Septic Arthritis and Osteomyelitis (< 30 years) - Curbside
Septic Arthritis and Osteomyelitis (< 30 years)
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Clinical concern for bacterial joint or bone infection
Exclusion Criteria
  • Toxic appearing

Consider orthopedic or infectious disease consult

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Evidence
Total Notes: 15
Evidence

1 Septic Arthritis and Osteomyelitis

Septic arthritis and osteomyelitis have significant overlap in their presentation, etiology and managment. Therefore, we have decided to combine the diagnostic and theraputic pathways. It should be noted that fungal organism may rarely cause septic arthritis and osteomyelitis and that these disease processess are not discussed in this pathway in detail.



References:
  1. Septic arthritis.
    Nade S
    Best Pract Res Clin Rheumatol. 2003;17(2):183.
  2. Acute osteomyelitis and septic arthritis in children.
    Goergens ED, McEvoy A, Watson M, Barrett IR
    J Paediatr Child Health. 2005;41(1-2):59.
  3. Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children's Hospital Basel.
    Bonhoeffer J, Haeberle B, Schaad UB, Heininger U
    Swiss Med Wkly. 2001;131(39-40):575.
  4. The incidence of joint involvement with adjacent osteomyelitis in pediatric patients.
    Perlman MH, Patzakis MJ, Kumar PJ, Holtom P
    J Pediatr Orthop. 2000;20(1):40.

2 Clinical features

Septic Arthritis

Infections of the joint can be caused by many different pathogens (bacteria, fungi, mycobacteria, and viruses). In this pathway we are referring to bacterial septic arthritis.

Although bacterial arthritis may have many different presentations depending on age, host factors and more; the "classic" presentation includes:

  • Fever
  • Joint pain
  • Swelling
  • Decreased mobility
  • Lower extremity location (hip, knee and ankle in 80 percent of cases)
  • Unilaterality (although 10 percent are bilateral)
  • Acute onset (2 - 5 days)
  • Constitutional symptoms (occasionally)

Transient synovitis is often in the differential with septic arthritis. Although benign, given the high risk of complications from missed septic arthritis, patients with transient synovitis are often evaluated, especially if involving a hip joint. Features that may help differentiate transient synovitis include:

  • Usually occurs in children between the ages of three and eight years (mean 6 years)
  • Generally well appearing
  • Recent upper respiratory tract infection

 

Osteomyelitis

Osteomyelitis may present in a large number of ways. The biggest differentiation is between hemotagiounous spread, direct inoculation or local spread of pre-existing infection.

Hematogenous

Hematogenous spread is the most common origin in children and young adults. The younger the child, the more likely the cause is to be hematogenous. This is due to unique anatomical characteristics of young children. The metaphyseal capillaries in young children are prominent and extend to the epiphyseal growth plate. Thus, with even transient bacteremia, these patients are at risk for bacterial invasion into the metaphysis and local infection. As children skeletally mature the cortex and periosteum become denser and metaphyseal capillaries atrophy decreasing the risk of infection. In children older than age ~5 a dense, fibrous periosteum has formed further decreasing the risk of periosteal abscess from hematogenous spread.

Hematogenous osteomyelitis diagnosis requires a high index of suspicion (especially in newborns) as it's symptoms overlap with many other disease processes. Studies looking at clinical signs and symptoms point to any patient with the constellation of fever, local pain and decreased mobility of an anatomical area are at increased risk of osteomyelitis.

Risk factors include:

  • Sepsis
  • Vascular access
  • Trauma (causing transient bacteremia)
  • Immunodeficiecies
  • Sickle Cell Disease (especially salmonella or other gram-negative organisms)

Direct Inoculation

Osteomyelitis may also occur from direct inoculation of the affected area. This most commonly occurs secondary to trauma or surgical procedure. Patients with open wounds near bones or recent surgery with new fever, pain and immobility should be considered for possible osteomyelitis.

Local Spread

Osteomyelitis may occur secondary to local invasion of previous infection. Overlying cellulitis, abscess or other bacterial infection should cause clinical concern for this method of inoculation.



