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DeFrancesco CJ, VanEenenaam DP, Hall CE, Desai VM, Orellana K, Sankar WN. Aspirations Dashed: Conventional Synovial Fluid Analysis Is Superior to Synovial Fluid and Blood Neutrophil-to-Lymphocyte Ratios in Diagnosing Pediatric Septic Arthritis of the Hip and Knee. J Pediatr Orthop 2024:01241398-990000000-00649. [PMID: 39210527 DOI: 10.1097/bpo.0000000000002785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Recent research suggests that synovial fluid neutrophil-to-lymphocyte ratio (SF-NLR) is a superior diagnostic for pyogenic septic arthritis (SA) in adults compared with synovial fluid white blood cell count (SF-WBC) ≥50,000 cells/μL or ≥90% polymorphonuclear leukocytes (SF-%PMN). Other research also indicates that the neutrophil-to-lymphocyte ratio in the blood (B-NLR) may be of diagnostic significance. However, it is not known whether these findings extend to the pediatric population. METHODS Medical records at a large urban tertiary-care children's hospital were queried for emergency department visits between 2012 and 2023, where synovial fluid (SF) analysis was performed to evaluate for SA of the hip or knee. Patients 18 years old and above were excluded. The "conventional composite test" (CCT) for SA was considered positive if SF analysis showed any of the following: (1) SF-WBC ≥50,000 cells/μL, (2) ≥90% PMNs, or (3) organisms reported on gram stain. Patients with aspirate and/or operating room (OR) cultures (or supplemental testing, ie, nucleic acid identification) revealing an offending organism were considered to have culture-positive septic arthritis (CPSA). The remaining patients were considered culture-negative (CN). Serum and SF test data were analyzed to assess their diagnostic utility in identifying CPSA. Receiver operating characteristic (ROC) curves were examined to compare the predictive value of SF-NLR and B-NLR versus conventional indicators of SA. RESULTS A total of 394 patients met the inclusion criteria. In all, 58.6% (n=231) were male, 67.5% (n=266) involved the knee, and 20.1% (n=79) had CPSA. Those with CPSA had higher ESR and CRP compared with CN patients (P<0.01). Bivariate testing did not show a difference in SF-NLR or B-NLR between those with CPSA and CN patients (P=0.93 and 0.37, respectively). The CCT showed 91% sensitivity and 35% specificity using conventional thresholds. ROC analysis showed that SF-WBC was superior to SF-NLR and B-NLR in the diagnosis of CPSA (AUC=0.71 vs. 0.50 and 0.53, respectively; both P<0.01). Among CCT (+) patients who ended up culture negative, Lyme testing was positive in 48.8% (100/205). CONCLUSION In contrast to adults, SF-NLR and B-NLR were not found to be strong diagnostic indicators of SA of the hip or knee in pediatric patients. This may be because competing diagnoses in children come with systemic inflammatory responses similar to that seen in pyogenic SA, while noninfectious conditions that might represent the major alternate diagnoses in adults do not increase systemic inflammatory markers as significantly. Given the high incidence of Lyme disease seen among patients in this study, this topic should be further studied at pediatric centers outside Lyme-endemic areas to better understand the generalizability of these findings. SIGNIFICANCE Despite excitement regarding SF-NLR and B-NLR as diagnostics for adult SA, these criteria appear less useful in the diagnosis of pyogenic SA in pediatric patients in Lyme-endemic areas.
