Osteoarticular Infections In Children Research Articles

Kingella kingae Causing Septic Arthritis of the Knee in an Immunocompetent Adult.

The bacterium Kingella kingae is a species of Gram-negative coccobacillus usually found in the oropharynx. This is an emerging pathogen reported to cause bacteraemia, endocarditis, and osteoarticular infections in children and endocarditis in the immunocompromised adult. However, there are few cases of isolated joint infections reported in the immunocompetent adult. Due to specific isolation techniques required, delay in diagnosis can compromise patient outcome. We report a rare case of septic arthritis of the knee in an immunocompetent adult caused by K. kingae.

High respiratory virus oropharyngeal carriage rate during Kingella kingae osteoarticular infections in children.

Kingella kingae osteoarticular (KKO) infections are frequently associated with upper respiratory tract infections. However, no comparative studies detecting respiratory viruses had ever been performed between KKO and non-KKO (NKO). Eighteen viruses were searched by FilmArray(®) Respiratory Panel (BioFire Diagnostics, UT, USA) in the oropharynx of 6-to-48-month-children admitted for KKO and NKO in 2013. At least one virus was detected in the oropharynx of 19/21 (90.5%) KKO and 3/8 (37.5%) NKO cases (p = 0.008). In KKO group, human rhinovirus was predominant (12/21; 57.1%), especially during winter (7/11; 63.6%) despite its low concomitant circulation (<10%). Human rhinovirus was found in 2/8 (25%) in NKO group. Higher prevalence of respiratory virus in oropharynx was observed in KKO than NKO, strengthening their putative role in KKO pathophysiology.

Osteomyelitis and septic arthritis in children

The cause, epidemiology, diagnosis, and treatment of osteoarticular infections have changed considerably in recent years. The current review includes the most up to date literature on pediatric septic arthritis and osteomyelitis. There is controversy over whether osteoarticular infection rates are increasing or decreasing. Changes in epidemiology may be related to improved methods of diagnosis. The pathogens responsible for osteoarticular infections in children have changed with alterations in immunization practices, emergence of resistant bacteria, and changes in patterns of immune modulating diseases and medications in children. Special culture techniques and PCR may help to identify pathogens that are difficult to culture. Surgical debridement is typically required for joint infections and chronic osteomyelitis, whereas acute osteomyelitis can typically be treated with medication alone. Needle aspiration/irrigation alone has been described as an alternative to surgical incision/drainage for septic arthritis, but this practice has not been widely adopted. Intravenous antibiotic therapy for 2-4 days followed by 20 days of oral therapy is effective for treating uncomplicated cases of osteomyelitis, whereas 2-4 days of intravenous antibiotics followed by 10 days of oral therapy is sufficient for septic arthritis. Steroids have shown some improved short-term clinical outcomes in patients with septic arthritis. Up to date knowledge of emerging pathogens, utilization of modern diagnostic techniques and implementation of new shorter treatment regimens can optimize the treatment of pediatric septic arthritis and osteomyelitis.

Significance of Negative Cultures in the Treatment of Acute Hematogenous Bone and Joint Infections in Children.

Synovial fluid and blood cultures often remain negative in acute bone and joint infections of childhood even when characteristic symptoms, signs, and/or radiologic proof are present. We analyzed 345 prospectively documented osteoarticular infections in children at age 3 months to 15 years. In 23% of the cases (N = 80), synovial, bone, and/or blood cultures remained negative. The characteristics of these cases were compared with patients with culture-positive bone and joint infections. The 2 groups did not differ in age or gender distribution, surgical procedures performed, or outcome. In the culture-negative cases, the initial serum C-reactive protein level was lower (58 vs 87 mg/L, P < .0001) and the hospital stay was shorter (8 vs 11 days, P < .0001). Bone and joint infections in which cultures fail to identify the causative agent can be treated similarly as culture-positive cases.

Pyogenic Sacroiliitis in Children: Two Case Reports

Pyogenic sacroiliitis is rare and accounts for approximately 1-2% of osteoarticular infections in children. Considerable delay between presentation and diagnosis is recognized. Two cases of pyogenic sacroiliitis are described. The first case is a 28-month-old girl presented with acute onset of fever, pain in the left hip, and limpness. Computed tomography (CT), bone scans, and magnetic resonance imaging (MRI) of the pelvis showed characteristic findings of infectious sacroiliitis, and blood cultures were negatives. The second case is a 13-year-old girl presented with acute onset of fever, pain in the right hip, and buttock, with inability to walk. The diagnosis of pyogenic sacroiliitis was confirmed by bone scans, and CT of the pelvis and blood cultures have identified Proteus mirabilis. The two children recovered fully after 6 weeks of antimicrobial therapy. Pyogenic sacroiliitis is an uncommon disease in children. The key to successful management is early diagnosis in which CT, bone scans, and MRI findings play a crucial role. If the diagnosis is established promptly, most patients can be managed successfully with antimicrobial therapy.

