Osteomyelitis and septic arthritis in children: current concepts

Multi-disciplinary management of neonatal acute osteomyelitis of jaws: A report of 2 cases

Background

Early diagnosis of neonatal osteomyelitis is often challenging due to the rarity of such cases and here we are presenting 2 case reports to add to the existing deficient literature. Case 1: A 15-day-old male infant presented with swelling and pus discharge from the anterior region of the mandible. Repeated culture and sensitivity tests revealed a transition from disseminated methicillin-sensitive S. aureus sepsis to methicillin-resistant sepsis. Moreover, there was swelling of the left elbow and right thigh. The Clinical diagnosis made was acute osteomyelitis of mandible associated with disseminated neonatal sepsis (LONS). A multidisciplinary approach was taken for the management by surgical debridement of the lesion alongwith removal of associated primary tooth buds, under specific antibiotic coverage. Case 2: A 20-day old male infant reported with pus discharge from upper lateral region of mouth past 10days. Personal history revealed, abscess in mother's right breast. A soft fluctuant pus pocket with draining sinus was present w.r.t.alveolar region of 54. CT revealed an osteolytic lesion of labial cortex of alveolar ridge in maxillary right first molar region. Pus specimen culture and sensitivity revealed growth of Staphylococcus aureus (MSSA). The clinical diagnosis of acute osteomyelitis of maxillawas made. Initially, antibiotics were prescribed which did not help and finally, surgical debridement accompanied by extraction of 54 tooth bud was done.

Conclusion

Acute osteomyelitis should always be considered as one of the differentials in infants with clinical signs of sepsis and Multidisciplinary management should be assured for the successful management of such cases.

Developing a nomogram for predicting acute complicated course in pediatric acute hematogenous osteomyelitis

BACKGROUND

The objective of this study was to develop and validate a nomogram for predicting the risk of an acute complicated course in pediatric patients with Acute Hematogenous Osteomyelitis (AHO).

METHODS

A predictive model was developed based on a dataset of 82 pediatric AHO patients. Clinical data, imaging findings, and laboratory results were systematically collected for all patients. Subsequently, biomarker indices were calculated based on the laboratory results to facilitate a comprehensive evaluation. Univariate and multivariate logistic regression analyses were conducted to identify factors influencing early adverse outcomes in AHO. A nomogram model was constructed based on independent factors and validated internally through bootstrap methods. The discriminative ability, calibration, and clinical utility of the nomogram model were assessed using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA), respectively. The developed nomogram model was compared with previously published A-score and Gouveia scoring systems.

RESULTS

Logistic regression analysis identified delayed source control, suppurative arthritis, albumin on admission, and platelet to lymphocyte ratio (PLR) as independent predictors of early adverse outcomes in pediatric AHO patients. The logistic regression model was formulated as: Log(P) = 7. 667-1.752 × delayed source control - 1.956 × suppurative arthritis - 0.154 × albumin on admission + 0.009 × PLR. The nomogram's AUC obtained through Bootstrap validation was 0.829 (95% CI: 0.740-0.918). Calibration plots showed good agreement between predictions and observations. Decision curve analysis demonstrated that the model achieved net benefits across all threshold probabilities. The predictive efficacy of our nomogram model for acute complicated course in pediatric AHO patients surpassed that of the A-score and Gouveia scores.

CONCLUSIONS

A predictive model for the acute complicated course of pediatric AHO was established based on four variables: delayed source control, suppurative arthritis, albumin on admission, and PLR. This model is practical, easy to use for clinicians, and can aid in guiding clinical treatment decisions.

Clinical characteristics of neonatal and infant osteomyelitis and septic arthritis: a multicenter retrospective study

OBJECTIVE

Signs and symptoms of osteomyelitis or septic arthritis in neonates and infants are often nonspecific and early-stage bone infections in infants may often go unnoticed. The objective of this study was to analyze the clinical characteristics of newborns and infants with osteomyelitis and septic arthritis to improve understanding of the disorder and to assist clinicians with diagnosis.

METHODS

A retrospective multicenter study was conducted on neonates (0-28 days old, n = 94) and infants (1-12 months old, n = 415) with osteoarticular infections. Data consisting of clinical characteristics, complications, laboratory outcomes, and the pathogenic microorganisms causing osteomyelitis were tabulated. The statistics were further broken down into two regions and the significant differences between neonates and infants were evaluated and compared to the literature.

RESULTS

Compared to infants, neonates had significantly lower incidences of fever (p < 0.0001), higher incidences of localized swelling (p = 0.0021), higher rate of infection at the humerus (p = 0.0016), higher percentage of Escherichia coli (p < 0.0001) and Klebsiella pneumoniae (p = 0.0039) infections, lower percentage of Staphylococcus aureus infections (p < 0.0001) and were more likely to develop septic arthritis (p < 0.0001).

CONCLUSION

Distinct differences were found between neonatal and infants with osteoarticular infections. Future studies should focus on improving diagnosis and subsequent treatment regimens for younger age groups.

Ultrasonography for the Detection of Osteomyelitis in Pediatric Patients With Soft Tissue Infection: A Pilot Study

OBJECTIVES

To demonstrate the usefulness of ultrasonography for differentiating soft tissue infections with or without osteomyelitis in pediatric patients who underwent ultrasonography and subsequent magnetic resonance imaging (MRI).

METHODS

Twenty-three patients were classified into 2 groups: 12 patients with and 11 patients without osteomyelitis based on MRI. Osteomyelitis using ultrasound is characterized by the presence of bone cortex irregularity and/or subperiosteal abscess formation. The diagnostic performance of ultrasonography for detecting osteomyelitis and subperiosteal abscess formation was compared with that of MRI. Diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were calculated with 95% confidence intervals (CIs).

RESULTS

Of 12 osteomyelitis cases, 11 had abnormal bone marrow enhancement (one residual case did not undergo contrast enhancement study) and 5 had subperiosteal abscesses. The diagnostic accuracy of ultrasonography for osteomyelitis was 82.6% (number of correct diagnosis of osteomyelitis/total number = 19/23; 95% CI, 61.2-95.0) and for detecting periosteal abscess was 95.7% (number of correct diagnosis of periosteal abscess/total number = 22/23; 95% CI, 78.1-99.9), respectively. The sensitivity and specificity of ultrasonography for detecting osteomyelitis were 66.7% (95% CI, 34.9-90.1) and 100% (95% CI, 71.5-100), respectively. The sensitivity and specificity of ultrasonography for detecting periosteal abscess were 80% (95% CI, 28.4-99.5), and 100% (95% CI, 81.5-100), respectively. One-third of osteomyelitis cases could not be detected using ultrasonography.

CONCLUSIONS

Ultrasonography may be useful for diagnosing osteomyelitis in pediatric patients; however, the technique appears limited by low sensitivity. However, it is more accurate for diagnosis of periosteal abscess in these patients.

Navigating the Enigma of Pediatric Musculoskeletal Infections: A Race Against Time

Musculoskeletal infection (MSKI) in children is a critical condition in pediatric orthopedics due to the potential for serious adverse outcomes, including multiorgan dysfunction syndrome, which can lead to death. The diagnosis and treatment of MSKI continue to evolve with advancements in infectious organisms, diagnostic technologies, and pharmacologic treatments. It is imperative for pediatric orthopedic surgeons and medical teams to remain up to date with the latest MSKI practices.

