dale jarka, md,cm, frcsc the children’s mercy … & joint infections •objectives: –compare...
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© The Children's Mercy Hospital 2016
Dale Jarka, MD,CM, FRCSC
The Children’s Mercy Hospitals & Clinics
Bone and Joint Infections –
Oh, My
1
Disclosures
• A: I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s) and/or
provider(s) of commercial services discussed in this
CME activity
• B: I do not intend to discuss an unapproved/investigative
use of a commercial product/device in my presentation
Objectives
• Compare and contrast the bacterial
causes of osteomyelitis and septic arthritis
in children
3
Practice Change
• In addition to local cultures, the learner will
obtain a blood culture in any child
suspected of having a bone and joint
infection
5
Bone & Joint Infections
• Objectives:
– Compare and contrast the bacterial causes of
osteomyelitis & septic arthritis in children
6
Bone & Joint Infections
• Objectives:
– Compare and contrast the bacterial causes of
osteomyelitis & septic arthritis in children
– Identify the importance of diagnosing pediatric
MSK infections
7
Bone & Joint Infections
• Objectives:
– Compare and contrast the bacterial causes of
osteomyelitis & septic arthritis in children
– Identify the importance of diagnosing pediatric
MSK infections
– Review appropriate diagnostic work-up
8
Bone & Joint Infections
• Rationale:
– Increasing number & virulence
– Challenging to recognize & treat
11
Bone & Joint Infections
• Rationale:
– Increasing number & virulence
– Challenging to recognize & treat
– High morbidity & mortality
12
Diagnosis?
• Presumptive septic hip:
– Fevers, elevated ESR/CRP
– Refusal to bear weight
– +hip joint effusion
24
Aspiration
• Septic arthritis
– > 50,000 WBC
– 20,000-50,000 WBC?
– (Cut-off for septic
arthritis is gray)
WBC = 78,000 (92% neutrophils)
Gm stain = Gm + cocci
Arthrotomy & Irrigation
• Obtain cultures
• Drain the hip joint
– decreases hydrostatic pressure
& reduce risk of AVN
– evacuates debris and bacterial
products
decrease inflammatory response
Antibiotic management
• Timing of antibiotics
JBJS 2015— “Antibiotic use (pre hospital or within
institution) not associated with lower rate of positive
surgical site cultures.”
Antibiotic management
• Choice and duration of antibiotics:
– Presumptive organism (staph. vs strep.)
– Now more likely to start w/ clinda (rather than Ancef)
– MSSA vs. MRSA:
• The former beginning to behave like the latter
Case 2
• 3 yo female
– limp 6 days
– now won’t bear weight on R leg
– Recent URI
– Afebrile
– Hip irritable w/ ROM
– WBC 18
– ESR 15
– CRP 1.6
30
Multivariate analysis Transient synovitis vs. septic arthritis
• Kocher MS, et al JBJS 81A, 1999
• 4 independent clinical predictors differentiate septic
arthritis & transient synovitis:
• History of fever >/= 38.5 degrees Celsius
• Non-weightbearing
• ESR > 40 mm/hr
• WBC > 12,000/mm3
Multivariate analysis Transient synovitis vs. septic arthritis
• Kocher MS, et al JBJS 81A, 1999
• Score Likelihood of septic arthritis
1 3%
2 40%
3 93%
4 99%
Fever NWB ESR>40 WBC>12 Probability SA
yes yes yes yes 99.8%
yes yes yes no 97.3%
yes yes no yes 95.2%
yes yes no no 57.8%
yes no yes yes 95.5%
yes no yes no 62.2%
yes no no yes 44.8%
yes no no no 5.3%
no yes yes yes 93.0%
no yes yes no 48.0%
no yes no yes 33.8%
no yes no no 3.4%
no no yes yes 35.3%
no no yes no 3.7%
no no no yes 2.1%
no no no no 1 in 700
Case 1 Fever(+), NWB (+), ESR 48 (+), WBC 10 (-)
Fever NWB ESR>40 WBC>12 Probability SA
yes yes yes yes 99.8%
yes yes yes no 97.3%
yes yes no yes 95.2%
yes yes no no 57.8%
yes no yes yes 95.5%
yes no yes no 62.2%
yes no no yes 44.8%
yes no no no 5.3%
no yes yes yes 93.0%
no yes yes no 48.0%
no yes no yes 33.8%
no yes no no 3.4%
no no yes yes 35.3%
no no yes no 3.7%
no no no yes 2.1%
no no no no 1 in 700
Case 2 Fever(-), NWB (+), ESR 15(-), WBC 18(+)
Septic hip vs. Transient Synovitis
• Other studies of same criteria: lower predictive
value in other populations
