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Moore-Lotridge SN, Daryoush JR, Wollenman CC, Gibian JT, Johnson SR, Thomsen IP, Schoenecker JG. CRP Predicts the Need to Escalate Care After Initial Debridement for Musculoskeletal Infection. J Pediatr Orthop 2024; 44:188-196. [PMID: 37997444 DOI: 10.1097/bpo.0000000000002573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND Musculoskeletal infections (MSKIs) are a major cause of morbidity in the pediatric population and account for nearly 1 in every 10 consultations with a pediatric orthopaedic provider at a tertiary care center. To prevent or deescalate the risk of adverse medical and musculoskeletal outcomes, timely medical intervention in the form of antibiotics and potential surgical debridement is required. While there have been numerous studies indicating the value of laboratory testing during the initial workup of a child with MSKI, few studies to date have examined the utility of longitudinal assessment of laboratory measures in the acute setting to monitor the efficacy of antibiotic therapy and/or surgical intervention. The purpose of this investigation was to retrospectively determine whether measuring changes in the inflammatory response could indicate the need for escalated care. Specifically, this study examined the hypothesis that serial measurements of C-reactive protein (CRP), immediately preoperatively and 2 days after surgical debridement, could predict the need for medical (change in antibiotics) or surgical (additional debridement) escalation. METHODS Retrospective review of pediatric patients undergoing operative debridement for the treatment of MSKI between September 2009 and December 2015 from whom laboratory data (CRP) was obtained preoperatively and at postoperative day (POD) 2. Patient demographics, the need for escalated care, and patient outcomes were evaluated. RESULTS Across 135 pediatric patients, preoperative CRP values >90 mg/L and a positive change in CRP at POD2 effectively predicted the need for escalation of care after initial surgical debridement (Area under the Receiver Operator Curve: 0.883). For each 10-unit increase in preoperative CRP or postoperative change in CRP, there was a 21% or 22% increased risk of needing escalated care, respectively. Stratification by preoperative CRP >90 mg/L and change in CRP postoperatively likewise correlated with increased rates of disseminated disease, percent tissue culture positivity, length of stay, and rate of adverse outcomes. CONCLUSIONS This study demonstrates the utility of serial CRP to assess the need for escalated care in patients being treated for MSKI. As serial CRP measurements become standard of practice in the acute setting, future prospective studies are needed to optimize the timing of CRP reassessment during inpatient hospitalization to prognosticate patient outcomes, weighing both improvements of patient care and clinical burden. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Affiliation(s)
| | | | | | | | | | - Isaac P Thomsen
- Department of Pediatrics
- Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Jonathan G Schoenecker
- Departments of Orthopedics
- Pathology, Microbiology and Immunology
- Pharmacology
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center
- Department of Pediatrics
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2
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Kendall IS, McGinn C, Sands AJ. Sore knee - why and when to call a cardiologist. Arch Dis Child Educ Pract Ed 2023; 108:450-455. [PMID: 37290895 DOI: 10.1136/archdischild-2023-325651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/28/2023] [Indexed: 06/10/2023]
Abstract
A young girl received a diagnosis of septic arthritis of the knee unresponsive to standard medical and surgical treatment. We report the patient's clinical journey with clinical commentary throughout, underlying the importance of differential diagnosis that may open several scenarios and a different final diagnosis accordingly. Finally, we will discuss the treatment and management of the patient's final diagnosis.