Trimethoprim-Sulfamethoxazole for Pediatric Osteoarticular Infections

BACKGROUND

Trimethoprim-sulfamethoxazole (TMP-SMX) is active against most Staphylococcus aureus isolates but is not widely used for the treatment of pediatric osteoarticular infections.

METHODS

This was a comparative effectiveness study of hospitalized patients ≤18 years treated with TMP-SMX vs. other antibiotic regimens for acute osteoarticular infections between 2016 and 2021 at 3 hospitals using inverse probability of treatment weighted propensity score analysis. The primary outcome was treatment failure, a composite of unanticipated emergency department (ED) or outpatient visits, hospital readmissions, extension, or change of antibiotic therapy due to inadequate clinical response, or death, all within 6 months after completing antibiotics. The secondary outcome was antibiotic-associated adverse events (AEs) within 6 months. The exposed group for the treatment failure analysis included children who received ≥7 days of TMP-SMX and did not experience treatment failure while on another antibiotic. Children receiving at least 1 dose of TMP-SMX were the exposed group for the AE analysis.

RESULTS

One-hundred and sixteen patients met eligibility criteria; 26 (22.4%) patients were classified into the TMP-SMX cohort and 90 (77.6%) into the other antibiotics cohort (most commonly clindamycin, vancomycin, and cefazolin). There was no significant difference in treatment failure between TMP-SMX and other antibiotics (43% vs. 19%; 95% CI .9-10.4). More patients in the TMP-SMX cohort experienced an unplanned ED or outpatient visit (OR 4.8, 95% CI 1.3-17.8). There was no difference in hospital readmission, antibiotic change, or duration extension. Exposure to TMP-SMX was associated with more AEs (41% vs. 19%, P = .012).

CONCLUSIONS

Treatment with TMP-SMX was not associated with greater clinical failure but was associated with more AEs compared to alternative agents for the treatment of pediatric acute osteoarticular infections.

Clinical study of drug-loaded calcium sulfate in the treatment of hematogenous osteomyelitis in children

BACKGROUND

At present, good results have been obtained in the treatment of hematogenous osteomyelitis(HO) in children by the use of drug-loaded calcium sulfate, but there are few clinical studies reported. The aim of this study was to investigate the clinical efficacy of radical debridement combined with drug-laden calcium sulphate antibiotics in paediatric haematogenous osteomyelitis.

METHODS

In this study, we retrospectively analyzed the clinical data of 15 cases of pediatric hematogenous osteomyelitis admitted to our hospital in recent years. A total of 15 pediatric patients with HO treated in our hospital from January 2018 to February 2022 were included for evaluation.

RESULTS

All 15 patients were treated with drug-laden calcium sulfate, and the antibiotic of choice was vancomycin in 14 cases and vancomycin combined with gentamicin in 1 case. The follow-up period ranged from 12 to 36 months, with a mean follow-up time of 24.73 months, and all children were treated with drug-laden calcium sulfate with satisfactory clinical outcomes. The results of serological examination showed that the preoperative white blood cell count level, C-reactive protein and erythrocyte sedimentation rate were higher than the postoperative ones, and the differences were statistically significant (P < 0.05).After the operation, referring to the treatment standard of McKee's osteomyelitis, 15 cases were cured without recurrence; According to the Lower Extremities Functional Scale, 12 cases were excellent, 2 cases were good and 1 case was moderate, with an excellent rate of 93.33%. Children with lower limb involvement could walk with full weight bearing, and gait was basically normal.

CONCLUSION

Drug-loaded calcium sulfate is a good therapeutic method for the treatment of hematogenous osteomyelitis in children, with a effect of reducing complications and reducing recurrence.

What's New in Pediatric Septic Arthritis? A Review of Pertinent Clinical Questions

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.

Management of transient bone osteoporosis: a systematic review

INTRODUCTION

Transient bone osteoporosis (TBO) is characterized by persistent pain, loss of function, no history of trauma and magnetic resonance image (MRI) findings of bone marrow edema.

SOURCE OF DATA

PubMed, Google scholar, EMABSE and Web of Science were accessed in February 2023. No time constrains were used for the search.

AREAS OF AGREEMENT

TBO is rare and misunderstood, typically affecting women during the third trimester of pregnancy or middle-aged men, leading to functional disability for 4-8 weeks followed by self-resolution of the symptoms.

AREAS OF CONTROVERSY

Given the limited evidence in the current literature, consensus on optimal management is lacking.

GROWING POINTS

This systematic review investigates current management of TBO.

AREAS TIMELY FOR DEVELOPING RESEARCH

A conservative approach leads to the resolution of symptoms and MRI findings at midterm follow-up. Administration of bisphosphonates might alleviate pain and accelerate both clinical and imaging recovery.

Meta-analysis of serum procalcitonin diagnostic test accuracy for osteomyelitis and septic arthritis in children

The purpose of this study was to evaluate the sensitivity, specificity, and predictive value of serum procalcitonin (PCT) for osteomyelitis and septic arthritis in children. PubMed, EMBase, and Cochrane Library were searched until 10 August 2021, for eligible literature focusing on PCT for the diagnosis of osteomyelitis and septic arthritis. Four articles with six studies were included in the diagnostic meta-analysis, a total of 654 children were examined for bacterial cultures in PCT, osteomyelitis, and septic arthritis. The results of diagnostic meta-analysis showed that the PCT had a sensitivity of 0.72, 95% confidence interval (CI) (0.65-0.79), specificity of 0.90, 95% CI (0.87-0.93), positive likelihood ratio (LR) of 3.87, 95% CI (2.53-5.90), negative LR of 0.39, 95% CI (0.22-0.70), and diagnostic odds ratio was 13.13, 95% CI (6.46-26.66), for the detection of osteomyelitis and septic arthritis using bacterial culture as the gold standard. Based on the summary receiver operating characteristic curve of PCT, it was found that the area under the curve of PCT was 0.88. In the evaluation of publication bias, the result of the regression line test showed that there was not publication bias (bias = 13.72; 95% CI, -1.84 to 29.28; P = 0.07). This study provided systematic review of the published literature on the diagnosis of osteomyelitis and septic arthritis in children using PCT, which may serve as a biomarker for diagnosis of osteomyelitis, but it has no direct evidences to support the diagnosis of septic arthritis. However, the specific optimal cutoff value of PCT and specific population still needed to be verified by large sample studies.

Biological Predictors of Osteoarticular Infection Due to K. kingae-A Retrospective Cohort Study of 247 Cases

Pediatric osteoarticular infections (OAIs) are serious conditions that can lead to severe septic complications, prolonged morbidity with long-term impaired function, and perturbed subsequent bone development. Kingella kingae (K. kingae) is currently accepted as the predominant pathogen in pediatric OAIs, especially among 6-48 month olds. The present study aimed to identify clinical and biological markers that would refine the detection of patients with an OAI due to K. kingae. We retrospectively studied every consecutive case of pediatric OAI admitted to our institution over 17 years. Medical records were examined for patient characteristics such as temperature at admission, affected segment, and biological parameters such as white blood cell (WBC) count, left shift, platelet count (PLT), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). The 247 patients included 52.2% males and 47.8% females and mean age was 18.5 ± 10 months old. Four patients were older than 48 months; none were younger than 6 months old. Mean temperature at admission was 37.4 ± 0.9 °C. Regarding biological parameters, mean WBC count was 12,700 ± 4180/mm3, left shift was only present in one patient, mean PLT was 419,000 ± 123,000/mm3, mean CRP was 26.6 ± 27.8 mg/L, and mean ESR was 35.0 ± 18.9 mm/h. Compared to the modified predictors of OAI defined by Kocher and Caird, 17.2% of our cases were above their cut-off values for temperature, 52.3% were above the WBC cut-off, 33.5% were above the ESR cut-off, and 46.4% were above the CRP cut-off. OAIs due to K. kingae frequently remain undetected using the classic biological parameters for investigating bacterial infections. As an addition to the predictors normally used (°C, WBC, CRP, and ESR), this study found that elevated platelet count was frequently present during OAIs caused by K. kingae. Although this biological characteristic was inconstant, its presence was highly significant and very suggestive of an invasive infection due to K. kingae.

