Pediatric Musculoskeletal Infections Research Articles

Neighborhood Deprivation and Treatment Challenges in Pediatric Musculoskeletal Infections: A Socioeconomic Analysis

Neighborhood Deprivation and Treatment Challenges in Pediatric Musculoskeletal Infections: A Socioeconomic Analysis

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.

Plasma Microbial Cell-Free DNA Sequencing for Pathogen Detection and Quantification in Children With Musculoskeletal Infections.

Nearly half of all pediatric musculoskeletal infections (MSKIs) are culture negative. Plasma microbial cell-free DNA (mcfDNA) sequencing is noninvasive and not prone to the barriers of culture. We evaluated the performance of plasma mcfDNA sequencing in identifying a pathogen, and examined the duration of pathogen detection in children with MSKIs. We conducted a prospective study of children, aged 6 months to 18 years, hospitalized from July 2019 to May 2022 with MSKIs, in whom we obtained serial plasma mcfDNA sequencing samples and compared the results with cultures. A pathogen was recovered by culture in 23 of 34 (68%) participants, and by initial mcfDNA sequencing in 25 of 31 (81%) participants. Multiple pathogens were detected in the majority (56%) of positive initial samples. Complete concordance with culture (all organisms accounted for by both methods) was 32%, partial concordance (at least one of the same organism(s) identified by both methods) was 36%, and discordance was 32%. mcfDNA sequencing was more likely to show concordance (complete or partial) if obtained prior to a surgical procedure (82%), compared with after (20%), (RR 4.12 [95% CI 1.25, 22.93], p = .02). There was no difference in concordance based on timing of antibiotics (presample antibiotics 60% vs no antibiotics 75%, RR 0.8 [95% CI 0.40, 1.46], p = .65]). mcfDNA sequencing was positive in 67% of culture-negative infections and detected a pathogen for a longer interval than blood culture (median 2 days [IQR 1, 6 days] vs 1 day [1, 1 day], p < .01). Plasma mcfDNA sequencing may be useful in culture-negative pediatric MSKIs if the sample is obtained prior to surgery. However, results must be interpreted in the appropriate clinical context as multiple pathogens are frequently detected supporting the need for diagnostic stewardship.

Imaging Findings in Pediatric Musculoskeletal Infection and Inflammation

Infections and inflammatory conditions of immature musculoskeletal systems in pediatric patients also affect the adjacent muscles, connective tissues, and joints. Rapid diagnosis leading to appropriate treatment can significantly impact the occurrence of complications and mortality rates due to these conditions. When a radiologist becomes familiar with the imaging findings of pediatric musculoskeletal infections and inflammatory diseases, rapid differential diagnoses and more timely and appropirate treatment could be possible. In this paper, we introduce the imaging findings of infectious and inflammatory diseases affecting the immature musculoskeletal system, such as osteomyelitis, pyogenic arthritis, juvenile idiopathic arthritis, and hemophilic arthritis, based on the anatomical and pathophysiological characteristics of the immature musculoskeletal system in children.

2946. Comparative Pharmacokinetics and Pharmacodynamics of Cefadroxil and Cephalexin for Pediatric Musculoskeletal Infections

