Treatment of Acute Septic Arthritis

Divya J

INF ESPID Reports and Reviews 203205 Treatment of Acute Septic Arthritis

ESPID Reports and Reviews Markus Pääkkönen, MD* and Heikki Peltola, MD†

ESPID Reports and Reviews Abstract: Acute septic arthritis is a rare, but DIAGNOSIS Clindamycin continues to be effective potentially devastating disease. The treatment is An acutely swollen, red, painful joint against most methicillin-resistant S. aureus xxxx initiated intravenously, but can be safely switched combined with high fever signal a potential (MRSA) strains.6 Clindamycin and vanco- to oral after 2–4 days providing large doses of a SA. Movement is limited in the affected joint mycin are ineffective against K. kingae for well-absorbing antibiotic and, for time-dependent and symptoms tend to increase progressively. which β-lactams are good choices. Interest- ingly, cheap trimethoprim-sulfamethoxazole Pediatr Infect Dis J antibiotics, 4 times-a-day administration are used. The child refuses weight-bearing when the Empiric treatment should always cover Staphy- lower limb is involved. This classical pattern is experiencing a renaissance in the treatment of MRSA.7 Vancomycin should be considered lococcus aureus and common respiratory patho- is often seen in cases caused by S. aureus, but in contrast SA caused by K. kingae may if resistance to clindamycin is common.2,8 An gens, whereas Kingella kingae and Salmonella Lippincott Williams & Wilkins develop insidiously. The characteristic signs expensive alternative is linezolid.8 Pneumo- are important only regionally. Studies conducted of SA may be difficult to detect in a child coccus and S. pyogenes do not usually cause by our group have shown that a total course of 10 with a septic hip joint, but neonates often problems in terms of resistance when high days may suffice for previously healthy children in assume a characteristic position with the hip doses are used. Hib has largely vanished from Hagerstown, MD a Western setting. Treatment of neonates, patients joint flexed and externally rotated. Serum the etiology of SA in regions with large-scale with immunodeficiency or cases caused by methi- C-reactive protein (CRP) and erythrocyte vaccinations. If this is not the case, unvacci- cillin-resistant S. aureus, may deserve a different sedimentation rate are sensitive in diagnos- nated children younger than 5 years should approach. tics, but erythrocyte sedimentation rate alter- receive concomitant ampicillin/or amoxicil- nates too slowly to be of much use in the fol- lin until the agent is identified.5 Key Words: septic arthritis, child, Staphylococcus low-up.1,5 Procalcitonin challenges CRP, but The optimal duration of intravenous aureus, clindamycin, C-reactive protein the measurement requires more time (CRP and oral treatment has been disputed for dec- 3,4 (Pediatr Infect Dis J 2013;32: 684–685) only needs a few minutes) and is more expen- ades. Severity of complications associated sive.1 Ultrasound detects joint effusion and with SA has led many authors to recommend can guide a diagnostic joint puncture, which months’ long medications with an initial intra- should always be attempted.4 In younger chil- venous period even for several weeks.1,2,4 In a cute septic arthritis (SA) in children is dren, the procedure is performed under anes- recent study, the majority of cases of SA were Amost often of hematogenous origin. In thesia. A purulent joint discharge, positive treated 3 to 5 days intravenously followed by a Western setting, the annual incidence is Gram stain and/or bacterial culture confirm 3 weeks of oral antibiotics.3 Current Infec- the diagnosis, whereas a traditional synovial around 4:100,000 children.1 Boys are more tious Diseases Society of America guideline fluid cytology is often difficult to interpret prone than girls. Hip, knee and ankle joints for MRSA SA states that the