Pediatric Septic Arthritis - Osteomyelitis: Evaluation & Management in the ED
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Emergency Department Management of Pediatric Septic Arthritis and Osteomyelitis (Infectious Disease CME and Pharmacology CME)

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Table of Contents
 
About This Issue

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

Table of Contents
  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

Table 1. Bacterial Etiology of Septic Arthritis and Osteomyelitis, by Age

Table 3. Clinical Features to Evaluate for Patients With Suspected Osteomyelitis

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.

  1. John J, Chandran L. Arthritis in children and adolescents. Pediatr Rev. 2011;32(11):470-479. (Review)
  2. Kang SN, Sanghera T, Mangwani J, et al. The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br. 2009;91(9):1127-1133. (Systematic review; 154 studies)
  3. Arnold JC, Bradley JS. Osteoarticular infections in children. Infect Dis Clin North Am. 2015;29(3):557-574. (Review)
  4. Montgomery NI, Epps HR. Pediatric septic arthritis. Orthop Clin North Am. 2017;48(2):209-216. (Review)
  5. Jagodzinski NA, Kanwar R, Graham K, et al. Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children. J Pediatr Orthop. 2009;29(5):518-525. (Prospective; 70 cases)
  6. Iliadis AD, Ramachandran M. Paediatric bone and joint infection. EFORT Open Rev. 2017;2(1):7-12. (Review)
  7. Jaramillo D, Dormans JP, Delgado J, et al. Hematogenous osteomyelitis in infants and children: imaging of a changing disease. Radiology. 2017;283(3):629-643. (Review)
  8. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. J Bone Joint Surg Br. 2012;94(5):584-595. (Systematic review; 132 articles)
  9. Chiappini E, Camposampiero C, Lazzeri S, et al. Epidemiology and management of acute haematogenous osteomyelitis in a tertiary paediatric center. Int J Environ Res Public Health. 2017;14(5). (Retrospective; 121 cases)
  10. Conrad DA. Acute hematogenous osteomyelitis. Pediatr Rev. 2010;31(11):464-471. (Review)
  11. Peltola H, Paakkonen M. Acute osteomyelitis in children. N Engl J Med. 2014;370(4):352-360. (Review)
  12. Yeo A, Ramachandran M. Acute haematogenous osteomyelitis in children. BMJ. 2014;348:g66. (Review)
  13. Stockmann C, Ampofo K, Pavia AT, et al. National trends in the incidence, outcomes and charges of pediatric osteoarticular infections, 1997-2012. Pediatr Infect Dis J. 2015;34(6):672-674. (Cross-sectional study)
  14. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999;81(12):1662-1670. (Retrospective; 282 cases)
  15. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2010;52(3):e18-e55. (Clinical practice guideline)
  16. Saavedra-Lozano J, Falup-Pecurariu O, Faust SN, et al. Bone and joint infections. Pediatr Infect Dis J. 2017;36(8):788-799. (Practice-based guidelines)
  17. Farrow L. A systematic review and meta-analysis regarding the use of corticosteroids in septic arthritis. BMC Musculoskelet Disord. 2015;16:241. (Systematic review, 6 articles; meta-analysis, 2 studies)
  18. Qin YF, Li ZJ, Li H. Corticosteroids as adjunctive therapy with antibiotics in the treatment of children with septic arthritis: a meta-analysis. Drug Des Devel Ther. 2018;12:2277-2284. (Meta-analysis; 4 studies)
  19. Howard-Jones AR, Isaacs D. Systematic review of duration and choice of systemic antibiotic therapy for acute haematogenous bacterial osteomyelitis in children. J Paediatr Child Health. 2013;49(9):760-768. (Systematic review; 34 studies, 6 randomized controlled trials and 28 observational studies)
  20. Agarwal A, Aggarwal AN. Bone and joint infections in children: septic arthritis. Indian J Pediatr. 2016;83(8):825-833. (Review)
  21. Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med. 1985;312(12):764-771. (Review)