– Luhmann et al. 59% predictive w/ all 4 variables
• Caird et al. JBJS 2006
– Evaluated Kocher criteria + CRP
– Fever (oral temp > 38.5°)
– CRP found to be strong independent risk factor
Importance of identifying infection
• Poor results of delayed diagnosis/treatment of septic hip
– Osteomyelitis
– Septic dislocation
– Avascular necrosis of femoral head
• Femoral head deformity
• Long term: leg length discrepancy
MRI: work up for infection
• JPO 2014, Gottschalk
– Improved diagnostic efficiency with MRI as
part of work up
• Decrease rate of reoperation
MRI: work up for infection
• Indications for MRI
– Negative hip aspiration
– Location and severity of infection
– Age of patient
– Availability of MRI
Case 3
• 12 month old male
– Won’t move arm
– “Nursemaid’s elbow” one
week ago
– Recent fevers, runny nose
Septic arthritis & osteomyelitis
• Shoulder, hip, ankle, elbow have metaphyseal bone within the joint capsule.
Septic arthritis & osteomyelitis
• 20% of infants with septic arthritis of hip have adjacent osteomyelitis
> 50% of neonates may have concomitant osteomyelitis
• High incidence of concomitant osteo and septic arthritis in adolescents
– Shoulder most at risk (Montgomery et al. JPO 2013)
– Related to duration of symptoms
Follow up
Saisu et al. JBJS 2007 Humeral shortening and inferior
shoulder subluxation as sequelae of septic shoulder arthritis
in neonates and infants.
17 months 12 years
Case 4
• 20 mo F
• Developed pain, refusal to bear weight at daycare
• Parents report temp 101º F
• Rhinorrhea prior week
• Otherwise healthy
Exam
• Afebrile, VS WNL
• Left leg flexed and externally rotated
• Pain and resistance with any movement of LLE
• Will allow manipulation of RLE
• No erythema or warmth on exam
Diagnosis?
• ? fever, refusal to WB
• WBC 17, ESR 29, CRP 3.5
• Septic arthritis vs transient synovitis
• Admitted overnight
• Started on NSAIDS
• MRI ordered for following morning
Hospital course • Exam after MRI
• Receiving Motrin overnight (no antibiotics)
• Afebrile
• Full passive range of motion of left hip without
any visible discomfort.
• Able to bear weight with limp
• Plan??
• Continue to observe.
Hospital day 2
Afebrile overnight. Patient with active and passive range of
motion of LLE. No erythema or swelling.
Infectious Disease, Pediatrics, Orthopedics ok with D/C
home.
Follow up
• Return visit to ED one day later:
• Temp 101º F at home
• Refusing to bear weight or move LLE
• Exam in ED
• PE - Afebrile, VS WNL
• Irritable with decreased active and passive ROM
of LLE.
• WBC 13.83 ESR 40 CRP 4.2
• US - left hip effusion 2.4 cm x 5 mm
• Admitted - NPO, OR
OR—septic arthritis
• To OR for aspiration and possible arthrotomy
• Aspiration - frank pus, sent for cultures
• Frank pus upon arthrotomy
• Started on Clindamycin q6H
Post op course
• POD1 - afebrile, active ROM LLE
– Cultures: Kingella Kingae
– Changed to Ancef with transition to Keflex (3 weeks)
Follow up
3 weeks postop – ID clinic
Doing well, labs normalized
Final visit with ortho at 3 months
Asymptomatic
Kingella Kingae
• Gram negative aerobe
• Patients 6-48 months, often in daycare
• Labs may only show mild elevations
• Specimen in blood culture bottle increases probability of
identifying
• PCR most sensitive method
Case 5 • 8 year old female
• CC: L knee pain (“fall during basketball”)
• PMH
– Asthma
– Recurrent UTIs
Exam
• T 39º C
• Knee exam:
– No swelling, ecchymosis, erythema
– TTP proximal tibia
• Xrays – negative for fracture
ED Plan
• Diagnosed with contusion vs sprain
• Urinalysis performed to work up fever
– Positive for UTI
– Discharge home on Bactrim, Ibuprofen
– Follow-up PCP
Follow up
• Returned to ED 4 days later with persistent knee pain
– Unable to ambulate, Temp at home 102º F
– T 37.3 HR 88 RR24 BP 110/60
• Urine cultures from prior visit
– E coli resistant to bactrim
– Rocephen administered
• Orthopaedic consult obtained for knee pain
– Swelling and TTP proximal tibia, no erythema
– Minimal pain with ROM of knee
– Unable to weight bear, NVI
Plan?
