Septic arthritis in children in resource limited and non-resource limited countries: an update on diagnosis and treatment

Performance characteristics of genus or species-specific Polymerase Chain Reaction (PCR) for the microbial diagnosis of joint infections: A systematic review and meta-analysis

Joint infections cause significant morbidity and mortality. Rapid diagnosis enables prompt initiation of appropriate antimicrobial therapy and surgical treatment. We conducted a systematic review and meta-analysis to evaluate the accuracy of genus- or species-specific polymerase chain reaction (PCR) in diagnosing joint infections. The literature databases were searched for articles from January 2010 to December 2022. The meta-analysis using the split component synthesis (SCS) method, included 20 studies with 2,457 adult participants. The pooled sensitivity, specificity, diagnostic odds ratio, and AUC of PCR were 49 % (95 % CI [37.9-60.2]), 95.7 % (95 % CI [91.6-97.8]), 21.32, and 0.82 respectively. Sensitivity was highest for sonicate fluid and lowest for periprosthetic tissue. The mean turnaround time to results was 4.7 hours (SD 1.1). PCR is a favourable option for diagnosing joint infections due to its rapid results, but it has low sensitivity. To enhance diagnostic yield, the test should be used in conjunction with other methods.

Case Report: Atypical acute compartment syndrome of the forearm in a child following minor trauma with consecutive osteomyelitis

Introduction

Forearm compartment syndrome (CS) in children is above all a clinical diagnosis whose main cause is traumatic. However, rarer causes such as infection can alter its clinical presentation.

Clinical case

An 8-year-old boy has been seen in the emergency department complaining of severe forearm pain under a splint in a mild traumatic context. The previous radiological imaging examination three days before had not revealed any fractures. On admission, he presented with major signs of skin inflammation, loss of mobility, paresthesia and a significant biological inflammatory syndrome. The acute CS diagnosis has been made and was treated, but its atypical presentation raised a series of etiological hypotheses, in particular infectious, even if it remains rare. Complementary imaging examinations confirmed the presence of osteomyelitis of the distal radius as well as an occult Salter-Harris II fracture.

Discussion

Beyond the classic "five P's of CS" -pain, paresthesia, paralysis, pallor and pulselessness-, CS's clinical presentations are multiple, especially in pediatric patients. In children, severe pain and increasing analgesic requirement must be indicators of a CS. We hypothesize that this patient sustained a nondisplaced Salter-Harris II fracture with a hematoma colonized by hematogenous osteomyelitis explaining its initial clinical presentation.

Conclusion

Hematogenous osteomyelitis complicated by CS is rare and may be accompanied by a traumatic history. It's atypical presentation in pediatric patients requires vigilance and prompt diagnosis given the disastrous and irreversible complications.

Appropriate Use of Antibiotic and Principles of Antimicrobial Stewardship in Children

Antibiotics account for over 10% of the overall drug expense of the National Health System in Italy in 2021. Their use in children is of particular interest on one side, because acute infections are very common in children, while they build their immunologic library of competence; on the other side, although many acute infections are expected and turn out to be of viral origin, caregivers will often ask the family doctor or primary care attending to reassure them by prescribing antibiotic treatment, although it may often be unnecessary. The inappropriate prescription of antibiotics in children may likely be a source not only of undue economic burden for the public health system but also of increasing development of antimicrobial resistance (AMR). Based on those issues, the inappropriate use of antibiotics in children should be avoided to reduce the risks of unnecessary toxicity, increase in health costs, lifelong effects, and selection of resistant organisms causing undue deaths. Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure an optimal use of antimicrobials to improve patient outcomes while limiting the risk of adverse events including AMR. The aim of this paper is to spread some concept of good use of antibiotics for pediatricians or every other physician involved in the choice to prescribe, or not, antibiotics in children. Several actions could be of help in this process, including the following: (1) identify patients with high probability of bacterial infection; (2) collect samples for culture study before starting antibiotic treatment if invasive bacterial infection is suspected; (3) select the appropriate antibiotic molecule based on local resistance and narrow spectrum for the suspected pathogen(s); avoid multi-antibiotic association; prescribe correct dosage; (4) choose the best route of administration (oral vs. parenteral) and the best schedule of administration for every prescription (i.e., multiple administration for beta lactam); (5) schedule clinical and laboratory re-evaluation with the aim to consider therapeutic de-escalation; (6) stop antibiotic administration as soon as possible, avoiding the application of "antibiotic course".

