Pediatric musculoskeletal infections

Abstract

Purpose of reviewThe aim of this article is to review the recent guidelines and literature regarding the diagnosis and the treatment of common pediatric musculoskeletal infections: septic arthritis, osteomyelitis, pyomyositis, and Lyme disease.Recent findingsIn the last decade, a better understanding of the causative organisms of common bacterial infections, including Kingella, leads to prompt targeted antimicrobial coverage in all musculoskeletal infections. Prompt diagnosis and treatment continues to be the mainstay in the treatment of children with osteoarticular infections. Efforts to improve early detection have lead to improving rapid lab diagnostic testing; however, more advanced diagnostics such as arthrocentesis for septic arthritis and MRI for osteomyelitis and pyomyositis, remain the gold standard. Shorter and narrowed antibiotic courses, with appropriate transition to outpatient oral treatment provide effective infection clearance and reduction in complications of disease.SummaryAdvances in diagnostics, including pathogen identification as well as imaging continues to improve our ability to diagnose and treat these infections, although still lack ability to provide definitive diagnosis without more invasive nor advanced techniques.

Pediatric Patients with Osteomyelitis and/or Septic Joint Undergoing Surgical Debridement Have Equivalent Short-Term Outcomes with or without Preoperative MRI

“…This is especially crucial when a patient is clinically deteriorating and/or there is concern for a septic joint. MRI is a powerful tool with high sensitivity and specificity for diagnosing osteomyelitis and septic arthritis [ 13 , 14 ]. Ultrasonography is another option to evaluate for a joint effusion and is an important tool in the workup of these patients, but MRI has higher sensitivity and specificity as well as increased interobserver reliability.…”

“…A recent retrospective study of 93 patients demonstrated a reduction in unplanned returns to the operating room from 50% to less than 27% after implementing new guidelines that mandated preoperative MRIs for all pediatric patients with suspected periarticular infections [ 17 ]. The downsides to preoperative MRI include its high costs and the additional time necessary to use the technique at most hospitals, especially when anesthesia is necessary [ 13 , 14 ]. Even with the extensive resources present at the pediatric tertiary referral centers included in this study, patients who underwent preoperative MRI experienced significantly greater time to surgery in both the main cohort and septic joint subgroup.…”

The use of the ratio of C-reactive protein to albumin for the diagnosis of pediatric septic arthritis

“…Furthermore, early diagnosis of PSA is important, as it may guide appropriate antibiotic administration and intravenous fluid resuscitation prior to surgical intervention ( 31 ). CAR upon admission could guide preoperative antibiotic selection, with the best cut-off point of CAR being 0.447.…”

Is the emergency MRI protocol for acute pediatric osteoarticular infection a luxury or an absolute priority?

“…Thus, by defining the anatomical and spatial extent of the infection, MRI provides orthopedic surgeons with some of the most precious information to establish the surgical indication, confirm the indication to arthrocenthesis or surgical drainage and finally plan the surgery. MRI for pediatric musculoskeletal infections has a sensitivity of 81%–100% and specificity 67%–94% compared to CT scan (sensitivity of 67%–100% and specificity 50%) ( 18 , 19 ). MRI allows the visualization of bone marrow oedema, indicating bone abscess formation, and extraosseous spread of the infection.…”

“…Multiple institutional guidelines have demonstrated that its earlier use remarkably improves the identification of OAIs surgical candidates, thus reducing the rate of sequelae and reoperations ( 1 , 5 , 6 , 12 – 16 , 20 – 24 ). Despite its benefits, the awareness of the resource intensity required by MRI has led to the development of multidisciplinary teams, to expedite the discussion around OAIs management among all the implicated stakeholders, such as pediatricians, orthopedic surgeons, anesthesiologists and radiologists ( 15 , 16 , 18 , 20 , 24 – 26 ). When facing OAIs these different specialists might not share the same definition of emergency, with consequent dissent about the diagnostic and therapeutic strategy.…”