Acute Musculoskeletal Infections Research Articles

A Rapid MRI Protocol for the Evaluation of Acute Pediatric Musculoskeletal Infections: Eliminating Contrast and Decreasing Anesthesia, Scan Time, and Hospital Length of Stay and Charges.

Acute musculoskeletal infection affects >1 in 6,000 children in the United States annually. Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of musculoskeletal infection, but it traditionally requires contrast and anesthesia for children, delaying management. A rapid MRI protocol involves MRI without anesthesia and with limited non-contrast sequences optimized for fluid detection and diffusion-weighted images to identify abscesses. We hypothesized that a rapid MRI protocol would improve imaging and treatment efficiency for pediatric patients undergoing musculoskeletal infection evaluation without substantially affecting accuracy. This was a single-center, retrospective study of patients undergoing evaluation for musculoskeletal infection before (60 patients in the traditional cohort [TC]) and after (68 patients in the rapid cohort [RC]) implementation of the rapid MRI protocol. Sociodemographic and clinical variables were extracted from electronic health records, and statistical comparisons were performed. The anesthesia rates were 53% for the TC and 4% for the RC, and the contrast administration rates were 88% for the TC and 0% for the RC. The median time to MRI after ordering was 6.5 hours (95% confidence interval [CI], 5.0 to 8.6 hours) for the TC and 2.2 hours (95% CI, 1.4 to 3.6 hours) for the RC (p < 0.01). The median duration of MRI was 63.2 minutes (95% CI, 56.8 to 69.6 minutes) for the TC and 24.0 minutes (95% CI, 21.1 to 29.5 minutes) for the RC (p < 0.01). The median hospital length of stay was 5.3 days (95% CI, 3.7 to 6.9 days) for the TC and 3.7 days (95% CI, 1.9 to 4.1 days) for the RC (p < 0.01). The median hospital charges were $47,309 (95% CI, $39,137 to $58,769) for the TC and $32,824 (95% CI, $22,865 to $45,339) for the RC (p < 0.01). Only 2 positive cases of musculoskeletal infection in the RC were missed on the initial imaging, but these instances were not attributable to the rapid protocol itself. Although 10 of 68 rapid MRI scans resulted in nondiagnostic outcomes due to patient motion, only 6 of 68 required repeat MRI with anesthesia. In patients evaluated for musculoskeletal infection, the rapid MRI protocol eliminated contrast and minimized anesthesia while improving MRI access and decreased scan and interpretation times, hospital length of stay, and hospital charges. The rapid MRI protocol had high sensitivity for diagnosing musculoskeletal infection and a low rate of imaging failure. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Rapid MRI Protocol for Acute Pediatric Musculoskeletal Infection Eliminates Contrast, Decreases Sedation, Scan and Interpretation Time, Hospital Length of Stay, and Charges