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Affiliation(s)
- Ian Scott Kendall
- Paediatric Cardiology, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Claire McGinn
- Paediatric Cardiology, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Andrew J Sands
- Paediatric Cardiology, Royal Belfast Hospital for Sick Children, Belfast, UK
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3
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Hachem A, Copley LAB. What's New in Pediatric Septic Arthritis? A Review of Pertinent Clinical Questions. J Pediatr Orthop 2023; 43:578-583. [PMID: 37332197 DOI: 10.1097/bpo.0000000000002453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
BACKGROUND The evaluation and treatment of children with septic arthritis (SA) is challenging and requires an organized approach to address the spectrum of pathogens which appear to aggregate in age-specific groups. Although evidence-based guidelines have recently been published for the evaluation and treatment of children with acute hematogenous osteomyelitis, there is a relative dearth of literature devoted exclusively to SA. METHODS Recently published guidance for the evaluation and treatment of children with SA was reviewed and evaluated with respect to pertinent clinical questions to summarize what is new in this area of practice for pediatric orthopaedic surgeons. RESULTS Evidence suggests that there is a profound difference between children with primary SA and those who have contiguous osteomyelitis. This disruption of the commonly accepted paradigm of a continuum of osteoarticular infections has important implications in the evaluation and treatment of children with primary SA. Clinical prediction algorithms have been established to help determine the applicability of magnetic resonance imaging during the evaluation of children suspected to have SA. Antibiotic duration for SA has been recently studied with some evidence in favor of short-course parenteral followed by short-course oral therapy may be successful if the pathogen is not methicillin-resistant Staphylococcus aureus . CONCLUSION Recent studies of children with SA have provided better guidance for evaluation and treatment to improve diagnostic accuracy, processes of evaluation, and clinical outcomes. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Ahmad Hachem
- Department of Pediatrics, College of Medicine-Jacksonville, University of Florida, Jacksonville, FL
| | - Lawson A B Copley
- Department of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, TX
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4
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Yagupsky P, Ceroni D. Editorial: An update on pediatric skeletal system infections. Front Pediatr 2023; 11:1128126. [PMID: 36861071 PMCID: PMC9969156 DOI: 10.3389/fped.2023.1128126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/17/2023] [Indexed: 02/15/2023] Open
Affiliation(s)
- Pablo Yagupsky
- Clinical Microbiology Laboratory, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dimitri Ceroni
- Unité Orthopédie Pédiatrique et de Traumatologie Infantile, Service de Chirurgie Pédiatrique, Hôpitaux Universitaires de Genève, Genève, Switzerland
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5
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Elbow Septic Arthritis caused by Klebsiella pneumoniae in a Newborn - Case Report and Literature Review. REV ROMANA MED LAB 2022. [DOI: 10.2478/rrlm-2022-0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Septic arthritis is a rare condition in children, especially in neonates. Early recognition and proper treatment are required to avoid serious complications. We present the case of a male newborn diagnosed with septic arthritis of the right elbow who was treated with repeated joint aspiration and i.v. antibiotics (Amikacin and Meropenem). Blood culture and joint cultures were positive for Klebsiella pneumoniae. The final outcome was good, with no apparent local or systemic complications. General considerations regarding this rare condition, etiology and treatment options are also included in the paper.
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6
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Alcobendas RM, Núñez E, Calvo C. Minimally invasive management of pediatric osteoarticular infections. Front Pediatr 2022; 10:1017035. [PMID: 36440331 PMCID: PMC9692125 DOI: 10.3389/fped.2022.1017035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Esmeralda Núñez
- Pediatrics Department, Hospital Materno-Infantil, Málaga, Spain
| | - Cristina Calvo
- Pediatric Infectious Diseases Department, Hospital Universitario La Paz, Fundación IdiPaz, Madrid, Spain.,Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain.,CIBER Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
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Gouveia C, Duarte M, Norte S, Arcangelo J, Pinto M, Correia C, Simões MJ, Canhão H, Tavares D. Kingella kingae Displaced S. aureus as the Most Common Cause of Acute Septic Arthritis in Children of All Ages. Pediatr Infect Dis J 2021; 40:623-627. [PMID: 33657599 DOI: 10.1097/inf.0000000000003105] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute septic arthritis (SA) still remains a challenge with significant worldwide morbidity. In recent years, Kingella kingae has emerged and treatment regimens have become shorter. We aim to analyze trends in SA etiology and management and to identify risk factors for complications. METHODS Longitudinal observational, single center study of children (<18 years old) with SA admitted to a tertiary care pediatric hospital, from 2003 to 2018, in 2 cohorts, before and after implementation of nucleic acid amplification assays (2014). Clinical, treatment and disease progression data were obtained. RESULTS A total of 247 children were identified, with an average annual incidence of 24.9/100,000, 57.9% males with a median age of 2 (1-6) years. In the last 5 years, a 1.7-fold increase in the annual incidence, a lower median age at diagnosis and an improved microbiologic yield (49%) was noticed. K. kingae became the most frequent bacteria (51.9%) followed by MSSA (19.2%) and S. pyogenes (9.6%). Children were more often treated for fewer intravenous days (10.7 vs. 13.2 days, P = 0.01) but had more complications (20.6% vs. 11.4%, P = 0.049) with a similar sequelae rate (3.7%). Risk factors for complications were C-reactive protein ≥80 mg/L and Staphylococcus aureus infection, and for sequelae at 6 months, age ≥4 years and CRP ≥ 80 mg/L. CONCLUSIONS The present study confirms that K. kingae was the most common causative organism of acute SA. There was a trend, although small, for decreasing antibiotic duration. Older children with high inflammatory parameters might be at higher risk of sequelae.