Abstract Background Methicillin-susceptible Staphylococcus aureus (MSSA) is one of the leading causes of pediatric musculoskeletal (MSK) infections, such as osteomyelitis and septic arthritis. MSSA MSK infections are treated initially with an IV antibiotic, followed by prolonged oral therapy. Cephalexin is the most used oral option due to long-standing clinical experience and its well-described pharmacokinetics (PK) in children. Cefadroxil could be an attractive alternative requiring less frequent dosing, but it has minimal pediatric clinical or PK data. In this study, we describe the comparative PK of cephalexin and cefadroxil in children with MSK infections and evaluate dosing regimens to achieve effective free time above the MIC (fT &amp;gt;MIC) for MSSA. Methods Children aged 6 months to 18 years admitted with an MSK infection were enrolled in a prospective, open-label, crossover study and given single oral doses of cefadroxil (50-75 mg/kg up to 2,000 mg) and cephalexin (50 mg/kg up to 1,375 mg). During a single dosing interval, 4-5 plasma samples were obtained per patient for each drug. Antibiotic concentrations were quantified using liquid chromatography-mass spectrometry. PK models were developed, and then Monte Carlo simulations were performed using various dosing regimens to estimate the probability of target attainment (PTA) for a range of pharmacodynamic (PD) targets, across various pediatric ages and common MSSA MICs (1-4 mg/L). Results Concentration-time data for cephalexin (n=15) and cefadroxil (n=14) were best described using a one-compartment model with first order absorption. PK parameters were notable for cefadroxil’s longer half-life than cephalexin. Monte Carlo simulation showed that cephalexin 120 mg/kg/day divided q8hrs (max 1,000 mg per dose) and cefadroxil 100 mg/kg/day divided q12hrs (max 1,500 mg) achieved &amp;gt;95% PTA for fT &amp;gt;MIC &amp;gt;40% for MICs up to 4 mg/L, though cephalexin QID and cefadroxil TID dosing were required to achieve higher PD goals. Conclusion Among pediatric patients with MSK infections, oral cefadroxil and cephalexin both achieve PD targets for efficacy against MSSA. Twice-daily cefadroxil should be further considered as an alternative to cephalexin for oral step-down therapy given its similar PTA and possibility for less frequent dosing. Disclosures Marc H. Scheetz, PharmD, MSc, Abbvie: Advisor/Consultant|ASHP: Honoraria|Chambless, Higdon, Richardson, Katz &amp; Griggs, LLP: Expert Testimony|Cidara: Advisor/Consultant|Entasis: Advisor/Consultant|F2G: Advisor/Consultant|GSK: Advisor/Consultant|Guidepoint Global: Honoraria|Hall, Booth, Smith, P.C.: Expert Testimony|Merck: Advisor/Consultant|Reminger Co., L.P.A: Expert Testimony|Spero: Advisor/Consultant|Takeda: Advisor/Consultant|Taylor, English, Duma, LLP: Expert Testimony|Third Pole Therapeutics: Advisor/Consultant Sarah K. Parker, MD, Pfizer: Grant/Research Support

The Impact of Institutional Clinical Care Guidelines on Treatment Outcomes in Pediatric Musculoskeletal Infection: A Systematic Review

Background: Pediatric musculoskeletal infections (MSKIs) are complicated to manage, and inconsistent approaches to care within an institution can negatively affect patient recovery. The aim of this systematic review is to assess the impact of implementing institutional clinical care guidelines (CCGs) on treatment outcomes in pediatric MSKIs.Methods: The authors carried out a systematic review of medical literature using the databases Embase and Medline. Ten comparative studies assessing quantitative treatment outcomes of pediatric patients with MSKIs before and after implementation of a CCG were included. Studies in adult populations and those lacking comparative analysis were excluded.Results: Implementing CCGs led to improvements in patient care and clinical outcomes. Outcomes assessed across papers varied. Implementation of CCGs for the management of pediatric patients with MSKIs was shown to shorten patients' length of stay, duration of IV and/or oral antibiotic therapy, and duration of clinical symptoms associated with MSKIs. There was also evidence of reduced financial costs, which was determined by cost-effective analysis in one study. Additionally, improved access to magnetic resonance imaging and better coordination between disciplines was discussed in some studies to benefit patients' outcomes by providing an earlier diagnosis and the ability to image concerns throughout treatment.Conclusions: CCGs for pediatric patients with MSKIs improve outcomes by decreasing length of stay and inpatient costs, promoting earlier transition from IV to oral antibiotics, decreasing central line use, encouraging coordination between disciplines, and prioritizing earlier access to MRI and surgery. Further research across existing literature regarding the impact of early access to MRI is of interest for the future.Level of Evidence: IIKey Concepts•Use of clinical care pathways to manage pediatric musculoskeletal infections improves patient outcomes.•Limiting unnecessary use of intravenous antibiotics in pediatric musculoskeletal infections decreases length of stay in hospital and central venous catheter use.•Clinical care pathways to manage pediatric musculoskeletal infections help decrease length of stay in hospital and overall hospital costs.•Implementing clinical care pathways to manage pediatric musculoskeletal infections can encourage earlier access to MRI.

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.