Introduction: Acute musculoskeletal infections (MSKi) affect >1:6000 children in the United States annually, which could lead to arthritis, chronic infection, limb deformity, and even death. MRI is the gold standard for MSKi diagnosis but traditionally requires contrast and anesthesia, delaying results and slowing treatment decision-making. A rapid MRI protocol is an unsedated MRI with limited non-contrast sequences optimized for fluid detection and diffusion-weighted images to help identify abscesses. The objective of this study was to compare MRI access, timing, treatment, length of stay, and charges between the traditional and rapid MRI protocols among pediatric patients undergoing MSKi evaluation.Methods: A single-center retrospective study was conducted among 128 patients undergoing MSKi evaluation before (“Traditional cohort” [TC] of 60 patients admitted in Jan-Dec 2019) and after implementation of the rapid MRI protocol (“rapid cohort” [RC] of 68 patients admitted in Jun 2021-Jul 2022). Demographic, clinical, and charge data were extracted from electronic health records. Mann-Whitney U tests were performed to compare the two groups.Results: Demographics and diagnoses were similar, while rates of sedation and contrast administration were significantly different (53% and 88% in TC versus 4% and 0% in RC). The median time to MRI after ordering was 6.5 hours (IQR=3.2, 12.2) in TC and 2.2 hours (IQR=1.1, 4.5) in RC (p<0.01). The median duration of MRI was 63.2 minutes (IQR=52.4, 85.3) in TC and 24.0 minutes (IQR=18.5, 41.1) in RC (p<0.01). The median time between ordering and receiving the MRI final interpretation was 13.5 hours (IQR=2.35-66.3) in TC and 7.0 hours (IQR=1.25- 41.7) in RC (P<0.01). The median hospital length of stay was 5.3 days (IQR=2.7, 7.9) in TC and 3.7 days (IQR=1.0, 5.8) in RC (p<0.01). The median charges were $47,309 (IQR=$27,696, $81,048) in TC and $32,824 (IQR=$13,563, $53,027) in RC (p<0.01). While 10/68 of rapid MRIs resulted in nondiagnostic outcomes due to patient motion, only 6/68 required repeat MRI with sedation. Only two cases of MSKi were missed upon initial rapid MRI, but these instances were not attributable to the rapid protocol itself.Conclusion: In patients being evaluated for MSKi, the rapid MRI protocol eliminated contrast and nearly eliminated sedation while leading to improved MRI access, scan and interpretation times, and significant decreases in hospital length of stay and charges. Future steps include continuing quality control, studying interobserver reliability between protocols, and multicenter program expansion.Significance: Pediatric MSKi carry a large treatment burden, and this rapid MRI protocol improves imaging access while eliminating contrast, decreasing sedation, scan time, length of stay, and hospital charges, with a <10% rescan rate.

Risk Factors for Venous Thromboembolic Events in Children With Acute Musculoskeletal Infections.

Venous thromboembolic events (VTE) complicate acute hematogenous musculoskeletal infections (MSKIs) among hospitalized children. However, there is limited guidance for which specific MSKI patients are at the greatest VTE risk. This study aimed to identify VTE risk factors for children hospitalized with MSKIs. A retrospective chart review was performed of children hospitalized with MSKIs at a single quaternary care pediatric hospital during a 9-year period. Patients with chronic MSKIs, non-hematogenous infections, or significant contributing comorbidities were excluded. Demographic and clinical characteristics were compared between patients with and without VTE using forward stepwise conditional multivariable logistic regression to identify VTE risk factors. Among 335 included patients, 7 (2.1%) developed a VTE. There was no difference in age, sex, or obesity rates for those with or without VTE. Patients with methicillin-resistant Staphylococcus aureus (MRSA) infections and/or critical illness were more likely to develop a VTE with summative adjusted odds ratios of 31.7 and 26.4, respectively. In addition, patients with VTEs had longer hospitalizations (median 4.7 vs. 12.8d, P <0.001), longer courses of intravenous antimicrobials (median 3.7 vs. 13.5d, P =0.001), and longer time to fever resolution (median 25.7 vs. 162h, P =0.004). VTE prevalence among children with acute MSKIs is low. MRSA infection and critical illness significantly increase the risk for VTE development in these patients. Future prospective studies are needed to determine if VTEs in high-risk MSKI patients can be prevented.