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

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

Acute osteoarticular infections in children are frequently forgotten multidiscipline emergencies: beyond the technical skills

Acute osteoarticular infections (AOI) should be treated as top emergencies. The first few days following the inception of infection are ultra-critical to long-term prognosis.A comprehensive road map for management of childhood AOI is still lacking despite recent advances in microbiology and imaging (magnetic resonance imaging). The many faces of childhood AOI warrant a multidiscipline approach to management.Laboratory and imaging findings of are still debatable and should not overshadow or delay a management plan based on the experienced physician's clinical judgment.Ample evidence-based practice supports the use of a few days of intravenous antibiotic administration followed by oral therapy until correlative clinical and basic laboratory (acute phase reactants) results improve.The growing body of evidence on 'high-risk' children/neonates of AOI warrants continual clinical extra-vigilance in identifying these patient subsets.Open drainage and debridement remain the mainstay of treatment of septic hips, whereas for other joints the use of alternative surgical techniques should be individualized or on case-by-case basis.Because the consequences of misdiagnosis of AOI are usually grave and permanent, proactive treatment/overtreatment is justified in the event of unconfirmed but suspicious diagnosis. Cite this article: EFORT Open Rev 2021;6:584-592. DOI: 10.1302/2058-5241.6.200155.

Septic Arthritis: An Evidence-Based Review of Diagnosis and Image-Guided Aspiration

OBJECTIVE. The purpose of this evidence-based review is to equip radiologists to discuss and interpret findings obtained with various imaging modalities, guide patient selection for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both native and prosthetic joints. CONCLUSION. Septic arthritis is an emergency that can lead to rapidly progressive, irreversible joint damage. Despite the urgency associated with this diagnosis, there remains a lack of consensus regarding many aspects of the management of native and periprosthetic joint infections.

Pediatric Septic Arthritis: An Update

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

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.

Epidemiology and Management of Acute Haematogenous Osteomyelitis in a Tertiary Paediatric Center

Background: Paediatric acute hematogenous osteomyelitis (AHOM) is a serious disease requiring early diagnosis and treatment. To review the clinical presentation, management and organisms responsible for AHOM, and to explore risk factors for complicated AHOM, a large cohort referring to a single center over a 6-year period was evaluated. Methods: Data from children with AHOM, hospitalized between 2010 and 2015, and aged > 1 month, were retrospectively collected and analyzed. Results: 121 children (median age 4.8 years; 55.4% males) were included. Fever at onset was present in 55/121 children (45.5%); the lower limb was most frequently affected (n = 68/121; 56.2%). Microbiological diagnosis (by culture and/or polymerase chain reaction (PCR)) was reached in 33.3% cases. Blood and pus/biopsy culture sensitivities were 32.4% and 46.4%, respectively. PCR sensitivity was 3.6% (2/55) on blood, and 66.6% (16/24) on pus/biopsy sample. Staphylococcus aureus was the most commonly identified pathogen (n = 20); no methicillin-resistant Staphylococcus aureus (MRSA) was isolated, 10.0% (n = 2) strains were Panton-Valentine-Leukocidin (PVL) producer; 48.8% (59/121) cases were complicated. At univariate analysis, factors associated with complicated AHOM were: recent fever episode, fever at onset, upper limb involvement, white blood count (WBC) ≥ 12,000/µL, C reactive protein (CRP) ≥ 10 mg/L, S. aureus infection. At multivariate analyses S. aureus infection remained the only risk factor for complicated AHOM (aOR = 3.388 (95%CI: 1.061–10.824); p-value = 0.039). Conclusions: In this study microbiological diagnosis was obtained in over one third of cases. Empiric treatment targeting methicillin-sensitive Staphylococcus aureus seems to be justified by available microbiological data.