Consensus in diagnostic definitions for bone or joint infections in children by a Delphi method with European French-speaking experts

Aim: Various diagnostic criteria have been proposed for bone or joint infection. This study used a Delphi process to determine the consensual definitions for arthritis, osteomyelitis and bone or joint infections in general in children. Methods: A group of European French‐speaking experts participated in an email Delphi process. Definitions were identified during a systematic search of the PubMed database. Five definitions of arthritis, eight for osteomyelitis and five for bone or joint infections in general were included in a three‐round process. We sought two sorts of definitions: definitions for ‘definitive’ diagnoses for epidemiological studies and definitions for ‘probable’ diagnoses for clinical or therapeutic studies, considering enlarged criteria. Results: Ten experts were involved in the Delphi process. A consensus was reached for a definitive diagnosis of arthritis, osteomyelitis and bone or joint infections in general. A consensus was also reached for a probable diagnosis of bone or joint infections in general. Conclusion: This Delphi process made consensus definitions and criteria available for bone or joint infections that could improve the comparability of both epidemiological and clinical studies. This is a first step to standardise diagnostic criteria and distinguish definitive and probable bone or joint infections in children.     

Choice of antibiotics in management of acute osteomyelitis and acute septic arthritis in children.

A survey of 158 children with acute haematogenous osteomyelitis, and of 94 children with acute septic arthritis over an 8-year period was made to determine which bacteria cause these infections. In the osteomyelitis group the organism most frequently detected was Staphylococcus aureus (74% of cases). In 16% of cases streptococci were found. Staph. aureus was also the most frequently grown organism in cases of acute septic arthritis (55% of cases), but Haemophilus influenzae accounted for 24% of positive cultures. On the basis of the survey it is the current practice of the author to use a combination of methicillin or cloxacillin and penicillin for acute haematogenous osteomyelitis, and methicilline or cloxacillin and ampicillin for acute septic arthritis. The choice of antibiotics is vitally important as treatment must start before the results of culture are known. Repeated evaluation of trends in the pattern of causative organisms is strongly recommended, in order to be aware of changing sensitivity of organisms to antibiotics.     

Pneumococcal osteomyelitis and arthritis in children. A hospital series and literature review

Twenty-nine children with pneumococcal osteomyelitis and/or arthritis, 11 of whom had osteomyelitis, were treated at Cook County Hospital, Chicago, Ill, in the past 20 years. They were mostly normal children with a single focus of infection. They represented more than 5% of the hospitalized children with a systemic pneumococcal infection. Most of the pneumococcal isolates were serotyped; serotype 19, in particular, seemed to be unusually common in these children. Twenty-three of the 29 children with pneumococcal osteomyelitis and/or arthritis had been hospitalized in the past 15 years. These 23 children were compared with 161 hospitalized children who had bone and joint infections with other isolated bacteria. The children with pneumococcal osteomyelitis and/or arthritis were indistinguishable from most of the other children, except by age. All but three of the children with pneumococcal osteomyelitis and/or arthritis were between the ages of 3 and 24 months. In this age group, Pneumococcus was the common isolate from children with osteomyelitis, and second only to Haemophilus influenzae from children with bacterial arthritis. Pneumococcal osteomyelitis and/or arthritis has never been rare; the medical literature describes at least 245 other children, most of whom were younger than 2 years.     

Pediatric pneumococcal bone and joint infections. The Pediatric Multicenter Pneumococcal Surveillance Study Group (PMPSSG)