PAEDIATRIC MULTIFOCAL MUSCULOSKELETAL SEPSIS: A 15-YEAR REVIEW OF OUTCOMES

Survival of sepsis has been documented worldwide, but little is documented about the long-term health outcomes of multifocal sepsis from acute musculoskeletal infection - the first study of its kind in New Zealand.Children admitted to the Paediatric Intensive Care Unit (PICU) from 1st January 2002 to 31st December 2017 with a musculoskeletal focus of infection were identified from hospital coding data. Notes review from discharge to present day determined survival and morbidity. Present-day clinical assessment of the musculoskeletal and respiratory systems along with questionnaires on health-related quality of life, mental health and sleep were performed.Seventy patients were studied. Seven children died acutely (five Pasifika and two Māori children) indicating 10% mortality. Long-term survival was favourable with no recorded deaths after discharge. Recurrence/chronic infection occurred in 23%, a mean of 1.1 year after discharge. Growth disturbance occurred in 18%, a mean of 3 years after discharge. The hip joint and proximal femur have the worst complications. Children under 2 years are most at risk of long-term disability. No patients had chronic respiratory illness beyond 90 days. Fifteen children had symptoms of acute neurological impairment, three of whom had permanent brain injury. Twenty-six survivors (41%) were assessed a mean of 8.2 years after discharge. Health-related quality of life scores were on par with normative data. Six patients and eight parents screened positive for moderate to severe post-traumatic stress disorder.Paediatric multifocal musculoskeletal sepsis can result in complex illness with long hospital stay and multi-organ complications. Māori and Pasifika children, those under two and those involving the proximal femur/or hip are most at risk. Other outcomes are favourable with no evidence of chronic lung disease or poor quality of life. A period of rehabilitation for children with identified acquired brain injury should be part of discharge planning.

Identifying predictors for source culture positivity in children with acute musculoskeletal infections.

Identifying the causative bacterial pathogen for children with acute hematogenous musculoskeletal infections (MSKIs) allows for improved care. The purpose of our study was to determine if clinical markers could predict which patients will have a causative pathogen found on source culture alone, thus being highest yield to undergo operative diagnostic procedures. A single-center, retrospective cohort study was performed. Medical records for patients between 6months and 18 years of age admitted between July 2014 and September 2018 with a discharge diagnosis of acute osteomyelitis, septic arthritis, or pyomyositis were reviewed. Patients were stratified based on results of blood and source cultures. Predictors of interest were screened on a univariable basis with significant predictors retained in a multivariate analysis. There were 170 patients included. No predictors were significantly associated with increased odds of having a causative pathogen found on source culture alone. Degree of C-reactive protein elevation and history of fever were associated with decreased odds of being source culture positive, OR (95% CI); 0.92 (0.87, 0.98) and 0.39 (0.19, 0.81), respectively. Predictive modeling failed to identify children with MSKIs whose causative pathogen was found by source culture alone. It is difficult to predict which MSKI patients will be highest yield for operative diagnostic procedures.

Characteristics of Children With Culture Negative Acute Hematogenous Musculoskeletal Infections.

Identifying the causative pathogen for acute hematogenous musculoskeletal infections (MSKIs) allows for directed antimicrobial therapy and diagnostic confidence. However, 20% to 50% of children with acute MSKIs remain culture negative. The objective of this study was to compare characteristics of culture negative MSKI patients to those where a pathogen is identified. Electronic medical records of children admitted between July 2014 to September 2018 to a single quaternary care pediatric hospital with acute MSKIs were retrospectively reviewed. Clinical and demographic characteristics were compared between culture positive and culture negative MSKIs. A total of 170 patients were included of whom 43 (25%) were culture negative. All culture negative patients had at least 1 culture type obtained, and the majority (84%) had both blood and source cultures performed. When compared with patients with a causative pathogen identified, culture negative patients were younger (2.3 vs. 9.8 y), smaller (13.5 vs. 31.6 kg), less likely to be febrile on arrival (56% vs. 77%), less likely to have an abscess on imaging (23% vs. 48%), and were more likely to have uncomplicated septic arthritis (35% vs. 8%). No critically ill patient was culture negative. Seven culture negative patients had additional Kingella kingae testing performed, none of which were positive. Despite targeted and standardized efforts to identify causative bacteria, 25% of children with acute MSKIs never have a pathogen identified. Culture negative patients are younger, less febrile, are less likely to have an abscess, and more likely to have isolated septic arthritis. This is a retrospective cohort study interested in identifying patient characteristics that predict rate of culture positivity for acute MSKIs. This study meets criteria for Level II evidence.

