Bone and Joint Infections Oh, My

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Amelia McCormick
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1 Bone and Joint Infections Oh, My Dale Jarka, MD,CM, FRCSC The Children s Mercy Hospitals & Clinics The Children's Mercy Hospital

2 Disclosures A: I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity B: I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation

3 Objectives Compare and contrast the bacterial causes of osteomyelitis and septic arthritis in children 3

4 Gap New information on bone and joint infections has been published 4

5 Practice Change In addition to local cultures, the learner will obtain a blood culture in any child suspected of having a bone and joint infection 5

6 Bone & Joint Infections Objectives: Compare and contrast the bacterial causes of osteomyelitis & septic arthritis in children 6

7 Bone & Joint Infections Objectives: Compare and contrast the bacterial causes of osteomyelitis & septic arthritis in children Identify the importance of diagnosing pediatric MSK infections 7

8 Bone & Joint Infections Objectives: Compare and contrast the bacterial causes of osteomyelitis & septic arthritis in children Identify the importance of diagnosing pediatric MSK infections Review appropriate diagnostic work-up 8

9 Bone & Joint Infections Rationale: 9

10 Bone & Joint Infections Rationale: Increasing number & virulence 10

11 Bone & Joint Infections Rationale: Increasing number & virulence Challenging to recognize & treat 11

12 Bone & Joint Infections Rationale: Increasing number & virulence Challenging to recognize & treat High morbidity & mortality 12

13 MSK Work Up Consider: Age & history Physical exam Radiology Lab 13

14 14

15 2 yo male Limping yesterday Case 1 Today refuses to bear weight

16 Case 1 No recent illness No trauma Febrile to 102º F in ER

17 Case 1 Exam: Doesn t move RLE Pain, crying with attempts at motion

18 Case 1 Lab results WBC 10 ESR 48 CRP 18 Blood cultures pending (remember to obtain!)

19 xrays Imaging

20 Ultrasound

21 Ultrasound

22 Ultrasound

23 Ultrasound

24 Diagnosis? Presumptive septic hip: Fevers, elevated ESR/CRP Refusal to bear weight +hip joint effusion 24

25 Diagnosis? Next step?? Aspiration by I.R.? Surgery? MRI first? 25

26 Gm stain = Gm + cocci Aspiration Septic arthritis > 50,000 WBC 20,000-50,000 WBC? (Cut-off for septic arthritis is gray) WBC = 78,000 (92% neutrophils)

27 Arthrotomy & Irrigation Obtain cultures Drain the hip joint decreases hydrostatic pressure & reduce risk of AVN evacuates debris and bacterial products decrease inflammatory response

28 Antibiotic management Timing of antibiotics JBJS 2015 Antibiotic use (pre hospital or within institution) not associated with lower rate of positive surgical site cultures.

29 Antibiotic management Choice and duration of antibiotics: Presumptive organism (staph. vs strep.) Now more likely to start w/ clinda (rather than Ancef) MSSA vs. MRSA: The former beginning to behave like the latter

30 Case 2 3 yo female limp 6 days now won t bear weight on R leg Recent URI Afebrile Hip irritable w/ ROM WBC 18 ESR 15 CRP

31 Case 2 Fluid analysis Cloudy 28,000 cells 68% neut. Gram stain no organism

32 Multivariate analysis Transient synovitis vs. septic arthritis Kocher MS, et al JBJS 81A, independent clinical predictors differentiate septic arthritis & transient synovitis: History of fever >/= 38.5 degrees Celsius Non-weightbearing ESR > 40 mm/hr WBC > 12,000/mm3

33 Multivariate analysis Transient synovitis vs. septic arthritis Kocher MS, et al JBJS 81A, 1999 Score Likelihood of septic arthritis 1 3% 2 40% 3 93% 4 99%

34 Case 1 Fever(+), NWB (+), ESR 48 (+), WBC 10 (-) Fever NWB ESR>40 WBC>12 Probability SA yes yes yes yes 99.8% yes yes yes no 97.3% yes yes no yes 95.2% ye s ye s no no 57.8% yes no yes yes 95.5% ye s no ye s no 62.2% ye s no no ye s 44.8% ye s no no no 5.3% no yes yes yes 93.0% no ye s ye s no 48.0% no ye s no ye s 33.8% no ye s no no 3.4% no no ye s ye s 35.3% no no ye s no 3.7% no no no ye s 2.1% no no no no 1 in 700