OBJECTIVE: To describe the clinical and microbiological characteristics of infants and children with bone and joint infections caused by penicillin-susceptible and penicillin-nonsusceptible strains of Streptococcus pneumoniae. DESIGN: Multicenter, prospective patient accrual; retrospective chart review of identified patients. SETTING: Eight children's hospitals in the United States. PARTICIPANTS: Forty-two children with bone and/or joint infections prospectively enrolled in the United States Pediatric Multicenter Pneumococcal Surveillance Study from September 1, 1993 to August 31, 1996. OUTCOME MEASURES: Data were collected on multiple variables, including age, gender, race, days of symptoms before and during hospitalization, antibiotic and surgical therapy, laboratory and imaging studies. RESULTS: Of the 42 children enrolled (21 bone, 21 joint infections), 14 had isolates that were not susceptible to penicillin. Eight of 16 (50%) strains isolated from children who received antibiotics within 4 weeks before hospitalization were not susceptible to penicillin, compared with 4 of 15 (27%) strains isolated from children without previous antibiotic exposure. Clinical response to therapy was similar between children infected by penicillin-susceptible strains compared with those infected by penicillin-nonsusceptible strains, including duration of hospitalization (9.1 days vs 11.2 days), days of intravenous antibiotic therapy (25.3 days vs 24.6 days), days of fever (3.6 days vs 3.1 days), and sequelae (14% vs 7%). The most commonly prescribed single agents for parenteral therapy in definitive treatment were ceftriaxone (36%), penicillin (15%), and clindamycin (15%). Oral therapy followed parenteral therapy in 56% of children. The mean (+/- standard deviation) duration of total antibiotic therapy in children with osteomyelitis was 57.5 +/- 48.6 days (range, 23-196 days) and 29.2 +/- 11.8 days (range, 12-67 days) for arthritis. Late sequelae (long-term destructive changes of the bone or joint) were documented in 5 (12%) children, 4 with osteomyelitis, and 1 with arthritis. Sequelae occurred in 30% of children with long bone osteomyelitis associated with infection in the adjacent joint. The age of children with sequelae was younger than those without sequelae (6.4 months vs 18.6 months). CONCLUSIONS: The demographic characteristics and anatomic sites of infection in our patients were similar to previously published series collected from single institutions before the emergence of significant antibiotic resistance in S pneumoniae. Our analysis suggests that children infected by penicillin-nonsusceptible strains have a similar clinical response to therapy when compared with children infected by penicillin-susceptible strains.     

Optimal imaging strategy for community-acquired Staphylococcus aureus musculoskeletal infections in children

BACKGROUND: Invasive musculoskeletal infections from community-acquired methicillin-resistant and methicillin-susceptible Staphylococcus aureus (CA-SA) are increasingly encountered in children. Imaging is frequently requested in these children for diagnosis and planning of therapeutic interventions. OBJECTIVE: To appraise the diagnostic efficacy of imaging practices performed for CA-SA osteomyelitis and its complications. MATERIALS AND METHODS: A retrospective review was conducted of the clinical charts and imaging studies of CA-SA osteomyelitis cases since 2001 at a large children's hospital. RESULTS: Of 199 children diagnosed with CA-SA osteomyelitis, 160 underwent MRI examination and 35 underwent bone scintigraphy. The sensitivity of MRI and bone scintigraphy for CA-SA osteomyelitis was 98% and 53%, respectively. In all discordant cases, MRI was correct compared to bone scintigraphy. Extraosseous complications of CA-SA osteomyelitis detected only by MRI included subperiosteal abscesses (n = 77), pyomyositis (n = 43), septic arthritis (n = 31), and deep venous thrombosis (n = 12). CONCLUSION: MRI is the preferred imaging modality for the investigation of pediatric CA-SA musculoskeletal infection because it offers superior sensitivity for osteomyelitis compared to bone scintigraphy and detects extraosseous complications that occur in a substantial proportion of patients.     

Pyomyositis in south Indian children

Thirty-two children with pyomyositis were studied. In 28 children, 23 boys and 5 girls, Staphylococcus aureus was the aetiological agent. The strains isolated were resistant to penicillin. The muscles of the thigh, back and upper arm were most frequently involved. Eight children had infections in other parts of the body, namely pneumonia, empyema, pericarditis, meningitis, osteomyelitis and arthritis. Two children died. At follow-up one child had chronic osteomyelitis. In four neonates, beta haemolytic streptococcus was the causative organism. All were septicaemic. One infant died.     