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Affiliation(s)
- Catarina Gouveia
- From the Infectious Diseases Unit, Hospital de Dona Estefânia, CHULC-EPE, Lisbon, Portugal
- Nova Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Mariana Duarte
- From the Infectious Diseases Unit, Hospital de Dona Estefânia, CHULC-EPE, Lisbon, Portugal
| | - Susana Norte
- Pediatric Orthopedic Unit, Hospital de Dona Estefânia, CHULC-EPE, Lisbon, Portugal
| | - Joana Arcangelo
- Pediatric Orthopedic Unit, Hospital de Dona Estefânia, CHULC-EPE, Lisbon, Portugal
| | - Margarida Pinto
- Patologia Clinica, Hospital de Dona Estefânia, CHULC-EPE, Lisbon, Portugal
| | - Cristina Correia
- Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisboa, Portugal
| | - Maria João Simões
- Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisboa, Portugal
| | - Helena Canhão
- Nova Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Delfin Tavares
- Pediatric Orthopedic Unit, Hospital de Dona Estefânia, CHULC-EPE, Lisbon, Portugal
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8
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Di Pietro GM, Borzani IM, Aleo S, Bosis S, Marchisio P, Tagliabue C. Pediatric Septic Arthritis of the Knee Due to a Multi-Sensitive Streptococcus pyogenes Strain Responsive to Clindamycin-A Case Report. CHILDREN-BASEL 2021; 8:children8030189. [PMID: 33802408 PMCID: PMC8001213 DOI: 10.3390/children8030189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Giada Maria Di Pietro
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
- Correspondence:
| | - Irene Maria Borzani
- Radiology Unit, Pediatric Division, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Sebastiano Aleo
- Paediatric Highly Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (S.A.); (S.B.); (C.T.)
| | - Samantha Bosis
- Paediatric Highly Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (S.A.); (S.B.); (C.T.)
| | - Paola Marchisio
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
| | - Claudia Tagliabue
- Paediatric Highly Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (S.A.); (S.B.); (C.T.)
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9
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Clinicoradiological outcomes following single-stage treatment using external fixator, copious bone grafting and high dose antibiotics for infected postosteomyelitic nonunion of femoral shaft. J Pediatr Orthop B 2021; 30:85-92. [PMID: 31821272 DOI: 10.1097/bpb.0000000000000704] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We aimed to study clinical and radiological outcomes following a 'single-stage protocol' in postosteomyelitic-infected nonunion of the femur in children. The report is based on a retrospective chart review (2010-2018) of 10 children below 12 years of age presenting with nonunion following a pathological fracture after osteomyelitis of hematogenous origin treated with above-mentioned operative modality. All patients were grade A (normal host) on the basis of the physiological classification. Patients with posttraumatic or surgical osteomyelitis were excluded. All patients were treated with a combination of debridement of dead bone and necrotic tissues, acute bone docking, use of external fixator and addition of copious nonvascularized autogenous bone graft obtained from fibula/tibia. The postsurgical period was covered by high dose broad spectrum antibiotics for 6 weeks. At follow up, union, infection, deformity, leg-length discrepancy, motion of hip and knee and ability to perform unaided walking was recorded. Mean age for studied patients (five males and five females) was 6.6 years. Average time elapsed since pathological fracture was 7.7 months (range: 3-15 months). MRSA and MSSA were cultured in three and four patients, respectively. Union occurred in all patients with average time of 3.7 months and total follow up being 2.9 years (range: 1-7 years). There was persistence of deep infection despite union in three patients. Average limb shortening was 4.3 cm (range: 2-7 cm). The knee motion was severely restricted (≤30°) in three patients. According to Paley's criteria, there were 2 excellent, 4 good, 2 fair and 2 poor results. Single-stage protocol as described above is a usable option for postosteomyelitic femoral nonunions in children. Union occurred in all cases. Healing occurred in three patients despite the persistence of infection. The restriction of range of motion at knee and limb length discrepancy was main complication encountered with this procedure.