Septic sacroiliitis in children-a diagnostic challenge

Septic sacroiliitis is rare and accounts for approximately 1-2% of osteoarticular infections in children. Diagnosis of this disease has been difficult in the past due to its deep location and may be delayed due to the lack of specific clinical signs and symptoms. We describe 2 paediatric patients with clinical-radiological signs of septic sacroiliitis. E., an 8-year-old boy, presented with right hip/back pain and pyrexia after physical exertion. Examination disclosed tenderness of the right sacroiliac joint and buttock. Laboratory indicators of infection were elevated. Bone scintigraphy showed increased uptake in the right sacroiliac joint, CT-scan revealed a lytic area, MRI pelvis showing right-sided sacroiliac joint fluid collection with adjacent oedema of the ileum. These findings led to diagnosis of septic sacroiliitis. R. a 5-year-old child, presented with buttock pain after physical stress, with slight fever. She had severe pain on stressing her left sacroiliac joint; increased inflammatory parameters and neutrophilia were detected also. MRI showed left ileum and sacral intraspongious oedema, with ipsilateral iliopsoas and buttock muscles involvement. The diagnosis of septic arthritis was made. The children were managed conservatively with 3 weeks of IV antibiotics and 3 weeks of oral antibiotics and showed good clinical response with no sequelae during follow-up. In conclusion, an early diagnosis of septic sacroiliitis is very important in order to avoid complications and to reserve surgical approach to unresponsive cases. Moreover, it is signalled the value of the physical effort as predisposing factor and the utility of the MRI, both in diagnostic and follow-up.

Microbiological profile of haematogenous osteoarticular infections in children

Staphylococcus aureus, Kingella kingae and β-hemolytic streptococcus are presently the most frequently identified bacteria in child haematogenous osteoarticular infection. To determine the microbiological profile (bacteria and antibiotic susceptibility) of osteoarticular infections in a paediatric hospital, so as to adapt treatment protocols to the ecology of the bacteria isolated. Prospective descriptive study, including children admitted for acute osteomyelitis or septic arthritis. A series of blood cultures was performed systematically on admission. In case of surgery, local samples were taken for bacteriology. Antibiotherapy was initiated and subsequently adapted to the bacteriological findings. One hundred and six children were included. Thirty-five were under (Group 1) and 71 over 3 years of age (Group 2). Ninety-five underwent surgery. Peroperative samples were positive in 61 cases and blood culture in 23. Bacteria were isolated in 22 patients in G1. Extended-spectrum β-lactamase-producing Klebsiella pneumoniae was isolated in five neonates who had passed through intensive care. Staphylococcus aureus was the most frequently isolated bacterium in G2 (n=40), and was methicillin-resistant (MRSA) in six children. Methicillin-susceptible Staphylococcus aureus was the most frequently isolated microorganism. Other than neonates who had passed through intensive care and the six patients with community-acquired MRSA infection, all isolated bacteria were susceptible to second-generation cephalosporins. II, prospective descriptive prognostic study.

Pyogenic sacroiliitis in children—a diagnostic challenge

Osteoarticular infections in paediatric patients are associated with significant morbidity. Pyogenic sacroiliitis is rare and accounts for approximately 1-2% of osteoarticular infections in children. Diagnosis of this disease has been difficult in the past due to its deep location and may be delayed due to the lack of specific clinical signs and symptoms. We identified 11 paediatric patients with clinical-radiological signs of pyogenic sacroiliitis during an 8-year period and observed an unusual cluster of four cases during the last 11months. Early diagnosis was possible due to a reproducible clinical pattern as well as radiological evidences of infection using magnetic resonance imaging and/or bone scintigraphy; most patients having predisposing factors. Staphylococcus aureus was the sole causative agent identified. All patients including two children with associated muscle abscesses were managed conservatively with antibiotic therapy only and showed good clinical response with no sequelae during follow-up. An algorithm for the correct and prompt diagnosis of this pathology is proposed. Standardised optimal therapy remains to be defined.