Long-Term Impact of a Clinical Care Guideline for Pediatric Acute Musculoskeletal Infections: Are Improved Outcomes Sustainable?

Acute hematogenous musculoskeletal infections are a common cause of hospitalization in children. A locally developed clinical care guideline (CCG) for acute musculoskeletal infections was implemented at our quaternary care pediatric hospital in July 2012. The purpose of this study was to evaluate the long-term sustainability of previously described improvements after CCG implementation. Clinical outcomes for children hospitalized with musculoskeletal infections at Children's Hospital Colorado from June 2009 through September 2018 were retrospectively reviewed. Patients were included if they had an International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision discharge diagnosis of acute osteomyelitis, septic arthritis, or pyomyositis and were between 6 months and 18 years of age at admission. Patients with underlying medical complexity or nonhematogenous musculoskeletal infections were excluded. Patients were categorized by date of admission as either "pre-CCG" (June 2009 to June 2011) or "sustain-CCG" (July 2014 to September 2018). Primary outcomes were hospital length of stay and intravenous antimicrobial length of therapy. From pre-CCG to sustain-CCG, median length of stay decreased by 1.29 days (5.56 vs 4.27; P < .004) and median length of therapy decreased by 5.04 days (8.33 vs 3.29; P < .0001). Statistical process control charts support that these were sustained improvements many years after CCG implementation. Additional secondary clinical improvements were observed in the sustain-CCG group including faster fever resolution, more consistent blood and source culture acquisition, and decreased central line placement. There was no increase in related readmissions or therapeutic failures in the sustain-CCG group. Implementation of a CCG to standardize care for musculoskeletal infections can be sustained many years after implementation.

Acute musculoskeletal infection in children: diagnostic difficulties and when to operate

Paediatric septic arthritis, osteomyelitis and pyomyositis are infrequent diagnoses in general orthopaedic practice. However, when they present they require early diagnosis and expeditious treatment to prevent sepsis and long-term morbidity. This is challenging as the early stages of each disease can closely mimic more common and often less significant pathologies. Here we aim to address the diagnostic challenges encountered in paediatric acute musculoskeletal infection and identify when urgent surgical intervention is required. In particular we cover which key symptoms and signs should be identified in the initial clinical assessment and how blood tests and imaging can help guide diagnosis, including the use of clinical predictive algorithms. We also discuss theories regarding disease pathogenesis and how different causative organisms can lead to a wide variety of clinical presentations. Finally we present up-to-date clinical evidence regarding treatment, whether this be via surgery or antibiotics alone.

Discriminative Accuracy of Procalcitonin and Traditional Biomarkers in Pediatric Acute Musculoskeletal Infection.

Septic arthritis (SA) is responsible for 20% of pediatric musculoskeletal infections (MSKI) and can have significant consequences. Early detection of SA is critical, and procalcitonin (PCT) has emerged as a promising biomarker. This study assessed the test performance of PCT and traditional biomarkers for suspected SA. We conducted a prospective study at two pediatric emergency departments (ED). Data collected measured serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, and PCT. Box and whisker plots were generated to compare the of the biomarkers by positive MSKI or a non-MSKI diagnosis. The diagnostic performance of biomarkers was examined using the area under the receiver operating characteristic curve (AUC), and optimal cut -points were identified using the Liu method. Procalcitonin performed reasonably well for detection of MSKI (AUC, 0.72; confidence interval [95% CI], 0.59-0.84). However, CRP and ESR performed better (AUC, 0.88 and 0.78, respectively). White blood cell count was not predictive of MSKI. Patients with a PCT value >0.1 ng/mL, ESR values >19.5 mm/h, and a temperature higher than 99.0°F were more than twice as likely to have acute MSKI. A high CRP level was most predictive of acute MSKI, and patients with levels >2.38 mg/dL were 3.5 times more likely to have acute MSKI. Procalcitonin is a potential biomarker for the clinical differential of MSKI in the pediatric ED. Additional research is warranted to establish the optimal diagnostic level for PCT, to increase sample size, and to examine any impact on cost.