Biomarkers for Pediatric Bacterial Musculoskeletal Infections in Lyme Disease–Endemic Regions

OBJECTIVES Bacterial musculoskeletal infections (MSKIs) are challenging to diagnose because of the clinical overlap with other conditions, including Lyme arthritis. We evaluated the performance of blood biomarkers for the diagnosis of MSKIs in Lyme disease–endemic regions. METHODS We conducted a secondary analysis of a prospective cohort study of children 1 to 21 years old with monoarthritis presenting to 1 of 8 Pedi Lyme Net emergency departments for evaluation of potential Lyme disease. Our primary outcome was an MSKI, which was defined as septic arthritis, osteomyelitis or pyomyositis. We compared the diagnostic accuracy of routinely available biomarkers (absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate, and procalcitonin) to white blood cells for the identification of an MSKI using the area under the receiver operating characteristic curve (AUC). RESULTS We identified 1423 children with monoarthritis, of which 82 (5.8%) had an MSKI, 405 (28.5%) Lyme arthritis, and 936 (65.8%) other inflammatory arthritis. When compared with white blood cell count (AUC, 0.63; 95% confidence interval [CI], 0.55–0.71), C-reactive protein (0.84; 95% CI, 0.80–0.89; P &amp;lt; .05), procalcitonin (0.82; 95% CI, 0.77–0.88; P &amp;lt; .05), and erythrocyte sedimentation rate (0.77; 95% CI, 0.71–0.82; P &amp;lt; .05) had higher AUCs, whereas absolute neutrophil count (0.67; 95% CI, 0.61–0.74; P &amp;lt; .11) had a similar AUC. CONCLUSIONS Commonly available biomarkers can assist in the initial approach to a potential MSKI in a child. However, no single biomarker has high enough accuracy to be used in isolation, especially in Lyme disease–endemic areas.

Comparison of Procalcitonin With Commonly Used Biomarkers and Algorithms for Evaluating Suspected Pediatric Musculoskeletal Infection in the Emergency Department.

It is difficult to distinguish between children with infectious versus noninfectious conditions of the musculoskeletal system during initial evaluation. Clinical predictive algorithms potentially support this effort but not without limitations. Procalcitonin (PCT) has been proposed as a biomarker to help differentiate infection from noninfection. This study evaluates the adoption and utility of PCT during initial infection evaluations and assesses test characteristics of commonly used parameters and algorithms. PCT was introduced for initial laboratory evaluation of the suspected musculoskeletal infection. Prospective enrollment occurred from July 2020 to November 2021 with 3 cohorts established after a retrospective review of final diagnoses at the end of treatment: 1) deep infection, 2) superficial infection, and 3) noninfection. Univariate and multivariate logistic regression analysis of parameters and diagnoses was performed. Test characteristics of individual and aggregated parameters were assessed. Among 258 children evaluated, 188 (72.9%) had PCT drawn during the evaluation. An increase of PCT acquisition from 67.8% to 82.4% occurred over the study timeframe. Eighty-five children were prospectively studied, including those with deep infection (n=21); superficial infection (n=10), and noninfection (n=54). Test characteristics of parameters showed accuracy ranging from 48.2% to 85.9%. PCT >0.1ng/mL independently predicted deep infection in 84.7% of cases, outperforming white blood cell, C-reactive protein (CRP), and absolute neutrophil count. Using study thresholds for CRP, erythrocyte sedimentation rate, PCT, and Temp improved accuracy to 89.4%. PCT is a potentially useful biomarker during the initial assessment of children suspected to have a musculoskeletal infection. Systematic evaluation using a combination of parameters improves the accuracy of assessment and assists predictive judgment under uncertainty. PCT <0.1ng/mL, erythrocyte sedimentation rate <18 mm/hr, CRP <3.3mg/dL, and temperature <37.8°C should reasonably reassure clinicians that deep musculoskeletal infection is less likely, given the high negative predictive value and collective accuracy of these parameters. Level III - Retrospective cohort comparison.

Magnetic resonance imaging protocols for pediatric acute hematogenous osteomyelitis.

