Update on Acute Bone and Joint Infections in Paediatrics: A Narrative Review on the Most Recent Evidence-Based Recommendations and Appropriate Antinfective Therapy

Abstract

Acute bone and joint infections (BJIs) in children may clinically occur as osteomyelitis (OM) or septic arthritis (SA). In clinical practice, one-third of cases present a combination of both conditions. BJIs are usually caused by the haematogenous dissemination of septic emboli carried to the terminal blood vessels of bone and joints from distant infectious processes during transient bacteraemia. Early diagnosis is the cornerstone for the successful management of BJI, but it is still a challenge for paediatricians, particularly due to its nonspecific clinical presentation and to the poor specificity of the laboratory and imaging first-line tests that are available in emergency departments. Moreover, microbiological diagnosis is often difficult to achieve with common blood cultures, and further investigations require invasive procedures. The aim of this narrative review is to provide the most recent evidence-based recommendations on appropriate antinfective therapy in BJI in children. We conducted a review of recent literature by examining the MEDLINE (Medical Literature Analysis and Retrieval System Online) database using the search engines PubMed and Google Scholar. The keywords used were “osteomyelitis”, OR “bone infection”, OR “septic arthritis”, AND “p(a)ediatric” OR “children”. When BJI diagnosis is clinically suspected or radiologically confirmed, empiric antibiotic therapy should be started as soon as possible. The choice of empiric antimicrobial therapy is based on the most likely causative pathogens according to patient age, immunisation status, underlying disease, and other clinical and epidemiological considerations, including the local prevalence of virulent pathogens, antibiotic bioavailability and bone penetration. Empiric antibiotic treatment consists of a short intravenous cycle based on anti-staphylococcal penicillin or a cephalosporin in children aged over 3 months with the addition of gentamicin in infants aged under 3 months. An oral regimen may be an option depending on the bioavailability of antibiotic chosen and clinical and laboratory data. Strict clinical and laboratory follow-up should be scheduled for the following 3–5 weeks. Further studies on the optimal therapeutic approach are needed in order to understand the best first-line regimen, the utility of biomarkers for the definition of therapy duration and treatment of complications.

Pediatric Septic Arthritis of the Knee Due to a Multi-Sensitive Streptococcus pyogenes Strain Responsive to Clindamycin—A Case Report

“…Due to the increase in antibiotic-resistant bacterial strains, it is necessary to pose an accurate etiological diagnosis. The current gold standard is the identification of a microorganism in the joint fluid or in blood culture, in addition to clinical or radiological findings compatible with bacterial arthritis [ 19 , 20 , 21 ]. Regarding children with acute symptoms and elevated CRP (>2.0 mg/dL) or ESR (>20 mm/h) values, Pääkkönen created a diagnostic algorithm for SA in which arthrocentesis is used to detect any purulent aspirate and to obtain a bacteriological sample [ 22 ].…”

“…The treatment of SA should be started without delay after synovial fluid and blood samples have been obtained, with high-dose empirical IV antibiotics [ 21 , 22 , 28 ].…”

“…The choice of an empirical antimicrobial therapy is based on the most likely causative pathogens according to the patient’s age, immunization status, underlying disease, Gram stain of the aspirate, and regional microbiological profile, including the prevalence of MRSA in the community. Being the most common cause of SA, an antibiotic against Staphylococcus aureus or MRSA should be always included [ 19 , 21 ].…”

“…If local clindamycin resistance rates are >10–25%, or in a setting of clindamycin inducible resistance, vancomycin should be preferred. Additional antimicrobics should be considered in children not immunized against Hib or in children between 3 and 36 months of age who could be infected by Kingella kingae [ 19 , 21 , 29 ].…”

Staphylococcus aureus Infections in the Paediatric Intensive Care Unit: Illustrated Cases

“…In Case 2, osteomyelitis was immediately suspected as the infant presented with septic shock and right ankle cellulitis. Osteomyelitis was the result of haematogenous dissemination of staphylococcal infection [ 10 ]. Early diagnosis is the cornerstone of the successful management of this disease [ 10 ].…”