References:
  1. Septic arthritis.
    Nade S
    Best Pract Res Clin Rheumatol. 2003;17(2):183.
  2. Septic arthritis in children.
    Morrey BF, Bianco AJ Jr, Rhodes KH
    Orthop Clin North Am. 1975;6(4):923.
  3. The bacterial etiology and antibiotic management of septic arthritis in infants and children.
    Nelson JD
    Pediatrics. 1972;50(3):437.
  4. Septic arthritis in children: relationship of causative pathogens, complications, and outcome.
    Wang CL, Wang SM, Yang YJ, Tsai CH, Liu CC
    J Microbiol Immunol Infect. 2003 Mar;36(1):41-6.
  5. Pyogenic arthritis in infants and children: a review of 95 cases.
    Welkon CJ, Long SS, Fisher MC, Alburger PD
    Pediatr Infect Dis. 1986;5(6):669.
  6. Septic arthritis and osteomyelitis in children.
    Fink CW, Nelson JD
    Clin Rheum Dis. 1986;12(2):423.
  7. Transient synovitis of the hip. Its incidence, epidemiology and relation to Perthes' disease.
    Landin LA, Danielsson LG, Wattsgård C
    J Bone Joint Surg Br. 1987;69(2):238.
  8. The characterization of transient synovitis of the hip in children
    Haueisen DC, Weiner DS, Weiner SD
    J Pediatr Orthop. 1986;6(1):11.
  9. Transient synovitis as a cause of painful limps in children.
    Do TT
    Curr Opin Pediatr. 2000;12(1):48.
  10. Evidence-based Diagnostics: Adult Septic Arthritis
    Carpenter CR, Schuur JD, Everett WW, Pines JM.
    Acad Emerg Med. Aug 2011; 18(8): 781–796.
  11. Acute osteomyelitis and septic arthritis in children.
    Goergens ED, McEvoy A, Watson M, Barrett IR,
    J Paediatr Child Health;41(1-2):59-62.
  12. Acute osteomyelitis in children: a review of 116 cases.
    Scott RJ, Christofersen MR, Robertson WW, Davidson RS, Rankin L, Drummond DS,
    J Pediatr Orthop;10(5):649-52.
  13. Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children's Hospital Basel.
    Bonhoeffer J, Haeberle B, Schaad UB, Heininger U,
    Swiss Med Wkly 2001 Oct;131(39-40):575-81.
  14. Acute osteomyelitis in children.
    Nelson JD,
    Infect. Dis. Clin. North Am. 1990 Sep;4(3):513-22.
  15. Epidemiology and outcome of osteomyelitis in the era of sequential intravenous-oral therapy.
    Karwowska A, Davies HD, Jadavji T,
    Pediatr. Infect. Dis. J. 1998 Nov;17(11):1021-6.
  16. Neonatal osteomyelitis.
    Knudsen CJ, Hoffman EB,
    J Bone Joint Surg Br 1990 Sep;72(5):846-51.
  17. Pathogenesis and treatment of acute hematogenous osteomyelitis: evaluation of current views with reference to an animal model.
    Emslie KR, Nade S,
    Rev. Infect. Dis.;8(6):841-9.
  18. MR imaging evaluation of subacute and chronic bone abscesses in children.
    Pyhi T, Azouz EM,
    Pediatr Radiol 2000 Nov;30(11):763-8.
  19. Chronic osteomyelitis in children.
    Ramos OM,
    Pediatr. Infect. Dis. J. 2002 May;21(5):431-2.

3 Diagnostic testing

Serum markers that are commonly elevated in septic arthritis and osteomyelitis include serum WBC, ESR and CRP. These have been shown to have better negative rather than positive predictive values however. In addition, they can be used to monitor for progression/resolution of disease. Blood cultures may identify organisms in up to 40 percent of septic joint patients and 30-50 percent in osteomyelitis.