Clinical and Radiographic Outcomes and Treatment Algorithm for Septic Arthritis in Children

BACKGROUND

Septic arthritis (SA) in children is an acute inflammatory disease of the joints. If not treated promptly, it could become a surgical emergency. The incidence of the disease in children in Europe is approximately 2-7 per 100,000 children. The aim of this systematic review was to investigate which of these treatments-arthrocentesis, arthrotomy, and arthroscopy-provides better results in children and when to use them.

METHODS

Three independent authors conducted a systematic review of PubMed, ScienceDirect, and MEDLINE databases to assess studies with any level of evidence that reported the surgical outcome of SA. Two senior investigators evaluated and approved each stage's findings.

RESULTS

A total of 488 articles were found. After screening, we chose 24 articles that were suitable for full-text reading based on the inclusion and exclusion criteria. The results of our analysis showed that there are no numerically significant differences reported in the literature on clinical and radiographic outcomes by surgical technique.

CONCLUSIONS

We developed an algorithm that could be used if septic arthritis is suspected. Based on our results, the surgical technique to be used will depend on the operator who will perform it.

In vitro Activity of Ceftaroline Against an International Collection of Kingella kingae Isolates Recovered From Carriers and Invasive Infections

BACKGROUND

Improvements in blood culture techniques and molecular-based diagnostics have led to increased recognition of Kingella kingae as an invasive human pathogen causing bacteremia, septic arthritis, osteomyelitis and endocarditis in young children. Serious disease and potentially life-threatening complications of infection due to K. kingae necessitate timely identification and appropriate antimicrobial therapy. Ceftaroline is a fifth-generation broad spectrum cephalosporin that possesses activity against Gram-negative and Gram-positive pathogens similar to third-generation cephalosporins, but also includes methicillin-resistant Staphylococcus aureus . This study reports the in vitro activity of ceftaroline and comparator agents against an international collection of K. kingae isolates.

METHODS

A collection of 308 K. kingae isolates was obtained primarily from children with bacteremia, endocarditis, osteoarticular infections or from asymptomatic pediatric carriers. Isolates were tested for antibiotic susceptibility using Clinical and Laboratory Standard Institute broth microdilution methodology and screened for β-lactamase production using a nitrocefin chromogenic test.

RESULTS

Ceftaroline inhibited all K. kingae isolates at ≤0.06 mg/L (MIC 50/90 , 0.015/0.03 mg/L). Ceftaroline MICs were similar to results with ceftriaxone (MIC 50/90 , 0.015/0.015 mg/L), meropenem (MIC 50/90 , 0.015/0.015 mg/L) and ampicillin-sulbactam (MIC 50/90 , 0.06/0.06 mg/L). Ceftaroline MICs were slightly lower than MICs for cefuroxime and amoxicillin/clavulanate (MIC 50/90 , 0.06/0.12 mg/L). MICs were high for clindamycin (MIC 50/90 , 2/4 mg/L) and oxacillin (MIC 50/90 , 4/8 mg/L). Sixteen isolates (5.2%) yielded a positive nitrocefin test indicating production of β-lactamase; ceftaroline demonstrated equivalent MICs against β-lactamase - positive and β-lactamase - negative strains (MIC 50/90 , 0.015/0.3 mg/L).

CONCLUSIONS

The potent activity of ceftaroline against this large international collection of K. kingae isolates supports further clinical evaluation in children.

Impact of guidelines implementation on empiric antibiotic treatment for pediatric uncomplicated osteomyelitis and septic arthritis over a ten-year period: Results of the ELECTRIC study (ostEomyeLitis and sEptiC arThritis tReatment in children)

Background

Due to the growing evidence of the efficacy of intravenous (IV) cefazolin with an early switch to oral cefalexin in uncomplicated pediatric osteomyelitis (OM) and septic arthritis (SA) in children, we changed our guidelines for empiric antibiotic therapy in these conditions. This study aims at evaluating the impact of the guidelines' implementation in reducing broad-spectrum antibiotic prescriptions, duration of IV antibiotic treatment and hospital stay, treatment failure and recurrence.

Materials and methods

This is a retrospective, observational, quasi-experimental study. The four years pre-intervention were compared to the six years, ten months post-intervention (January 2012, through December 2015; January 2016, through October 31st, 2022). All patients aged 3 months to 18 years with OM or SA were evaluated for inclusion. Each population was divided into three groups: pre-intervention, post-intervention not following the guidelines, and post-intervention following the guidelines. Differences in antibiotic prescriptions such as Days of Therapy (DOT), activity spectrum and Length of Therapy (LOT), length of hospital stay (LOS), broad-spectrum antibiotics duration (bsDOT), treatment failure and relapse at six months were analyzed as outcomes.

Results

Of 87 included patients, 48 were diagnosed with OM (8 pre-intervention, 9 post-intervention not following the guidelines and 31 post-intervention following the guidelines) and 39 with SA (9 pre-intervention, 12 post-intervention not following the guidelines and 18 post-intervention following the guidelines). In OM patients, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group, with also the lowest proportion of patients discharged on IV treatment. Notably, significantly fewer cases required surgery in the post-intervention groups. Considering SA, LOS, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group. The treatment failure rate was comparable among all groups for both OM and SA. There were no relapse cases. The overall adherence was between 72 and 100%.

Conclusions

The implementation of guidelines was effective in decreasing the extensive use of broad-spectrum antibiotics and combination therapy for both OM and SA. Our results show the applicability, safety, and efficacy of a narrow-spectrum IV empirical antibiotic regimen with cefazolin, followed by oral monotherapy with first/second-generation cephalosporins, which was non-inferior to broad-spectrum regimens.