Joint and bone infections due to anaerobic bacteria in children

The current review describes the microbiology, diagnosis and management of septic arthritis and osteomyelitis due to anaerobic bacteria in children. Staphylococcus aureus, Haemophilus influenzae type-b, and Group A streptococcus, Streptococcus pneumoniae, Kingela kingae, Neisseria meningiditis and Salmonella spp are the predominant aerobic bacteria that cause arthritis in children. Gonococcal arthritis can occur in sexually active adolescents. The predominant aerobes causing osteomyelitis in children are S. aureus, H. influenzae type-b, Gram-negative enteric bacteria, beta-hemolytic streptococci, S. pneumoniae, K. kingae, Bartonella henselae and Borrelia burgdorferi. Anaerobes have rarely been reported as a cause of these infections in children. The main anaerobes in arthritis include anaerobic Gram negative bacilli including Bacteroides fragilis group, Fusobacterium spp., Clostridium spp. and Peptostreptococcus spp. Most of the cases of anaerobic arthritis, in contrast to anaerobic osteomyelitis, involved a single isolate. Most of the cases of anaerobic arthritis are secondary to hematogenous spread. Many patients with osteomyelitis due to anaerobic bacteria have evidence of anaerobic infection elsewhere in the body, which is the source of the organisms involved in osteomyelitis. Treatment of arthritis and osteomyelitis involving anaerobic bacteria includes symptomatic therapy, immobilization in some cases, adequate drainage of purulent material and antibiotic therapy effective to these organisms.     

Kingella kingae osteoarticular infections in children. A report of a series of eight new cases]

Kingella kingae is a Gram-negative bacillus which belongs to the Neisseriaceae family. Its involvement in osteoarticular infections is relatively recent. METHODS AND RESULTS: We report eight cases of Kingella kingae osteoarticular infections that have been diagnosed at the paediatric surgical centre of Rouen University Hospital since October 1995. Six boys and two girls (mean age: 30.6 months) presented with osteomyelitis in six cases and arthritis in two. Only 75% of patients had a fever at time of diagnosis. The biological findings were slightly modified. All samples were obtained from blood, bone or joint fluid. These samples were systematically inoculated into a blood culture tube. Positive Kingella kingae culture was achieved in seven local samples and in one blood culture. All children received two antibiotics via intravenous injection while waiting for the bacteriologic results. Later, the antibiotic treatment (amoxycillin) was given per os. The mean duration of treatment was 33 days. Patients were given intravenous treatment for a period of only ten days. Six patients were followed up for a period of more than 18 months and outcome was always uneventful. DISCUSSION: Kingella kingae is usually present in the nasopharyngeal mucosa and spreads in the blood due to various infections. Different types of Kingella kingae infection have been reported with a large frequency of osteoarticular infection. CONCLUSION: This type of infection does not present any unusual characteristics as compared to other osteoarticular infections. Because of its antibiotic sensitivity treatment duration could be reduced. Kingella kingae is a fragile microbe and its culture is often difficult; therefore, it is important to use blood culture tubes to inoculate joint fluid and bone samples.     

Oral pristinamycin therapy for bone and joint infections in children. A report of 50 cases (author's transl)

50 children with bone and joint infections (acute osteomyelitis, suppurative acute arthritis, osteoarthritis) were treated with pristinamycin. The responsible bacterium was most often but not exclusively Staphylococcus aureus; its sensitivity to various antibiotics is discussed. The value of biochemical tests for diagnosis and follow-up is emphasized; the potency of this drug avoids the need for intravenous therapy. A therapeutic protocol according to age, type of and sensitivity of the germs is proposed.     

Management of septic arthritis

Septic arthritis in children remains a serious disease with the potential for significant systemic and musculoskeletal morbidity. Staphlococcus aureus is the most common cause of bone and joint infections in all age groups. Microbial invasion of the synovial space occurs typically results from hematogenous seeding. Diagnosis in neonates and young infants can be difficult since the clinical signs are much less specific in these age groups. Early diagnosis by needle aspiration of the affected joint and prompt initiation of appropriate antimicrobial therapy in conjunction with drainage of the affected joint is critical to avoid destruction of the articular cartilage and prevent disability. Septic arthritis in infants and children should always be managed by a pediatrician in close consultation with an orthopedic surgeon. Empiric antibiotic regimens should always include adequate anti-staphylococcal coverage. Antibiotic treatment should be started with appropriate doses of intravenous antibiotics. Switch to oral antibiotic therapy can be made when patient demonstrates clinical improvement. A minimum of 3-4 weeks of therapy is recommended. Close follow-up is warranted to monitor the growth of the affected limb until skeletal maturity.     

Haemophilus influenzae type b osteomyelitis.