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Lyons TW, Kahane CG, Nigrovic LE. Managing the Swollen Knee in a Child. Ann Emerg Med 2024:S0196-0644(24)00292-0. [PMID: 38970569 DOI: 10.1016/j.annemergmed.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 07/08/2024]
Affiliation(s)
- Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital/Harvard Medical School, Boston, MA.
| | - Caroline G Kahane
- Division of Emergency Medicine, Boston Children's Hospital/Harvard Medical School, Boston, MA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital/Harvard Medical School, Boston, MA
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Dechnik A, Kahane CG, Nigrovic LE, Lyons TW. Utility of Synovial Fluid Biomarkers for Culture-Positive Septic Arthritis in a Lyme Disease-Endemic Region. Pediatr Emerg Care 2024; 40:e82-e88. [PMID: 38563800 DOI: 10.1097/pec.0000000000003188] [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: 04/04/2024]
Abstract
OBJECTIVE To evaluate the performance of synovial fluid biomarkers to identify children with culture-positive septic arthritis. METHODS We identified children 6 months to 18 years old presenting to a single emergency department between 2007 and 2022 undergoing evaluation for septic arthritis defined by having a synovial fluid culture obtained. Our primary outcome was septic arthritis defined by a positive synovial fluid culture. We evaluated the ability of synovial fluid biomarkers to identify children with septic arthritis using area under the receiver operating characteristic curve (AUC) analyses. We measured the sensitivity and specificity of commonly used synovial fluid biomarkers. RESULTS We included 796 children, of whom 79 (10%) had septic arthritis. Compared with synovial white blood cell count (AUC, 0.72; 95% confidence interval [CI], 0.65-0.78), absolute neutrophil count (AUC, 0.72; 95% CI, 0.66-0.79; P = 0.09), percent neutrophils (AUC, 0.66; 95% CI, 0.60-0.71; P = 0.12), and glucose (AUC, 0.78; 95% CI, 0.67-0.90; P = 0.33) performed similarly, whereas protein (AUC, 0.52; 95% CI, 0.40-0.63, P = 0.04) had lower diagnostic accuracy. Synovial fluid white blood cell count ≥50,000 cells/μL had a sensitivity of 62.0% (95% CI, 50.4%-72.7%) and a specificity of 67.0% (95% CI, 63.4%-70.4%), whereas a positive synovial fluid Gram stain had a sensitivity of 48.1% (95% CI, 36.5%-59.7%) and specificity of 99.1% (95% CI, 98.1%-99.7%) for septic arthritis. CONCLUSIONS None of the routinely available synovial fluid biomarkers had sufficient accuracy to be used in isolation in the identification of children with septic arthritis. New approaches including multivariate clinical prediction rules and novel biomarkers are needed.
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Affiliation(s)
- Andzelika Dechnik
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University, New York, NY
| | - Caroline G Kahane
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Zhang J, Stevenson A, Zhou AK, Khan F, Geetala R, Krkovic M. The accuracy and diagnostic value of gram staining joint aspirates in suspected joint infections. Hip Int 2024; 34:546-552. [PMID: 38414226 PMCID: PMC11264559 DOI: 10.1177/11207000241230927] [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: 07/19/2023] [Accepted: 01/13/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Septic arthritis is a debilitating condition with prolonged treatment and adverse outcomes. A gram stain is often performed from the joint aspirate sample, followed by a definitive culture. In our study, we assessed the accuracy of gram staining for suspected septic arthritis and explored factors associated with positive culture growth and false negatives in the gram stain. METHODS We retrospectively reviewed joint aspirates performed from 2015-2021 at a major trauma centre. Aspirates not cultured for septic arthritis were excluded. Data collected included aspirate site, gram stain and culture result delay, patient demographics, orthopaedic/rheumatological history, and comorbidities. Outcomes measured were gram stain sensitivity and specificity. Factors influencing positive cultures and false negative gram stain results were analysed using logistic regression. RESULTS Of 408 joint aspirates meeting the criteria, 37 did not undergo initial gram staining. Gram stain sensitivity was 30.4%, specificity was 97.6%. The delay from aspirate to definitive gram stain and culture results was 1.1 and 5.4 days, respectively Logistic regression identified that prosthetic joint(p = 0.007), past joint infections(p = 0.006), arthritis(p < 0.001), hypertension(p = 0.007), diabetes(p = 0.019) were positively associated with positive cultures. Past joint infections(p = 0.004) were positively associated with false negative gram stain results. Patients on antibiotics during the aspirate had a higher risk of false negative gram stain results (OR = 5.538, 95%CI, 2.802-10.948; p < 0.001). CONCLUSIONS In conclusion, the initial gram stain has limited sensitivity and caution should be exercised when interpreting negative results. Vigilance is crucial when the highlighted comorbidities or antibiotic use are present, to assess patients with potential joint infections.