  22. Montgomery CO, Siegel E, Blasier RD, et al. Concurrent septic arthritis and osteomyelitis in children. J Pediatr Orthop. 2013;33(4):464-467. (Retrospective; 200 cases)
  23. Auh JS, Binns HJ, Katz BZ. Retrospective assessment of subacute or chronic osteomyelitis in children and young adults. Clin Pediatr (Phila). 2004;43(6):549-555. (Retrospective; 52 cases)
  24. Moumile K, Merckx J, Glorion C, et al. Bacterial aetiology of acute osteoarticular infections in children. Acta Paediatr. 2005;94(4):419-422. (Retrospective; 407 cases)
  25. Cunningham R, Cockayne A, Humphreys H. Clinical and molecular aspects of the pathogenesis of Staphylococcus aureus bone and joint infections. J Med Microbiol. 1996;44(3):157-164. (Review)
  26. Bocchini CE, Hulten KG, Mason EO, Jr., et al. Panton-Valentine leukocidin genes are associated with enhanced inflammatory response and local disease in acute hematogenous Staphylococcus aureus osteomyelitis in children. Pediatrics. 2006;117(2):433-440. (Retrospective; 89 cases)
  27. Dohin B, Gillet Y, Kohler R, et al. Pediatric bone and joint infections caused by Panton-Valentine leukocidin-positive Staphylococcus aureus. Pediatr Infect Dis J. 2007;26(11):1042-1048. (Retrospective; 14 cases)
  28. Mediamolle N, Mallet C, Aupiais C, et al. Bone and joint infections in infants under three months of age. Acta Paediatr. 2018. (Retrospective; 71 cases)
  29. Lundy DW, Kehl DK. Increasing prevalence of Kingella kingae in osteoarticular infections in young children. J Pediatr Orthop. 1998;18(2):262-267. (Retrospective; 60 cases)
  30. Gafur OA, Copley LA, Hollmig ST, et al. The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines. J Pediatr Orthop. 2008;28(7):777-785. (Retrospective; 554 cases)
  31. Howard AW, Viskontas D, Sabbagh C. Reduction in osteomyelitis and septic arthritis related to Haemophilus influenzae type B vaccination. J Pediatr Orthop. 1999;19(6):705-709. (Retrospective review; 560 cases)
  32. Burnett MW, Bass JW, Cook BA. Etiology of osteomyelitis complicating sickle cell disease. Pediatrics. 1998;101(2):296-297. (Review)
  33. Adeyokunnu AA, Hendrickse RG. Salmonella osteomyelitis in childhood. A report of 63 cases seen in Nigerian children of whom 57 had sickle cell anaemia. Arch Dis Child. 1980;55(3):175-184. (Retrospective; 63 cases)
  34. Anand AJ, Glatt AE. Salmonella osteomyelitis and arthritis in sickle cell disease. Semin Arthritis Rheum. 1994;24(3):211-221. (Review)
  35. Krogstad P. Bacterial arthritis: epidemiology, pathogenesis, and microbiology in infants and children. UptoDate. (Review)
  36. Luhmann SJ, Jones A, Schootman M, et al. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg Am. 2004;86(5):956-962. (Retrospective; 163 cases)
  37. Loyer EM, DuBrow RA, David CL, et al. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR Am J Roentgenol. 1996;166(1):149-152. (Review)
  38. Wall C, Donnan L. Septic arthritis in children. Aust Fam Physician. 2015;44(4):213-215. (Review)
  39. Clark M. Overview of causes of limp in children. UptoDate. (Review)
  40. Karkenny AJ, Tauberg BM, Otsuka NY. Pediatric hip disorders: slipped capital femoral epiphysis and Legg-Calve-Perthes disease. Pediatr Rev. 2018;39(9):454-463. (Review)
  41. Bockenstedt LK, Wormser GP. Review: unraveling Lyme disease. Arthritis Rheumatol. 2014;66(9):2313-2323. (Review)
  42. Baldwin KD, Brusalis CM, Nduaguba AM, et al. Predictive factors for differentiating between septic arthritis and Lyme disease of the knee in children. J Bone Joint Surg Am. 2016;98(9):721-728. (Retrospective; 189 cases)
  43. King SM, Laxer RM, Manson D, et al. Chronic recurrent multifocal osteomyelitis: a noninfectious inflammatory process. Pediatr Infect Dis J. 1987;6(10):907-911. (Prospective; 7 cases)