Osteoarticular Infections in Children: Accurately Distinguishing between MSSA and Kingella kingae

Introduction: Osteoarticular infections (OAIs) constitute serious paediatric conditions that may cause severe complications. Identifying the causative organism is one of the mainstays of the care process, since its detection will confirm the diagnosis, enable adjustments to antibiotic therapy and thus optimize outcomes. Two bacteria account for the majority of OAIs before 16 years of age: Staphylococcus aureus is known for affecting the older child, whereas Kingella kingae affects infants and children younger than 4 years old. We aimed to better define clinical characteristic and biological criteria for prompt diagnosis and discrimination between these two OAI. Materials and methods: We retrospectively studied 335 children, gathering 100 K. kingae and 116 S. aureus bacteriologically proven OAIs. Age, gender, temperature at admission, involved bone or joint, and laboratory data including bacterial cultures were collected for analysis. Comparisons between patients with OAI due to K. kingae and those with OAI due to S. aureus were performed using the Mann−Whitney and Kruskal−Wallis tests. Six cut-off discrimination criteria (age, admission’s T°, WBC, CRP, ESR and platelet count) were defined, and their respective ability to differentiate between OAI patients due to K. kingae versus those with S. aureus was assessed by nonparametric receiver operating characteristic (ROC) curves. Results: Univariate analysis demonstrated significant differences between the two populations for age of patients, temperature at admission, CRP, ESR, WBC, and platelet count. AUC assessed by ROC curves demonstrated an exquisite ability to discriminate between the two populations for age of the patients; whereas AUC for CRP (0.79), temperature at admission (0.76), and platelet count (0.76) indicated a fair accuracy to discriminate between the two populations. Accuracy to discriminate between the two subgroups of patients was considered as poor for WBC (AUC = 0.62), and failed for ESR (AUC = 0.58). On the basis of our results, the best model to predict K. kingae OAI included of the following cut-offs for each parameter: age < 43 months, temperature at admission < 37.9 °C, CRP < 32.5 mg/L, and platelet count > 361,500/mm3. Conclusions: OAI caused by K. kingae affects primarily infants and toddlers aged less than 4 years, whereas most of the children with OAI due to MSSA were aged 4 years and more. Considering our experience on the ground, only three variables were very suggestive of an OAI caused by K. kingae, i.e., age of less than 4 years, platelet count > 400,000, and a CRP level below 32.5 mg/L, whereas WBC and ESR were relatively of limited use in clinical practice.

Pediatric Emergency MRI

There is an overall increase in the use of imaging in the pediatric emergency room setting, which is accompanied by a reduction in computed tomography examinations performed mainly due to the increased awareness of the risks of ionizing radiation. Advances in MRI technology have led to shortened scan time, decreased motion sensitivity, and improved spatial resolution. With increased access to MRI in the emergency room setting, the goal of this article is to review major applications of MR in pediatric emergency room patients.

Effects of prophylactic antibiotic administration and antibiotic timing on culture results and clinical outcomes of paediatric musculoskeletal infection: a protocol for a randomised controlled clinical trial

INTRODUCTION

Musculoskeletal infection (MSI) is a common cause of morbidity among the paediatric population. Some clinicians recommend withholding prophylactic antibiotics until culture collection with an aim to improve the culture sensitivity. However, a recent retrospective study reported that prophylactic antibiotic administration did not affect culture sensitivities in either disseminated or local MSI in paediatric population, which is surprising. The aim of the present study is to investigate the effects of prophylactic antibiotic administration and the timing of antibiotic administration on culture sensitivity and clinical outcomes of paediatric MSI.

METHODS AND ANALYSIS

A randomised controlled clinical trial will be carried out. Individuals aged 0-18 years with a diagnosis of MSI will be screened and evaluated at the Shenzhen Children's Hospital. The participants will be randomly allocated into four groups, and they will receive the antibiotic treatment at different time points, that is, 1 week, 3 days, 1 day prior to tissue culture collection and 1 day after tissue culture collection, respectively. The primary outcome will be culture sensitivity. In addition, the disease-related markers including white blood cell count, C reactive protein, erythrocyte sedimentation rate, vital signs as well as the length of hospital stay will be measured or recorded accordingly. Using χ² tests, the rates of positive cultures will be compared between different groups. Statistical comparisons between the different patient groups regarding the confounding and outcome variables will be conducted using independent t-tests, Mann-Whitney U tests, χ² tests and Fisher's exact tests as appropriate with the significance level set to 5% (p<0.05).

ETHICS AND DISSEMINATION

This study has received ethical approval. The findings will be disseminated both in scientific conferences and peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2100041631.

Clinical Scores Predict Acute and Chronic Complications in Pediatric Osteomyelitis: An External Validation

BACKGROUND

Pediatric acute hematogenous osteomyelitis (AHO) outcomes are highly dependent on the disease severity. Recently, the A-SCORE and C-SCORE, were proposed as predictors of an acute complicated course and chronic morbidity, respectively. The purpose of this study was to externally validate the A-SCORE and C-SCORE at a single institution.

METHODS

This IRB-approved retrospective chart review included AHO patients admitted at a tertiary referral hospital between October 1, 2015 and December 31, 2019. The inclusion criteria were ages 0 to 18 and clinical response to treatment. The exclusion criteria were immunocompromised status or penetrating inoculation.

RESULTS

The A-SCORE demonstrated an area under the receiver operator curve (ROC area) of >86% with regards to all acute complications. It also demonstrated sensitivities >85% and specificities >92% at the cut-off of 4 (Youden index) for all acute complications. The C-SCORE demonstrated an ROC area of 100% with regards to chronic osteomyelitis. It also demonstrated sensitivities >70% and specificities >93% for the chronic morbidity variables seen in our population at the cut-off of 3 (Youden index.).

CONCLUSIONS

These novel composite clinical scores, in combination with clinical judgment, could help guide early care decisions. The A-SCORE and C-SCORE are useful risk stratification tools in the management of pediatric AHO and in predicting acute complicated courses or chronic sequelae of AHO, respectively. These scoring systems, if integrated into standardized pediatric AHO guidelines, can allow clinicians to stratify the AHO population and guide clinical decision making.

LEVEL OF EVIDENCE

Level III (prognostic study, retrospective chart review).

Ultrasound-Guided Needle Aspiration of Subperiosteal Abscess in a Child with Acute Osteomyelitis of the Fibula: A Case Report

CASE

An 8-year-old boy with left lateral ankle pain was diagnosed with acute osteomyelitis after methicillin-susceptible Staphylococcus aureus was identified in a subperiosteal abscess in the distal fibula that had been aspirated using an ultrasound-guided needle. Symptoms improved after 2 weeks of intravenous and 4 weeks of oral antimicrobial therapy; no additional treatment was required. No growth retardation or sequelae were observed at the 6-year follow-up.

CONCLUSIONS

In acute osteomyelitis, the identification of subperiosteal abscess is key for early diagnosis. Ultrasound evaluation of the distal fibula should also be considered in the diagnosis of lateral ankle pain in children.

A Journey into Animal Models of Human Osteomyelitis: A Review

Osteomyelitis is an infection of the bone characterized by progressive inflammatory destruction and apposition of new bone that can spread via the hematogenous route (hematogenous osteomyelitis (HO)), contiguous spread (contiguous osteomyelitis (CO)), and direct inoculation (osteomyelitis associated with peripheral vascular insufficiency (PVI)). Given the significant financial burden posed by osteomyelitis patient management, the development of new preventive and treatment methods is warranted. To achieve this objective, implementing animal models (AMs) of infection such as rats, mice, rabbits, avians, dogs, sheep, goats, and pigs might be of the essence. This review provides a literature analysis of the AMs developed and used to study osteomyelitis. Historical relevance and clinical applicability were taken into account to choose the best AMs, and some study methods are briefly described. Furthermore, the most significant strengths and limitations of each species as AM are discussed, as no single model incorporates all features of osteomyelitis. HO's clinical manifestation results in extreme variability between patients due to multiple variables (e.g., age, sex, route of infection, anatomical location, and concomitant diseases) that could alter clinical studies. However, these variables can be controlled and tested through different animal models.