Plain x-rays may be useful although they may be normal at the time of presentation. For suspected hip septic arthritis x-rays may help in the deferential diagnosis as many other etiologies may cause hip pain. In suspected osteomyelitis, x-rays are often useful in identifying the source of infection although x-rays may be negative at the time of presentation. This is dependent on the onset duration at presentation as bony distruction is often not visible until after 10 - 21 days. With the common overlap between suspected joint infection and osteomyelitis, we recommend that all patients recieve plain x-rays of the affected area. 



References:
  1. Pyogenic arthritis in infants and children: a review of 95 cases.
    Welkon CJ, Long SS, Fisher MC, Alburger PD
    Pediatr Infect Dis. 1986;5(6):669.
  2. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests.
    Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM
    Ann Emerg Med. 1992;21(12):1418.
  3. Sensitivity of objective parameters in the diagnosis of pediatric septic hips.
    Klein DM, Barbera C, Gray ST, Spero CR, Perrier G, Teicher JL
    Clin Orthop Relat Res. 1997 May;(338):153-9.
  4. Assessment of the test characteristics of C-reactive protein for septic arthritis in children.
    Levine MJ, McGuire KJ, McGowan KL, Flynn JM
    J Pediatr Orthop. 2003;23(3):373.
  5. Acute septic arthritis in infancy and childhood.
    Shaw BA, Kasser JR
    Clin Orthop Relat Res. 1990 Aug;(257):212-25.
  6. Serum C-reactive protein, erythrocyte sedimentation rate and white blood cell count in septic arthritis of children.
    Kallio MJ, Unkila-Kallio L, Aalto K, Peltola H
    Pediatr Infect Dis J. 1997;16(4):411.
  7. Childhood osteomyelitis and septic arthritis.
    Wall EJ
    Curr Opin Pediatr. 1998;10(1):73.
  8. Antibiotics in the treatment of acute osteomyelitis and acute septic arthritis in children.
    Nade S, Robertson FW, Taylor TK
    Med J Aust. 1974;2(19):703.
  9. Acute osteomyelitis in children: a review of 116 cases.
    Scott RJ, Christofersen MR, Robertson WW Jr, Davidson RS, Rankin L, Drummond DS
    J Pediatr Orthop. 1990;10(5):649.
  10. Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children.
    Unkila-Kallio L, Kallio MJ, Eskola J, Peltola H
    Pediatrics. 1994;93(1):59.
  11. How useful are laboratory investigations in the emergency department evaluation of possible osteomyelitis?
    Harris JC, Caesar DH, Davison C, Phibbs R, Than MP
    Emerg Med Australas. 2011 Jun;23(3):317-30.
  12. Unreliability of radiographic diagnosis of septic hip in children.
    Volberg FM, Sumner TE, Abramson JS, Winchester PH
    Pediatrics. 1984;74(1):118.
  13. Infectious and inflammatory arthritis.
    Gutierrez K
    Principles and Practice of Pediatric Infectious Diseases, 4thElsevier Saunders, Edinburgh 2012. p.477.
  14. Septic arthritis.
    Mitchell M, Howard B, Haller J, Sartoris DJ, Resnick D
    Radiol Clin North Am. 1988;26(6):1295.
  15. Early roentgen observations in acute osteomyelitis.
    Capitanio MA, Kirkpatrick JA
    Am J Roentgenol Radium Ther Nucl Med. 1970;108(3):488.
  16. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip.
    Kocher MS, Mandiga R, Murphy JM, Goldmann D, Harper M, Sundel R, Ecklund K, Kasser JR
    J Bone Joint Surg Am. 2003;85-A(6):994.
  17. Evidence-based Diagnostics: Adult Septic Arthritis
    Carpenter CR, Schuur JD, Everett WW, Pines JM.
    Acad Emerg Med. Aug 2011; 18(8): 781–796.

4 Differentiating joint infections

Differentiating between a bone and joint infection is often difficulty. Factors that may lead towards concern of a joint infection include:

  • Acute presentation
  • History of joint trauma
  • History concerning for N. gonorrhoeae (sexual activity, skin lesions, within seven days of the start of their menstrual cycle)
  • Signs of inflammation directly over joint
  • Joint effusion

The diagnosis of hip septic arthritis is further difficult as it may have a subtle presentation. In addition to fever, pain, swelling and decreased mobility; signs of irritability, fever without a source, pseudoparalysis and decreased oral intake in young children or developmentally delayed adolescents/adults should prompt concern.