  44. Goergens ED, McEvoy A, Watson M, et al. Acute osteomyelitis and septic arthritis in children. J Paediatr Child Health. 2005;41(1-2):59-62. (Retrospective; 149 cases)
  45. Krogstad P. Bacterial arthritis: clinical features and diagnosis in infants and children. UptoDate. (Review)
  46. Merali HS, Reisman J, Wang LT. Emergency department management of acute hematogenous osteomyelitis in children. Pediatr Emerg Med Pract. 2014;11(2):1-18. (Review)
  47. Paakkonen M, Kallio MJ, Lankinen P, et al. Preceding trauma in childhood hematogenous bone and joint infections. J Pediatr Orthop B. 2014;23(2):196-199. (Prospective; 345 cases)
  48. Frank G, Mahoney HM, Eppes SC. Musculoskeletal infections in children. Pediatr Clin North Am. 2005;52(4):1083-1106. (Review)
  49. Herman MJ, Martinek M. The limping child. Pediatr Rev. 2015;36(5):184-195. (Review)
  50. Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg. 2001;9(3):166-175. (Review)
  51. Wong M, Isaacs D, Howman-Giles R, et al. Clinical and diagnostic features of osteomyelitis occurring in the first three months of life. Pediatr Infect Dis J. 1995;14(12):1047-1053. (Retrospective; 94 cases)
  52. Fox L, Sprunt K. Neonatal osteomyelitis. Pediatrics. 1978;62(4):535-542. (Retrospective; 45 cases)
  53. Zawin JK, Hoffer FA, Rand FF, et al. Joint effusion in children with an irritable hip: US diagnosis and aspiration. Radiology. 1993;187(2):459-463. (Prospective; 96 cases)
  54. Del Beccaro MA, Champoux AN, Bockers T, et al. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med. 1992;21(12):1418-1422. (Comparative study; 132 patients)
  55. Harris JC, Caesar DH, Davison C, et al. How useful are laboratory investigations in the emergency department evaluation of possible osteomyelitis? Emerg Med Australas. 2011;23(3):317-330. (Review)
  56. Levine MJ, McGuire KJ, McGowan KL, et al. Assessment of the test characteristics of C-reactive protein for septic arthritis in children. J Pediatr Orthop. 2003;23(3):373-377. (Retrospective; 133 cases)
  57. Scott RJ, Christofersen MR, Robertson WW Jr, et al. Acute osteomyelitis in children: a review of 116 cases. J Pediatr Orthop. 1990;10(5):649-652. (Retrospective; 116 cases)
  58. Unkila-Kallio L, Kallio MJ, Eskola J, et al. Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics. 1994;93(1):59-62. (Prospective; 44 cases)
  59. Roine I, Faingezicht I, Arguedas A, et al. Serial serum C-reactive protein to monitor recovery from acute hematogenous osteomyelitis in children. Pediatr Infect Dis J. 1995;14(1):40-44. (Prospective; 63 cases)
  60. Unkila-Kallio L, Kallio MJ, Peltola H. The usefulness of C-reactive protein levels in the identification of concurrent septic arthritis in children who have acute hematogenous osteomyelitis. A comparison with the usefulness of the erythrocyte sedimentation rate and the white blood-cell count. J Bone Joint Surg Am. 1994;76(6):848-853. (Prospective; 36 cases)
  61. Patel L, Michael J, Schroeder L, et al. Can a septic hip decision rule aid in the evaluation of suspected pediatric musculoskeletal infections? J Emerg Med. 2019. (Retrospective; 109 cases)
  62. Singhal R, Perry DC, Khan FN, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br. 2011;93(11):1556-1561. (Retrospective; 311 patients)
  63. Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004;86-A(8):1629-1635. (Prospective; 103 cases)
  64. Jung ST, Rowe SM, Moon ES, et al. Significance of laboratory and radiologic findings for differentiating between septic arthritis and transient synovitis of the hip. J Pediatr Orthop. 2003;23(3):368-372. (Retrospective; 97 patients)
  65. Leach P. Transient synovitis or septic arthritis? Evaluating the Kocher criteria. Taming the SRU. Accessed November 15, 2019. (Website article)
  66. Nade S. Septic arthritis. Best Pract Res Clin Rheumatol. 2003;17(2):183-200. (Review)
