Septic Arthritis in Children - Guideline for the Management of
|Last review: 15/03/2018|
|Next review: 15/03/2021|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2018|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the Management of Septic Arthritis in Children.
Septic Arthritis in Children
These guidelines apply to children (>1 month and ≤16 years old) with suspected acute joint infection (septic arthritis).
Diagnosis is made by aspiration / washout of the joint, ideally before antibiotics. Suspicion of Diagnosis (and so need for aspiration / washout) is clinically based:
Examination: Look for joint swelling, inflammation and tenderness to palpation. Movement will be restricted. Assess systemic signs of infection. In infancy the only sign may be “pseudoparalysis”. EXAMINE ALL JOINTS, as presence of arthritis in more than one joint may help prompt consideration of a non-infectious patient.
Irritable hip (also known as transient synovitis, reactive arthritis) is common in walking children and needs to be differentiated from hip sepsis. Irritable hip is a generally milder non-infective inflammatory and non-progressive condition without systemic features. It can mimic early sepsis.
In addition many children with Juvenile idiopathic arthritis / reactive arthritis affecting joints other than a hip can be apyrexial, systemically well and have normal inflammatory markers. Blood tests such as Rheumatoid factor or ANA are rarely of use to discriminate infectious vs. non-infectious arthritis and are not offered acutely by the laboratory. If in doubt senior orthopaedic assessment is required. Consider a Consultant Paediatric Rheumatological opinion - details of on-call consultant through LGI switchboard.
IN THE CASE OF HIP SEPSIS UNDERTREATMENT RESULTS IN RAPID JOINT DESTRUCTION SO FORMAL SURGICAL EXPOSURE AND WASHOUT IS REQUIRED.
Awake aspiration is possible in older mature children with parental support. Entonox sedation helps. Awake aspiration helps in doubtful/borderline cases. Using the criteria listed above the majority of cases will proceed to general anaesthetic and theatre so a selective approach should be adopted. Where there is doubt seek a senior orthopaedic opinion. Keep the child starved.
Consider discussing with the on-call Consultant Paediatric Rheumatological, if you think the child may have a non-infectious cause of arthritis.
Adjuvant antimicrobial treatment is also required (see below).
Empirical antimicrobial treatment
Children and infants age 1 month to 5 years:
Children age 5 years to 16 years:
In haematogenous joint sepsis with the exception of skin rashes e.g. chickenpox a primary focus is seldom identified.
Reactive arthritides, rheumatological diseases including juvenile idiopathic arthritis and transient synovitis of the hip/irritable hip http://lthweb/sites/emibank/guidelines-folder/pages/copy_of_management-of-the-atraumatic-limping-child can confuse particularly in the early stages but these are generally milder illnesses compared to joint sepsis. They can be associated with raised CRP, neutrophilia and fevers, but in the presence of these findings it is usually appropriate to initially assume the possibility of septic arthritis, unless there are other features specific to an autoimmune disease. Consider a Consultant Paediatric Rheumatological opinion - details of on-call consultant through LGI switchboard.
The most common causes of septic arthritis in children in England and Wales during the early 1990s were: Staphylococcus aureus, Streptococcus pneumoniae, beta-haemolytic streptococci [mostly A and B] and Haemophilus influenzae, which caused 44% of cases in the under 10 year olds (Ryan et al., 1997). While most of the pathogens have not changed in more recent studies (Peltola et al., 2009), two significant developments have occurred:
The most common causes of septic arthritis in children >5 to 16 years are Staphylococcus aureus and streptococci (Yagupsky et al., 1992) but Gram negatives continue to cause a small proportion of cases. Neisseria meningitidis, Haemophilus influenzae, Enterobacteriacaea [“coliforms”], and other streptococci are uncommon causes of septic arthritis in children (Yagupsky et al., 1992).
In some parts of the world community-acquired MRSA is more prevalent and a cause of septic arthritis in children (Yamagishi et al., 2009).
Culture negative septic arthritis
PCR on bone biopsy is required to make a diagnosis. Tuberculosis should be considered in more insidious infections with epidemiological risk factors or typical radiological findings.
1. Blood tests
Recommendation: Full blood count and CRP should be sent from all patients being treated with intravenous antimicrobials at baseline.
2. Joint aspiration
Recommendation : Joint aspirate should be sent in a sterile container for Gram stain and cultures and inoculated directly in BACTEC™ Peds Plus™ blood culture bottle.
Inoculation of synovial fluid directly into blood culture bottles improves bacteriologic diagnosis of paediatric septic arthritis and facilitates better detection of fastidious organisms e.g. Kingella kingae
Bone lysis and periosteal elevation indicate associated adjacent osteomyelitis but X-ray changes are usually absent during the initial 10 days or so of the evolution of bone infection. X-rays may occasionally demonstrate the painful limb is in fact broken or has some other pathological lesion. Established hip sepsis can cause hip subluxation and even dislocation.