References:
  1. The acute arthritis-dermatitis syndrome. The changing importance of Neisseria gonorrhoeae and Neisseria meningitidis.
    Rompalo AM, Hook EW 3rd, Roberts PL, Ramsey PG, Handsfield HH, Holmes KK
    Arch Intern Med. 1987;147(2):281.
  2. Disseminated gonococcal infection.
    Holmes KK, Counts GW, Beaty HN
    Ann Intern Med. 1971;74(6):979.
  3. Acute osteomyelitis and septic arthritis in children.
    Goergens ED, McEvoy A, Watson M, Barrett IR
    J Paediatr Child Health. 2005;41(1-2):59.
  4. Septic arthritis.
    Nade S
    Best Pract Res Clin Rheumatol. 2003;17(2):183.
  5. Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children's Hospital Basel.
    Bonhoeffer J, Haeberle B, Schaad UB, Heininger U
    Swiss Med Wkly. 2001;131(39-40):575.
  6. The incidence of joint involvement with adjacent osteomyelitis in pediatric patients.
    Perlman MH, Patzakis MJ, Kumar PJ, Holtom P
    J Pediatr Orthop. 2000;20(1):40.

5 Hip Ultrasound

A high negative predictive value (up to 100 percent) allows the use of hip ultrasound to guide the need for hip arthrocentisis in patients with suspected hip septic arthritis. However, false negatives have been reported related to use less than 24 hours from symptom onset. The positive predictive value is NOT adequate, therefore, patients with positive findings of effusion should undergo diagnostic aspiration. Given the difficulty of this procedure, ultrasound guidance is recommended.



References:
  1. Joint effusion in children with an irritable hip: US diagnosis and aspiration.
    Zawin JK, Hoffer FA, Rand FF, Teele RL
    Radiology. 1993;187(2):459.
  2. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment.
    Jaramillo D, Treves ST, Kasser JR, Harper M, Sundel R, Laor T
    AJR Am J Roentgenol. 1995;165(2):399.
  3. Causes of false-negative ultrasound scans in the diagnosis of septic arthritis of the hip in children.
    Gordon JE, Huang M, Dobbs M, Luhmann SJ, Szymanski DA, Schoenecker PL
    J Pediatr Orthop. 2002;22(3):312.
  4. Sonography of the painful hip in children: 500 consecutive cases.
    Miralles M, Gonzalez G, Pulpeiro JR, Millán JM, Gordillo I, Serrano C, Olcoz F, Martinez A
    AJR Am J Roentgenol. 1989;152(3):579.
  5. Anterior joint capsule of the normal hip and in children with transient synovitis: US study with anatomic and histologic correlation.
    Robben SG, Lequin MH, Diepstraten AF, den Hollander JC, Entius CA, Meradji M
    Radiology. 1999;210(2):499.
  6. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip.
    Kocher MS, Mandiga R, Murphy JM, Goldmann D, Harper M, Sundel R, Ecklund K, Kasser JR
    J Bone Joint Surg Am. 2003;85-A(6):994.

6 Arthrocentesis

Synovial fluid analysis is the primary criterion for the diagnosis of bacterial arthritis and may improve patient comfort.

  • Gram-stain of suggestive organisms, although non-definitive, strongly suggest bacterial infection. 
  • Synovial WBC > 50,000 cells/microL, with left-shift (>90 percent) of leukocytes suggests bacterial arthritis although this is neither sensitive nor specific. In addition, some organisms may have synovial WBC counts less than 50,000.
  • Although 40 to 50 percent of joint aspirates are sterile in patients with bacterial arthritis (synovial fluid is bacteriostatic), culture of synovial fluid is vital diagnostic criterion for bacterial arthritis. It should be noted that some organisms (K. kingaeN. gonorrhoeae) may not grow in normal synovial culture mediums.
  • Other cultures or diagnostic methods should be considered for patients at high risk of specific disease processes (sickle cell disease, lyme, gonnorrhoeae, etc.).