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10
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Griswold BG, Sheppard E, Pitts C, Gilbert SR, Khoury JG. The Introduction of a Preoperative MRI Protocol Significantly Reduces Unplanned Return to the Operating Room in the Treatment of Pediatric Osteoarticular Infections. J Pediatr Orthop 2020; 40:97-102. [PMID: 31923170 DOI: 10.1097/bpo.0000000000001113] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pediatric osteoarticular infection can cause severe morbidity. Some infectious loci may be difficult to identify clinically, and there may be more than one. There is little agreement regarding the appropriate use of preoperative magnetic resonance imaging (MRI) in this setting. After noting an unacceptably high rate of unplanned returns to the operating room for recurrent infection, clinicians at a tertiary care children's hospital noticed many patients had adjacent foci of infection on postoperative MRI. As a result, patients experienced prolonged treatment courses and multiple surgeries. An interdisciplinary team instituted practice guidelines whereby all patients with suspected osteoarticular infection underwent MRI for planned debridement during a reserved morning slot with a surgical suite on hold to proceed directly to surgery if indicated. Images were reviewed in real time to form the surgical plan. Young patients that required sedation for MRI were taken to surgery under the same anesthetic used for MRI without being awakened. The purpose of our retrospective study is to determine if implementing the practice guidelines for acute management of osteoarticular infection reduced unplanned returns to the operating room. METHODS A total of 93 patients with osteoarticular infection were included in this study. A total of 40 cases, group A, were treated before implementing practice guidelines; 53 cases, group B, were treated after implementing practice guidelines. Our primary outcomes of interest were the identification of adjacent infections prior to surgery and need for repeat surgery, either planned or unplanned. RESULTS Implementation of these guidelines reduced repeat surgery from 50% of patients to <27% (P=0.0099). Of patients requiring repeat surgery, 85% (n=17) were unplanned in group A versus 60% (n=9) in group B (P=0.0099). Adjacent infections were identified in 47.5% (n=19) of patients in group A, versus 60% (n=32) in group B. Adjacent infections were known before surgery in 32% (n=6) of patients in group A versus 72% (n=23) in group B. There were no statistically significant differences in initial patient characteristics or sites of infection. CONCLUSIONS Implementing these guidelines reduced the need for repeat surgery in this population. It is difficult to predict with sufficient accuracy which patients need preoperative MRI. While resource intensive, preoperative MRI appears to offer substantial benefit in preoperative planning.
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Affiliation(s)
- Branum G Griswold
- Department of Orthopedic Surgery, University of Alabama, Birmingham, AL
| | - Evan Sheppard
- Department of Orthopedic Surgery, University of Alabama, Birmingham, AL
| | - Charlie Pitts
- Department of Orthopedic Surgery, University of Alabama, Birmingham, AL
| | - Shawn R Gilbert
- Department of Orthopedic Surgery, University of Alabama, Birmingham, AL
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11
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Holmen JE, Yi J. Pyogenic Arthritis. Pediatr Ann 2019; 48:e354-e359. [PMID: 31505009 DOI: 10.3928/19382359-20190816-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The incidence of septic arthritis among children in developed countries is estimated to be 4 to 10 cases per 100,000 children per year, peaking at about age 3 years. The most common causative organism is Staphylococcus aureus, although the microbiology varies by age. Prompt diagnosis and treatment is critical to prevent long-term sequelae. Empiric therapy should target the most likely causative organism(s) and total duration generally falls between 10 days and 4 weeks depending on clinical course, patient age, and organism. A short intravenous course is sufficient in most cases. Unusual and alternate causes of arthritis should be considered in special cases. [Pediatr Ann. 2019;48(9):e354-e359.].
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Tran Quang V, Bidet P, Birgy A, Caseris M, Basmaci R, Bonacorsi S. Susceptibility testing of Kingella kingae to cefazolin. Clin Microbiol Infect 2018; 24:312-313. [DOI: 10.1016/j.cmi.2017.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 09/22/2017] [Accepted: 10/03/2017] [Indexed: 11/15/2022]
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13
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Hospach T, Hedrich C, Fernandez F, Girschick H, Borte M, Günther A, Martin L, Hahn G, von Kalle T, Horneff G, Kallinich T, Huppertz HI. Bakterielle Arthritis bei Kindern und Jugendlichen, Schwerpunkt Diagnostik. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0326-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Pääkkönen M. Septic arthritis in children: diagnosis and treatment. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2017; 8:65-68. [PMID: 29388627 PMCID: PMC5774603 DOI: 10.2147/phmt.s115429] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Acute septic arthritis in children is usually hematogenous. It is more common in boys, and it most often affects the large joints of the lower limb. Diagnosis is based on cultures obtained from the infected joint and is supported by C-reactive protein blood test or ultrasound imaging. Staphylococcus aureus is the most common causative agent and is the primary target for empiric treatment. First-generation cephalosporins and clindamycin are suitable antibiotics. Vancomycin is utilized in areas with high rates of clindamycin- and methicillin-resistant S. aureus. After a short intravenous administration of 2–4 days, a total course of 2 weeks is sufficient in uncomplicated cases. Early antibiotic treatment has significantly improved the prognosis in high-income settings, but uncomplicated recovery is compromised if the treatment is delayed. Complications such as symptomatic osteoarthritis or avascular necrosis of the femoral head develop slowly. A long follow-up of 1–2 years is required to detect all possible sequelae.