• Patient admitted to peds team
– MRI ordered
– Infectious disease team consulted
– Positive Blood culture –Gram positive cocci in
clusters
Surgical Treatment
• Irrigation and debridement left proximal
tibial subperiosteal abscess
– Extensive purulent material
– Cultures
Surgical Treatment
• Procedure repeated 2 days later
– 2º to severity of infection
– Persistent post-operative fevers
Disposition
• Discharge home 3 days post initial surgery
• Culture – MSSA
• Cephalexin for 6 weeks
• Follow-up with ID and Ortho post-operatively
• TTWB with crutches
Case 5
• 7 yo presents with inability to weight bear
• Knee swelling 4-5 days
– Noted after playing in bounce house
– Minimal symptoms
• Now more swelling, over last 24 hours
decreased ability to weight bear
Exam
• T 38.6º C
• Knee + large effusion
• Minimal tenderness over knee
• ROM 0º-110º, pain with flexion
Differential diagnosis
• Septic knee
• Transient synovitis:
– Not aware this exists outside of the hip
• ID consulted, discussed
• History: travel across US, ? Tick bite in Colorado
Diagnosis
• Went to OR for repeat aspirate & arthrotomy
• Fluid slightly cloudy
• + Lyme PCR
• Completed course of amoxicillin
Case 6
• 15 yo male
– 3 week h/o worsening right thigh/back pain
– Fell x2 playing volleyball 3 weeks prior
• Visited PCP twice
– NSAIDs, Oral Steroid Taper, Flexeril
• Two episodes of emesis the week
• Denies fevers, chills, recent illness
Exam • General:
– Afebrile, vitals stable
– In obvious discomfort
• MSK exam
– Right hip is flexed, externally rotated
– Will not allow ROM of RLE
– Will not bear weight
Work up
• WBC – 14.7
• ESR – 66
• CRP –11.8
• Blood cultures +
• Ultrasound
– moderate right hip effusion
with synovial hypertrophy
Work up
• Diagnosis?
• Additional tests?
• Right hip aspirate: positive for gram (+) cocci in clusters
• Admitted to PICU for septicemia
Work up
• Diagnosis?
• Additional tests?
• Right hip aspirate: positive for gram (+) cocci in clusters
Work up
• Diagnosis?
• Additional tests?
• Right hip aspirate: positive for gram (+) cocci in clusters
• Admitted to PICU for septicemia
Clinical Course
• Admitted to PICU for resuscitation
– Started on clindamycin and ceftriaxone
– Switched to vancomycin after ID consult
• Surgery next day with IR and Orthopedics
– IR – percutanous drainage of right thigh abscess
– Arthrotomy & irrigation right septic hip
Clinical Course
– Stable after surgery
– Cultures positive for MSSA
– Treated in hospital with Cefazolin, discharged home on Cephalexin
Clinical Course
• Discharged from ID and Orthopedic clinic after
completing 8 week course of Cephalexin
• 1 month later presented to ED with left lower
quadrant pain, nausea, vomiting, fever.
– WBC 8, CRP 31.7, ESR 54
– US showed trace left hip effusion.
Recurrence
• Left pelvic osteomyelitis with associated abscess.
• Treatment – drainage by IR
• Cultures – grew MSSA
• Abx – 8 weeks of Linezolid.
• Doing well at last follow-up visit.
Take-home Messages
• Consider MSK infection with limb disuse
• Obtain blood cultures with labs
• Image early (U/S, MRI)
• Toddlers may have K. kingae (mild presentation)
• Adolescents can have infections too!
103
Practice Change
• In addition to local cultures, the learner will
obtain a blood culture in any child
suspected of having a bone and joint
infection
104
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