References:
  1. Routine analysis of synovial fluid cells is of value in the differential diagnosis of arthritis in children.
    Kunnamo I, Pelkonen P
    J Rheumatol. 1986;13(6):1076.
  2. Does this adult patient have septic arthritis?
    Margaretten ME, Kohlwes J, Moore D, Bent S
    JAMA. 2007;297(13):1478.
  3. Markedly raised synovial fluid leucocyte counts not associated with infectious arthritis in children.
    Baldassare AR, Chang F, Zuckner J
    Ann Rheum Dis. 1978;37(5):404.
  4. Synovial fluid tests. What should be ordered?
    Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE
    JAMA. 1990;264(8):1009.
  5. Septic arthritis and osteomyelitis in children.
    Fink CW, Nelson JD
    Clin Rheum Dis. 1986;12(2):423.
  6. Another look at synovial fluid leukocytosis and infection.
    Coutlakis PJ, Roberts WN, Wise CM
    J Clin Rheumatol. 2002;8(2):67.
  7. The bacterial etiology and antibiotic management of septic arthritis in infants and children.
    Nelson JD
    Pediatrics. 1972;50(3):437.
  8. Pyogenic arthritis in infants and children: a review of 95 cases.
    Welkon CJ, Long SS, Fisher MC, Alburger PD
    Pediatr Infect Dis. 1986;5(6):669.
  9. Septic arthritis in childhood. A 13-year review.
    Barton LL, Dunkle LM, Habib FH
    Am J Dis Child. 1987;141(8):898.
  10. Antibiotics in the treatment of acute osteomyelitis and acute septic arthritis in children.
    Nade S, Robertson FW, Taylor TK
    Med J Aust. 1974;2(19):703.
  11. Septic arthritis in childhood.
    Wiley JJ, Fraser GA
    Can J Surg. 1979;22(4):326.
  12. Outbreak of osteomyelitis/septic arthritis caused by Kingella kingae among child care center attendees.
    Kiang KM, Ogunmodede F, Juni BA, Boxrud DJ, Glennen A, Bartkus JM, Cebelinski EA, Harriman K, Koop S, Faville R, Danila R, Lynfield R
    Pediatrics. 2005;116(2):e206.
  13. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip.
    Kocher MS, Mandiga R, Murphy JM, Goldmann D, Harper M, Sundel R, Ecklund K, Kasser JR
    J Bone Joint Surg Am. 2003;85-A(6):994.

7 Kocher criteria

In patients concerning for hip septic arthritis validated clinical prediction rules exist to differentiate low vs. high risk patients and thus the need for hip arthrocentisis. Factors included in the clinical prediction rule are:

  • Non-weight-bearing on affected side
  • Fever > 38.5
  • CRP > 2 mg/dL or ESR > 40 mm/hr
  • Serum WBC > 12k

The positive predictive value was less than 0.2 percent for zero predictors, 3.0 percent for one predictor, 40.0 percent for two predictors, 93.1 percent for three predictors, and 99.6 percent for four predictors. Most providers agree that patients with no fever and negative lab values are at very low risk and can be followed clinically.



References:
  1. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm.
    Kocher MS, Zurakowski D, Kasser JR.
    J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.
  2. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children.
    Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR.
    J Bone Joint Surg Am. 2004 Aug;86-A(8):1629-35.
  3. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study.
    Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP
    J Bone Joint Surg Am. 2006;88(6):1251.
  4. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children.
    Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, Sampath JS, Bruce CE
    J Bone Joint Surg Br. 2011 Nov;93(11):1556-61.

8 IR guidance arthrocentesis

Arthrocentesis of the hip can be a difficult procedure without radiologic visualization of the joint space. In children less than 8 years ultrasound guidance may be superior to fluoroscopy in visualization of cartilaginous structures. In other joints where difficulty in arthrocenteisis is encountered, consultation with interventional radiology for real-time guidance may be useful.



