empiric antibiotic regimens should always include adequate anti-staphylococcal coverage. Antibiotic treatment should be started with appropriate doses of intravenous antibiotics. Switch to oral antibiotic therapy can be made when patient demonstrates clinical improvement. A minimum of 3-4 weeks of therapy is recommended. Close follow-up is warranted to monitor the growth of the affected limb until skeletal maturity.

Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms

BACKGROUND

Differentiation between septic arthritis and transient synovitis of the hip in children can be difficult. Kocher et al. recently developed a clinical prediction algorithm for septic arthritis based on four clinical variables: history of fever, non-weight-bearing, an erythrocyte sedimentation rate of >or=40 mm/hr, and a serum white blood-cell count of >12000/mm(3) (>12.0 x 10(9)/L). The purpose of this study was to apply this clinical algorithm retrospectively to determine its predictive value in our patient population.

METHODS

A retrospective review was performed to identify all children who had undergone a hip arthrocentesis for the evaluation of an irritable hip at our institution between 1992 and 2000. One hundred and sixty-three patients with 165 involved hips satisfied the criteria for inclusion in the study and were classified as having true septic arthritis (twenty hips), presumed septic arthritis (twenty-seven hips), or transient synovitis (118 hips).

RESULTS

Patients with septic arthritis (true and presumed; forty-seven hips) differed significantly (p < 0.05) from patients with transient synovitis (118 hips) with regard to the erythrocyte sedimentation rate, differential of serum white blood-cell count, total white blood-cell count and differential in the synovial fluid, gender, previous health-care visits, and history of fever. If the four independent multivariate predictors of septic arthritis proposed by Kocher et al. were present, the predicted probability of the patient having septic arthritis was 59% in our study, in contrast to the 99.6% predicted probability in the patient population described by Kocher et al. Statistical analyses demonstrated that the best model to describe our patient population was based on three variables: a history of fever, a serum total white blood-cell count of >12000/mm(3) (>12.0 x 10(9)/L), and a previous health-care visit. When all three variables were present, the predicted probability of the patient having septic arthritis was 71%.

CONCLUSIONS

Although the use of a clinical prediction algorithm to differentiate between septic arthritis and transient synovitis may have improved the utility of existing technology and medical care to facilitate the diagnosis at the institution at which the algorithm originated, application of the algorithm proposed by Kocher et al. or of our three-variable model does not appear to be valid at other institutions.

Laboratory tests in adults with monoarticular arthritis: can they rule out a septic joint?

It is difficult to differentiate septic arthritis from other causes of monoarticular arthritis solely with a history and physical examination. The clinician must rely on ancillary tests to make a diagnosis, such as the white blood cell count of peripheral blood (WBC), the erythrocyte sedimentation rate (ESR), and the white blood cell count of the joint fluid (jWBC) obtained from arthrocentesis. Although it is known that septic arthritis is associated with abnormalities in these tests, the majority of the data are based on studies in the pediatric population. In addition, although several emergency medicine texts indicate that a jWBC greater than 50,000 cells/mm(3) is "positive," it is known that septic arthritis can occur in patients with low jWBCs.

OBJECTIVES

To determine whether specific ancillary tests have sufficiently high sensitivities to rule out septic arthritis in adults.

METHODS

This was a retrospective consecutive case series of patients from an urban emergency department (ED). Patients at least 18 years old who had septic arthritis confirmed by positive arthrocentesis culture or operative findings were included in the study. WBC greater than 11,000 cells/mm(3), ESR greater than 30 mm/hr, and jWBC greater than 50,000 cells/mm(3) were considered elevated.

RESULTS

Seventy-three patients met the inclusion criteria. The sensitivities of an elevated WBC, ESR, or jWBC in adults who had septic arthritis were 48%, 96%, and 64%, respectively. There were broad ranges of WBC, ESR, or jWBC among the patients. More than one third of adult patients with septic arthritis had jWBCs less than 50,000 cells/mm(3). All patients had an abnormality in at least one of these tests.

CONCLUSIONS

The WBC, ESR, and jWBC are extremely variable in adults with septic arthritis. Laboratory tests do not rule out septic arthritis with accuracy.

Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children

BACKGROUND

Septic arthritis is associated with residual dysfunction in 10 to 25% of affected children. Concentrations of cytokines detected in synovial fluid of children with bacterial arthritis correlate with the severity of inflammation. Treatment with dexamethasone decreased cartilage degradation in experimental Haemophilus influenzae b and Staphylococcus aureus arthritis.

ENDPOINTS

To decrease the number of patients with residual dysfunction of the affected joint at the end of therapy and at 6 and 12 months and to speed clinical recovery by the administration of dexamethasone.