Acute Community-acquired Osteoarticular Infections in Children: High Incidence of Concomitant Bone and Joint Involvement

Pediatric acute osteoarticular infections remain a challenging clinical issue for physicians. This paper provides recent clinical experiences on acute community-acquired osteoarticular infections in children in Taiwan. Children with acute community-acquired osteoarticular infections admitted to hospital were retrospectively reviewed and the findings compared with related infections in Taiwan published during the past 10 years. We enrolled 27 children in our study, and reviewed 692 patients reported from six major studies in Taiwan. Of the 27 patients, 15 (55.6%) had concomitant bone and joint involvement. Blood cultures were positive in 44.4% of the children in this study and 48-52% in the other studies. Pathogens could be identified in 66.7% of our children and 63-76% in the other studies, when surgical specimens were available for culture. Staphylococcus aureus was consistently the most common pathogen found in all studies. Of the S. aureus isolates, methicillin-resistant S. aureus accounted for 13.3% in our study and 22-24% in the others. Concomitant osteomyelitis and septic arthritis occurred in over half of our patients. The long-term effect of combined bone and joint infection on bone growth remains to be determined. Surgical intervention remains an important component of management of osteoarticular infections. Our findings are consistent with current recommendations of aggressive microbiology diagnosis and initiation of empirical monotherapy with oxacillin or oxacillin plus an agent effective against Gram-negative bacteria in most cases of community-acquired osteoarticular infections.

Tratamiento intravenoso inicial abreviado en 70 pacientes pediátricos con infecciones osteo-articulares

Osteoarticular infections (OAI) are infrequent in pediatrics and there is controversy on the need for prolonged use of intravenous antimicrobials.To characterize and describe evolution and complications of a regimen of 7 days initial intravenous antibiotic treatment for OAI in children, completing 4-6 weeks of total treatment.In a large pediatric hospital, 70 children younger than 15 years of age were diagnosed with OAI between March 2003 and December 2004. Children received 7 days of intravenous antibiotics followed by 3 to 5 weeks of oral treatment.Incidence of OAI in this hospital was 1.8:10000. Patients mean age was 6.4 +/-4.4 years and 60% presented with septic arthritis, 36% osteomyelitis and 4% osteoarthritis. In 80% of cases, the infection was located in the lower extremity. Positive cultures were obtained in 59% predominating Staphylococcus aureus (46.5%). Seven patients had prolonged pain or persistently high or increasing serum C reactive protein levels and were maintained on prolonged intravenous therapy. None of the 63 children with 7 day intravenous antimicrobials nor the 7 children with prolonged intravenous use developed a complication in the short-term follow up.Seven days of intravenous antibiotic for the initial phase of OAI treatment was effective in a majority of children and may be recommended.

Short duration of initial intravenous treatment in 70 pediatric patients with osteoarticular infections

Osteoarticular infections (OAI) are infrequent in pediatrics and there is controversy on the need for prolonged use of intravenous antimicrobials. To characterize and describe evolution and complications of a regimen of 7 days initial intravenous antibiotic treatment for OAI in children, completing 4-6 weeks of total treatment. In a large pediatric hospital, 70 children younger than 15 years of age were diagnosed with OAI between March 2003 and December 2004. Children received 7 days of intravenous antibiotics followed by 3 to 5 weeks of oral treatment. Incidence of OAI in this hospital was 1.8:10000. Patients mean age was 6.4 +/-4.4 years and 60% presented with septic arthritis, 36% osteomyelitis and 4% osteoarthritis. In 80% of cases, the infection was located in the lower extremity. Positive cultures were obtained in 59% predominating Staphylococcus aureus (46.5%). Seven patients had prolonged pain or persistently high or increasing serum C reactive protein levels and were maintained on prolonged intravenous therapy. None of the 63 children with 7 day intravenous antimicrobials nor the 7 children with prolonged intravenous use developed a complication in the short-term follow up. Seven days of intravenous antibiotic for the initial phase of OAI treatment was effective in a majority of children and may be recommended.

Trombosis venosa profunda asociada a infección osteoarticular en dos hermanos con deficiencia de antitrombina III

The development of deep vein thrombosis in an osteoarticular infection in children is rare. We report the case of two siblings with an osteoarticular infection in the hip and in the knee, respectively, who developed deep vein thrombosis and, in one sibling, pulmonary thromboembolism. The only hematological alteration found was reduction of anti-thrombin III in both patients. This reduction was acquired and secondary to sepsis due to Staphylococcus aureus. Anti-thrombin III levels recovered after 2 weeks of treatment. The association of deep vein thrombosis and osteoarticular infection with sepsis should lead to suspicion of hematological deficiencies, including acquired anti-thrombin III deficiency.