The efficacy of 16S ribosomal DNA sequencing in the diagnosis of bacteria from blood, bone and synovial fluid samples of children with musculoskeletal infections.

BackgroundMusculoskeletal infections are among the most common bacterial infections in children leading to hospitalization, invasive procedures and prolonged antibiotic administration. Blood, synovial and sometimes tissue cultures are essential for the diagnosis and treatment of musculoskeletal infections; 16S ribosomal DNA (rDNA) sequencing is a novel diagnostic tool for the detection of bacteria.While the yield of 16S rDNA sequencing in synovial fluid was previously assessed, data regarding the efficacy of this method from blood samples or partially treated children with suspected musculoskeletal infections is lacking.In this study we assessed the yield of 16S rDNA sequencing in blood, bone and synovial samples of children with musculoskeletal infections.MethodsBlood, synovial and bone samples were collected from children with suspected musculoskeletal infections and analyzed for the presence of 16S rDNA, the results were then compared with the benchmark microbial cultures.ResultsDuring the study period, 41 children (18 boys and 23 girls) with suspected acute musculoskeletal infection were enrolled. A positive blood culture was found in 6/31 cases (19.4%) with methicillin-susceptible Staphylococcus aureus being the most commonly isolated bacterium. No significant 16S rDNA detection in blood samples was recorded.Synovial fluid culture was positive in 6/28 samples (21%), Kingella kingae being the most common pathogen. When using the 16S rDNA sequencing method, the rate of positive results in synovial fluid was higher with bacterial detection in 12/23 (52%) samples. The 16S rDNA sequencing method was also able to identify pathogens in samples taken from partially treated children where cultures were negative with 16S rDNA detection in 5/5 samples.ConclusionAlthough 16S rDNA sequencing may increase the yield of bacterial detection in synovial samples of patients with musculoskeletal infections, there is no benefit from applying this method on blood samples. The 16S rDNA sequencing method may be particularly beneficial when antibiotic treatment was started prior to synovial fluid sampling.Level of EvidenceLevel-II diagnostic study

Clinical Care Guideline for Improving Pediatric Acute Musculoskeletal Infection Outcomes.

Acute pediatric musculoskeletal infections are common, leading to significant use of resources and antimicrobial exposure. In order to decrease variability and improve the quality of care, Children's Hospital Colorado implemented a clinical care guideline (CCG) for these infections. The purpose of this study is to evaluate clinical and resource outcomes PRE and POST this CCG. Retrospective chart review evaluated patients admitted to a large pediatric quaternary referral center (CHCO) diagnosed with acute osteomyelitis, septic arthritis, pyomyositis, and/or musculoskeletal abscess prior to and after guideline implementation. Primary outcomes included length of stay and overall antibiotic use, with additional secondary clinical, process, and therapeutic outcomes examined. 82 patients were identified in both the pre-CCG and post-CCG cohorts. There was a reduction in the median of all primary outcomes, including length of stay (0.6 median days decrease, P = .04), length of IV antibiotic therapy (4.9 median days decrease, P < .0001), and days of IV antibiotic therapy (6.4 median days decrease, P = .0004). Our median length of stay post-CCG was 4.9 days, the shortest reported length of stay for pediatric acute musculoskeletal infections to date. Additionally, there was a 24.5 hour reduction in median length of fever (P = .02), faster CRP normalization (P < .0001), 50% decrease in the number of related readmissions (P = .02), 34% decrease in central venous catheters placed (P < .0001), decreased time to first culture (P = .02), and 79% pathogen identification post-CCG (P = .056). Implementation of a CCG for acute musculoskeletal infections improves patient, process and resource outcomes.