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Affiliation(s)
- Markus Pääkkönen
- Department of Pediatric Orthopaedic Surgery.,Department of Hand Surgery, Turku University Hospital and the University of Turku, Turku, Finland
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15
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Epidemiology and Management of Acute, Uncomplicated Septic Arthritis and Osteomyelitis: Spanish Multicenter Study. Pediatr Infect Dis J 2016; 35:1288-1293. [PMID: 27455444 DOI: 10.1097/inf.0000000000001309] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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16
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Li Y, Zhou Q, Liu Y, Chen W, Li J, Yuan Z, Yong B, Xu H. Delayed treatment of septic arthritis in the neonate: A review of 52 cases. Medicine (Baltimore) 2016; 95:e5682. [PMID: 28002339 PMCID: PMC5181823 DOI: 10.1097/md.0000000000005682] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
There is still controversy on the management of septic arthritis in neonates. This study aims to investigate the treatment of septic arthritis in neonates.We reviewed 52 neonates (37 males and 15 females) with septic arthritis in our hospital during 2004 to 2015. The mean age at onset of infection was 17.5 ± 7.6 days, mean age at admission was 32.6 ± 10.7 days. A total of 56 joints were involved (22 knees, 18 shoulders, 13 hips, and 3 other joints). Thiryt-six patients underwent surgical drainage, 14 patients were treated nonoperatively, 2 families refused treatment. Forty-four patients (48 joints) were followed for 4.5 ± 1.2 years. Based on treatment, these 48 joints were divided into an operative group and a nonoperative group. Clinical presentations, imaging examination results, treatments, and outcomes were analyzed.Among the patients who were followed-up, the time from onset to treatment in the operatively managed group (12.7 ± 8.1 days) was significantly shorter than that in the conservatively managed group (20.0 ± 8.2 days). There were no significant differences between both groups on the age at onset, age at admission, imaging score, length of hospital stay, WBC counts, and intravenous medication time. Thirty-five sites (72.9%) recovered completely. There was no significant difference on recovery rate between operative and nonoperative group. Only 33.3% of the hips recovered, this was significantly lower than that of knee/ankle (85.0%) and shoulder/elbow (78.9%). Sequels were found in 13 joints. Logistic regression indicated that sex, imaging score, and hip joint involvement were predictors of sequel. One point of imaging score increased the risk of sequels by a factor of 2.960, and hip joint involvement increased the risk of sequels by a factor of 12.712. Females were more likely to have sequels than males.Surgical drainage is recommended for early diagnosed neonatal septic arthritis and hip infections. A conservative approach may be more efficient for patients whose diagnosis and treatment had been delayed for more than 2 weeks. Antibiotics should be administered intravenously for 2 weeks and then orally for another 2 weeks. First-generation cephalosporin and clindamycin are recommended empirical antibiotics before causative agent and its resistance pattern are known.
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Chiappini E, Mastrolia MV, Galli L, De Martino M, Lazzeri S. Septic arthritis in children in resource limited and non-resource limited countries: an update on diagnosis and treatment. Expert Rev Anti Infect Ther 2016; 14:1087-1096. [PMID: 27629150 DOI: 10.1080/14787210.2016.1235973] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Septic arthritis (SA) is an orthopedic emergency in childhood. It is uncommon in high resource settings. However, an incidence of 5-20 per 100,000 children has been reported in low-income countries. Area covered: The predictive value of serum markers is still under debate and the proposed diagnostic algorithms for SA are not sufficiently validated in children. Recent data suggest that short-course intravenous treatment, followed by oral therapy, is as effective as traditional long-term treatment. Results from three randomized controlled trials suggest that the addition of systemic steroids may accelerate clinical improvement. Minimally invasive surgical techniques have been proposed for treatment in recent years. Expert commentary: The causes and the epidemiology of septic arthritis will continue to mutate according to the changes in immunization practices, bacterial resistance patterns and the implementation of PCR techniques. Future research should focus on the assessment of appropriate antibiotic regimens and surgical procedures.