Three children had osteomyelitis due to Haemophilus influenzae type b. They were seen with signs and symptoms indistinguishable from infection caused by other organisms. One child was initially misdiagnosed as having septic arthritis because of failure to appreciate that Hemophilus may also cause bone infection. In the second patient osteomyelitis and arthritis developed during ampicillin sodium therapy for treatment of Hemophilus meningitis. His initial infection was caused by an ampicillin-sensitive isolate but his orthopedic infection subsequently responded to therapy only after changing to a regimen of chloramphenicol. In the third patient, bone scintigraphy was helpful in diagnosis since serial roentgenograms were not diagnostic of osteomyelitis. The anticapsular antibody responses of these patients were measured by radioimmune assay. The levels found were low but comparable to age-matched control children with H influenzae type b meningitis.     

Acute osteomyelitis and septic arthritis in children: one year experience]

To describe bacteriologic epidemiology of bone and joint infections, a total of 52 osteomyelitis, 52 arthritis and 20 osteoarthritis of children aged one month to 15 years during a one-year period (2001) were included in a retrospective unicentric review. The mean age was 3,9 +/-3,6 years. Fever and pain were the most common clinical symptoms. The site of infection was single in 95%, involving lower extremities in 80%. Bone scintigraphy was abnormal in 71% of osteomyelitis. Positive cultures was obtained in 29% of all cases (blood cultures: 20%, aspiration cultures: 29%), but in 42% of cases which have both blood and aspiration cultures. Thirty-six bacteria were identified: 19 Staphylococcus (14 aureus), ten Streptococcus (four pneumoniae), three Salmonella, three Kingella kingae, one Moraxella. All the isolates were susceptible to the empiric antibiotic therapy. Outcome was good in 100% of osteomyelitis and in 96% of arthritis.     

Pyogenic arthritis associated with adjacent osteomyelitis: identification of the sequela-prone child.

We treated 96 cases of pyogenic arthritis from January 1, 1980, to December 31, 1990, 16 of whom had adjacent osteomyelitis. Presenting symptoms in the latter were indistinguishable from those in 80 cases of primary pyogenic arthritis with regard to involved joints, aspirate findings and pathogens; however, adjacent osteomyelitis patients tended to be younger and were more likely to be symptomatic more than 7 days and to have received prior antibiotics. Prompt joint drainage was done in 15 of 16 cases but adjacent osteomyelitis was recognized in only 5. Bone scan was misleading in 3 of the 4 cases where it was performed as part of the initial evaluation. Persistent pain, swelling and/or fever occurred in 9 patients, 6 of whom underwent further joint drainage. Radiographs were diagnostic in 1 patient at admission, 10 during hospitalization and in 5 at follow-up. Sequelae were found in 8 of 13 patients with bone and joint infections vs. 8 of 41 patients with primary joint infection. Patients with a positive culture from the hip or shoulder who had been pretreated with antibiotics had the worst prognosis. Osteomyelitis should be considered in patients who present with symptoms and signs of pyogenic arthritis for longer than 1 week, especially if they have received prior antibiotics. Earlier recognition and bone debridement may improve outcome.     

Detection of osteomyelitis and septic arthritis by nuclear magnetic resonance tomography in children

Suspected osteomyelitis or septic arthritis, respectively, is usually proven by means of clinical symptoms, laboratory data and microbiologic findings of blood cultures and joint fluids. In the early phase of the diseases conventional X-rays are not helpful. Imaging with isotopes is the most important procedure to describe localisation and extension of the inflammatory processes. Nuclear magnetic resonance imaging as a newer method is capable to detect these inflammatory processes very early, precisely and without discomfort for the patient. In four children with osteomyelitis and in one infant with septic arthritis, respectively, we were able to confirm the clinical diagnosis in a very early phase of the disease. In the patient with septic arthritis nuclear magnetic resonance was the only imaging procedure successfully localising the inflammatory process. Nuclear magnetic resonance imaging localises precisely inflammatory bone and joint diseases during the early stage of the disease.     

Bone and joint infections in children

Bone and joint infections are a significant cause of morbidity in infants and young children. Although many principles regarding pathogenesis, diagnosis, and treatment of infection have remained constant over the years, other aspects of this important pediatric diagnosis are continuing to evolve. This article reviews current information regarding pathogenesis, epidemiology, and microbiology of pediatric bone and joint infections and the clinical presentation, diagnosis, and treatment of these infections.     

