Septic Arthritis in Children - Guideline for the Management of |
Publication: 30/11/2010 |
Next review: 29/06/2025 |
Clinical Guideline |
CURRENT |
ID: 2332 |
Approved By: Improving Antimicrobial Prescribing Group |
Copyright© Leeds Teaching Hospitals NHS Trust 2022 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
SEPTIC ARTHRITIS IN CHILDREN
- Diagnostics and investigations
- Examination
- Non-antimicrobial management
- Aspiration/surgery
- Empirical treatment
- Review by 72
- Directed therapy
- Treatment failure
- Footnotes
These guidelines apply to children (>1 month and ≤16 years old) with suspected acute joint infection (septic arthritis). For patients aged 17 and over please refer to the adult septic arthritis guideline.
DIAGNOSTICS AND INVESTIGATIONS
Septic arthritis in children usually has a rapid onset with progressive pain in affected region. The hip and knee are the most commonly affected joints. Fever and systemic upset is common but variable. In infants and younger children the parent may report reduced use of limb or limping. Multifocal septic arthritis is very uncommon in children who are not immunosuppressed and raises the possibility of a non-infectious ‘rheumatological’ cause. Ask about: penicillin [and other] allergies and information on previous MRSA carriage/infection.
For patients with a presumed diagnosis of Septic Arthritis in children, the following diagnostic tests should be taken to confirm diagnosis:
All patients | Blood cultures [before antimicrobials] |
FBC (including considering possibility of leukaemia) |
|
CRP |
|
Joint aspiration (see below) |
|
A plain x-ray of affected joint(s) and adjacent bones. |
|
Ultrasound scan (MRI is an alternative if available) |
|
PCR on bone biopsy |
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.
http://lthweb/sites/emibank/guidelines-folder/pages/copy_of_management-of-the-atraumatic-limping-child
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 Rheumatologist’s opinion - details of on-call consultant through LGI switchboard.
There should be a low threshold for patients who are clinically challenging when examining their hips such as those intubated on PICU to have Ultrasounds of hips to rule out hip effusions.
Patients who are immune-compromised should have careful assessment of all joints if concern as has been raised regarding the possibility of joint infection (again low threshold for radiological imaging of joints which are difficult to assess whether effusions are present).
Patients who fail to improve as expected following surgery and antibiotics, should be discussed within the MDT forum to consider further imaging or repeat surgery.
NON-ANTIMICROBIAL MANGEMENT
- Fluid resuscitation as necessary.
- Pain relief
- Splintage of peripheral joint in a ‘back-slab’ cast as recommended by orthopaedic surgeon.
ASPIRATION/SURGERY
When clinical suspicion of infection within a joint, the joint should be evacuated urgently. In the large majority turbid fluid or frank pus will be aspirated which is presumptive evidence of infection. Joint aspirate should be sent in a sterile container for Gram stain and cultures and inoculated directly in BACTEC™ Peds Plus™ blood culture bottle. In this case proceed to mini arthrotomy or washout using wide bore arthroscopic cannula.
Because undertreated hip infection causes rapid joint destruction SUSPICION OF HIP SEPSIS REQUIRES PROMPT FORMAL SURGICAL EXPLORATION AND WASHOUT.
Consider discussing with the on-call Consultant Paediatric Rheumatology, if you think the child may have a non-infectious cause of arthritis.
Adjuvant antimicrobial treatment is also required (see below).
EMPIRICAL TREATMENT
UNLESS THE CHILD HAS SEPTICAEMIA, DO NOT START ANTIMICROBIALS UNTIL BLOOD CULTURES & JOINT FLUID SAMPLES HAVE BEEN TAKEN (AS SOON AS POSSIBLE).
Doses below assume normal renal and hepatic function: consult product literature or pharmacy for further information if patient has renal or hepatic impairment.