Pediatric musculoskeletal infection can be a challenging clinical diagnosis. MRI protocols should be tailored appropriately to diagnose and localize sites of infection, to determine alternative pathologies that could explain the child's presentation, and to identify complications that could alter treatment or lead to devastating consequences in growing bones. In this review, we discuss MRI protocols tailored for suspected acute appendicular musculoskeletal infection in children. These protocols are based on patient age in order to generally reflect the developmental stage of the child, the corresponding relevant anatomy and physiology, and the skeletal maturity-dependent physiopathology of musculoskeletal infections.

D-dimer may aid in the diagnosis of pediatric musculoskeletal infections: a prospective study.

Musculoskeletal infections, including septic arthritis, osteomyelitis, and soft tissue infections, are critical morbidity factors for children and adolescents. This study investigated the role of D-dimer levels for diagnosing childhood musculoskeletal infections. This single-center prospective study was initiated in April 2020 following approval from the local ethics committee. The study included 54 children, divided into the infection group ( n = 21), comprising patients who underwent surgical treatment for childhood musculoskeletal infections and had macroscopically visible purulent discharge during surgery, and the control group ( n = 33), comprising healthy children. In the infection group, the mean values of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), plasma D-dimer, and white blood cell (WBC) were 39.42 ± 27.00 mm/h, 101.50 ± 76.90 mg/l, 2.34 ± 2.59 mg/l, and 15.55 ± 6.86 × 10 9 /l, respectively. On comparison, the infection group showed higher levels of WBC, CRP, ESR, D-dimer, and neutrophil-to-lymphocyte ratio than the control group. When the D-dimer cutoff value of 0.43 mg/l was taken, it was observed that it had 95.2% sensitivity and 81.8% specificity. The area under curve (AUC) of the above-mentioned parameters calculated via receiver operating characteristic curves showed CRP levels as the optimum predictor of childhood musculoskeletal infections, followed by the ESR, plasma D-dimer, and WBC levels in descending order (AUC: 0.999, 0.997, 0.986, and 0.935, respectively). D-dimer is another test, which in combination with other conventional established tests (CRP and ESR) can be helpful in diagnosis of pediatric infection. We recommend the addition of D-Dimer to ESR, CRP, and WBC as a first-line investigation in cases with suspected pediatric musculoskeletal infections.

Identifying the Causative Pathogen in Pediatric Musculoskeletal Infections: Moving the Debate Forward

Identifying the Causative Pathogen in Pediatric Musculoskeletal Infections: Moving the Debate Forward

Musculoskeletal Infections In Pediatric Patients at Saiful Anwar General Hospital: Observation for 5 Years

Musculoskeletal infection in pediatrics is a disorder that can cause significant disability. Follow-up evaluation is mandatory to ensure good long-term results. However, there is no data regarding this in Indonesia. The purpose of this study was to describe the epidemiology of musculoskeletal infections in pediatrics in Indonesia. This study is an observational epidemiological study of all pediatric musculoskeletal infection patients at Saiful Anwar Hospital Malang, Indonesia. All data were obtained from the database of the Department of Orthopedics and Traumatology of Saiful Anwar Hospital for the 2016-2020 period. A total of 71 patients were included in this study. The data collected were age, gender, diagnosis, anatomic location, treatment, and outcome. There were 48 (67.60%) male and 23 (32.39%) female patients in our study. The most frequent site of infection was the lower extremities (57.75%), followed by the spine (35.21%). In this study, the highest incidence occurred in children (6-12 years) followed by adolescents (12-18 years). This study also showed similar findings to other studies for the site of infection where the most common infection involved the lower extremities. Multidisciplinary treatment must be undertaken to reach an accurate diagnosis, determine the need for surgery, and monitor response to treatment.

Novel Uses of Traditional Algorithms for Septic Arthritis.