Recommendation: Ultrasound scanning (U/S) of the affected joint should be undertaken in children with a suspicion of joint sepsis. The false negative rate is low (<5%). In young children where the history is poor and clinical findings inconclusive U/S of adjacent joints is helpful e.g. image both hips and knees.[Evidence level B ]
Recommendation: Magnetic resonance imaging [MRI] is useful in cases where diagnostic uncertainty remains. [Evidence level B]
|Empirical Antimicrobial Treatment|
DO NOT START ANTIMICROBIALS UNTIL Blood Cultures & JOINT FLUID SAMPLES HAVE BEEN TAKEN.
Children age 5 years to 16 years:
Recommendation: Initial antimicrobial therapy for septic arthritis should be intravenous.
|Directed Antimicrobial Treatment (when microbiology results are known)|
In culture negative cases directed therapy is not possible but empirically in >90%+ cases monotherapy with Flucloxacillin is appropriate. In a child commenced on Flucloxacillin and Ceftriaxone for severe sepsis and suspected meningococcal infection, Ceftriaxone can usually be stopped if Blood Cultures do not grow meningococci and meningococcal PCR on blood samples is negative.
Table 1 Directed antimicrobial regimens for osteomyelitis in children and infants. *Provided isolate is susceptible.
|Duration of Treatment|
Recommendation: 14 day course of antimicrobial therapy, if the clinical response is good and the C-reactive protein level normalizes (<20mg/L) shortly after initiation of treatment.
Recommendation: Slow responders (e.g. CRP remaining elevated (>20mg/L) or persistent fever or systemic signs of infection at 96 hours) require 3-4 weeks antimicrobial therapy.
Various regimes have been described from one week IV therapy to six weeks IV then step-down oral therapy. Until recently there was no RCT evidence to guide this issue. A randomized, multicentre prospective trial of children aged 3 months to 15 years with culture-positive septic arthritis has now concluded that large doses of well-absorbed antimicrobials for <2 weeks (initially administered intravenously) are sufficient for treatment of most cases of childhood septic arthritis (Peltola et al., 2009). Patients were randomized to receive Clindamycin or a first-generation cephalosporin for 10 days (short term) or 30 days (long term). Intravenous therapy was given for the first 2-4 days. Of the total 130 cases, 63 patients were in the short-term treatment group, and 67 were in the long-term treatment group. The median durations of antimicrobial treatment were 10 days and 30 days, respectively. All patients recovered without sequelae (Peltola et al., 2009)
|Switch to oral agent(s)|
Recommendation: Initial IV treatment is mandatory and should continue for at least 3 days.
Recommendation: If the clinical response is good [usual case] as indicated by the child’s general well-being [feeding etc.], rapidly resolving temperature and rapidly falling CRP [preferably < 20mg/L] then oral antibiotics can be substituted.
Recommendation: Hospital discharge should be at least 24 hrs. after switch to oral antimicrobials to confirm continuing improvement.
Slow/non-responders: In patients that fail to respond by 96 hours, the causative pathogen may not be sensitive to empirical regimens or abscess formation/recurrent joint sepsis or underlying osteomyelitis may be compromising antimicrobial activity. Repeat aspiration or surgical drainage may be required.
|Clinical condition:||Suspected septic arthritis in children|
|Target patient group:||All children with suspected septic arthritis|
|Target professional group(s):||Pharmacists
Secondary Care Doctors
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. [Where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other]
- Kan, J. H., Young, R. S., Yu, C. & Hernanz-Schulman, M. Clinical impact of gadolinium in the MRI diagnosis of musculoskeletal infection in children. Pediatr Radiol.
- Kulhanjian, J., Dunphy, M. G., Hamstra, S., Levernier, K., Rankin, M., Petru, A. & Azimi, P. (1989). Randomized comparative study of ampicillin/sulbactam vs. ceftriaxone for treatment of soft tissue and skeletal infections in children. The Pediatric infectious disease journal 8, 605-610.
- Peltola, H., Paakkonen, M., Kallio, P. & Kallio, M. J. (2009). 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 48, 1201-1210.
- Rasmont, Q., Yombi, J. C., Van der Linden, D. & Docquier, P. L. (2008). Osteoarticular infections in Belgian children: a survey of clinical, biological, radiological and microbiological data. Acta orthopaedica Belgica 74, 374-385.
- Ryan, M. J., Kavanagh, R., Wall, P. G. & Hazleman, B. L. (1997). Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period. Br J Rheumatol 36, 370-373.
- Yagupsky, P., Dagan, R., Howard, C. W., Einhorn, M., Kassis, I. & Simu, A. (1992). High prevalence of Kingella kingae in joint fluid from children with septic arthritis revealed by the BACTEC blood culture system. J Clin Microbiol 30, 1278-1281.
- Yamagishi, Y., Togawa, M. & Shiomi, M. (2009). Septic arthritis and acute hematogenous osteomyelitis in childhood at a tertiary hospital in Japan. Pediatr Int 51, 371-376.
- Yuan, H. C., Wu, K. G., Chen, C. J., Tang, R. B. & Hwang, B. T. (2006). Characteristics and outcome of septic arthritis in children. J Microbiol Immunol Infect 39, 342-347.
- Zaoutis, T., Localio, A. R., Leckerman, K., Saddlemire, S., Bertoch, D. & Keren, R. (2009). Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics 123, 636-642.
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