Septic Arthritis in Children

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

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

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 IV 50–60 mg/kg (max. 1.5 grams) 6-hourly	Vancomycin IV 15 mg/kg 6-hourly (maximum of 2 grams/day). Adjust dose according to plasma concentrations, aim for ‘trough’ levels of 10-20mg/L). PLEASE NOTE: this dose is DIFFERENT to BNF-C PLUS Ciprofloxacin IV 10 mg/kg (max. 400 mg) 8-hourly	Vancomycin IV 15 mg/kg 6-hourly (maximum of 2 grams/day). Adjust dose according to plasma concentrations, aim for ‘trough’ levels of 10-20mg/L). PLEASE NOTE: this dose is DIFFERENT to BNF-C PLUS Cefuroxime IV 50–60 mg/kg (max. 1.5 grams) 6-hourly
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 PO 24mg/kg 12-hourly	Co-trimoxazole PO 24mg/kg 12-hourly
5 - 16 years²	Flucloxacillin IV 50 mg/kg (max. 2 grams) 6-hourly	Intravenous Vancomycin monotherapy (dose as above)	Intravenous Vancomycin monotherapy (dose as above)
Oral switch in culture negative cases	Flucloxacillin PO 25 mg/kg (max. 1 gram) 4 times daily. Round dose to nearest capsule size (250 mg or 500mg).	Clindamycin PO 6mg/kg (max 450mg) 6-hourly	Clindamycin PO 6mg/kg (max 450mg) 6-hourly

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. A - Afebrile for 24 hours C - Clinically improving E - Eating and drinking D - not Deep seated infection Septic arthritis is a deep seated infection however an oral switch can be considered in some cases after a minimum of 3 days of IV therapy (see empirical table for more details).
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]	IV Flucloxacillin			50 mg/kg (max. 2 grams) 6-hourly	PO Flucloxacillin		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 ¹		OR	10 mg/kg (max 1.2g) 6-hourly	PO Clindamycin ¹		6 mg/kg 4 times daily (the minimum dose is 37.5 mg 3 times daily). Round dose to nearest capsule size (150 mg or 300mg). An unlicensed oral liquid 75 mg/5mL is available if required.
	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. DOSE DIFFERENT TO BNF-C
*Staphylococcus aureus* [methicillin resistant] (Clindamycin or Vancomycin + Rifampicin	IV Clindamycin ¹	OR	AND	10 mg/kg (max 1.2g) 6-hourly	PO Clindamycin if susceptible or D/W Microbiology if Clindamycin resistant ( dose as above)
	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. DOSE DIFFERENT TO BNF-C
	PO/IV Rifampicin ¹			10 mg/kg (max. 600 mg) 12-hourly
Beta-haemolytic Streptococcus	IV Benzyl penicillin			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 ¹		OR	10 mg/kg (max 1.2g) 6-hourly	PO Clindamycin ¹		6 mg/kg 4 times daily (the minimum dose is 37.5 mg 3 times daily). Round dose to nearest capsule size (150 mg or 300mg). An unlicensed oral liquid 75 mg/5mL is available if required.
	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. DOSE DIFFERENT TO BNF-C
*Streptococcus pneumoniae*	IV Benzyl penicillin			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. DOSE DIFFERENT TO BNF-C	PO Clindamycin ¹		6 mg/kg 4 times daily (the minimum dose is 37.5 mg 3 times daily). Round dose to nearest capsule size (150 mg or 300mg). An unlicensed oral liquid 75 mg/5mL is available if required.
*Neisseria meningitidis*	IV Benzyl penicillin			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* *choice dependant on susceptibility*	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* *choice dependant on susceptibility*	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

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