Global epidemiology of childhood bone and joint infection: a systematic review

Epidemiology of childhood bone and joint disease during the COVID-19 pandemic in New Zealand

PURPOSE

It is unknown whether social distancing impacts frequency of presentation and severity of childhood bone and joint infection (BJI). In New Zealand, the COVID-19 disease elimination strategy involved strict social isolation policies spanning March 2020-September 2022. Examination of this period may provide insight around risk factors for BJI.

METHODS

A retrospective review of all patients < 16 years with presumed acute haematogenous osteomyelitis (AHO) or septic arthritis (SA) treated in the Auckland region was performed between 2018 and 2023. Frequency and severity of presentations has been examined before, during, and after periods of social restriction. Severe cases included those with intensive care admission, recurrent infection, or multiple surgeries. Pre-hospital experience, length of stay, and disease outcomes have also been assessed.

RESULTS

A total of 563 cases met inclusion criteria. Compared to the pre-pandemic period, monthly case averages reduced between April 2020 to September 2022 (10.1 vs. 7.9 cases/month, p = 0.008). Separating cases by causative microbiology shows a statistically significant drop in culture negative and Kingella kingae mediated BJI cases (4.2 vs. 2.9 cases/month, p = 0.006) but not for cases secondary to Staphylococcus aureus and Streptococcus pyogenes (4.2 vs. 3.9 cases/month, p = 0.6). The frequency of severe disease reduced during this period (5.6 vs. 4.1 cases/month, p = 0.01) together with lower rates of recurrent infection (9% vs. 4%, p = 0.03).

CONCLUSION

The COVID-19 management strategy in New Zealand utilised strict social isolation, mask wearing, and hand hygiene measures to control disease spread between 2020 and 2022. These measures coincided with reduction in frequency and severity of presentations for childhood BJI.

Potential value of a rapid syndromic multiplex PCR for the diagnosis of native and prosthetic joint infections: a real-world evidence study

Introduction: The BIOFIRE Joint Infection (JI) Panel is a diagnostic tool that uses multiplex-PCR testing to detect microorganisms in synovial fluid specimens from patients suspected of having septic arthritis (SA) on native joints or prosthetic joint infections (PJIs). Methods: A study was conducted across 34 clinical sites in 19 European and Middle Eastern countries from March 2021 to June 2022 to assess the effectiveness of the BIOFIRE JI Panel. Results: A total of 1527 samples were collected from patients suspected of SA or PJI, with an overall agreement of 88.4 % and 85 % respectively between the JI Panel and synovial fluid cultures (SFCs). The JI Panel detected more positive samples and microorganisms than SFC, with a notable difference on Staphylococcus aureus, Streptococcus species, Enterococcus faecalis, Kingella kingae, Neisseria gonorrhoeae, and anaerobic bacteria. The study found that the BIOFIRE JI Panel has a high utility in the real-world clinical setting for suspected SA and PJI, providing diagnostic results in approximately 1 h. The user experience was positive, implying a potential benefit of rapidity of results' turnover in optimising patient management strategies. Conclusion: The study suggests that the BIOFIRE JI Panel could potentially optimise patient management and antimicrobial therapy, thus highlighting its importance in the clinical setting.

Detection of Cutibacterium (Propionibacterium) acnes in orthopaedic surgery: serious problem or contamination?

PURPOSE

Bone and joint infections are an important and increasing problem. Whether intraoperatively detected bacteria should be considered relevant or not is often difficult to assess. This retrospective cohort study analyzes the relevance of C. acnes cultured from deep intraoperative specimens.

METHODS

All deep tissue samples collected intraoperatively between 2015 and 2020 from a quartiary care provider were evaluated for detection of C. acnes and its therapeutical consequences. Infection rates were determined according to a standardized definition and protocol and analyzed in dependence of patient's demographic data (age and gender), operative parameters (type of surgery, body region/location of surgery, and impression of the surgeon), and initiated therapy.

RESULTS

In 270 cases of more than 8500 samples, C. acnes was detected. In 30%, the detection was considered an infection. The number of samples taken and tested positive for C. acnes correlated significantly with its classification as a cause of infection. If more than one sample of the patient was positive, the detection was significantly more likely to be treated as infection (p < 0.001). In 76% of cases, a consultation to the infectious diseases (ID) department took place regarding the classification of the pathogen detection and the therapy to be carried out. Almost all of the tested isolates demonstrated the wild-type susceptibility for penicillin and clindamycin.

CONCLUSION

Intraoperative detection of skin-colonizing bacteria such as C. acnes is not always synonymous with infection. In particular, if other examination results contradict an infection (pathological sample without evidence of an infectious event, detection of malignant cells, etc.), the situation must be considered in a very differentiated manner. Interdisciplinary boards, for example, are suitable for this purpose. Care should be taken to obtain a sufficiently large number of tissue samples for microbiological examination to be able to better classify the result.

Quality of life in children up to 13 years following acute haematogenous osteomyelitis

Acute haematogenous osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Previous research on sequelae from AHO rarely considers outcomes more than 2 years following treatment. This study aims to establish the quality of life of patients diagnosed with AHO in childhood up to 13 years after diagnosis, evaluating the impact on social, emotional, physical, and school function. Children treated for AHO between 2008 and 2018 at a tertiary referral centre in New Zealand were identified. Paediatric Quality of Life Inventory (PedsQL) questionnaires were conducted via phone with either the child or primary caregiver and responses analysed. Forty patients met inclusion criteria, were contactable by phone, and consented to participate. The mean age was 7 years (range 0-15) and most were female (60%). Health-related quality of life (HRQOL) was scored as a percentage with most participants scoring >80% ( n  = 27). Those who do experience reduced quality of life following treatment for AHO were likely to complain of pain, stiffness, or anxiety. The impact of significant childhood illness on mental health was not adequately captured by the PedsQL but was highlighted in qualitative feedback. The majority of children treated for AHO reported excellent HRQOL up to 13 years following treatment although a negative impact on mental health was reported using qualitative analysis. A refined scoring system is needed to assess the long-term impact of musculoskeletal infection. Patient case series, Level IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Retrospective study, Level III.

Early CRP Trends in Childhood Osteomyelitis Predict Complicated Disease

BACKGROUND

Acute hematogenous osteomyelitis (AHO) remains a cause of severe illness among children. Contemporary research aims to identify predictors of acute and chronic complications. Trends in C-reactive protein (CRP) after treatment initiation may predict disease course. We have sought to identify factors associated with acute and chronic complications in the New Zealand population.

METHODS

A retrospective review of all patients younger than16 years with presumed AHO presenting to a tertiary referral centre between 2008 and 2018 was performed. Multivariate was analysis used to identify factors associated with an acute or chronic complication. An "acute" complication was defined as the need for 2 or more surgical procedures, a hospital stays longer than 14 days, or recurrence despite intravenous antibiotics. A "chronic" complication was defined as growth or limb length discrepancy, avascular necrosis, chronic osteomyelitis, pathologic fracture, frozen joint, or dislocation.

RESULTS

One hundred fifty-one cases met the inclusion criteria. The median age was 8 years (69.5% male). Within this cohort, 53 (34%) experienced an acute complication and 18 (12%) a chronic complication. Regression analysis showed that contiguous disease, delayed presentation, and failure to reduce CRP by 50% at day 4/5 predicted an acutely complicated disease course. Chronic complication was predicted by the need for surgical management and failed CRP reduction by 50% at day 4/5.

CONCLUSIONS

CRP trends over 96 hours after the commencement of treatment differentiate patients with AHO likely to experience severe disease.

LEVEL OF EVIDENCE

Level II, retrospective study.