Pediatric musculoskeletal infection (MSKI) is a bacterial infection of the bone, joint, and/or muscle that can be difficult to diagnose. The Kocher and Caird algorithms were developed to distinguish septic arthritis (SA) from transient synovitis (TS) in the hip. These algorithms have been applied to all patients presenting with painful, swollen monoarticular joints regardless of suspicion for SA. The aim of this analysis was to assess the test performance of Kocher and Caird to distinguish MSKI among all pediatric patients presenting with monoarticular joint pain. A secondary aim was to validate the original algorithms. We conducted a secondary analysis of a prospective cohort study evaluating the test performance of procalcitonin for suspected SA in a pediatric emergency department. Patients aged 0 to 16 years old who presented with a painful or swollen monoarticular joint were considered for enrollment. We compared the test performance of the traditional algorithms in an expanded population of MSKI versus alternate joint pain using sensitivity, specificity, and area under the curve (AUC). As a sensitivity analysis, missing data for predictors like temperature, erythrocyte sedimentation rate, C-reactive protein, and inability to bear weight were multiply imputed using the Stata program, mi impute, for changed equations. The Caird algorithm had better test performance compared to the Kocher in all populations. Both algorithms were most discriminative in comparing SA to TS in all joints (AUC: 0.84 Caird and 0.75 Kocher). However, the Caird criteria performed almost as well discriminating MSKI from other causes of monoarticular joint pain in all joints (AUC: 0.79; 95% confidence interval: 0.72, 0.85) and nonhip joints (AUC: 0.80; 95% confidence interval: 0.71, 0.88). Based on the findings of this study, it is clinically reasonable to apply the Caird algorithm to pediatric patients presenting with monoarticular joint pain of medium and large joints such as the knee, ankle, shoulder, elbow, and wrist, in addition to the hip. Level III-retrospective study of novel applications of SA algorithms.

The Utility of Routine Radiographic Monitoring in Pediatric Osteoarticular Infections.

Pediatric musculoskeletal (MSK) infections broadly include isolated osteomyelitis (OM), septic arthritis (SA), and combined infections (OM+SA). These diagnoses are often monitored with serum inflammatory markers and serial radiographs to monitor treatment response and development of negative sequelae, despite limited data supporting these practices. The purpose of this study is to evaluate the utility of obtaining serial radiographic follow-up for pediatric osteoarticular infections. An institutional review board-approved retrospective review was completed. Children 18 years and below admitted to a single institution with a culture/biopsy-proven diagnosis of OM, SA, or OM+SA. All postdischarge radiographs were reviewed and retrospectively categorized as either routine (scheduled) or reactive. Routine radiographs were obtained regardless of clinical presentation. Reactive radiographs were obtained in patients presenting with the sign of an altered clinical course. Negative sequelae, defined as growth arrest/disturbance, pathologic fracture, recurrent MSK infection, and underlying neoplastic process, were recorded and tracked. Descriptive statistics were used to summarize demographic and outcome variables. Number needed to screen (NNS) was defined as the inverse of the incidence of negative sequelae detected. A total of 131 patients were included for analysis, with a mean age of 11.9 years (SD: 4.96 y). Ninety (69%) patients were diagnosed and treated for OM, 25 (19%) for SA, and 16 (12%) for combined infections. A total of 329 radiographs were obtained following discharge. Of those obtained, 287 (88%) were routine, resulting in the detection of 2 (0.7%) negative sequelae and a resultant NNS of 143 radiographs (95% confidence interval: 36-573). The remaining 39 were reactive radiographs, resulting in the detection of 2 (5.1%) negative sequelae with an NNS of 20 radiographs (95% confidence interval: 5-78). While radiographs remain a widely utilized tool to screen for the development of negative sequelae in pediatric osteoarticular infections, they rarely alter management in the absence of other concerning clinical signs or symptoms such as recurrent fevers, swelling of the extremity, or limb deformity. Moreover, routine radiographic surveillance should be replaced with a reactive radiographic protocol. Level III-retrospective comparative study.