  67. Coutlakis PJ, Roberts WN, Wise CM. Another look at synovial fluid leukocytosis and infection. J Clin Rheumatol. 2002;8(2):67-71. (Retrospective; 202 patients)
  68. Choe H, Inaba Y, Kobayashi N, et al. Use of real-time polymerase chain reaction for the diagnosis of infection and differentiation between gram-positive and gram-negative septic arthritis in children. J Pediatr Orthop. 2013;33(3):e28-e33. (Prospective; 20 cases)
  69. Paakkonen M. Septic arthritis in children: diagnosis and treatment. Pediatric Health Med Ther. 2017;8:65-68. (Review)
  70. Fritz JM, McDonald JR. Osteomyelitis: approach to diagnosis and treatment. Phys Sportsmed. 2008;36(1):nihpa116823. (Review)
  71. Mackowiak PA, Smith JW, Jones SR. Osteomyelitis. N Engl J Med. 1980;303(26):1532. (Letter to the Editor)
  72. Sconfienza LM, Signore A, Cassar-Pullicino V, et al. Diagnosis of peripheral bone and prosthetic joint infections: overview on the consensus documents by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur Radiol. 2019;29(12):6425-6438. (Review of consensus statements)
  73. Ochsner AJ. The treatment of acute osteomyelitis. Cal State J Med. 1924;22(1):3-5. (Review)
  74. Calhoun JH, Manring MM, Shirtliff M. Osteomyelitis of the long bones. Semin Plast Surg. 2009;23(2):59-72. (Review)
  75. McNeil JC, Forbes AR, Vallejo JG, et al. Role of operative or interventional radiology-guided cultures for osteomyelitis. Pediatrics. 2016;137(5). (Retrospective; 250 cases)
  76. Nade S. Acute septic arthritis in infancy and childhood. J Bone Joint Surg Br. 1983;65(3):234-241. (Review)
  77. Karmazyn B. Imaging approach to acute hematogenous osteomyelitis in children: an update. Semin Ultrasound CT MR. 2010;31(2):100-106. (Review)
  78. Tsung JW, Blaivas M. Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound. J Emerg Med. 2008;35(4):393-399. (Case series; 5 cases)
  79. Zamzam MM. The role of ultrasound in differentiating septic arthritis from transient synovitis of the hip in children. J Pediatr Orthop B. 2006;15(6):418-422. (Retrospective; 154 patients)
  80. Schleifer J, Liteplo AS, Kharasch S. Point-of-care ultrasound in a child with chest wall pain and rib osteomyelitis. J Emerg Med. 2019. (Case report; 1 patient)
  81. Lu CH, Hsiao YF, Hsu HC, et al. Can ultrasound differentiate acute erosive arthritis associated with osteomyelitis, rheumatoid arthritis, or gouty arthritis? Int J Rheum Dis. 2019. (Prospective; 33 patients)
  82. Dodwell ER. Osteomyelitis and septic arthritis in children: current concepts. Curr Opin Pediatr. 2013;25(1):58-63. (Review)
  83. Labbe JL, Peres O, Leclair O, et al. Acute osteomyelitis in children: the pathogenesis revisited? Orthop Traumatol Surg Res. 2010;96(3):268-275. (Prospective; 450 patients)
  84. Lee YJ, Sadigh S, Mankad K, et al. The imaging of osteomyelitis. Quant Imaging Med Surg. 2016;6(2):184-198. (Review)
  85. Yang WJ, Im SA, Lim GY, et al. MR imaging of transient synovitis: differentiation from septic arthritis. Pediatr Radiol. 2006;36(11):1154-1158. (Retrospective; 67 patients)
  86. Monsalve J, Kan JH, Schallert EK, et al. Septic arthritis in children: frequency of coexisting unsuspected osteomyelitis and implications on imaging work-up and management. AJR Am J Roentgenol. 2015;204(6):1289-1295. (Retrospective; 162 cases)
  87. Rosenfeld S, Bernstein DT, Daram S, et al. Predicting the presence of adjacent infections in septic arthritis in children. J Pediatr Orthop. 2016;36(1):70-74. (Retrospective; 87 cases)
  88. Gutierrez K. Infectious and inflammatory arthritis. Principles and Practice of Pediatric Infectious Diseases. 4th ed. Edinburgh: Elsevier Saunders; 2012:477-483. (Book chapter)
  89. Steer AC, Carapetis JR. Acute hematogenous osteomyelitis in children: recognition and management. Paediatr Drugs. 2004;6(6):333-346. (Review)