The Use of Biomarkers in the Early Diagnosis of Septic Arthritis and Osteomyelitis-A Pilot Study

BACKGROUND

The diagnosis of septic arthritis (SA) and osteomyelitis (OM) has remained challenging in the pediatric population, often accompanied by delays and requiring invasive interventions. The purpose of this pilot study is to identify a novel panel of biomarkers and cytokines that can accurately differentiate SA and OM at initial presentation using serum alone.

METHODS

Twenty patients below 18 years old whose working diagnosis included SA (n=10) and OM (n=10) were identified. Serum was collected at initial evaluation. Each sample underwent seven ELISA [C1-C2, COMP, CS-846, hyaluronan, procalcitonin, PIIANP, C-terminal telopeptide of type II collagen (CTX-II)] and 65-plex cytokine panels. Principal component and Lasso regression analysis were performed to identify a limited set of predictive biomarkers.

RESULTS

Mean age was 4.7 and 9.5 years in SA and OM patients, respectively (P=0.029). 50% of SA patients presented within 24 hours of symptom onset, compared with 0% of OM patients (P=0.033). 30% of SA patients were discharged home with an incorrect diagnosis and re-presented to the emergency department days later. At time of presentation: temperature ≥38.5°C was present in 10% of SA and 40% of OM patients (P=0.12), mean erythrocyte sedimentation rate (mm/h) was 51.6 in SA and 44.9 in OM patients (P=0.63), mean C-reactive protein (mg/dL) was 55.8 in SA and 71.8 in OM patients (P=0.53), and mean white blood cells (K/mm3) was 12.5 in SA and 10.4 in OM patients (P=0.34). 90% of SA patients presented with ≤2 of the Kocher criteria. 100% of SA and 40% of OM patients underwent surgery. 70% of SA cultures were culture negative, 10% MSSA, 10% Kingella, and 10% Strep pyogenes. 40% of OM cultures were culture negative, 50% MSSA, and 10% MRSA. Four biomarkers [CTx-II, transforming growth factor alpha (TGF-α), monocyte chemoattractant protein 1 (MCP-1), B cell-attracting chemokine 1] were identified that were able to classify and differentiate 18 of the 20 SA and OM cases correctly, with 90% sensitivity and 80% specificity.

CONCLUSIONS

This pilot study identifies a panel of biomarkers that can differentiate between SA and OM at initial presentation using serum alone.

LEVEL OF EVIDENCE

Level II-diagnostic study.

ACR Appropriateness Criteria® Osteomyelitis or Septic Arthritis-Child (Excluding Axial Skeleton)

Imaging plays an integral role in the evaluation of suspected musculoskeletal infections in children, not only in the accurate identification of infection such as osteomyelitis or septic arthritis, but also in guiding management. Various diagnostic modalities serve different purposes in the assessment of suspected pediatric musculoskeletal infections. The purpose of this document is to provide imaging guidance in the most frequently encountered clinical scenarios in which osteomyelitis and/or septic arthritis are suspected, outside of the axial skeleton. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion.

The recent bacterial etiology of childhood osteoarticular infections focusing on the vaccine initiation for Streptococcus pneumoniae and Haemophilus influenzae: A single-center retrospective analysis in Japan

Background

Pediatric acute osteomyelitis and septic arthritis can destroy growth plate cartilage and joint cartilage, causing permanent deformities and growth disorders. Preventing the contraction of osteoarticular infections is important. Various types of bacteria cause osteoarticular infections in children. Since 2013, when routine vaccination against Streptococcus pneumoniae and Haemophilus influenzae was initiated in Japan, diseases caused by these bacteria (other than osteoarticular infection) are reported to decrease. In this study, we aimed to re-confirm the actual situation including the presence of pathogenic bacteria of pediatric bone and joint infections.

Methods

The subjects were patients of 15 years old or younger who had been diagnosed with acute osteomyelitis or septic arthritis and received initial treatment in our hospital from April 1995 to March 2019. We obtained information from the medical records and analyzed them statistically.

Results

There were 65 patients with 65 bones with acute osteomyelitis, and 120 patients with 124 joints with septic arthritis. The pathogenic bacteria were identified in 26 (40.0%) osteomyelitis patients and 59 (49.2%) septic arthritis patients. Staphylococcus aureus was the most common pathogenic bacterium, and S. pneumoniae and H. influenzae were identified in four and seven patients respectively, frequently in younger patients. After routine vaccination against S. pneumoniae and H. influenzae, these bacteria were no longer detected in patients under five years old.

Conclusions

The efficacy of the S. pneumoniae and H. influenzae vaccine against orthopedic infectious diseases in Japan was indicated.

Is Early Surgical Intervention Necessary for Acute Neonatal Humeral Epiphyseal Osteomyelitis: A Retrospective Study of 31 Patients

Objective: To review the treatment experience of neonatal humeral epiphyseal osteomyelitis retrospectively. Study design: Retrospective cohort study of infants with neonatal humeral epiphyseal osteomyelitis. Patients were divided into conservative group and surgical group, and the surgical group was subdivided into early and delayed surgical group. Results: In total, there were 7 patients in the conservative group and 24 in the surgical group. The length of hospital stay and intravenous course of antibiotic therapy were both significantly shorter in the surgical group (p < 0.001). The full recovery rate was also higher in the surgical group (83.3%) than the conservative group (14.3%) (p < 0.001). Early surgery group (n = 14) had an insignificantly higher positive rate of pus/aspirate culture and full recovery rate than delayed surgery group (n = 10). Conclusion: Surgical treatment for neonatal humeral epiphyseal osteomyelitis demonstrated significantly higher rates of positive culture for the pathogen, a shorter course of intravenous oral antibiotics, and lower incidence of growth abnormality than conservative treatment. In our institution, most of culture outcome Gram-positive bacteria, and early surgical treatment was recommended with better outcome than delayed surgical group. Empirical antibiotics should be tailored to the epidemiological characteristics of local virulent bacteria.

Chronic Osteomyelitis of Long Bones: Imaging Pearls and Pitfalls in Pediatrics

Chronic bacterial osteomyelitis is characterized by progressive inflammatory bone destruction and apposition of new bone most often caused by pyogenic bacteria. Clinical findings are nonspecific, and serum inflammatory markers can be normal. Prompt diagnosis and treatment are essential. Left untreated, chronic infection can lead to high morbidity and mortality. Imaging's major role is to suggest the correct diagnosis, exclude other diagnoses that can mimic osteomyelitis, document extent of disease, and guide interventions such as image-guided biopsy or surgical debridement. Several conditions can mimic chronic osteomyelitis clinically and radiographically. The main differential diagnoses include an oncologic process, chronic nonbacterial or chronic recurrent multifocal osteomyelitis, bone infarct in sickle cell disease, osteoid osteoma, and stress reaction/fracture. The oncologic process to consider includes metastatic neuroblastoma and Langerhans cell histiocytosis in a child younger than five years or leukemia, Ewing sarcoma, and osteosarcoma in the older age group. However, these lesions can typically be excluded based on radiographs and magnetic resonance imaging findings. Therefore, radiologist familiarity with imaging findings and mimickers is essential. In this article, we briefly review the epidemiologic, clinical, and histopathologic features of chronic bacterial osteomyelitis and emphasize imaging pearls and pitfalls, with discussion of the most common differential diagnoses.