Empirical options for Septic Arthritis in Children | |||
Duration of treatment: If the clinical response is good and the C-reactive protein level normalizes (<20mg/L) shortly after initiation of treatment: 14 day course of antimicrobial therapy. Slow responders (e.g. CRP remaining elevated (>20mg/L) or persistent fever or systemic signs of infection at 96 hours): 3-4 weeks antimicrobial therapy. Treatment should be given IV for a minimum of 3 days before considering an IV to oral switch. 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. Hospital discharge should be at least 24 hours after switch to oral antimicrobials to confirm continuing improvement. |
|||
Patient Age |
No penicillin or cephalosporin allergy or MRSA colonisation |
True immediate-type penicillin or cephalosporin allergy |
Previous MRSA infection or colonisation |
1 month - 5 years |
Cefuroxime |
Vancomycin IV |
Vancomycin IV |
Oral switch in culture negative cases |
Cephalexin PO 25 mg/kg 4 times daily (max. 1 g 4 times daily). Round dose to nearest capsule size (250 mg or 500mg). |
Co-trimoxazole |
Co-trimoxazole |
5 - 16 years2 |
Flucloxacillin IV 50 mg/kg |
Intravenous Vancomycin monotherapy (dose as above) |
Intravenous Vancomycin monotherapy (dose as above) |
Oral switch in culture negative cases |
Flucloxacillin PO |
Clindamycin |
Clindamycin |
REVIEW BY 72
By 72 hours of antimicrobial treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis.
If your patient in on IV treatment this should be reviewed daily.
The review, outcome and future plans (where appropriate) should be documented in the medical notes.
If the diagnosis of septic arthritis is still correct your options are now:
IVOS | If your initial diagnosis is correct and the patient is prescribed IV antibiotics, review whether an oral switch is appropriate using the ACED criteria (see below). If they meet all 4 criteria consider switching using the oral options listed in the table above. |
Stop |
If no signs of infection and diagnostics support this decision. |
Change |
If the patient is not clinically responding, check microbiology results to see if directed therapy is required or you may need to consider an alternative diagnosis. |
Continue |
If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch. Document the reason for continuing. |
DIRECTED THERAPY
Doses below assume normal renal and hepatic function: consult product literature or pharmacy for further information if patient has renal or hepatic impairment.
Please note when prescribing high dose oral antibiotics (e.g. Amoxicillin , Flucloxacillin ) patients may experience an increase in gastrointestinal upset (nausea and diarrhoea).
Pathogen | Initial treatment |
Oral antibiotic switch |
|||||
Antimicrobial Agent |
Dose |
Antimicrobial Agent[s] |
Dose |
||||
Duration of treatment: see above in empirical table |
|||||||
Staphylococcus aureus [Meticillin susceptible] |
50 mg/kg (max. 2 grams) 6-hourly |
25 mg/kg (max. 1 gram) 4 times daily. Round dose to nearest capsule size (250 mg or 500mg). Take dose 1 hour before food to improve absorption. Doses of up to 2 grams QDS have been prescribed previously but are associated with a high incidence of GI side effects (nausea and diarrhoea). |
|||||
Second choice (e.g. true allergy to first choice1) |
IV Clindamycin |
OR |
10 mg/kg (max 1.2g) 6-hourly |
PO Clindamycin |
6 mg/kg 4 times daily (the minimum dose is 37.5 mg 3 times daily). |
||
IV Vancomycin |
15 mg/kg 6-hourly (maximum of 2 grams/day). Adjust dose according to plasma concentrations, aim for ‘trough’ levels of 10-20mg/L. |
||||||
Staphylococcus aureus [methicillin resistant] |
IV Clindamycin |
OR |
AND |
10 mg/kg (max 1.2g) 6-hourly |
PO Clindamycin |
||
IV Vancomycin |
15 mg/kg 6-hourly (maximum of 2 grams/day). Adjust dose according to plasma concentrations, aim for ‘trough’ levels of 10-20mg/L. |
||||||
PO/IV Rifampicin 1 |