METHODS

In a double blind manner we randomly selected 123 children with suspected hematogenous bacterial arthritis to receive dexamethasone or saline for 4 days. Antibiotic therapy was tailored according to age and the recovered pathogen.

RESULTS

Of the 123 children enrolled, 61 were assigned to the dexamethasone group and 62 to the placebo group. Only 50 and 50 patients in each group were evaluable. The 2 groups of patients were comparable with respect to age, sex, duration of symptoms, pathogen, affected joint and therapeutic and diagnostic procedures. Staphylococcus aureus accounted for 67% of the isolates, Haemophilus influenzae type b for 13% and Streptococcus pneumoniae for 9%. Dexamethasone therapy reduced residual dysfunction at the end of therapy, P = 0.000068; at 6 months, P = 0.00007; and at 12 months, P = 0.00053 of follow-up and shortened the duration of symptoms (P = 0.001) during the acute phase. The 26% incidence of residual dysfunction in the control patients was similar to the 25% found in other series.

CONCLUSIONS

A short course of dexamethasone reduced residual joint dysfunction and shortened significantly the duration of symptoms in children with documented hematogenous septic arthritis. These results suggest that a 4-day course of low dose dexamethasone given early benefits children with hematogenous septic arthritis.

Laboratory monitoring in pediatric acute osteomyelitis and septic arthritis

The purpose of the current study was to determine the usefulness of erythrocyte sedimentation rate and C-reactive protein in pediatric bone and joint infections treated with and without surgery. The medical records of 50 patients admitted for acute osteomyelitis, septic arthritis, or both were reviewed retrospectively. There were 22 patients with septic arthritis, 20 with osteomyelitis, and eight with osteomyelitis with adjacent septic arthritis. There were 25 patients each in the surgical and nonsurgical groups. There was a statistically significant difference between the two groups regarding mean days to peak and normalization of erythrocyte sedimentation rate values and normalization of C-reactive protein values. Statistically significant differences were revealed for the mean days to normalization of erythrocyte sedimentation rate and C-reactive protein values among the patients with a diagnosis of osteomyelitis, septic arthritis, or both. The mean days to peak and normalization for erythrocyte sedimentation rate and C-reactive protein were twice as long in the surgical group as compared with the nonsurgical group. Complete recovery was achieved by all patients. This information should help the clinician in the diagnosis and treatment of children having surgery for acute osteomyelitis and septic arthritis.

Advances in the management of septic arthritis

Bacterial arthritis still is a common and serious problem at mayor urban medical centers and is one of the most rapidly destructive forms of acute arthritis. The yearly incidence of bacterial arthritis varies from 2 to 10 per 100,000 in the general population to 30 to 70 per 100,000 in patients with rheumatoid arthritis and in patients with joint prostheses. Irreversible loss of joint function may develop in up to 50% of the patients. Despite better antimicrobial agents and improved hospital care, the fatality rate for this medical problem has not changed substantially during the past 25 years. An understanding of the risk factors and the pathogenesis of nongonoccocal bacterial arthritis and other forms of infectious arthritis, primarily in the context of a differential diagnosis and treatment, are important in order to avoid the delay in making a correct diagnosis and to improve the prognosis.

Painful knee--an unusual cause secondary to pseudomonas septic arthritis of the hip

A child presented with knee pain, the cause of pain was found on further investigation to be due chondrolysis of the hip joint secondary to a pseudomonas aeruginosa septic arthritis. The patient functionally did well following a subtotal synovectomy and prolonged treatment with appropriate antibiotics.

Monitoring of blood parameters following anterior cervical fusion

OBJECT

Both C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) were measured prospectively in 51 cases in which uncomplicated cervical anterior fusion was performed. The object of the authors was to quantify the differences in the responses of these parameters recorded in the immediate postoperative period and to determine factors influencing their course.

METHODS

Nineteen one-level, 23 two-level, and nine three-level procedures for disc herniation and degenerative disease of the cervical spine were performed in 22 female and 29 male patients (mean age 49.2 years). Blood samples were obtained 1 day before as well as on 10 consecutive days and 3 months following anterior cervical fusion. Serum CRP level was measured using a fluorescence polarization immunoassay and ESR was determined from the same samples. Operative time, the number of blood transfusions, and drugs administered in the postoperative period were recorded. In addition, hemoglobin, hematocrit, red blood cell count, platelet count, white cell count, and axillary body temperature were checked daily.

CONCLUSIONS

Monitoring of CRP level is superior to that of ESR for early detection of infections after cervical spine surgery. Although CRP was not related to any of the factors that have been proposed to explain its peak value variance in previous studies, individual acute-phase protein metabolism response to tissue affection appears to be a more decisive element in this respect.