Kingella kingae Osteoarticular Infections Approached through the Prism of the Pediatric Orthopedist

Nowadays, Kingella kingae (K. kingae) is considered as the main bacterial cause of osteoarticular infections (OAI) in children aged less than 48 months. Next to classical acute hematogenous osteomyelitis and septic arthritis, invasive K. kingae infections can also give rise to atypical osteoarticular infections, such as cellulitis, pyomyositis, bursitis, or tendon sheath infections. Clinically, K. kingae OAI are usually characterized by a mild clinical presentation and by a modest biologic inflammatory response to infection. Most of the time, children with skeletal system infections due to K. kingae would not require invasive surgical procedures, except maybe for excluding pyogenic germs' implication. In addition, K. kingae's OAI respond well even to short antibiotics treatments, and, therefore, the management of these infections requires only short hospitalization, and most of the patients can then be treated safely as outpatients.

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

OBJECTIVE

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

INTRODUCTION

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

INCLUSION CRITERIA

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

METHODS

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

RESULTS

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

CONCLUSION

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

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019140276.

Pediatric osteoarticular infection: trend in surgically treated patients and association of methicillin-resistant Staphylococcus aureus with requirement of secondary procedures

Acute pediatric osteoarticular infection demonstrates variability in both presentation and response to treatment. Many respond to antibiotics ± single operation, while some require multiple surgeries. Currently, it is difficult to predict who may require additional procedures. Infections due to methicillin-resistant Staphylococcus aureus (MRSA) have been associated with more complications. The purpose of this study is to determine MRSA trends and degree of association with the occurrence of multiple procedures. We performed a retrospective analysis of surgically treated pediatric (1 month-18 years) patients for acute osteomyelitis and septic arthritis at a tertiary children's hospital from 2003-2017. The cohort was divided into single-procedure and multiple-procedure groups. A total of 753 patients were studied with a mean age of 7.05 years (2.4 months-17.9 years). We identified 645/753 (85.6%) patients who were treated with a single-procedure and 108/753 (14.4%) patients who required multiple- procedures. The lower extremity (hip, knee, tibia, and femur) was most commonly involved. The epidemiologic trend runs almost parallel between two groups with a peak in 2009. The odds ratio for multiple-procedures was 2.0 [95% confidence interval (CI), 1.2-3.1; P = 0.002] with dual infection (osteomyelitis + septic arthritis), 2.6 (95% CI, 1.6-4.4; P = 0.001) with high-risk conditions and 4.6 (95% CI, 3.0-7.1; P < 0.001) if MRSA was present. MRSA significantly predicts the requirement of additional operative procedures for the treatment of osteoarticular infections in children. Besides clinical deterioration and other markers, the presence of MRSA can be a considerable indicator for a planned secondary-procedure. Level III retrospective cohort study.

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

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

Indications and Future Perspectives of a Minimally Invasive Ultrasound-guided Double-needle Joint Lavage

Arthroscopic joint lavage was proposed as a treatment option for different joint conditions such as septic or inflammatory arthritis. Ultrasound (US) is today considered a fundamental tool in musculoskeletal diseases as for diagnostic and guide for interventional procedures such as synovial fluid sampling and drug injections. To enable faster recovery and to have an alternative to surgery, to reduce risks and costs, we performed an US-guided double-needle lavage of the shoulder joint. Here, we present two different clinical cases, the first with septic arthritis and the second with recalcitrant gouty arthritis, successfully treated with this technique.

Characteristics of Musculoskeletal Involvement in Pediatric Patients with Disseminated Sepsis in a Tertiary Care Center

BACKGROUND

Pediatric bone and joint infections account for one of the major causes of childhood morbidity. Disseminated sepsis being a systemic disorder with multisystem involvement, overshadows the timely recognition of bone and joint infections. Hence, we did this cross sectional study to evaluate the prevalence of septic arthritis and osteomyelitis in disseminated sepsis in children, the organisms implicated, and their antibiotic sensitivities.

METHODS

We prospectively collected data from 1st July 2016 to 31st September 2017 of children aged less than 12 years with disseminated sepsis, i.e., patients with fever and two or more sites of focal infection of anatomically non-contiguous tissues.

RESULTS

Fifty-four patients of disseminated disease were included, of which 25 patients (46.3%) had osteoarticular infections. Septic arthritis was seen in 17 patients, and osteomyelitis was seen in 12 patients. The most common joint was hip (41.6%), and the most common bone involved was femur (53.8%). Blood culture showed MRSA in 28% and MSSA in 20%. Joint and bone aspirates showed S. aureus in 56% with 28% of MRSA and MSSA each. All Staphylococcus aureus organisms were found sensitive to vancomycin and teicoplanin. The mean values of CRP, duration of stay and duration of intravenous antibiotic was higher in MRSA infected patients compared to MSSA patients.

CONCLUSIONS

Staphylococcus aureus is the most prevalent organism in musculoskeletal infection in disseminated sepsis children, with vancomycin sensitivity of 100% and methicillin sensitivity of 46.2% only. Cases of osteoarticular involvement with MRSA were higher compared to MSSA among the cases of disseminated disease. The prevalence of osteoarticular involvement is high in disseminated sepsis in children and increased clinical suspicion for such must be maintained.

Impact of antibiotic pretreatment on cultures in children with osteomyelitis and septic arthritis: a retrospective review

BACKGROUND

In the management of pediatric osteomyelitis or septic arthritis, delay in treatment may affect outcome, while receipt of antibiotics prior to culture may affect culture results. We aimed to determine if pathogen identification decreased in cultures that were pretreated with antibiotics.

METHODS

We conducted a retrospective cohort study of 584 hospitalized children between 30 days and 18 years of age admitted to two tertiary children's hospitals. Logistic regression assessed the effect of antibiotic duration on blood, bone, joint aspirate, and "other" culture positivity.

RESULTS

Overall, 42% of blood cultures, 70% of bone cultures, 39% of joint cultures, and 70% of "other" cultures were positive. Compared with children who did not receive antibiotics prior to culture, there were no significant differences in odds of a positive culture in children whose cultures were pretreated with antibiotics for any of the culture types [OR (95% CI) 0.90 (0.56-1.44) for blood cultures, 0.77 (0.25-2.34) for bone cultures, 0.71 (0.39-1.28) for joint cultures, 1.18 (0.58-2.41) "for other" cultures; all p > 0.05]. Furthermore, the duration (hours) of antibiotics in the pretreated cultures was also not a significant predictor of culture positivity (OR ranged from 0.99-1.00 for all cultures, p > 0.05).

CONCLUSIONS

Culture positivity was not associated with antibiotic pretreatment in any of the samples, even for longer duration of antibiotics prior to culture, though the small sample size of subgroups is an important limitation. In pediatric patients hospitalized with osteomyelitis and/or septic arthritis, early initiation of antibiotics may not affect culture positivity.