References:
  1. Pediatric hip effusions: evaluation with power Doppler sonography.
    Strouse PJ, DiPietro MA, Adler RS
    Radiology. 1998;206(3):731.

9 Synovial fluid analysis

Synovial WBC > 50,000 cells/microL, with left-shift (>90 percent) of leukocytes suggests bacterial arthritis although this is neither sensitive nor specific. In addition, some organisms may have synovial WBC counts less than 50,000 and some disease processes (e.g. serum sickness, reactive arthritis, JIA) may have synovial WBC greater than 50,000.



References:
  1. Septic arthritis and osteomyelitis in children.
    Fink CW, Nelson JD
    Clin Rheum Dis. 1986;12(2):423.
  2. Does this adult patient have septic arthritis?
    Margaretten ME, Kohlwes J, Moore D, Bent S
    JAMA. 2007;297(13):1478.
  3. Another look at synovial fluid leukocytosis and infection.
    Coutlakis PJ, Roberts WN, Wise CM
    J Clin Rheumatol. 2002;8(2):67.
  4. Markedly raised synovial fluid leucocyte counts not associated with infectious arthritis in children.
    Baldassare AR, Chang F, Zuckner J
    Ann Rheum Dis. 1978;37(5):404.
  5. Evidence-based Diagnostics: Adult Septic Arthritis
    Carpenter CR, Schuur JD, Everett WW, Pines JM.
    Acad Emerg Med. Aug 2011; 18(8): 781–796.

10 Ultrasound

For patients whose clinical history is concerning for osteomyelitis and who cannot tolerate MRI, ultrasound may be used to help identify periosteal fluid collections that need to be drained.



References:
  1. Percutaneous drainage of subperiosteal abscess: a potential treatment for osteomyelitis.
    Hoffer FA, Emans J
    Pediatr Radiol. 1996;26(12):879.

11 MRI

MRI is the imaging of choice (sensitivity 92 - 97 percent) for the evaluation of osteomyelitis if the patient can tolerate the procedure. In addition, it may be useful for operative planning. Effusion from septic arthritis can also be seen on MRI with high sensitivity. Patients with negative hip ultrasounds for septic arthritis, but continued concern for hip pain should undergo MRI as it may show osteomyelitis.



References:
  1. Optimal imaging strategy for community-acquired Staphylococcus aureus musculoskeletal infections in children.
    Browne LP, Mason EO, Kaplan SL, Cassady CI, Krishnamurthy R, Guillerman RP
    Pediatr Radiol. 2008;38(8):841.
  2. Value of MRI after recent diagnostic or surgical intervention in children with suspected osteomyelitis.
    Kan JH, Hilmes MA, Martus JE, Yu C, Hernanz-Schulman M
    AJR Am J Roentgenol. 2008;191(5):1595.
  3. Acute hematogenous osteomyelitis of children: assessment of skeletal scintigraphy-based diagnosis in the era of MRI.
    Connolly LP, Connolly SA, Drubach LA, Jaramillo D, Treves ST
    J Nucl Med. 2002;43(10):1310.
  4. Pelvic osteomyelitis: a diagnostic challenge in children.
    Weber-Chrysochoou C, Corti N, Goetschel P, Altermatt S, Huisman TA, Berger C
    J Pediatr Surg. 2007;42(3):553.
  5. Usefulness of magnetic resonance imaging for the diagnosis of acute musculoskeletal infections in children.
    Mazur JM, Ross G, Cummings J, Hahn GA Jr, McCluskey WP
    J Pediatr Orthop. 1995;15(2):144.
  6. Cartilaginous epiphysis and growth plate: normal and abnormal MR imaging findings.
    Jaramillo D, Hoffer FA
    AJR Am J Roentgenol. 1992;158(5):1105.

12 Atypical presentation

Certain patient populations and host factors change the risk, etiology and management strategies for septic arthritis and osteomyelitis. Neonates may have different pathogens (group B streptococcus, N. gonorrhoeae, and gram-negative bacilli) as may immunocompromised patients. Consultation with an infectious disease specialist is often appropriate with these patients.