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Affiliation(s)
- Elena Chiappini
- a Pediatric Infectious Disease Unit , Anna Meyer Children's University Hospital , Florence , Italy
| | - Maria Vincenza Mastrolia
- a Pediatric Infectious Disease Unit , Anna Meyer Children's University Hospital , Florence , Italy
| | - Luisa Galli
- a Pediatric Infectious Disease Unit , Anna Meyer Children's University Hospital , Florence , Italy
| | - Maurizio De Martino
- b Meyer Health Campus , Anna Meyer Children's University Hospital , Florence , Italy
| | - Simone Lazzeri
- c Orthopaedics and Traumatology Department , Anna Meyer Children's University Hospital , Florence , Italy
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Agarwal A, Aggarwal AN. Bone and Joint Infections in Children: Septic Arthritis. Indian J Pediatr 2016; 83:825-33. [PMID: 26189923 DOI: 10.1007/s12098-015-1816-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/09/2015] [Indexed: 10/23/2022]
Abstract
The pathological invasion of a joint and subsequent inflammation is known as septic arthritis. The knee and hip are the most frequently involved joints. Staphylococcus aureus is the most common cause of septic arthritis in children. An acute onset of illness with an inflamed painful joint and restricted movements and inability to use joint (pseudoparalysis) clinically indicates septic arthritis. The diagnosis is difficult in a neonate or young child where refusal to feed, crying, discomfort during change of diaper (if hip is involved) or attempted joint movement may be the only findings. Fever and other systemic signs may also be absent in neonates. Septic arthritis is diagnosed clinically, supported by appropriate radiological and laboratory investigations. The peripheral blood white cell count is frequently raised with a predominance of polymorphonuclear cells. The acute phase reactants such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are often markedly raised. Ultrasonography and MRI are preferred investigations in pediatric septic arthritis. Determination of infecting organism in septic arthritis is the key to the correct antibiotic choice, treatment duration and overall management. Joint aspirate and/or blood culture should be obtained before starting antibiotic treatment. Several effective antibiotic regimes are available for managing septic arthritis in children. Presence of large collections, thick pus, joint loculations and pus evacuating into surrounding soft tissues are main indications for surgical drainage. Joint aspiration can be a practical alternative in case the lesion is diagnosed early, with uncomplicated presentations and superficial joints.
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Affiliation(s)
- Anil Agarwal
- Department of Orthopedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, 110031, India.
| | - Aditya N Aggarwal
- Department of Orthopedics, UCMS and GTB Hospital, Shahdara, Delhi, India
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Update on the Management of Pediatric Acute Osteomyelitis and Septic Arthritis. Int J Mol Sci 2016; 17:ijms17060855. [PMID: 27258258 PMCID: PMC4926389 DOI: 10.3390/ijms17060855] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 05/26/2016] [Accepted: 05/26/2016] [Indexed: 12/15/2022] Open
Abstract
Acute osteomyelitis and septic arthritis are two infections whose frequencies are increasing in pediatric patients. Acute osteomyelitis and septic arthritis need to be carefully assessed, diagnosed, and treated to avoid devastating sequelae. Traditionally, the treatment of acute osteoarticular infection in pediatrics was based on prolonged intravenous anti-infective therapy. However, results from clinical trials have suggested that in uncomplicated cases, a short course of a few days of parenteral antibiotics followed by oral therapy is safe and effective. The aim of this review is to provide clinicians an update on recent controversies and advances regarding the management of acute osteomyelitis and septic arthritis in children. In recent years, the emergence of bacterial species resistant to commonly used antibiotics that are particularly aggressive highlights the necessity for further research to optimize treatment approaches and to develop new molecules able to fight the war against acute osteoarticular infection in pediatric patients.
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Arthroscopic Treatment of Septic Arthritis of the Elbow in a 4-Year-Old Girl. Case Rep Orthop 2015; 2015:853974. [PMID: 26713167 PMCID: PMC4680102 DOI: 10.1155/2015/853974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/23/2015] [Indexed: 11/25/2022] Open
Abstract
Pediatric septic arthritis is uncommon and has been traditionally treated by joint aspiration or open arthrotomy. There are some reports about arthroscopic surgery in pediatric septic arthritis of the knee, hip, and shoulder. However, there is no report for the case of elbow. We report a case of pediatric septic arthritis of elbow treated with arthroscopically with good clinical condition at 3-year follow-up. This paper is based on a report first published in Japanese (Tojo (2012)).