exact duration of due to considerable overlap between differ- therapy should be individualized, but typically 2013 are frequently affected. Staphylococcus 1 ent types of arthritides. In addition to con- a minimum of 3 to 4 weeks is recommended.8 aureus is the most common causative agent, ventional agar plates, aerobic blood culture In our prospective, randomized trial, a total followed by respiratory pathogens Strepto- bottles are required to detect K. kingae, and of 10 days of high-dose clindamycin or a coccus pyogenes, Streptococcus pneumoniae although special techniques are not required, first-generation cephalosporin was sufficient 2–4 Copyright © 2013 by Lippincott Williams & Wilkins and Haemophilus influenzae type b (Hib). an automated system with capability to detect in uncomplicated cases caused by methicil- Kingella kingae and Salmonella spp. are this pathogen should be used. lin-sensitive S. aureus.4,5 The treatment was regionally important agents. started intravenously, usually for no more 00 TREATMENT than 2 to 4 days, and the course was com- Intravenous antibiotic is instituted pleted orally to a total duration of 10 days. From the *Department of Orthopaedics and Trau- almost always before the causative agent has One lesson learned from our largest-to- 00 matology, University of Turku, Turku University been identified by cultures. The role of S. date trial4 was that CRP was of great value, not Hospital, Turku; and †Department of Pediatrics, only in the diagnostics but also in monitoring University of Helsinki, Children’s Hospital, Hel- aureus is overwhelming and its local resist- sinki University Central Hospital, Helsinki, Fin- ance pattern dictates the choice of antibiotic.1 the course of illness, and in the decision to dis- 0891-3668 land. Large doses of clindamycin (≥40 mg/kg/day continue antibiotics. Our cutoff level was set at M.P. received funding support from Foundation for divided in 4 equal doses, qid) or a first-gen- 20 mg/L; once this level was reached, the med- Pediatric Research, Finland, and Turku University ication was stopped, provided most symptoms Hospital Foundation for Education and Research. eration cephalosporin (≥150 mg/kg/day, qid) 10.1097/INF.0b013e31828e1721 H.P. received funding support from Foundation have been our choices against methicillin- and signs had subsided. This occurred usu- for Pediatric Research, Finland. H.P. works as a sensitive S. aureus strains,5 but staphylococcal ally in a week or so. In cases of concomitant consultant for Serum Institute of India Ltd. The penicillins would likely work as well unless osteomyelitis, we routinely extended the total authors have no other funding or conflicts of inter- The Pediatric Infectious Disease Journal est to disclose. exceptionally large oral doses lead to diarrhea. course to 20 days. Our treatment algorithm is Address for correspondence: Markus Pääkkönen, MD, The same dosing applies to both parenteral depicted in Figure 1. Turku University Hospital, PO Box 52, 20521 Turku, and oral administration. If a first-generation It should, however, be kept in mind Finland. E-mail: [email protected]. cephalosporin is not available for intravenous that a 10-day treatment course is not an uni- 32 Copyright © 2013 by Lippincott Williams & Wilkins ISSN: 0891-3668/13/3206-684 administration, a second-generation cephalo- versally accepted standard of care, 1 of the DOI: 10.1097/INF.0b013e31828e1721 sporin may also be used as a substitute. reasons being that it has not yet been tested 6 The ESPID Reports and Reviews of Pediatric Infectious Diseases series topics, authors and contents are chosen and approved independently by the Editorial Board of ESPID. June 684 | www.pidj.com The Pediatric Infectious Disease Journal • Volume 32, Number 6, June 2013 2013 The Pediatric Infectious Disease Journal • Volume 32, Number 6, June 2013 ESPID Reports and Reviews