Clinical Epidemiology and Outcomes of Pediatric Musculoskeletal Infections

To understand the epidemiology of acute hematogenous osteomyelitis and septic arthritis, including clinical and demographic features, microbiology, treatment approaches, treatment-associated complications, and outcomes. Retrospective cohort study of 453 children with acute hematogenous osteomyelitis and/or septic arthritis from 2009 to2015. Among the 453 patients, 218 (48%) had acute hematogenous osteomyelitis, 132 (29%) had septic arthritis, and 103 (23%) had concurrent acute hematogenous osteomyelitis/septic arthritis. Treatment failure/recurrent infection occurred in 41 patients (9%). Patients with concurrent acute hematogenous osteomyelitis/septic arthritis had longer hospital stays, longer duration of antibiotic therapy, and were more likely to have prolonged bacteremia and require intensive care. Staphylococcus aureus was identified in 228 (51%) patients, of which 114 (50%) were methicillin-resistant S aureus. Compared with septic arthritis, acute hematogenous osteomyelitis and concurrent acute hematogenous osteomyelitis/septic arthritis were associated with higher odds of treatment failure (OR, 8.19; 95% CI, 2.02-33.21 [P=.003]; and OR, 14.43; 95% CI, 3.39-61.37 [P<.001], respectively). The need for more than 1 surgical procedure was also associated with higher odds of treatment failure (OR, 2.98; 95% CI, 1.18-7.52; P=.021). Early change to oral antibiotic therapy was not associated with treatment failure (OR, 0.64; 95% CI, 0.24-1.74; P=.386). Most (73%) medically attended treatment complications occurred while on parenteral therapy. Musculoskeletal infections are challenging pediatric infections. S aureus remains the most common pathogen, with methicillin-resistant S aureus accounting for 25% of all cases. Concurrent acute hematogenous osteomyelitis/septic arthritis is associated with more severe disease and worse outcomes. Fewer treatment-related complications occurred while on oral therapy. Early transition to oral therapy was not associated with treatment failure.

Updates and Advances: Pediatric Musculoskeletal Infection Imaging Made Easier for Radiologists and Clinicians.

Infants and children often present with a wide range of musculoskeletal (MSK) infections in daily clinical practice. This can vary from relatively benign superficial infections such as cellulitis to destructive osseous and articular infections and life-threatening deep soft tissue processes such as necrotizing fasciitis. Imaging evaluation plays an essential role for initial detection and follow-up evaluation of pediatric MSK infections. Therefore, a clear and up-to-date knowledge of imaging manifestations in MSK infections in infants and children is imperative for timely and accurate diagnosis that, in turn, can result in optimal patient management. This article reviews an up-to-date practical imaging techniques, the differences between pediatric and adult MSK infections, the spectrum of pediatric MSK infections, and mimics of pediatric MSK infections encountered in daily clinical practice by radiologists and clinicians.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States

ObjectiveAdequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States.Study designEighteen institutions from the Children’s ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported.Results87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI.ConclusionAt large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 ‘rule-out’ MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution’s pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

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.

Systematic Review of Kingella kingae Musculoskeletal Infection in Children: Epidemiology, Impact and Management Strategies.

Kingella kingae, a pathogen often responsible for musculoskeletal infections in children is the most common cause of septic arthritis and osteomyelitis in children 6 to 36 months of age. The aim of this study was to perform a systematic review of previous studies to determine the proportion of K. kingae in bacteriologically proven musculoskeletal infections among the pediatric population. A secondary objective was to describe the diagnostic strategies and outcome of patients with musculoskeletal infections caused by K. kingae. A systematic review was conducted to identify publications that report on musculoskeletal infections caused by K. kingae in the pediatric population (patients 0 to <18 years old with microbiologic culture and/or polymerase chain reaction (PCR) confirmation of K. kingae and a description of the musculoskeletal infection involved). Of 144 studies included in this review, we sought to determine the proportion of K. kingae pediatric musculoskeletal infections. A total of 711 (30.8%) out of 2308 pediatric cases with culture and/or PCR proven musculoskeletal infections had K. kingae successfully identified from twenty-nine studies. Of the 1070 patients who were aged less than 48 months, K. kingae was the organism identified in 47.6% of infections. We found the average age from the collated studies to be 17.73 months. Of 520 pediatric musculoskeletal patients in which K. kingae infections were identified and where the studies reported the sites of infection, a large proportion of cases (65%) were joint infections. This was followed by 18.4% osteoarticular infection (concomitant bone and joint involvement), with isolated bone and spine at 11.9% and 3.5%, respectively. Twenty-one papers reported clinical and laboratory findings in children with confirmed K. kingae infection. The median temperature reported at admission was 37.9°C and mean was 38.2°C. Fourteen studies reported on impact and treatment, with the majority of children experiencing good clinical outcome and function following antibiotic treatment with no serious orthopaedic sequelae.