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Agout C, Lakhal W, Fournier J, de Bodman C, Bonnard C. Arthroscopic treatment of septic arthritis of the knee in children. Orthop Traumatol Surg Res 2015; 101:S333-6. [PMID: 26421608 DOI: 10.1016/j.otsr.2015.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/30/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Childhood septic arthritis of the knee is a serious disease that can impair growth and cause serious functional sequelae. There are few data on arthroscopic treatment in children, and series were always less than 20 cases. HYPOTHESIS The objective of this study was to assess clinical and radiographic results of arthroscopic drainage combined with antibiotic therapy for the treatment of childhood septic arthritis of the knee. The hypothesis was that arthroscopic treatment is also effective in children. MATERIALS AND METHODS A retrospective study, conducted between January 2003 and December 2012, included patients under 15 years of age with septic arthritis of the knee treated by arthroscopic drainage with a minimum of 2 years' follow-up. RESULTS Fifty-six patients, with a mean age at surgery of 3.4 years (range, 3 months to 12 years), were included. Staphylococcus aureus was the most common causative organism. Two patients (3.6%) had recurrence, successfully treated by repeat arthroscopic drainage. Mean Lysholm score was 96.9 (range, 70-100) and mean KOOS-Child pain, symptoms, daily life, sports and quality of life scores were respectively 97 (81-100), 95 (75-100), 98 (89-100), 93 (71-100) and 95 (70-100) at a mean 65 months' follow-up. Ranges of motion were normal. Radiology found no joint damage. DISCUSSION AND CONCLUSION Arthroscopic drainage combined with antibiotic treatment is a simple and effective treatment for childhood septic arthritis of the knee and is for our reference attitude. It can also be indicated in case of recurrence. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- C Agout
- Service de chirurgie orthopédique pédiatrique, université F.-Rabelais, hôpital G.-de-Clocheville, CHU de Tours, boulevard Béranger, 37044 Tours, France.
| | - W Lakhal
- Service de chirurgie orthopédique pédiatrique, université F.-Rabelais, hôpital G.-de-Clocheville, CHU de Tours, boulevard Béranger, 37044 Tours, France
| | - J Fournier
- Service de chirurgie orthopédique pédiatrique, université F.-Rabelais, hôpital G.-de-Clocheville, CHU de Tours, boulevard Béranger, 37044 Tours, France
| | - C de Bodman
- Service de chirurgie orthopédique pédiatrique, université F.-Rabelais, hôpital G.-de-Clocheville, CHU de Tours, boulevard Béranger, 37044 Tours, France
| | - C Bonnard
- Service de chirurgie orthopédique pédiatrique, université F.-Rabelais, hôpital G.-de-Clocheville, CHU de Tours, boulevard Béranger, 37044 Tours, France
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Saavedra-Lozano J, Calvo C, Huguet Carol R, Rodrigo C, Núñez E, Pérez C, Merino R, Rojo P, Obando I, Downey F, Colino E, García J, Cilleruelo M, Torner F, García L. Documento de Consenso SEIP-SERPE-SEOP sobre etiopatogenia y diagnóstico de la osteomielitis aguda y artritis séptica no complicadas. An Pediatr (Barc) 2015; 83:216.e1-10. [DOI: 10.1016/j.anpedi.2014.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/18/2014] [Indexed: 10/24/2022] Open
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Saavedra-Lozano J, Calvo C, Huguet Carol R, Rodrigo C, Núñez-Cuadros E, Pérez Méndez C, Merino R, Rojo P, Obando I, Downey F, Colino E, García J, Cilleruelo M, Torner F, García L. SEIP-SERPE-SEOP consensus document on aetiopathogenesis and diagnosis of uncomplicated acute osteomyelitis and septic arthritis. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2015.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Spencer CH, Patwardhan A. Pediatric Rheumatology for the Primary Care Clinicians-Recognizing Patterns of Disease. Curr Probl Pediatr Adolesc Health Care 2015. [PMID: 26205101 DOI: 10.1016/j.cppeds.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This review presents a diagnostic approach to musculoskeletal and rheumatic diseases in children for primary care clinicians. The focus is on juvenile idiopathic arthritis (JIA) as the major arthritis disease in children. It is necessary to know the personalities of these JIA categories. It is also crucial to be able to recognize the common infectious, orthopedic and mechanical, malignant, genetic, other rheumatic diseases, and other miscellaneous syndromes that can mimic JIA. To do so requires recognition of clinical patterns using a thorough musculoskeletal and rheumatic history and repeated complete physical exams with emphasis on the musculoskeletal exam. It also requires targeted and limited laboratory testing with careful follow-up over time.