Epidemiology and Management of Acute Hematogenous Osteomyelitis, Neonatal Osteomyelitis and Spondylodiscitis in a Third Level Paediatric Center

Acute hematogenous osteomyelitis (AHOM) is a rare pathology in pediatric population. The aim of this study is to analyse the epidemiological data and the management, compared to European Society for Paediatric Infectious Disease (ESPID, European Society for Pediatric Infectious Diseases) guidelines 2017 of 216 children with AHOM, divided in three cohorts (neonatal-onset osteomyelitis, those with vertebral involvement and other types of osteomyelitis). We conducted a retrospective single center study, evaluating data from all the children (aged 0–18 years) consecutively admitted to the Meyer Children’s Hospital, during a period of ten years (1 January 2010–31 December 2019). Isolation of pathogen was possible in 65 patients and S. aureus was the most frequently involved (43/65 children). Magnetic Resonance Imaging (MRI, magnetic resonance imaging) was performed in 201/216 cases and was compatible with osteomyelitis in 185/201 of these children (92.03%). In the neonatal-onset osteomyelitis group the percentage of diagnostic ultrasound for osteomyelitis was 36.36% significantly higher than the other groups. The median duration of total antibiotic therapy was 37.5 days. In total, 186/199 children recovered without complications. The present study delineates three heterogeneous cohorts of patients. S. aureus is confirmed as the first pathogen for isolation in all three groups analysed. MRI represent a gold standard for diagnosis. Longer duration of antibiotics treatment was performed in neonatal and spondylodiscitis group, compared to the other types of osteomyelitis.

First report of Kingella kingae diagnosed in pediatric bone and joint infections in Morocco

BACKGROUND

The progress of diagnostic strategies and molecular methods improved the detection of Kingella kingae in bone and joint infections, and now, Kingella kingae is being increasingly recognized as the most frequent cause of bone and joint infection BJI in early childhood. The main objective of this prospective study is to report the frequency of Kingella Kingae in negative culture bone and joint pediatric infections, and to describe the clinical and biologic features of these children.

METHODS

From December 2016 to June 2019, we selected all hospitalized patients with suspected BJI. When culture was negative on the fifth day, children under 10 years were subsequently included in the study, and PCR assay was performed systematically for researching K. kingae specific gene cpn60. Microbial culture and identification were made using standard bacteriological methods. The demographics, clinical, laboratory, radiographic and clinical features were reviewed from medical records.

RESULTS

We enrolled 65 children with culture negative BJI, 46 of them having under 10 years old have been screened for the cpn60 gene. Thus, the gene encoding Kingella kingae was positive for 27 BJI cases (58.7%). The mean age of children was 3.02 years, 55.6% were aged 6 months-4 years and 29.6% of them were aged 5-10 years. The male to female ratio was 1.7 and 16 cases (59.26%) occurred during the fall-winter period. The most frequent BJI type was septic arthritis (77.8%) and the most affected sites were knee (51.9%) and hip (37.0%). We recorded a mild clinical picture with normal to mildly raised inflammatory markers. All patients had good clinical and functional outcomes, with no serious orthopedic sequelae..

CONCLUSION

K kingae is an important pathogen of culture-negative BJI in Moroccan children. PCR testing should be performed in culture-negative cases of children not only in the typical age range of 6 months to 4 years. When implemented in the routine clinical microbiology laboratory, a specific K. kingae PCR assay can provide a better diagnostic performance of BJI.

A case of canine Salmonella spp. osteomyelitis with secondary fracture following dog bite

An immature canine was attacked by another dog in a kennel facility and sustained multiple wounds to the lateral right forelimb and cranial right lateral thoracic region. General surgical and antimicrobial therapies were instituted immediately. The patient battled with recurrent infections and subsequent delayed healing. After approximately 35 days from the initial injury, the patient became acutely lame and febrile. The persistently open wounds were cultured and returned positive for Salmonella spp. Within the following days, the patient became painful, and the lameness progressed significantly. Radiographs confirmed pathologic humeral fracture, and the patient was referred for specialty evaluation. Zoonotic preventative protocols were adopted at the specialty facility upon arrival. Complete forequarter limb amputation was curative in this patient.

Novel therapeutic interventions towards improved management of septic arthritis

Septic arthritis (SA) represents a medical emergency that needs immediate diagnosis and urgent treatment. Despite aggressive treatment and rapid diagnosis of the causative agent, the mortality and lifelong disability, associated with septic arthritis remain high as close to 11%. Moreover, with the rise in drug resistance, the rates of failure of conventional antibiotic therapy have also increased. Among the etiological agents frequently isolated from cases of septic arthritis, Staphylococcus aureus emerges as a dominating pathogen, and to worsen, the rise in methicillin-resistant S. aureus (MRSA) isolates in bone and joint infections is worrisome. MRSA associated cases of septic arthritis exhibit higher mortality, longer hospital stay, and higher treatment failure with poorer clinical outcomes as compared to cases caused by the sensitive strain i.e methicillin-sensitive S. aureus (MSSA).

In addition to this, equal or even greater damage is imposed by the exacerbated immune response mounted by the patient’s body in a futile attempt to eradicate the bacteria. The antibiotic therapy may not be sufficient enough to control the progression of damage to the joint involved thus, adding to higher mortality and disability rates despite the prompt and timely start of treatment. This situation implies that efforts and focus towards studying/understanding new strategies for improved management of sepsis arthritis is prudent and worth exploring.

The review article aims to give a complete insight into the new therapeutic approaches studied by workers lately in this field. To the best of our knowledge studies highlighting the novel therapeutic strategies against septic arthritis are limited in the literature, although articles on pathogenic mechanism and choice of antibiotics for therapy, current treatment algorithms followed have been discussed by workers in the past. The present study presents and discusses the new alternative approaches, their mechanism of action, proof of concept, and work done so far towards their clinical success. This will surely help to enlighten the researchers with comprehensive knowledge of the new interventions that can be used as an adjunct therapy along with conventional treatment protocol for improved success rates.

Prediction of Adverse Outcomes in Pediatric Acute Hematogenous Osteomyelitis

BACKGROUND

Clinicians cannot reliably predict complications of acute hematogenous osteomyelitis (AHO).

METHODS

Consecutive cases of AHO from 2 pediatric centers in the United States were analyzed retrospectively to develop clinical tools from data obtained within 96 hours of hospitalization to predict acute and chronic complications of AHO. Two novel composite prediction scores derived from multivariable logistic regression modeling were compared with a previously published severity of illness (SOI) score, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) using area under the receiver operating characteristic curve analyses.

RESULTS

The causative organisms were identified in 73% of 261 cases. Bacteremia (45%), abscesses (38%), and associated suppurative arthritis (23%) were relatively common. Acute or chronic complications occurred in 24% and 11% of patients, respectively. Multivariable logistic regression identified bone abscess (odds ratio [OR], 2.3 [95% confidence interval {CI}, 1.0-5.2]), fever > 48 hours (OR, 2.7 [95% CI, 1.2-6.0]), suppurative arthritis (OR, 3.2 [95% CI, 1.3-7.5]), disseminated disease (OR, 4.6 [95% CI, 1.5-14.3]), and delayed source control (OR, 5.1 [95% CI, 1.4-19.0]) as strong predictors of acute complications. In a separate model, CRP ≥ 100 mg/L at 2-4 days after antibiotics (OR, 2.7 [95% CI, 1.0-7.3]), disseminated disease (OR, 3.3 [95% CI, 1.1-10.0]), and requirement for bone debridement (OR, 6.7 [95% CI, 2.1-21.0]) strongly predicted chronic morbidity. These variables were combined to create weighted composite prediction scores for acute (A-SCORE) and chronic (C-SCORE) osteomyelitis, which were superior to SOI, CRP, and ESR and had negative predictive values > 90%.

CONCLUSIONS

Two novel composite clinical scores were superior to existing tools to predict complications of pediatric AHO.