Septic Arthritis in Children: Frequency of Coexisting Unsuspected Osteomyelitis and Implications on Imaging Work-Up and Management

Osteomyelitis and septic arthritis clinically present at any age with overlapping signs and symptoms. The purposes of this study were to evaluate the demographic distribution of septic arthritis and osteomyelitis in children and to explore optimal imaging guidelines for these patients. We performed a retrospective study of children up to 18 years old who were treated for osteomyelitis or septic arthritis between January 2011 and September 2013. All patients underwent MRI without previous intervention. Studies were reviewed to determine the incidence of septic arthritis or superimposed osteomyelitis. The reference diagnosis was based on the combined review by the orthopedic surgeon and infectious disease notes, discharge summary, operative report, and MRI examination. One hundred sixty-two children who underwent 177 MRI examinations were diagnosed with acute musculoskeletal infection. One hundred three patients were included in the septic arthritis category, of whom 70 (68%) had septic arthritis with osteomyelitis. Seventy-four (42.1%) patients had isolated osteomyelitis without septic arthritis. Children under 2 years old were more likely to have septic arthritis (either isolated or with osteomyelitis) than isolated osteomyelitis compared with older children (p = 0.0003). In children who underwent MRI for suspected musculoskeletal infection, septic arthritis was more prevalent in children under the age of 2 years than in older children. However, both septic arthritis and osteomyelitis were found frequently in older children. Musculoskeletal infection imaging workup guidelines for children of all ages should address the frequent association of osteomyelitis and septic arthritis. We recommend that MRI should be used in the evaluation of suspected musculoskeletal infections in children, and the nearest joint should always be included to evaluate the extent of articular disease.

Akutní infekce pohybového ústrojí: srovnání peroperačních metod pro detekci bakteriální infekce

Akutní infekce pohybového ústrojí: srovnání peroperačních metod pro detekci bakteriální infekce

Usefulness of Magnetic Resonance Imaging for the Diagnosis of Acute Musculoskeletal Infections in Children

Summary: A 30-month prospective study was conducted on 43 children who presented with clinical findings suggestive of acute hematogenous musculoskeletal infection. Magnctic rcsonancc imaging (MRI) was found to be ex-tremely sensitive (0.97) and specific (0.92) in helping to diagnose these infections, with only one false positive and one false negative study. Bone scans are more likely to yield false positive and negative examinations. MRI is particularly useful in difficult cases in which there are conflicting clinical data or infection involving the spine or pelvis. After MRI demonstrates the location of the discase proccss, histologic and/or bacteriologic confirmation of the etiology is still mandatory.

Usefulness of Magnetic Resonance Imaging for the Diagnosis of Acute Musculoskeletal Infections in Children

A 30-month prospective study was conducted on 43 children who presented with clinical findings suggestive of acute hematogenous musculoskeletal infection. Magnetic resonance imaging (MRI) was found to be extremely sensitive (0.97) and specific (0.92) in helping to diagnose these infections, with only one false positive and one false negative study. Bone scans are more likely to yield false positive and negative examinations. MRI is particularly useful in difficult cases in which there are conflicting clinical data or infection involving the spine or pelvis. After MRI demonstrates the location of the disease process, histologic and/or bacteriologic confirmation of the etiology is still mandatory.

Gallium scintigraphy for diagnosis of septic arthritis and osteomyelitis in children.

Thirty-four children with presumptive acute osteomyelitis or septic arthritis underwent early gallium-67 citrate scintigraphy and have been retrospectively reviewed. Diagnostic accuracy using this technique was 91%. Gallium-67 citrate is a more reliable radiopharmaceutical agent for the detection of selected acute musculoskeletal infections than either technetium methylene diphosphonate or indium-111. However, the radiation dosage from gallium is higher than from other radiopharmaceutical agents, and the authors would recommend its use only in cases where the diagnosis cannot be made on the basis of clinical, laboratory, or plain roentgenographic criteria.