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MacLean SBM, Timmis C, Evans S, Lawniczak D, Nijran A, Bache E. Preoperative antibiotics for septic arthritis in children: delay in diagnosis. J Orthop Surg (Hong Kong) 2015; 23:80-3. [PMID: 25920651 DOI: 10.1177/230949901502300119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To review the records of 50 children who underwent open joint washout for septic arthritis with (n=25) or without (n=25) preoperative antibiotics. METHODS Records of 50 children who underwent open joint washout for presumed septic arthritis with (n=25) or without (n=25) preoperative antibiotics were reviewed. 17 boys and 8 girls aged 3 weeks to 16 years (median, 1.5 years) who were prescribed preoperative antibiotics before joint washout were compared with 12 boys and 13 girls aged one month to 14 years (median, 2 years) who were not. Following arthrotomy and washout, all patients were commenced on high-dose intravenous antibiotics. Patients were followed up for 6 to 18 months until asymptomatic. RESULTS Patients who were referred from places other than our emergency department were twice as likely to have been prescribed preoperative antibiotics (p=0.0032). Patients prescribed preoperative antibiotics had a longer median (range) time from symptom onset to joint washout (8 [2-23] vs. 4 [1-29] days, p=0.05) and a higher mean erythrocyte sedimentation rate (93.1 vs. 54.3 mm/h, p=0.023) at presentation. Nonetheless, the 2 groups were comparable for weight bearing status, fever, and positive culture, as well as the mean (range) duration of antibiotic treatment (4.9 [4-7] vs. 4.7 [1-8] weeks, p=0.586). CONCLUSION Preoperative antibiotics should be avoided in the management of septic arthritis in children. Their prescription delays diagnosis and definitive surgery, and leads to additional washouts and complications. A high index of suspicion and expedite referral to a specialist paediatric orthopaedic unit is needed if septic arthritis is suspected.
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Abstract
Acute septic arthritis is a rare, but potentially devastating disease. The treatment is initiated intravenously, but can be safely switched to oral after 2-4 days providing large doses of a well-absorbing antibiotic and, for time-dependent antibiotics, 4 times-a-day administration are used. Empiric treatment should always cover Staphylococcus aureus and common respiratory pathogens, whereas Kingella kingae and Salmonella are important only regionally. Studies conducted by our group have shown that a total course of 10 days may suffice for previously healthy children in a Western setting. Treatment of neonates, patients with immunodeficiency or cases caused by methicillin-resistant S. aureus, may deserve a different approach.
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Pääkkönen M, Kallio MJT, Kallio PE, Peltola H. Significance of Negative Cultures in the Treatment of Acute Hematogenous Bone and Joint Infections in Children. J Pediatric Infect Dis Soc 2013; 2:119-25. [PMID: 26619459 DOI: 10.1093/jpids/pis108] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 10/04/2012] [Indexed: 11/13/2022]
Abstract
BACKGROUND Synovial fluid and blood cultures often remain negative in acute bone and joint infections of childhood even when characteristic symptoms, signs, and/or radiologic proof are present. METHODS We analyzed 345 prospectively documented osteoarticular infections in children at age 3 months to 15 years. In 23% of the cases (N = 80), synovial, bone, and/or blood cultures remained negative. The characteristics of these cases were compared with patients with culture-positive bone and joint infections. RESULTS The 2 groups did not differ in age or gender distribution, surgical procedures performed, or outcome. In the culture-negative cases, the initial serum C-reactive protein level was lower (58 vs 87 mg/L, P < .0001) and the hospital stay was shorter (8 vs 11 days, P < .0001). CONCLUSIONS Bone and joint infections in which cultures fail to identify the causative agent can be treated similarly as culture-positive cases.
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Affiliation(s)
- Markus Pääkkönen
- Department of Orthopedic Surgery, Turku University Hospital and University of Turku; Departments of Children's Hospital, Helsinki University Central Hospital, Finland
| | - Markku J T Kallio
- Pediatrics and Children's Hospital, Helsinki University Central Hospital, Finland
| | - Pentti E Kallio
- Pediatric Surgery, University of Helsinki Children's Hospital, Helsinki University Central Hospital, Finland
| | - Heikki Peltola
- Pediatrics and Children's Hospital, Helsinki University Central Hospital, Finland
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Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e318280c6c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pääkkönen M, Kallio MJT, Kallio PE, Peltola H. Shortened hospital stay for childhood bone and joint infections: Analysis of 265 prospectively collected culture-positive cases in 1983–2005. ACTA ACUST UNITED AC 2012; 44:683-8. [DOI: 10.3109/00365548.2012.673729] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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