Clinical, biological and bacteriological characteristics of osteoarticular infections in infants less than 12 months of age

Aim: This retrospective study's objective was to evaluate osteoarticular infection in infants less than 12 months of age, with a particular focus on biological features and bacteriological etiology. Material & methods: We retrospectively reviewed the medical records of every infant younger than 12 months old admitted in our institution for a suspected osteoarticular infection between January 1980 and December 2016. Results: Sixty-nine patients records were reviewed, including eight neonates, 16 infants from 1 to 5 months old, and 45 from 6 to 12 months old. Conclusion: Neonates and infants aged from 6 to 12 months old were more exposed to infections. Staphylococcus aureus remained the main pathogen in children <6 months, whereas Kingella kingae has become the most frequently isolated microorganism in infants aged from 6 to 12 months old.

Pain for Greater Than 4 Days Is Highly Predictive of Concomitant Osteomyelitis in Children With Septic Arthritis

BACKGROUND

There is no evidence-based consensus on the risk factors for concomitant osteomyelitis and septic arthritis. The purpose of this study was to investigate clinical parameters predictive of concomitant osteomyelitis in children with septic arthritis.

METHODS

A retrospective review was conducted on patients with septic arthritis with magnetic resonance imaging (MRI) between January 2004 and October 2016 at a tertiary care pediatric hospital. Medical charts were reviewed for information including symptoms, diagnosis of osteomyelitis, serum laboratory studies, joint fluid analyses, imaging results, and treatment. Positive diagnosis of osteomyelitis was defined as a hyperintense signal of osseous structures on T2-weighted MRI consistent with infection per attending pediatric radiologist final read.

RESULTS

A total of 71 patients with 73 septic joints were included. The mean age was 6±4 (0.1 to 17) years and the mean follow-up was 14.9±24.1 (1.0 to 133.1) months. Septic arthritis with concomitant osteomyelitis occurred in 43 of 71 (61%) patients, whereas 28 of 71 (39%) patients had septic arthritis alone. Inflammatory markers such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein on admission were not associated with concomitant osteomyelitis. Multivariate logistic regression revealed that positive joint fluid bacterial culture (P=0.021) and pain for >4 days before admission (P=0.004) are independent risk factors for concomitant osteomyelitis in children with septic arthritis. Among the 24 septic arthritis patients with pain for >4 days before presentation, 96% (23/24) had concomitant osteomyelitis, whereas 43% (20/47) of patients with pain for ≤4 days had concomitant osteomyelitis.

CONCLUSION

Pain for >4 days before presentation is an independent predictor of osteomyelitis in children with septic arthritis. In pediatric septic arthritis, MRI should be considered, particularly in patients presenting with pain for >4 days as 96% of these patients had concomitant osteomyelitis.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

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

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

External Validation of an Algorithm to Predict Adjacent Musculoskeletal Infection in Pediatric Patients With Septic Arthritis

BACKGROUND

Septic arthritis (SA) remains a potentially morbid disease in the pediatric population. Magnetic resonance imaging (MRI) is the most sensitive tool for recognizing associated osteomyelitis and intramuscular abscess, but is a limited resource. The aim of this study is to externally validate a previously developed algorithm (Rosenfeld and colleagues) to predict adjacent infection in pediatric patients diagnosed with SA.

METHODS

We identified 120 children under 16 with presumed SA presenting to a tertiary referral center between 2008 and 2018. Patients without confirmed SA, those with insufficient data, and patients who did not receive perioperative MRI were excluded, leaving 53 patients. The previous algorithm suggests that patient age (above 4 y), C-reactive protein (>8.9 mg/L), platelet count (<310×10cells/µL), duration of symptoms (>3 d), and absolute neutrophil count (>7.2×10cells/µL) are risk factors for adjacent infection, with 3 or more variables signifying a "positive" result. Comparing against the gold standard of MRI, the accuracy of the algorithm was validated in terms of sensitivity, specificity, likelihood ratio (LR), and positive and negative predictive value. Discrimination and calibration of this algorithm have been assessed using receiver operating curve analysis and calibration plots.

RESULTS

The sensitivity and specificity of criteria from Rosenfeld algorithm were 73% and 44%, respectively. Receiver operating curve showed poor discrimination [area under the curve=0.54, confidence interval (CI): 0.26-0.83]. The positive predictive value was 55.9% and the negative predictive value was 63.1% with LR +1.23 (CI: 0.87-1.98) and LR -0.61 (CI 0.28-1.30). Only 53% of patients with 4 or more criteria had an adjacent infection on MRI. Examining our cohort, children with a positive MRI finding had higher mean C-reactive protein (77 vs. 122 mg/L, P=0.04) and were more likely to have waited >72 hours days between symptom onset and hospital presentation (P=0.03).

CONCLUSION

Although treatment algorithms are an attractive tool to guide clinicians and resource allocation, they need to take into account the local population characteristics before routine implementation.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Oropharyngeal Carriage of Kingella kingae and Transient Synovitis of the Hip in Young Children: A Case-control Study

BACKGROUND

Transient synovitis of the hip affects mostly preschool children, and its etiology is unknown. Kingella kingae has been identified recently as a common etiologic agent of osteoarticular infections (OAI) in young children and could potentially be associated to transient synovitis of the hip. The main objective of this study was to evaluate the association between transient synovitis of the hip and oropharyngeal carriage of K. kingae among preschool children.

METHODS

This was a prospective case-control study conducted at a tertiary care pediatric emergency department. Cases were children between 6 and 71 months of ages with a diagnosis of transient synovitis of the hip. For each transient synovitis case, an age-matched control was recruited among children presenting for a trauma. A second control group included children with any OAI. The independent variable was the presence of oropharyngeal K. kingae identified by a specific polymerase chain reaction assay. The primary analysis was the association between oropharyngeal K. kingae carriage and final diagnosis.

RESULTS

A total of 73 children were included in the study. Among them, 25 had a transient synovitis, 16 an OAI, and 22 controls. Baseline demographics were similar between the groups. There was no difference in oropharyngeal carriage of K. kingae for children with transient synovitis (5/25; 0.20) in comparison to controls (3/22; 0.14), while it was higher for children with OAI (10/16; 0.63).

CONCLUSIONS

There is no association between oropharyngeal K. kingae and transient synovitis of the hip among preschool children.

Current Concepts in Pediatric Septic Arthritis

Septic arthritis continues to present challenges regarding the clinical diagnosis, workup, and definitive management. Urgent management is essential, so treating surgeons must efficiently work through differential diagnoses, identify concomitant infections, and do a timely irrigation and débridement. The incidence of methicillin-resistant Staphylococcus aureus is increasing, typically resulting in a more rapid progression of symptoms with more severe clinical presentation. The diagnostic utility of MRI has resulted in improved detection of concomitant septic arthritis and osteomyelitis, although MRI must not substantially delay definitive management. Early diagnosis followed by urgent irrigation and débridement and antibiotic therapy are essential for satisfactory long-term outcomes. Antibiotics should not be administered until blood cultures and arthrocentesis fluid are obtained, except in rare cases of a septic or toxic patient. Once cultures are obtained, empiric antibiotic therapy should commence and provide coverage for the most likely pathogens, given the patient's age. Laboratory markers, especially C-reactive protein, should be followed until normalization and correlate with resolution of clinical symptoms. Definitive antibiotic selection should be shared with a pediatric infectious disease specialist, who can help guide the duration of treatment.