  90. Howard JB, Highgenboten CL, Nelson JD. Residual effects of septic arthritis in infancy and childhood. JAMA. 1976;236(8):932-935. (Retrospective; 49 cases)
  91. Bradley J. Alternative to consider during cefotaxime shortage. AAP News. 2015;E150225-1. (Letter)
  92. Krogstad P. Bacterial arthritis: treatment and outcome in infants and children. UptoDate. (Review)
  93. Krogstad P. Septic arthritis. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases 8th ed. Elsevier; 2019:529-532. (Book Chapter)
  94. Paakkonen M, Peltola H. Treatment of acute septic arthritis. Pediatr Infect Dis J. 2013;32(6):684-685. (Review)
  95. Paakkonen M, Peltola H. Management of a child with suspected acute septic arthritis. Arch Dis Child. 2012;97(3):287-292. (Review)
  96. Peltola H, Paakkonen M, Kallio P, et al. Prospective, randomized trial of 10 days versus 30 days of antimicrobial treatment, including a short-term course of parenteral therapy, for childhood septic arthritis. Clin Infect Dis. 2009;48(9):1201-1210. (Prospective; 130 cases)
  97. Paakkonen M, Kallio MJ, Kallio PE, et al. Sensitivity of erythrocyte sedimentation rate and C-reactive protein in childhood bone and joint infections. Clin Orthop Relat Res. 2010;468(3):861-866. (Prospective; 265 cases)
  98. Howard A, Wilson M. Septic arthritis in children. BMJ. 2010;341:c4407. (Review)
  99. Xu G, Spoerri M, Rutz E. Surgical treatment options for septic arthritis of the hip in children. Afr J Paediatr Surg. 2016;13(1):1-5. (Review)
  100. Fogel I, Amir J, Bar-On E, et al. Dexamethasone therapy for septic arthritis in children. Pediatrics. 2015;136(4):e776-e782. (Retrospective; 116 cases)
  101. Paterson DC. Acute suppurative arthritis in infancy and childhood. J Bone Joint Surg Br. 1970;52(3):474-482. (Review)
  102. El-Sayed AM. Treatment of early septic arthritis of the hip in children: comparison of results of open arthrotomy versus arthroscopic drainage. J Child Orthop. 2008;2(3):229-237. (Prospective; 20 cases)
  103. Kocher MS, Lee B. Hip arthroscopy in children and adolescents. Orthop Clin North Am. 2006;37(2):233-240. (Review)
  104. DeAngelis NA, Busconi BD. Hip arthroscopy in the pediatric population. Clin Orthop Relat Res. 2003(406):60-63. (Review)
  105. Journeau P, Wein F, Popkov D, et al. Hip septic arthritis in children: assessment of treatment using needle aspiration/irrigation. Orthop Traumatol Surg Res. 2011;97(3):308-313. (Retrospective; 43 cases)
  106. Calvo C, Nunez E, Camacho M, et al. Epidemiology and management of acute, uncomplicated septic arthritis and osteomyelitis: Spanish multicenter study. Pediatr Infect Dis J. 2016;35(12):1288-1293. (Retrospective; 641 cases)
  107. Thomsen I, Creech CB. Advances in the diagnosis and management of pediatric osteomyelitis. Curr Infect Dis Rep. 2011;13(5):451-460. (Review)
  108. Lipsky BA. Treating diabetic foot osteomyelitis primarily with surgery or antibiotics: have we answered the question? Diabetes Care. 2014;37(3):593-595. (Comment)
  109. Hatzenbuehler J, Pulling TJ. Diagnosis and management of osteomyelitis. Am Fam Physician. 2011;84(9):1027-1033. (Review)
  110. Lima AL, Oliveira PR, Carvalho VC, et al. Recommendations for the treatment of osteomyelitis. Braz J Infect Dis. 2014;18(5):526-534. (Review)
  111. Krogstad P. Hematogenous osteomyelitis in children: management. UptoDate. (Review)
  112. Krogstad P. Osteomyelitis. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. 8th ed. Philadelphia, PA: Elsevier. 2019:516-529. (Book chapter)
  113. DeRonde KJ, Girotto JE, Nicolau DP. Management of pediatric acute hematogenous osteomyelitis, part I: antimicrobial stewardship approach and review of therapies for methicillin-susceptible Staphylococcus aureus, Streptococcus pyogenes, and Kingella kingae. Pharmacotherapy. 2018;38(9):947-966. (Review)
