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Pediatric Orthopaedics
Musculoskeletal infection in children:
literature review and update 20072009
Lawson A. B. Copley
ABSTRACT
The epidemiology of musculoskeletal infection is affected by
local community factors and must be evaluated by each
healthcare facility regarding the most common causative
organisms, antibiotic resistance patterns, and disease severity.
Because substantial time, effort, and resources are devoted to
managing the evaluation and treatment of children with these
infections, a coordinated and collaborative process of care
should be established to ensure that timely and efficient
intervention is enacted so as to improve clinical outcomes and
avoid adverse sequelae. This review summarizes the recent
literature regarding pediatric musculoskeletal infections.
Keywords
deep venous thrombosis, osteomyelits, pyomyositis, septic
arthritis
INTRODUCTION
OSTEOMYELITIS
The epidemiology of osteomyelitis is community dependent. A report from Oslo, Norway indicated a stable annual
incidence rate of 13 per 100,000, whereas a 2.8-fold increase
was noted in the annualized per capita incidence reported
in Dallas, Texas when comparison was made to an historic
reference group from 20 years earlier.1,10 The Norway study
reported no children with MRSA infections, while the Texas
study identified methicillin resistance in 43% of children
with osteomyelitis.1,10
The diagnosis of osteomyelitis is facilitated by prompt
supplemental imaging. MRI arguably has become the most
useful tool in portraying the anatomic and spatial extent
of the infection and provides guidance for the surgical
approach, when indicated.1,5,6 The value of MRI does not
appear to be compromised when it is performed in the
aftermath of initial invasive procedures such as aspiration or
surgical debridement.6 However, it is arguable that such
procedures may better be delayed until an expedited MRI
can be arranged to ensure that the aspiration or decompression is directed at the epicenter of the inflammation and all
potential foci.1,6 This, of course, requires a collaborative
interaction between orthopaedic surgery, radiology, and
anesthesia. Color power Doppler sonography has been
reported as a potential adjunct in the early diagnosis of
osteomyelitis and may indeed prove useful on rare occasions
when an MRI would be substantially delayed.11
The clinical evaluation of a child, laboratory findings, and
imaging results often are adequate to guide surgical decision
making. In general, surgery is necessary for osteomyelitis
associated with abscesses or in children who have not
demonstrated clinical and laboratory improvement within
an appropriate timeframe after the initiation of empiric
antibiotic treatment.
Beyond the decision for surgical decompression, the
mainstay of treatment for osteomyelitis involves proper
antibiotic selection, dosing, route, and duration. In the
absence of a specific organism and antibiotic sensitivities,
the choice of antibiotic is regionally variable and driven by
the local prevalence of CA-MRSA.12 Ample experience
suggests that sequential parenteral to oral therapy is
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SEPTIC ARTHRITIS
Current recommendations for the treatment of septic
arthritis involve making the diagnosis in a timely manner,
aspirating the joint for fluid examination and culture, and
performing prompt and thorough joint irrigation and debridement. This sometimes requires judicious clinical judgment from an experienced physician.18 The differentiation
between septic arthritis and transient synovitis remains
challenging in some cases, and it is important to gather all
of the relevant clinical and laboratory information to weigh
in the evaluation. While observation of non-steroidal antiinflammatory medication is possible in patients with
suspected transient synovitis, this process can be expedited
and abbreviated by joint aspiration to ensure that septic
arthritis is not overlooked.
Culture negative septic arthritis is more common than
other culture negative forms of musculoskeletal infection.
This is because joint fluid appears to exert an inhibitory
effect on the growth of most bacteria. Sending joint fluid in
an aerobic blood culture bottle allows the broth to dilute the
joint fluid and improve the potential for positive culture
identification of the causative organism. This practice is
essential when concern exists for possible Kingella kingae
infection in children between the ages of 6 months and
4 years.
Surgical decompression of the septic joint should be
timely, particularly in the neonatal and infantile periods
because this is thought to reduce the likelihood and severity
PYOMYOSITIS
There have been numerous recent publications regarding
the identification of non-tropical pyomyositis in children
who have no underlying risk factor or disease that might
impair the immune sytem.1,21--28 This may reflect, in part,
the recent change in epidemiology of pediatric musculoskeletal infection, particularly in temperate climates. CA-MRSA
may have evolved to the point where an increased invasive
behavior is demonstrated, resulting in the potential to infect
striated muscle.
It is important to be aware that severe complications have
been reported in association with pyomyositis in children,
including compartment syndrome, deep venous thrombosis, septic pulmonary emboli, and toxic shock.1,27,28 A high
index of suspicion and vigilant early intervention is
necessary to debride the foci of infection. Intensive medical
management may be necessary to stabilize these children.
Pyomyositis associated with abscess is best managed by
surgical or CT-guided drainage and antibiotic treatment.