10 mg/kg (max. 600 mg) 12-hourly |
||||||
Beta-haemolytic Streptococcus |
50 mg/kg (max 2.4g) 6-hourly (4-hourly if signs of sepsis) |
PO Amoxicillin |
25 mg/kg (max. 1 gram) 3 times daily. Round dose to nearest capsule size (250 mg or 500mg). |
||||
Second choice (e.g. true allergy to first choice) |
IV Clindamycin |
OR |
10 mg/kg (max 1.2g) 6-hourly |
PO Clindamycin |
6 mg/kg 4 times daily (the minimum dose is 37.5 mg 3 times daily). |
||
IV Vancomycin |
15 mg/kg 6-hourly (maximum of 2 grams/day). Adjust dose according to plasma concentrations, aim for ‘trough’ levels of 10-20mg/L. |
||||||
Streptococcus pneumoniae |
50 mg/kg (max 2.4g) 6-hourly (4-hourly if signs of sepsis) |
PO Amoxicillin |
25 mg/kg (max. 1 gram) 3 times daily. Round dose to nearest capsule size (250 mg or 500mg). |
||||
Second choice (e.g. true allergy to first choice) |
IV Vancomycin |
15 mg/kg 6-hourly (maximum of 2 grams/day). Adjust dose according to plasma concentrations, aim for ‘trough’ levels of 10-20mg/L. |
PO Clindamycin |
6 mg/kg 4 times daily (the minimum dose is 37.5 mg 3 times daily). |
|||
Neisseria meningitidis |
50 mg/kg (max 2.4g) 6-hourly (4-hourly if signs of sepsis) |
PO Amoxicillin |
25 mg/kg (max. 1 gram) 3 times daily. Round dose to nearest capsule size (250 mg or 500mg). |
||||
Second choice (e.g. true allergy to first choice) |
D/W Microbiology according to susceptibility |
D/W Microbiology according to susceptibility |
|||||
Haemophilus influenzae |
IV Amoxicillin |
|
50 mg/kg (max 2g) 6-hourly (4-hourly if signs of sepsis) |
D/W Microbiology according to susceptibility |
|||
IV Cefotaxime |
50 mg/kg 8-hourly, increased in life threatening or severe infection to 50 mg/kg 6-hourly (max. 12 grams daily). |
||||||
Second choice (e.g. true allergy to first choice) |
D/W Microbiology according to susceptibility |
D/W Microbiology according to susceptibility |
|||||
Kingella kingae |
IV Amoxicillin |
OR |
50 mg/kg (max 2g) 6-hourly (4-hourly if signs of sepsis) |
PO Cephalexin |
OR |
25 mg/kg 4 times daily (max. 1 g 4 times daily). Round dose to nearest capsule size (250 mg or 500mg). |
|
IV Cefuroxime |
50 mg/kg (max. 1.5 grams) 6-hourly (60mg/kg (max 1.5grams) if signs of sepsis) |
PO Amoxicillin |
25 mg/kg (max. 1 gram) 3 times daily. Round dose to nearest capsule size (250 mg or 500mg). |
||||
Pseudomonas aeruginosa |
IV Ceftazidime (preferred option) |
OR |
50 mg/kg 8-hourly (max. 6 grams daily). |
D/W Microbiology according to susceptibility |
|||
IV Piperacillin/tazobactam (second choice) |
90 mg/kg 8-hourly; (max 4.5 grams 6-hourly). (Note: the mg/kg dose is that of the combined piperacillin and tazobactam product) |
||||||
IV Meropenem (third choice) |
20 mg/kg (max 2g) 8-hourly |
||||||
Second choice (e.g. true allergy to first choice) |
D/W Microbiology according to susceptibility |
D/W Microbiology according to susceptibility |
TREATMENT FAILURE
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. Discuss with senior orthopaedic surgeon and microbiology and consider paediatric rheumatological opinion.
FOOTNOTES
- Provided isolate is susceptible.
- In the sick child [> 5 years to 16 years] with concurrent features of meningococcal meningitis or meningococcal bloodstream infection it is wise to extend the spectrum initially by adding ceftriaxone as per the meningitis guidelines pending Blood Cultures and PCR.
|
Provenance
Record: | 2332 |
Objective: | |
Clinical condition: | Suspected septic arthritis in children |
Target patient group: | All children with suspected septic arthritis |
Target professional group(s): | Pharmacists Secondary Care Doctors |
Adapted from: |
Evidence base
- 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.
Approved By
Improving Antimicrobial Prescribing Group
Document history
LHP version 2.0
Related information
Not supplied
Equity and Diversity
The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.