  114. Sinkin JC, Wood BC, Sauerhammer TM, et al. Salmonella osteomyelitis of the hand in an infant with sickle cell disease. Plast Reconstr Surg Glob Open. 2015;3(1):e298. (Case report; 1 case)
  115. Atkins BL, Price EH, Tillyer L, et al. Salmonella osteomyelitis in sickle cell disease children in the East End of London. J Infect. 1997;34(2):133-138. (Case series; 5 patients)
  116. Marti-Carvajal AJ, Agreda-Perez LH. Antibiotics for treating osteomyelitis in people with sickle cell disease. Cochrane Database Syst Rev. 2016;11:CD007175. (Systematic review)
  117. Arnold JC, Cannavino CR, Ross MK, et al. Acute bacterial osteoarticular infections: eight-year analysis of C-reactive protein for oral step-down therapy. Pediatrics. 2012;130(4):e821-e828. (Retrospective; 194 cases)
  118. Yagupsky P. Antibiotic susceptibility of Kingella kingae isolates from children with skeletal system infections. Pediatr Infect Dis J. 2012;31(2):212. (Letter to the editor)
  119. Peltola H, Paakkonen M, Kallio P, et al. Short- versus long-term antimicrobial treatment for acute hematogenous osteomyelitis of childhood: prospective, randomized trial on 131 culture-positive cases. Pediatr Infect Dis J. 2010;29(12):1123-1128. (Randomized controlled trial; 131 cases)
  120. Kaplan SL. Osteomyelitis in children. Infect Dis Clin North Am. 2005;19(4):787-797. (Review)
  121. Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. 2002;15(4):527-544. (Review)
  122. Kobayashi S, Murayama S, Takanashi S, et al. Clinical features and prognoses of 23 patients with chronic granulomatous disease followed for 21 years by a single hospital in Japan. Eur J Pediatr. 2008;167(12):1389-1394. (Prospective; 23 cases)
  123. Galluzzo ML, Hernandez C, Davila MT, et al. Clinical and histopathological features and a unique spectrum of organisms significantly associated with chronic granulomatous disease osteomyelitis during childhood. Clin Infect Dis. 2008;46(5):745-749. (Case control study; 46 cases)
  124. Zhang Z, Li H, Li H, et al. Clinical experience of debridement combined with resorbable bone graft substitute mixed with antibiotic in the treatment for infants with osteomyelitis. J Orthop Surg Res. 2018;13(1):218. (Prospective; 22 cases)
  125. Canavese F, Corradin M, Khan A, et al. Successful treatment of chronic osteomyelitis in children with debridement, antibiotic-laden cement spacer and bone graft substitute. Eur J Orthop Surg Traumatol. 2017;27(2):221-228. (Retrospective; 5 cases)
  126. Yagupsky P, Porsch E, St Geme JW 3rd. Kingella kingae: an emerging pathogen in young children. Pediatrics. 2011;127(3):557-565. (Review)
  127. Ilharreborde B, Bidet P, Lorrot M, et al. New real-time PCR-based method for Kingella kingae DNA detection: application to samples collected from 89 children with acute arthritis. J Clin Microbiol. 2009;47(6):1837-1841. (Prospective; 89 cases)
  128. Harel L, Prais D, Bar-On E, et al. Dexamethasone therapy for septic arthritis in children: results of a randomized double-blind placebo-controlled study. J Pediatr Orthop. 2011;31(2):211-215. (Randomized controlled trial; 49 cases)
  129. Riise OR, Kirkhus E, Handeland KS, et al. Childhood osteomyelitis-incidence and differentiation from other acute onset musculoskeletal features in a population-based study. BMC Pediatr. 2008;8:45. (Prospective; 473 cases)
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Publication Information
Authors

Prakriti Gill, MD; Jennifer E. Sanders, MD

Peer Reviewed By

Richard M. Cantor, MD, FAAP, FACEP; Susan Fraymovich, DO

Publication Date

December 2, 2019

CME Expiration Date

December 2, 2022

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 0.5 Pharmacology CME credits.

Pub Med ID: 31765551

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