Empiric coverage should be directed toward the two most
common causative organisms Staphylococcus aureus and
Group A beta hemolytic streptococcus. Duration of treatment typically is 3--4 weeks with good clinical outcomes in
the most children.
CONCLUSION
Pediatric musculoskeletal infection represents a wide array
of conditions including osteomyelitis, septic arthritis,
pyomyositis, and absess. The broad spectra of clinical
manifestations and disease severity create diagnostic and
treatment challenges and necessitate a collaborative, multidisciplinary approach to provide efficient and thorough
care. Good clinical judgment, awareness of potential
complications and timely intervention are helpful to
achieve good clinical outcomes. Early acquisition of MRI
to derive a comprehensive picture of the anatomic and
spatial extent of the infection will guide surgical decision
making and adequate decompression of the foci of infection, when necessary. Awareness of the potential threat of
CA-MRSA within a given community will orient empiric
antibiotic coverage and raise concern for the potential of
increased severity of illness and a greater risk for certain
complications, such as deep venous thrombosis. There is a
need for high quality, prospective research, and the development of evidence-based clinical practice guidelines to
help improve care of children with this disease.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the period of review,
have been highlighted as:
of special interest.
of outstanding interest.
1. Gafur OA, Copley LA, Hollmig ST, et al. The impact of the
current epidemiology of pediatric musculoskeletal infection on
evaluation and treatment guidelines. J Pediatr Orthop. 2008;
28:777--785.
This retrospective study suggests a novel classification strategy for
pediatric musculoskeletal infection that offers a framework for
assessing the severity of illness. It offers evidence to suggest that CAMRSA is partly responsible for the changing epidemiology of this
disease within the reporting community.
2. Saavedra-Lozano J, Mejias A, Ahmad N, et al. Changing trends
in acute osteomyelitis in children: impact of methicillinresistant Staphylococcus aureus infections. J Pediatr Orthop. 2008;
28:569--575.
This is an excellent comparison of the clinical manifestations of
musculoskeletal infection as a factor of CA-MRSA compared against
MSSA, osteomyelitis caused by other organisms, and culture negative
osteomyelitis. The attempt at defining the severity of illness for these
children is a valuable endeavor, and these authors have done a great
job in this regard.
3. Hawkshead JJ, Patel NB, Steele RW, et al. Comparative severity
of pediatric osteomyelitis attributable to methicillin-resistant
versus methicillin-sensitive Staphylococcus aureus. J Pediatr Orthop.
2009; 29:85--90.
Another valid effort to define severity of illness and draw distinction
between MRSA and MSSA sub-groups. The conclusion that MRSA
produces more severe infection and requires more aggressive surgical
and medical management is consistent with our experience.
Mitchell PD, Hunt DM, Lyall H, et al. Panton-Valentine
4.
leukocidin-secreting Staphylococcus aureus causing severe musculoskeletal sepsis in children. J Bone Joint Surg. 2007; 89:1239--1242.
Panton-Valentine leukocidin has been recently and repeatedly cited
as a putative virulence factor in S. aureus infections. However, there
are 39 genetically encoded proteins in the S. aureus genome. It
is unclear that PVL is the only culprit. As the USA 300 clone becomes
increasingly recognized within the Houston area as the predominant strain of S. aureus most are also being identified as PVL raising
some question as to the validity that this report echoes. Further
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17. Connolly SA, Connolly LP, Drubach LA, et al. MRI for detection
of abscess in acute osteomyelitis of the pelvis in children. AJR.
2007; 189:867--872.
18. Mathews CJ, Coakley G. Septic arthritis: current diagnostic
and therapeutic algorithm. Curr Opin Theumatol. 2008; 20:
457--462.
19. Smith MJ, White RA, Gainor BJ. Combined technique for
draining septic arthritis of the pediatric hip. Am J Orthop. 2007;
36:165--166.
20. Lavy CBD, Thyoka M. For how long should antibiotics be given
in acute paediatric septic arthritis? A prospective audit of 96
cases. Tropical Doctor. 2007; 37:195--197.
21. Block AA, Marshall C, Ratcliffe A, et al. Staphylococcal pyomyositis in a temperate region: epidemiology and modern management. MJA. 2008; 189:323--325.
22. Van den Bergh MR, Schiering IAM, Gubler FM, et al. Pyomyositis: a limping diagnosis. Eur J Pediatr. 2007; 166:259--261.
23. Ovadia D, Ezra E, Ben-Sira L, et al. Primary pyomyositis in
children: a retrospective analysis of 11 cases. J Pediatr Orthop B.
2007; 16:153--159.
24. Taksande A, Vilhekar K, Gupta S. Primary pyomyositis in a
child. Int J Infect Disease. 2008; E1--E3.
25. Weinberg J, Friedman S, Sood S, et al. Tropical myositis
(pyomyositis) in children in temperate climates: a report of 3