Primary Septic Arthritis in Children Demonstrates Presumed and Confirmed Varieties Which Require Age-specific Evaluation and Treatment Strategies

Abstract

Background: There is uncertainty involved in the evaluation and treatment of children suspected to have septic arthritis particularly when no causative pathogen is confirmed. This study evaluates children with primary septic arthritis to refine the processes of evaluation and treatment and improve the rate of pathogen confirmation. Methods: Children suspected to have septic arthritis from 2009 to 2019 were retrospectively studied. Diagnosis of primary septic arthritis, defined as hematogenous joint infection without associated osteomyelitis, was established by clinical evaluation, radiology and laboratory results, including joint fluid analysis. Excluded cases were categorized by etiology. Children with primary septic arthritis were divided into confirmed and presumed cohorts for statistical comparison. Results: A total of 355 children (average age 4.4 y, range 0.05 to 18 y) were initially treated as septic arthritis. Eighty-seven (24.5%) were excluded due to other conditions, including 34 (9.6%) with noninfectious conditions. Among 268 children with primary septic arthritis, 134 were confirmed and 134 were presumed. A higher rate of 16S polymerase chain reaction (PCR) acquisition (71.6% vs. 45.5%) occurred in the confirmed cohort. Overall yield for various methods of pathogen identification were 27 of 239 (11.3%) by blood culture, 83 of 268 (31.0%) by joint fluid culture and 85 of 157 (54.1%) by PCR. PCR identified a pathogen in 87.5% of children with confirmed septic arthritis.Antibiotic pretreatment was associated with a lower rate of joint fluid culture positivity. Pathogens aggregated within specific age groups. The 4 to 9-year-old age group displayed the widest spectrum of pathogens with limited predictability. Conclusions: This study emphasizes the need for systematic processes of evaluation and treatment for children suspected to have primary septic arthritis, including minimization of antibiotic pretreatment, age-based empiric antibiotic selection, and sufficient follow-up to ensure noninfectious conditions are distinguished in culture-negative cases. Extended observation, before intervention, may be appropriate for some children.

Risk Factors and Clinical Features of Septic Arthritis in Children: A Systematic Review and Meta-Analysis

“…For research, our review identi es some knowledge gaps and limitations that need to be addressed in future studies. First, there is a lack of standardized de nitions and criteria for septic arthritis in children, which may affect the comparability and validity of the results across studies [14][15][16]. Second, there is a lack of data on some risk factors (such as genetic predisposition or environmental exposure) and clinical features (such as laboratory tests or imaging ndings) that may be useful for diagnosis or prognosis of septic arthritis in children [17][18][19].…”

What’s New in Pediatric Septic Arthritis? A Review of Pertinent Clinical Questions

“…11,12 However, S. aureus remains the most common pathogen isolated from children over 4 years of age. 13,14 There has also been noted a geographical numerical discrepancy for the distribution of cases of pediatric SA in the United States with the South census region encompassing 40% of the reported cases between 2016 and 2019, almost the cases of Northeast and West census region combined (19%, respectively) (Fig. 1).…”

“…14 K. kingae, for example, is the most common pathogen identified in children 6 to 48 months of age. 14 Children with K. kingae tend to have a milder initial presentation. In one study, children with SA caused by K. kingae had lower CRP (4.8 vs. 9.3 mg/dL) than children with other confirmed pathogens.…”

“…In Europe, where there is widespread use of molecular diagnostic techniques, K. kingae has been established as the most common pathogen causing both osteomyelitis and SA in children less than 4 years of age 11,12 . However, S. aureus remains the most common pathogen isolated from children over 4 years of age 13,14 . There has also been noted a geographical numerical discrepancy for the distribution of cases of pediatric SA in the United States with the South census region encompassing 40% of the reported cases between 2016 and 2019, almost the cases of Northeast and West census region combined (19%, respectively) (Fig.…”

The role of metagenomic next-generation sequencing in the pathogen detection of invasive osteoarticular infection

“…The diagnosis and treatment of IOI is more complicated than that of primary osteoarticular infection (POI). POI can be hematologically transmitted from other sites of infection, sometimes with no identifiable cause (Funk and Copley, 2017;Klosterman et al, 2022). The pathogenic spectrum of POI is relatively simple (Muñoz-Egea et al, 2014;Muñoz-Gallego et al, 2020;Yombi et al, 2012), but the pathogenic spectrum of IOI is quite broad due to the invasive medical interventions.…”