Emergency Department Management of Pediatric Septic Arthritis and Osteomyelitis

Table of Contents

 

Septic arthritis and osteomyelitis often present with a subacute course of illness and vague signs and symptoms. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated to avoid adverse sequalae. This issue provides evidence-based recommendations for the diagnosis and management of pediatric patients with septic arthritis and/or osteomyelitis and offers guidance for appropriate antibiotic treatment. You will learn:

The most common causative organisms for pediatric septic arthritis and osteomyelitis, based on patient age

Key aspects of the history and physical examination that will help to narrow the differential diagnosis

Which laboratory markers are better predictors and which can be used to effectively monitor a response to treatment

To use the Kocher criteria to distinguish between septic arthritis and transient synovitis

Which imaging studies should be ordered first and which can be used if the initial studies are inconclusive

Recommendations for which antibiotics to administer as well as the appropriate duration for antibiotic treatment

1. Abstract
2. Case Presentations
3. Introduction
   1. Septic Arthritis
   2. Osteomyelitis
4. Critical Appraisal of the Literature
5. Pathophysiology
6. Epidemiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Septic Arthritis
      2. Osteomyelitis
10. Diagnostic Studies
    1. Laboratory Markers
       1. Septic Arthritis
       2. Osteomyelitis
    2. Imaging
       1. Radiography
          • Septic Arthritis  
          • Osteomyelitis
       2. Ultrasound
          • Septic Arthritis
          • Osteomyelitis
       3. Additional Imaging Studies
          • Septic Arthritis
          • Osteomyelitis
11. Treatment
    1. Septic Arthritis
       1. Empiric Treatment
       2. Duration of Antibiotic Therapy
       3. Surgical Intervention
    2. Osteomyelitis
       1. Empiric Treatment
       2. Duration of Therapy
       3. Surgical Intervention
12. Special Circumstances
    1. Bone and Joint Infections in Patients With Surgical Implants
    2. Osteomyelitis in Immunocompromised Patients
13. Controversies and Cutting Edge
    1. Needle Aspiration Alone for Debridement of the Septic Joint
    2. Resorbable Bone Graft Substitute Mixed With Antibiotic for Treatment of Infants With Osteomyelitis
    3. Use of Polymerase Chain Reaction for Detection of Kingella kingae in Patients With Osteomyelitis
    4. Use of Corticosteroids for Septic Arthritis
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls in the Management of Pediatric Septic Arthritis and Osteomyelitis
18. Case Conclusions
19. Clinical Pathways
    1. Clinical Pathway for Diagnosis and Management of Pediatric Septic Arthritis
    2. Clinical Pathway for Diagnosis and Management of Pediatric Acute Hematogenous Osteomyelitis
20. Tables and Figures
    1. Table 1. Bacterial Etiology of Septic Arthritis and Osteomyelitis, by Age
    2. Table 2. Differential Diagnosis for the Limping Child
    3. Table 3. Clinical Features to Evaluate for Patients With Suspected Osteomyelitis
    4. Table 4. Kocher Criteria and the Likelihood of Septic Arthritis
    5. Table 5. Antibiotics for Treatment of Pediatric Septic Arthritis/Osteomyelitis
    6. Figure 1. Patient With Septic Arthritis Holding the Right Hip Flexed, Externally Rotated, and Abducted
    7. Figure 2. Septic Arthritis of the Knee Demonstrating Soft-Tissue Swelling of the Knee in a Neonate
    8. Figure 3. Ultrasound of the Hips
    9. Figure 4. Ultrasound Showing the Subperiosteal Abscess of Osteomyelitis
    10. Figure 5. Septic Arthritis on Magnetic Resonance Imaging
    11. Figure 6. Osteomyelitis on Magnetic Resonance Imaging
21. References

Abstract

Septic arthritis and osteomyelitis in pediatric patients represent true emergencies, and can quickly threaten life and limb. A high index of suspicion should be maintained, as these conditions often present with a subacute course of illness and vague signs and symptoms. Septic arthritis and osteomyelitis can occur concurrently, so suspicion for one should also prompt investigation for the other. The diagnostic evaluation should include blood work as well as samples from the infected joint or bone for culture. Management with antibiotics is a standard approach, but the duration of antibiotic therapy is controversial. This issue reviews the current literature and provides an evidence-based approach for the evaluation and management of pediatric patients with septic arthritis and osteomyelitis.