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Affiliation(s)
- James Zhang
- Clinical School of Medicine, University of Cambridge, Cambridge, England, UK
- Addenbrooke’s Hospital, Cambridge, England, UK
- Basildon University Hospital, Basildon, England, UK
| | - Anna Stevenson
- Clinical School of Medicine, University of Cambridge, Cambridge, England, UK
- Addenbrooke’s Hospital, Cambridge, England, UK
| | | | - Faris Khan
- Clinical School of Medicine, University of Cambridge, Cambridge, England, UK
| | - Rahul Geetala
- Clinical School of Medicine, University of Cambridge, Cambridge, England, UK
- Addenbrooke’s Hospital, Cambridge, England, UK
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Woods CR, Bradley JS, Chatterjee A, Kronman MP, Arnold SR, Robinson J, Copley LA, Arrieta AC, Fowler SL, Harrison C, Eppes SC, Creech CB, Stadler LP, Shah SS, Mazur LJ, Carrillo-Marquez MA, Allen CH, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics. J Pediatric Infect Dis Soc 2024; 13:1-59. [PMID: 37941444 DOI: 10.1093/jpids/piad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee Health Sciences Center College of Medicine Chattanooga, Chattanooga, Tennessee
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, School of Medicine, and Rady Children's Hospital, San Diego, California
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Antonio C Arrieta
- Division of Infectious Diseases, Children's Hospital of Orange County and University of California, Irvine, California
| | - Sandra L Fowler
- Division of Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas
| | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada
- University of Montreal Research Center, Montreal, Quebec, Canada
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Dey M, Al-Attar M, Peruffo L, Coope A, Zhao SS, Duffield S, Goodson N. Assessment and diagnosis of the acute hot joint: a systematic review and meta-analysis. Rheumatology (Oxford) 2023; 62:1740-1756. [PMID: 36264140 PMCID: PMC10152293 DOI: 10.1093/rheumatology/keac606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/15/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Prompt diagnosis of septic arthritis (SA) in acute native hot joints is essential for avoiding unnecessary antibiotics and hospital admissions. We evaluated the utility of synovial fluid (SF) and serum tests in differentiating causes of acute hot joints. METHODS We performed a systematic literature review of diagnostic testing for acute hot joints. Articles were included if studying ≥1 serum or SF test(s) for an acute hot joint, compared with clinical assessment and SF microscopy and culture. English-language articles only were included, without date restriction. The following were recorded for each test, threshold and diagnosis: sensitivity, specificity, positive/negative predictive values and likelihood ratios. For directly comparable tests (i.e. identical fluid, test and threshold), bivariate random-effects meta-analysis was used to pool sensitivity, specificity, and areas under the curves. RESULTS A total of 8443 articles were identified, and 49 were ultimately included. Information on 28 distinct markers in SF and serum, differentiating septic from non-septic joints, was extracted. Most had been tested at multiple diagnostic thresholds, yielding a total of 27 serum markers and 156 SF markers. Due to heterogeneity of study design, outcomes and thresholds, meta-analysis was possible for only eight SF tests, all differentiating septic from non-septic joints. Of these, leucocyte esterase had the highest pooled sensitivity [0.94 (0.70, 0.99)] with good pooled specificity [0.74 (0.67, 0.81)]. CONCLUSION Our review demonstrates many single tests, individually with diagnostic utility but suboptimal accuracy for exclusion of native joint infection. A combination of several tests with or without a stratification score is required for optimizing rapid assessment of the hot joint.