Septic arthritis in children

Septic arthritis is an important osteoarticular infection in children. There is insufficient data on its pattern of presentation and sequelae in our environment. To identify the aetiologic factors, patterns of presentation and sequelae of septic arthritis in Nigerian children. A retrospective analysis of the clinical, roentgenographic and laboratory records of children with septic arthritis admitted over a 14-year period to Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria was undertaken. Ninety three patients with septic arthritis involving 104 joints with a mean age of 4.5 years +/- SD (range 2 months to 15 years) were studied. The most commonly involved joint was the hip (48.4%) though the shoulder was the most commonly affected joint in infancy (36%). Trauma (a history of fall and intramuscular injection) was associated in 28% of the cases. Staphylococcus aureus was the predominant aetiologic bacterial agent (50%) even in patients with sickle cell disease. Anaemia was a common complication (64.5%). The overall result of treatment was unsatisfactory as only 37.7% had complete resolution while most had varying degrees of joint destruction resulting in limb length discrepancy and ankylosis.

Specific Real-Time Polymerase Chain Reaction Places Kingella kingae as the Most Common Cause of Osteoarticular Infections in Young Children

The use of universal 16S rDNA polymerase chain reaction (PCR) has recently shown that the place of Kingella kingae in osteoarticular infections (OAI) in young children has been underestimated, but this technique is not the most sensitive or the most rapid method for molecular diagnosis. We developed a specific real-time PCR method to detect K. kingae DNA and applied it to the etiologic diagnosis of OAI. All children admitted to a pediatric unit for OAI between January 2004 and December 2005 were enrolled in this prospective study. Culture-negative osteoarticular specimens were tested by 16S rDNA PCR and by K. kingae-specific real-time PCR when sufficient sample remained. By culture alone, a pathogen was identified in 45% of the 131 specimens tested (Staphylococcus aureus, n = 25; K. kingae, n = 17; others, n = 18). 16S rDNA PCR and K. kingae-specific PCR were both applied to 61 of the culture-negative samples. The combination of culture and 16S rDNA PCR identified a pathogen in 61% of cases (K. kingae DNA, n = 16; DNA of other microorganisms, n = 5). Specific real-time PCR identified a further 6 cases caused by K. kingae and confirmed all 16 universal PCR-positive cases, bringing the overall documentation rate to 66%. K. kingae was the leading cause of OAI in this pediatric series (n = 39, 45%), followed by S. aureus (n = 25, 29%) The K. kingae-specific real-time PCR places K. kingae as the leading cause of OAI in children at our hospital.

Kingella kingaespondylodiscitis in a child

Most osteoarticular infections in children are due to Staphylococcus aureus. In this case, the isolation of Kingella kingae by image guided disc aspiration resulted in modification and optimization of treatment. We take a look at a case of spondylodiscitis in a young child and review some of the current literature with regards to Kingella kingae infections.

Changing Patterns of Acute Hematogenous Osteomyelitis and Septic Arthritis

An increase in the incidence and severity of acute osteoarticular infections in children was perceived after the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) in our community. This study was performed to describe changes in the epidemiology and clinical features of acute osteoarticular infections. The records of patients discharged from Le Bonheur Children's Medical Center with a diagnosis of acute osteoarticular infection between 2000 and 2004 were reviewed. Data regarding signs and symptoms, diagnostic testing, therapeutics, surgery, and hospital course were collected. There were 158 cases of acute osteoarticular infection. The incidence increased from 2.6 to 6.0 per 1000 admissions between 2000 and 2004. The proportion of infections caused by methicillin-susceptible S. aureus (MSSA) remained constant (10%-13%) and that caused by MRSA rose from 4% to 40%. There was no difference between MRSA and MSSA patients in the duration of fever or pain before diagnosis. Seventy-one percent of patients with MRSA had subperiosteal abscesses compared with 38% with MSSA (P = 0.02). Ninety-one percent of MRSA patients required a surgical procedure compared with 62% of MSSA patients (P < 0.001). Median hospital stay was 7 days for MSSA patients and 10 days for MRSA patients (P = 0.0001). Three patients developed chronic osteomyelitis, 2 with MRSA. There was no association between a delay in institution of appropriate antibiotic therapy and presence of subperiosteal abscess (P = 0.8). There has been an increase in the incidence and severity of acute osteoarticular infections in Memphis. Patients with community-associated MRSA infections are at higher risk of subperiosteal abscess requiring surgical intervention.

