For how long should antibiotics be given in acute paediatric septic arthritis? A prospective audit of 96 cases

Ninety-six cases of uncomplicated acute septic arthritis in children aged 12 years and under were treated by arthrotomy under general anaesthesia, saline washout and antibiotics for six weeks. They were prospectively studied for 24 weeks to assess clinical, haematological and radiological changes. Clinical improvement was most marked in the first two weeks and did not change significantly after six weeks. Haematological indices (haemoglobin concentration, serum white cell count and erythrocyte sedimentation rate) all improved from the start of treatment and continued to improve throughout the study, even after antibiotics were finished. Radiological changes in the bone adjacent to the infected joint were noted to be present in 21 cases by two weeks after presentation, and in a further 10 cases by six weeks after presentation, suggesting some continued infective activity in the bone adjacent to the septic joint even after two weeks of antibiotics. No new radiological changes were noted after six weeks. It is therefore suggested that antibiotics in septic arthritis should be continued for six weeks.

Does long-term chloramphenicol cause anaemia in Malawi?

Common clinical practice in many tropical paediatric departments is that chloramphenicol courses are limited to 2 weeks due to concerns about anaemia. However, this approach is not supported by current research and animal models. We used chloramphenicol for 6 weeks in 146 children with septic arthritis. All the children improved clinically. Most children were anaemic on presentation (mean haemoglobin [Hb] 8.43 SD 1.9), but the anaemia improved rapidly with clinical resolution of the infection and was maintained at 6 months after presentation (mean Hb 10.57 SD 1.86).

Advanced necrotizing enterocolitis part 2: recurrence of necrotizing enterocolitis

AIM OF THE STUDY

The aim of this study was to report incidence and clinical outcomes of recurrent necrotizing enterocolitis (NEC).

METHODS

Review of infants treated for recurrent episode(s) of NEC at a tertiary Neonatal Surgical Intensive Care Unit over 8 years (January 2002 to February 2011). Demographic, clinical, radiological, and operative data were analyzed and compared using Mann-Whitney or Fisher's exact tests. Data are reported as median (range).

RESULTS

A total of 212 consecutive infants were referred for surgical evaluation and treatment of NEC (Bell stage II or III). Of these patients, 22 (10%) had suspected recurrent NEC: in 11 of these the primary episode was Bell stage I successfully treated before coming to our institution (suspected recurrent NEC); in the remaining 11, the primary episode was confirmed (Bell stage II or III) NEC successfully treated in our hospital. Birth weight, gestational age at birth, corrected gestational age, weight on admission, gender, need for surgery, stricture, and mortality rates were similar between infants with recurrent NEC and those with a single episode. Long-term parenteral nutrition (PN) dependency (>28 days) was significantly more common following recurrent NEC compared with a single episode. Among the infants with recurrent NEC, medical therapy alone was not successful in the majority (82%) of cases during the first episode and all required surgery during the recurrent episode.

CONCLUSION

Infants (10%) referred for surgical treatment of NEC develop recurrence of the disease. Surprisingly, these infants have similar mortality and stricture rates to those with a single episode. However, the incidence of long-term PN dependency was significantly increased in those with recurrent episodes of NEC.

Advanced necrotizing enterocolitis part 1: mortality

AIM OF THE STUDY

The aim of this study was to investigate the factors associated with mortality in infants referred for the surgical treatment of advanced necrotizing enterocolitis (NEC).

METHODS

Retrospective review of all infants with confirmed (Bell stage II or III) NEC treated in our unit during the past 8 years (January 2002 to December 2010). Data for survivors and nonsurvivors were compared using Mann-Whitney test and Fisher's exact test and are reported as median (range).

RESULTS

Of the 205 infants with NEC, 35 (17%) were medically managed; 170 (83%) had surgery; 66 (32%) infants died; all had received surgery. Survivors and nonsurvivors were comparable for gestational age, birth weight, and gender distribution. Overall mortality was 32%, the highest mortality was in infants with pan-intestinal disease (86%) but remained significant in those with less severe disease (multifocal 39%; focal disease 21%). The commonest cause of mortality was multiple organ dysfunction syndrome and nearly half of the nonsurvivors had care withdrawn.

CONCLUSION

Despite improvement in neonatal care, overall mortality (32%) for advanced NEC has not changed in 10 years. Mortality is significant even with minimal bowel involvement.

Clinical features and microbiology in 204 cases of septic arthritis in Malawian children

We examined 204 children (137 boys and 67 girls) aged 12 years and under with septic arthritis. Their mean age was 31.1 months (1 to 144; SD 41.6). The most common joints affected were the knees and shoulders. Joints in the upper limb were affected more often in younger children and in the lower limb in those who were older. The mean age for an infection was 12 months in the shoulder and 73 months in the hip. The most common organisms cultured were species of Salmonella.

Septic arthritis of the shoulder in children in Malawi

We undertook a prospective study of 61 children in Malawi with septic arthritis of the shoulder. They were randomised into two groups, treated by aspiration (group 1, 31 patients) or arthrotomy (group 2, 30 patients). Both received antibiotics for six weeks. We studied the results of blood tests, microbiology, and the clinical and radiological outcome one year after diagnosis. Only one patient was sickle-cell positive and three were HIV-positive. Non-typhoidal Salmonella species accounted for 86% (19/22) of the positive joint cultures in group 1 and 73% (16/22) in group 2. Of the 33 radiographs available for review at follow-up at six months, 23 (70%) showed evidence of glenohumeral damage. There was no statistical difference in radiological outcome for the two groups. We devised and validated a scoring system, the Blantyre Septic Joint Score, for the assessment of joints based upon swelling, tenderness, function and range of movement. Despite the radiological changes only one of the 24 joints examined at one year had any deficit in these parameters. There was no statistical difference in the clinical outcome for the two treatment groups at any stage during the period of follow-up.

Septic arthritis of the shoulder in children in Malawi. A randomised, prospective study of aspiration versus arthrotomy and washout

We undertook a prospective study of 61 children in Malawi with septic arthritis of the shoulder. They were randomised into two groups, treated by aspiration (group 1, 31 patients) or arthrotomy (group 2, 30 patients). Both received antibiotics for six weeks. We studied the results of blood tests, microbiology, and the clinical and radiological outcome one year after diagnosis. Only one patient was sickle-cell positive and three were HIV-positive. Non-typhoidal Salmonella species accounted for 86% (19/22) of the positive joint cultures in group 1 and 73% (16/22) in group 2. Of the 33 radiographs available for review at follow-up at six months, 23 (70%) showed evidence of glenohumeral damage. There was no statistical difference in radiological outcome for the two groups. We devised and validated a scoring system, the Blantyre Septic Joint Score, for the assessment of joints based upon swelling, tenderness, function and range of movement. Despite the radiological changes only one of the 24 joints examined at one year had any deficit in these parameters. There was no statistical difference in the clinical outcome for the two treatment groups at any stage during the period of follow-up.