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Affiliation(s)
- Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Rheumatology, Queen Elizabeth Hospital, London, UK
| | | | - Leticia Peruffo
- School of Medicine, Federal University of Parana, Curitiba, Brazil
| | - Ashley Coope
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sizheng Steven Zhao
- Versus Arthritis Centre for Epidemiology, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Stephen Duffield
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Nicola Goodson
- Department of Rheumatology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Diagnostic Utility of Synovial Fluid Cell Counts and CRP in Pediatric Knee Arthritis: A 10-Year Monocentric, Retrospective Study. CHILDREN 2022; 9:children9091367. [PMID: 36138676 PMCID: PMC9498181 DOI: 10.3390/children9091367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022]
Abstract
Background: Orthopedic surgeons often use the intra-articular white blood counts (WBCs) and the percentage of polymorphonuclear cells (PMN) in the diagnosis of an acute swollen and painful knee joint in children. Today, there is no established threshold for the synovial WBC, and their differentiation, as indicative of native joint knee bacterial arthritis. We determine the sensitivity and specificity of synovial WBCs and PMN percentages in the prediction of a community-acquired, acute bacterial native joint septic arthritis (SA) in the pediatric population. Methods: A retrospective study on healthy children 0–16 years of age who underwent knee joint aspiration for a community-acquired, acute irritable knee effusion in our tertiary-care children’s hospital between May 2009 and April 2019 was conducted. We divided the study population into two groups according to the detection of bacterial arthritis in the synovial fluid (bacterial arthritis versus its absence) and compared the intra-articular leukocyte and C-reactive protein (CRP) levels. Results: Overall, we found a statistically significant difference regarding the total CRP (p = 0.017), leukocyte or PMN counts (p ≤ 0.001 in favor of a bacterial arthritis). In contrast, the percentage of the neutrophils was not determinant for the later confirmation of bacterial pathogens, and we were unable to establish diagnostically determining minimal thresholds of the intra-articular CRP and leukocyte levels. Conclusions: This pilot study suggests that either the leukocyte or PMN counts may be associated with a bacterial origin of knee arthritis in children. We plan a larger prospective interventional study in the future to confirm these findings including the investigation of other joint aspirate biomarkers.
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Al-Tawil K, Quiney F, Pirkis L, Birkett N, Rooney A. Gram stain microscopy in septic arthritis. Acta Orthop Belg 2021. [DOI: 10.52628/87.3.23] [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
Septic arthritis is a serious condition that can lead to rapid destruction of joint if it is not rapidly diagnosed and treated appropriately. The reported annual incidence is 10 in 100 000 although this increases to 70 in 100 000 in those with risk factors for developing septic arthritis mainly rheumatoid arthritis and immune-compromised patients. The aim of this study is to examine the sensitivity and specificity, and thus the clinical usefulness, of gram stain results. This was a single centre, retrospective case series. All joint aspirates over a three year period from May 2015 to April 2018 were reviewed. The gram stain and final culture results noted. 830 samples were included from both native and replaced joints. Native joints accounted for a total of 701 cases (84%) of the aspirates, whilst those obtained from prosthetic joints 129 (16%). In 74 (9%) cases there was a discrepancy between the gram stain and culture results. The sensitivity of the gram stain in this case series is 22% and the specificity of the test is 99.6%. The clinician should have a low threshold for overlooking a negative gram stain result and place greater emphases on the clinical findings in conjunction with biochemical markers.
