Osteoarticular Infections Following Open or Penetrating Trauma in Children in the Era of Community-Acquired MRSA

Abstract

BackgroundMost cases of pediatric osteoarticular infections (OAI) are hematogenous in nature and secondary to Staphylococcus aureus. The emergence of community-acquired MRSA (CA-MRSA) in the early 2000s led to an evolution of disease presentation and management for pediatric OAI. OAI in children can also occur through direct inoculation of microorganisms secondary to penetrating or open trauma. No studies have evaluated the microbiology or outcomes of trauma-related OAI (TROAI) in children in the era of CA-MRSA.MethodsCases were identified from the inpatient infectious diseases consultation database at Texas Children’s Hospital from Jan 1, 2011- Dec 31, 2016. TROAI cases were those in which OAI developed following a clear history of penetrating trauma, open fracture, crush injury or traumatic amputation. Only cases with radiographic evidence of bone abscess, gross appearance of infection at time of surgery and/or positive cultures from bone or joint were included. Complications included recurrence of infection, pathologic fracture or chronic osteomyelitis.Results692 consultations for OAI were performed during the study period with 32 meeting inclusion criteria; TROAI accounted for 2.8/10,000 hospital admissions. The median age of patients was 8.53 years. In 65.6% at least one organism was isolated and the most commonly isolated organisms were S. aureus (25%, 15.6% MRSA) and Enterobacter cloacae (25%, Figures 1 and 2). 83.9% of patients had at least one surgical procedure and 43.8% underwent ≥2 procedures. The presence of fungi (P = 0.01), atypical mycobacteria (P = 0.04), MRSA (P = 0.02) and/or polymicrobial infection (P = 0.001) were more common among cases requiring multiple surgeries. 84.4% of patients were discharged on oral therapy. 12.5% of patients developed complications and this was more common with E. cloacae (37.5% vs. 4.2%, P = 0.03).ConclusionTROAI are relatively uncommon in children but cause significant morbidity. While MRSA contributes substantially to TROAI and is associated with multiple surgical procedures, the highly diverse microbiology emphasizes the importance of obtaining cultures for microbiologic diagnosis and management. Clinicians should be aware of the frequency of E. cloacae in TROAI and its high risk for sequelae.Disclosures S. L. Kaplan, Allergan: Grant Investigator, Grant recipient and This grant pertains to unrelated research