dale jarka, md,cm, frcsc the children’s mercy … & joint infections •objectives: –compare...

© 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

Gap

• New information on bone and joint

infections has been published

4

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


• Objectives:



– Identify the importance of diagnosing pediatric

MSK infections

7


• Objectives:



– Identify the importance of diagnosing pediatric

MSK infections

– Review appropriate diagnostic work-up

8


• Rationale:

9


• Rationale:

– Increasing number & virulence

10


• Rationale:


– Challenging to recognize & treat

11


• Rationale:


– Challenging to recognize & treat

– High morbidity & mortality

12

MSK Work Up

• Consider:

– Age & history

– Physical exam

– Radiology

– Lab

13

Case 1

• 2 yo male

• Limping yesterday

• Today refuses to bear

weight

Case 1

• No recent illness

• No trauma

• Febrile to 102º F in ER

Case 1

• Exam:

– Doesn’t move RLE

– Pain, crying with attempts at motion

Case 1

• Lab results

– WBC 10

– ESR 48

– CRP 18

– Blood cultures pending (remember to obtain!)

Imaging

• xrays

Ultrasound

Diagnosis?

• Presumptive septic hip:

– Fevers, elevated ESR/CRP

– Refusal to bear weight

– +hip joint effusion

24

Diagnosis?

• Next step??

– Aspiration by I.R.?

– Surgery?

– MRI first?

25

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

Case 2

• Fluid

analysis

– Cloudy

– 28,000 cells

• 68% neut.

– Gram stain

• no organism

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

Importance of identifying infection

• If neglected

– Sepsis

– Death

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

Other imaging?

Additional studies

• Labs

– WBC 18.3

– ESR 60

– CRP 8.4

– Blood cultures pending

Next step?

Surgery

• Arthrotomy & irrigation of shoulder

6 months postop

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

http://www.ejbjs.org/content/vol89/issue8/images/large/JBJA0890817840G08.jpeg

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

Work up

• Labs:

– WBC 17

– ESR 29

– CRP 3.5

– Blood cultures pending

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

• Work up?

– Labs

• WBC 16 ESR 73 CRP 18.2

• Blood cultures pending

Diagnosis?

• Musculoskeletal infection vs untreated UTI

with knee injury?

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

2 Months Post-op

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

Work up?

• ESR 44

• CRP 2.3

• WBC 8

• Aspiration

– 55 ml fluid

– 24,000 WBC

Next step?

• Admitted

• Exam after aspiration:

– Painless knee

– Full ROM

– Able to weight bear

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?


Work up

• Diagnosis?



• Admitted to PICU for septicemia

Osteomyelitis & Abscess

Osteomyelitis

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.

Osteomyelitis

MRI: Pelvic osteomyelitis, deep pelvic

abscess

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.

Follow-up

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

Thank you!

105

dale jarka, md,cm, frcsc the children’s mercy … & joint infections •objectives: –compare...

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