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El-Sobky T, Mahmoud S. Acute osteoarticular infections in children are frequently forgotten multidiscipline emergencies: beyond the technical skills. EFORT Open Rev 2021; 6:584-592. [PMID: 34377550 PMCID: PMC8335954 DOI: 10.1302/2058-5241.6.200155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Tamer El-Sobky
- Division of Paediatric Orthopaedics, Department of Orthopaedic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Shady Mahmoud
- Division of Paediatric Orthopaedics, Department of Orthopaedic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Kolbeck L, Haertlé M, Graulich T, Ettinger M, Suero EM, Krettek C, Omar M. Leukocyte Esterase and Glucose Reagent Test Can Rule in and Rule out Septic Arthritis. In Vivo 2021; 35:1625-1632. [PMID: 33910845 DOI: 10.21873/invivo.12420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/11/2021] [Accepted: 02/02/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Septic arthritis (SA) requires rapid diagnosis and therapy to avoid joint damage. This study evaluated the diagnostic accuracy of leukocyte esterase (LE) and glucose (GLC) strip tests for diagnosing SA. PATIENTS AND METHODS Synovial fluids from 455 patients with atraumatic joint effusions were assessed prospectively over a 5-year period with LE and glucose strip tests. Results were compared to modified Newman criteria for diagnosing joint infections. Synovial fluid cultures, crystal, blood and synovial cell analyses were also performed. RESULTS Forty-one patients had SA and 252 non-SA. A positive LE reading combined with negative glucose reading could detect SA with 100% specificity, 85% sensitivity, 100% positive predictive value (PPV) and 98% negative predictive value (NPV). Positive synovial LE reading alone detected SA with 82% specificity, 95% sensitivity, 47% PPV, and 99% NPV. CONCLUSION Combined LE and glucose strip tests represent a low-cost tool for rapidly diagnosing or ruling out SA.
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Affiliation(s)
- Louisa Kolbeck
- Trauma Department, Hannover Medical School, Hannover, Germany;
| | - Marco Haertlé
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Tilman Graulich
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Max Ettinger
- Orthopedic Surgery Department, Hannover Medical School, Hannover, Germany
| | - Eduardo M Suero
- Department of General Trauma and Reconstructive Surgery, Ludwig-Maximilians-University, Munich, Germany
| | | | - Mohamed Omar
- Trauma Department, Hannover Medical School, Hannover, Germany
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Swarup I, Meza BC, Weltsch D, Jina AA, Lawrence JT, Baldwin KD. Septic Arthritis of the Knee in Children: A Critical Analysis Review. JBJS Rev 2021; 8:e0069. [PMID: 32105243 DOI: 10.2106/jbjs.rvw.19.00069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» 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.
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Affiliation(s)
- Ishaan Swarup
- UCSF Benioff Children's Hospital, Oakland, California
| | - Blake C Meza
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel Weltsch
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - John T Lawrence
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Keith D Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Shin CH, Lim C, Kim TS, Choi EH, Cho TJ, Choi IH, Yoo WJ. Effective and Rapid Microbial Identification in Pediatric Osteoarticular Infections Using Blood Culture Bottles. J Bone Joint Surg Am 2020; 102:1792-1798. [PMID: 33086346 DOI: 10.2106/jbjs.20.00219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The detection and identification of pathogenic microorganisms are essential for the treatment of osteoarticular infection. However, obtaining a sufficient amount of specimen from pediatric patients is often difficult. Herein, we aimed to demonstrate the effectiveness of the blood culture bottle (BCB) system in pediatric osteoarticular infections. We hypothesized that our BCB culture method is superior to the conventional swab and tissue culture methods in terms of required specimen size, incubation time, and microbial identification rate. METHODS We analyzed the prospectively collected data of pediatric patients who underwent surgical treatment for osteoarticular infections between August 2016 and October 2019. Four needles were dipped in the infected fluid or tissue during the surgical procedure as soon as the infected area was exposed and were used to inoculate 2 aerobic pediatric BCBs and 2 anaerobic general BCBs. We also collected 2 conventional swab samples and 2 tissue samples from the identical area. The microbial identification rate and the time required for identification were compared between BCB, swab, and tissue cultures. RESULTS Forty patients constituted the study group; 13 patients had osteomyelitis, 17 patients had septic arthritis, and 10 patients had both. Of these 40 patients, the microbial identification rate was higher with BCB cultures (27 [68%]) than with swab cultures (18 [45%]; p = 0.004) or tissue cultures (15 [38%]; p < 0.001). Nine samples (9 patients [23%]) were only positive in the BCB culture. Positive microbial growth was not detected with conventional culture methods when microorganisms did not grow on the BCB culture. Compared with swab culture (4.3 ± 1.1 days; p < 0.001) or tissue culture (4.4 ± 1.1 days; p < 0.001), the BCB culture reduced the time required for microbial identification (3.5 ± 0.9 days). CONCLUSIONS In pediatric osteoarticular infections, the BCB culture system improved the microbial identification rate, reduced the time to identification, and permitted a smaller-volume specimen, compared with traditional culture systems. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chang Ho Shin