Septic arthritis and acute hematogenous osteomyelitis in childhood at a tertiary hospital in Japan

Background:  The aim of the present study was to describe the clinical features of septic arthritis (SA) and acute hematogenous osteomyelitis (AHO) in children and to assess the impact of health-care-associated infections and antimicrobial resistance.
Methods:  A retrospective review of medical records of children presenting to Osaka City General Hospital with SA and AHO was undertaken during an 85 month period. The following data were assessed: location at onset, age and gender, risk factors, involved joints and/or bones, symptoms and time of presentation, causative agents and sensitivity to antibiotics, treatments and late complications.
Results:  There were four health-care-associated (HCAI) and 20 community-acquired infections (CAI). The latency period from initial presentation to diagnosis was relatively longer in HCAI than CAI. The most common pathogen was methicillin-resistant Staphylococcus aureus (MRSA). Twenty percent of CAI patients and half of the HCAI patients were treated empirically for MRSA. All patients with complications had MRSA infection.
Conclusion:  Many pediatric patients with SA were not treated initially with optimal antibiotics. Although surgical intervention was almost inevitably required, selection and administration of effective antibiotics was necessary not only to cure the current infection but also to prevent metastatic infection. In Japan, empiric treatment of SA and AHO should include first-line antibiotics against MRSA.     

Randomized comparative study of ampicillin/sulbactam vs. ceftriaxone for treatment of soft tissue and skeletal infections in children

In a prospective study 105 children hospitalized with soft tissue infection, 11 children with suppurative arthritis and 9 children with osteomyelitis were treated with either parenterally administered ampicillin/sulbactam or ceftriaxone. Treatment was randomized using a computer-generated table in a 2:1 fashion: 84 patients received ampicillin/sulbactam and 41 patients received ceftriaxone. Organisms isolated from wound site or blood cultures included Staphylococcus aureus (33), Streptococcus pyogenes (19), Haemophilus influenzae (9) including 4 beta-lactamase-positive organisms, Streptococcus pneumoniae (5), Neisseria gonorrhoeae (3) and 9 other organisms. Clinical and bacteriologic response was satisfactory in 100% of the ampicillin/sulbactam-treated patients and in 93% of the ceftriaxone-treated patients. Two patients with S. aureus infections treated with ceftriaxone had a delayed response and required change in therapy to parenterally administered oxacillin. Ampicillin/sulbactam represents a potentially useful single agent for the treatment of cellulitis and bone or joint infections in pediatric patients.     

Septic arthritis in patients followed-up in neonatal intensive care unit

BACKGROUND: Septic arthritis is an uncommon, but serious disorder in neonates. Most patients survive with permanent handicaps. Due to the rarity of this condition in neonates and paucity of signs and symptoms, the diagnosis of septic arthritis in newborns is more difficult than in older children. METHODS: Septic arthritis or suppurative arthritis is an infection of the joint by a variety of microorganisms, including bacteria, viruses, mycobacteria and fungi. Purulent synovial fluid, positive culture and positive Gram stain were accepted as a gold standard for exact diagnosis. Fourteen neonates who were followed-up in a neonatal intensive care unit, with septic arthritis, were included in a study based on a review of medical reports and a long-term clinical and radiological follow-up. Clinical symptoms, bacteriology, risk factors and outcomes are discussed. RESULTS: Staphylococcus aureus was the predominant causative organism. Risk factors for septic arthritis were prematurity (4/14), umbilical catheterization or venous catheterization (3/14), sepsis (3/14), perinatal asphyxia (2/14) and difficult birth (1/14). All cases of septic arthritis in neonates were improved without squealae except in two patients. One patient died and one patient had severe squealae. In these two patients, the duration of disease from clinical onset to initiation of therapy was long. CONCLUSIONS: The most important prognostic factor in predicting a favorable outcome in neonatal septic arthritis is early diagnosis and therapy. When appropriate treatment is delayed, catastrophic sequelae are inevitable. Early diagnosis of the condition and rapid removal of pus are mandatory for the survival of the joint. Long-term follow-up may reveal effects of epiphyseal damage, early degenerative changes and limitation of the range of motion.     

Limb disuse in a newborn

Osteomyelitis in the neonate is an entity distinct from that in older children. We report a case that had a benign onset, insidious course, and multiple foci of involvement. The unique metaphyseal blood supply of early infancy permitted coexisting septic arthritis. Signs of limb disuse, limitation of motion, and swelling over distal bone or joint space should prompt the emergency physician to entertain the possibility of osteomyelitis. Early diagnosis and intervention on the part of the emergency physician may prevent or alleviate sequelae of this disease.