Case Presentations

A 15-month-old boy presents to the ED with sudden onset of fever to 39.5°C (103.1°F), left knee swelling, and refusal to bear weight. His mother reports that the boy fell 2 days prior. He had a minor abrasion with some mild swelling to the left knee, but he was walking normally. This morning, the boy woke up with a fever, increased swelling and warmth of the left knee, and he refused to bear weight on the left leg. He is otherwise healthy, with no medical or surgical history. Aside from ibuprofen, he has not been given any other medication. His vital signs are notable for fever and tachycardia. During the physical examination, he refuses to walk and asks to be held. The right knee is normal, with normal range of motion. The left knee is erythematous, swollen, and has limited range of motion. You discuss with the mother that the differential diagnosis for this presentation is broad, and you would like to obtain some lab tests and imaging. You order acetaminophen for the persistent fever as well as a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, blood cultures, and plain radiography. You begin to think: Do you need to obtain additional imaging studies? What procedures should be performed?

A 4-year-old boy presents to the ED with intermittent fever, right leg pain, and difficulty walking the last 3 days. His parents report that the child has a history of sickle cell disease and takes folic acid and penicillin for infection prophylaxis. The patient has never had surgery. On physical examination, there is point tenderness over the right thigh and an area of overlying edema, and the boy's vital signs are within the normal limits for his age. You order a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, blood cultures, bone culture, and plain radiography. What special bacterial pathogen must be considered in this case? How does this affect antibiotic treatment?

Introduction

Pediatric patients with septic arthritis (SA) and osteomyelitis (OM) commonly present to the emergency department (ED) with vague and nonspecific complaints, but fever and joint pain are usually present. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated.

Septic Arthritis

Acute SA, or pyogenic arthritis, is a bacterial invasion of the synovium and joint space followed by an inflammatory process.¹ SA can threaten both life and limb due to its potential for rapid destruction of the joint, causing significant disability within hours to days. Presenting symptoms vary based on age. Neonates and infants present with signs of septicemia, cellulitis, or fever without a source. Older children most commonly present with fever, joint pain, limited range of motion around the affected joint, and/or refusal to bear weight. SA is a surgical emergency, and it has a reported annual incidence of 1 to 37 cases per 100,000 children per year, although there is variation in different geographic areas.² Peak incidence in the pediatric population is between 2 and 3 years of age, and boys are more commonly affected than girls.³

SA is often a hematogenous infection in children. The most commonly affected locations in the body are the large joints of the lower limbs (hip, knee, and ankle), accounting for approximately 80% of cases;³ the knee is the most commonly affected joint.^4,5 SA most often affects previously healthy children, but certain groups are at higher risk for infection; these higher-risk individuals include patients who are immunocompromised (eg, diabetic patients, HIV-positive patients, patients who are on corticosteroid therapy), patients who were premature infants, or patients who have chronic illnesses requiring frequent phlebotomy.⁶

Risk Management Pitfalls in the Management of Pediatric Septic Arthritis and Osteomyelitis

2. “The patient presented with vague/nonspecific pain. I didn’t consider a bone or joint infection.”

Both pediatric SA and OM present in a similar fashion, and the initial symptoms may be vague and nonspecific, so it is important to maintain a high index of suspicion. A thorough musculoskeletal examination should be completed and imaging should be obtained in order to fully assess the joint/bone involved.^48,50

8. “I wanted to tailor the antibiotics to the specific microbial pathogen, so I decided to wait for culture results prior to starting antibiotic therapy.”

Ideally, empiric antibiotic therapy should be started after obtaining a reliable culture sample, but the initiation of antibiotics should not be delayed while awaiting results of culture samples. The antibiotics are geared toward the organisms known to be the most likely cause of SA and OM.²²

10. “I instructed my patient to continue antibiotics at least until his symptoms improved.”

Incomplete antibiotic treatment duration and/or microbial coverage can attribute to antibiotic resistance and recurrence of symptoms. Both OM and SA require initial inpatient parenteral antibiotic therapy followed by oral antibiotic therapy lasting several weeks.⁶

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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