References:
  1. Epidemiology, etiology, and clinical features of septic arthritis in children younger than 24 months.
    Yagupsky P, Bar-Ziv Y, Howard CB, Dagan R
    Arch Pediatr Adolesc Med. 1995;149(5):537.
  2. Diagnostic pitfalls in septic arthritis of the hip in infants and children.
    Chung SM, Pollis RE
    Clin Pediatr (Phila). 1975;14(8):758.
  3. Septic arthritis in young infants: clinical and microbiologic correlations and therapeutic implications.
    Dan M
    Rev Infect Dis. 1984;6(2):147.

13 Empiric antibiotic selection

S. aureus and group A streptococcus are the most common pathogens in pathway population and antibiotics should target these organisms. Our recommendations are Cefazolin or if there is a known penicillin allergy, Clindamycin. In populations where 10 percent or more of community S. aureus isolates are methicillin resistant then MRSA coverage using Vancomycin or Clindamycin is warranted.



References:
  1. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children.
    Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF, Infectious Diseases Society of America
    Clin Infect Dis. 2011;52(3):e18.
  2. Osteomyelitis in infants and children. A review of 163 cases.
    Dich VQ, Nelson JD, Haltalin KC
    Am J Dis Child. 1975;129(11):1273.
  3. Acute osteomyelitis in children.
    Nelson JD
    Infect Dis Clin North Am. 1990;4(3):513.
  4. Epidemiology and outcome of osteomyelitis in the era of sequential intravenous-oral therapy.
    Karwowska A, Davies HD, Jadavji T
    Pediatr Infect Dis J. 1998;17(11):1021.
  5. Shorter courses of parenteral antibiotic therapy do not appear to influence response rates for children with acute hematogenous osteomyelitis: a systematic review.
    Le Saux N, Howard A, Barrowman NJ, Gaboury I, Sampson M, Moher D
    BMC Infect Dis. 2002;2:16.
  6. Benefits and risks of sequential parenteral--oral cephalosporin therapy for suppurative bone and joint infections.
    Nelson JD, Bucholz RW, Kusmiesz H, Shelton S
    J Pediatr Orthop. 1982;2(3):255.
  7. Osteomyelitis in children.
    Kaplan SL
    Infect Dis Clin North Am. 2005;19(4):787.

14 Gonococcal testing

Gonococcal arthritis is often part of a disseminated gonococcal (GC) infection with symptoms of acute polyarthralgias, polyarthritis, or oligoarthritis. Dermatitis and skin leasions are also sometimes associated. Desseminated disease is an uncommon complication of GC infection. Most patients are sexually active, < 40 years and otherwise healthy. Patients with complement deficiencies, Systemic lupus erythematosus or females who are pregnant or recently pregnant or have recently menstruated are at higher risk.

GC arthritis synovial cell counts are commonly around 50,000 but can be as low as 10,000 so treatment may be indicated if suspicion is high. Testing of relevant locations of synovial, skin, urethral or cervical, rectal, and pharyngeal specimens using nucleic acid amplification testing (NAAT) should be done.

 



References:
  1. Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms.
    O'Brien JP, Goldenberg DL, Rice PA
    Medicine (Baltimore). 1983;62(6):395.
  2. Gonococcal arthritis (disseminated gonococcal infection).
    Rice PA
    Infect Dis Clin North Am. 2005;19(4):853.
  3. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae--2014.
    Centers for Disease Control and Prevention
    MMWR Recomm Rep. 2014;63(RR-02):1.

15 Lyme testing

Patients who live in or have traveled to Lyme endemic areas should be evaluated for their risk of Lyme arthritis. Symptoms consistent with an erythema migrans lesion, migratory arthralgias or arthritis involving one or a few large joints should be considered for potential late Lyme disease. Serologic testing for anti-B. burgdorferi antibodies involves a sensitive ELISA (IgM, IgG) followed by a more specific Western blot.



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