Update on the management of skin, soft-tissue, and osteoarticular infections in children

To provide an update on the diagnosis and management of skin, soft-tissue, and osteoarticular infections in children. Our understanding of the epidemiology of skin and soft-tissue infections and osteoarticular infections is changing rapidly. Community-associated methicillin-resistant Staphylococcus aureus has become a predominant cause of childhood skin and soft-tissue infections. Kingella kingae is also increasingly identified as a cause of osteoarticular infections. Challenges in Staphylococcus aureus treatment and Kingella kingae identification are changing the approach to skin and soft-tissue infections and osteoarticular infections. Community-associated methicillin-resistant Staphylococcus aureus should be considered a cause of skin and soft-tissue infections. Empiric antimicrobial choices should be modified in areas in which there is a more than 10% prevalence of community-associated methicillin-resistant Staphylococcus aureus infection. Decontamination of shared sports equipment should be undertaken to minimize person-to-person spread. No established guideline for eradication of carriage of community-associated methicillin-resistant Staphylococcus aureus exists. Kingella kingae is a more prevalent cause of osteoarticular infections than previously recognized and can cause outbreaks of invasive infection via person-to-person transmission. Modification of culturing procedures for osteoarticular infections including inoculation of infected joint fluid and bone in blood-culture bottles should be considered.

Kingella kingae: An Emerging Pathogen of Acute Osteoarticular Infections in Children: In Reply

<i>Kingella kingae</i>: An Emerging Pathogen of Acute Osteoarticular Infections in Children: In Reply

Kingella kingae: An Emerging Pathogen of Acute Osteoarticular Infections in Children

To the Editor.—We read with interest the Pediatrics electronic pages article by Kiang et al,1“Outbreaks of Osteomyelitis/Septic Arthritis Caused by Kingella kingae Among Child Care Center Attendees.” K kingae has emerged as an important pathogen of acute osteoarticular infections in children. It may be responsible for up to 50% of previously undiagnosed suppurative bone and joint infections in children <2 years of age.2 The bacteriologic data of clinically suspected osteoarticular infections affecting 406 children hospitalized in the pediatric orthopedic surgical unit of the Necker-Enfants Malades Hospital (Paris, France) during a 3.5-year period (1999–2002) were reviewed retrospectively.3 The bacterial cultures from clinical specimens were positive in 74 cases (18%): 38 cases of septic arthritis and 36 cases of bone infections (osteitis, osteomyelitis, or osteoarthritis). The most commonly recovered pathogen was Staphylococcus aureus (44%) followed by K kingae (14%), Streptococcus pyogenes (10%), and Streptococcus pneumoniae (10%). K kingae was isolated most frequently among children <36 months of age.In recent years, there have been an increasing number of reports on osteoarticular infections caused by K kingae in young children,1,3 which may be the result of improved isolation techniques and clinical suspicion (eg, infection among child care center attendees,1 arthritis following stomatitis4). Recovery of this fastidious bacterium can be improved significantly by inoculation of synovial fluid and bone exudates into an aerobic blood-culture bottle with a continuous monitoring system and holding-culture plates for up to 7 days.5 Physicians who are caring for children with skeletal infections should be aware of this fastidious organism.

Bacterial aetiology of acute osteoarticular infections in children

To study the bacterial aetiology of acute osteoarticular infections in children and to analyse the efficiency of culture methods. Bacteriological data of 407 cases of clinically suspected osteoarticular infections affecting 406 children hospitalized in an orthopaedic surgery department between 1999 and 2002 were retrospectively reviewed. Bacterial cultures from clinical specimens were positive in 74 cases (18%): 38 cases of septic arthritis and 36 cases of bone infections (osteitis, osteomyelitis or osteoarthritis). The use of liquid medium bottles to grow bacteria from articular fluids increased the rate of positive cultures compared to the use of standard solid media (p = 0.0001). The most commonly recovered pathogen was Staphylococcus aureus (44%) followed by Kingella kingae (14%), Streptococcus pyogenes (10%) and Streptococcus pneumoniae (10%). K. kingae was most frequently isolated among children under 36 mo of age (p = 0.0003), whereas S. aureus was most frequently isolated among children over 36 mo (p = 0.0015). By improving our culture method, we observed a recrudescence of isolation of K. kingae, but S. aureus remains the main pathogen isolated from osteoarticular infections in children. This finding is useful for the adaptation of a probabilistic antibiotic treatment of these infections.