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Chaemoon Lim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, Republic of Korea
| | - Taek Soo Kim
- Department of Laboratory Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Hwa Choi
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Tae-Joon Cho
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - In Ho Choi
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Won Joon Yoo
- Divisions of Pediatric Orthopaedics (C.H.S., T.-J.C., I.H.C., and W.J.Y.), and Pediatrics (E.H.C.), Seoul National University Children's Hospital, Seoul, Republic of Korea
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Swarup I, LaValva S, Shah R, Sankar WN. Septic Arthritis of the Hip in Children: A Critical Analysis Review. JBJS Rev 2020; 8:e0103. [PMID: 32224630 DOI: 10.2106/jbjs.rvw.19.00103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Septic arthritis of the hip is a common and potentially devastating condition in children. Septic arthritis is most commonly caused by Staphylococcus aureus, but other pathogens should be considered on the basis of patient age and presence of risk factors. Diagnosis of septic arthritis is based on history and physical examination, laboratory tests, radiographs, ultrasound, and arthrocentesis. Treatment comprises empiric antibiotics and joint debridement, and antibiotics are subsequently tailored on the basis of culture data, local resistance patterns, and clinical response. Late sequelae of septic arthritis include osteonecrosis, chondrolysis, growth disturbance, subluxation or dislocation, and progressive ankylosis. Surgical treatments to address these issues have been described.
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Affiliation(s)
- Ishaan Swarup
- UCSF Benioff Children's Hospital, Oakland, California
| | - Scott LaValva
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ronit Shah
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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14
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Vanderhave K, Cho RH, Liu R. What's New in Pediatric Orthopaedic Surgery. J Bone Joint Surg Am 2020; 102:275-282. [PMID: 31804237 DOI: 10.2106/jbjs.19.01143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Robert H Cho
- Shriners for Children Medical Center, Los Angeles, California
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15
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Abstract
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.
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16
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Bolboacă SD. Medical Diagnostic Tests: A Review of Test Anatomy, Phases, and Statistical Treatment of Data. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2019; 2019:1891569. [PMID: 31275427 PMCID: PMC6558629 DOI: 10.1155/2019/1891569] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 04/25/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022]
Abstract
Diagnostic tests are approaches used in clinical practice to identify with high accuracy the disease of a particular patient and thus to provide early and proper treatment. Reporting high-quality results of diagnostic tests, for both basic and advanced methods, is solely the responsibility of the authors. Despite the existence of recommendation and standards regarding the content or format of statistical aspects, the quality of what and how the statistic is reported when a diagnostic test is assessed varied from excellent to very poor. This article briefly reviews the steps in the evaluation of a diagnostic test from the anatomy, to the role in clinical practice, and to the statistical methods used to show their performances. The statistical approaches are linked with the phase, clinical question, and objective and are accompanied by examples. More details are provided for phase I and II studies while the statistical treatment of phase III and IV is just briefly presented. Several free online resources useful in the calculation of some statistics are also given.
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Affiliation(s)
- Sorana D. Bolboacă
- Department of Medical Informatics and Biostatistics, Iuliu Hațieganu University of Medicine and Pharmacy Cluj-Napoca, Louis Pasteur Str., No. 6, 400349 Cluj-Napoca, Romania
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