in MRSA cases. We therefore recommend, at developed. Already a delay of more than 5 instituted, first intravenously for a few days, least so far, our 10-day course only for previ- days from the onset of symptoms seems to then orally to a minimum of 10 days. However, ously healthy children beyond neonatal age affect adversely on recovery,4 and such a exceptionally large doses (≥40 or ≥150 mg/kg/ whose SA is not due to agent such as Salmo- wait is regrettably common in developing day till a maximum daily dose of 2–4 g or ~3 g, nella (uncommon in Western settings). These countries. In the United States, the MRSA- respectively) and a qid regimen are used for patients, as the neonates and those with an USA300 strain and Panton-Valentine leu- these time-dependent antibiotics.1,4,5 Once immunocompromise, likely need treatment kocidin gene have associated with a severe CRP has declined below 20 mg/L, the antibi- to be individually tailored. Nonsteroidal disease with a longer duration of fever.2 otic can usually be discontinued if most symp- anti-inflammatory agents are administered Extended antibiotic treatment for MRSA has toms and signs are alleviated. Patients who at the discretion of the attending physician. been recommended, but prospective trials are have not responded uneventfully may benefit Adjuvant dexamethasone seems to slightly lacking.2,8 In our series, methicillin-sensitive from prolonged treatment. Because sequelae quicken recovery without reducing the fre- S. aureus cases were treated as those caused may develop insidiously, a follow-up for at quency or extent of complications.9 by other agents, and there was no difference least a year is well-founded.4,5 in outcome.10 All this said, complications or devia- tions from the expected course of disease COMPLICATIONS occur in medicine. However, the difficult-to- Because a dismal outcome—death, OUR PRACTICAL APPROACH TO treat cases present a minority and can usually avascular necrosis of the femoral head, TREATMENT AND CONCLUSIONS be detected by simple tools such as sequential arthrosis, an so on—may still be the ultimate Our approach to potential childhood SA CRP determinations.4‍ outcome of complicated SA, some further is straightforward: a diagnostic joint aspiration aspects have to be taken into account. The (under anesthesia at least in younger children) REFERENCES prognosis worsens if a child presents late is performed and if SA is diagnosed, clinda- 1. Pääkkönen M, Peltola H. Management of a child after significant cartilage destruction has mycin or a first-generation cephalosporin is with suspected acute septic arthritis. Arch Dis Child. 2012;97:287–292. 2. Carrillo-Marquez MA, Hulten KG, Hammerman W, et al. USA300 is the predominant genotype causing Staphylococcus aureus septic arthritis in children. Pediatr Infect Dis J. 2009;28:1076–1080. 3. Jagodzinski NA, Kanwar R, Graham K, et al. Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children. J Pediatr Orthop. 2009;29:518–525. 4. Peltola H, Pääkkönen M, Kallio P, et al.; Osteomyelitis-Septic Arthritis (OM-SA) Study Group. Prospective, randomized trial of 10 days versus 30 days of antimicrobial treatment, includ- ing a short-term course of parenteral therapy, for childhood septic arthritis. Clin Infect Dis. 2009;48:1201–1210. 5. Peltola H, Pääkkönen M, Kallio P, et al.; OM-SA Study Group. Clindamycin vs. first-generation cephalosporins for acute osteoarticular infections of childhood–a prospective quasi-randomized controlled trial. Clin Microbiol Infect. 2012;18:582–589. 6. Martínez-Aguilar G, Hammerman WA, Mason EO Jr, et al. Clindamycin treatment of inva- sive infections caused by community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus in children. Pediatr Infect Dis J. 2003;22:593–598. 7. Messina AF, Namtu K, Guild M, et al. Trimethoprim-sulfamethoxazole therapy for children with acute osteomyelitis. Pediatr Infect Dis J. 2011;30:1019–1021. 8. Liu C, Bayer A, Cosgrove SE, et al.; Infectious Diseases Society of America. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:e18–e55. 9. Harel L, Prais D, Bar-On E, et al. Dexamethasone therapy for septic arthritis in children: results of a randomized double-blind placebo-controlled study. J Pediatr Orthop. 2011;31:211–215. 10. Pääkkönen M, Kallio PE, Kallio MJ, et al. Management of osteoarticular infections caused by Staphylococcus aureus is similar to that of other etiologies: analysis of 199 staphylococcal FIGURE 1. Algorithm for determining the length of the intravenous and total antibi- bone and joint infections. Pediatr Infect Dis J. otic treatment in childhood acute osteoarticular infections. D indicates days. 2012;31:436–438.