35 Case 2 Fever(-), NWB (+), ESR 15(-), WBC 18(+) Fever NWB ESR>40 WBC>12 Probability SA yes yes yes yes 99.8% yes yes yes no 97.3% yes yes no yes 95.2% ye s ye s no no 57.8% yes no yes yes 95.5% ye s no ye s no 62.2% ye s no no ye s 44.8% ye s no no no 5.3% no yes yes yes 93.0% no ye s ye s no 48.0% no ye s no ye s 33.8% no ye s no no 3.4% no no ye s ye s 35.3% no no ye s no 3.7% no no no ye s 2.1% no no no no 1 in 700

36 Septic hip vs. Transient Synovitis Other studies of same criteria: lower predictive value in other populations Luhmann et al. 59% predictive w/ all 4 variables Caird et al. JBJS 2006 Evaluated Kocher criteria + CRP Fever (oral temp > 38.5 ) CRP found to be strong independent risk factor

37 Importance of identifying infection Poor results of delayed diagnosis/treatment of septic hip Osteomyelitis Septic dislocation Avascular necrosis of femoral head Femoral head deformity Long term: leg length discrepancy

38 Importance of identifying infection If neglected Sepsis Death

39 MRI: work up for infection JPO 2014, Gottschalk Improved diagnostic efficiency with MRI as part of work up Decrease rate of reoperation

40 MRI: work up for infection Indications for MRI Negative hip aspiration Location and severity of infection Age of patient Availability of MRI

41 12 month old male Won t move arm Case 3 Nursemaid s elbow one week ago Recent fevers, runny nose

43 Other imaging?

44 Other imaging?

45 Additional studies Labs WBC 18.3 ESR 60 CRP 8.4 Blood cultures pending

46 Next step?

47 Surgery Arthrotomy & irrigation of shoulder

48 6 months postop

49 Septic arthritis & osteomyelitis Shoulder, hip, ankle, elbow have metaphyseal bone within the joint capsule.

50 Septic arthritis & osteomyelitis 20% of infants with septic arthritis of hip have adjacent osteomyelitis > 50% of neonates may have concomitant osteomyelitis High incidence of concomitant osteo and septic arthritis in adolescents Shoulder most at risk (Montgomery et al. JPO 2013) Related to duration of symptoms

51 Follow up 17 months 12 years Saisu et al. JBJS 2007 Humeral shortening and inferior shoulder subluxation as sequelae of septic shoulder arthritis in neonates and infants.

52 Case 4 20 mo F Developed pain, refusal to bear weight at daycare Parents report temp 101º F Rhinorrhea prior week Otherwise healthy

53 Exam Afebrile, VS WNL Left leg flexed and externally rotated Pain and resistance with any movement of LLE Will allow manipulation of RLE No erythema or warmth on exam

54 Labs: Work up WBC 17 ESR 29 CRP 3.5 Blood cultures pending

56 Diagnosis?? fever, refusal to WB WBC 17, ESR 29, CRP 3.5 Septic arthritis vs transient synovitis Admitted overnight Started on NSAIDS MRI ordered for following morning

58 Exam after MRI Hospital course Receiving Motrin overnight (no antibiotics) Afebrile Full passive range of motion of left hip without any visible discomfort. Able to bear weight with limp Plan?? Continue to observe.

59 Hospital day 2 Afebrile overnight. Patient with active and passive range of motion of LLE. No erythema or swelling. Infectious Disease, Pediatrics, Orthopedics ok with D/C home.

60 Follow up Return visit to ED one day later: Temp 101º F at home Refusing to bear weight or move LLE Exam in ED PE - Afebrile, VS WNL Irritable with decreased active and passive ROM of LLE. WBC ESR 40 CRP 4.2 US - left hip effusion 2.4 cm x 5 mm Admitted - NPO, OR

61 OR septic arthritis To OR for aspiration and possible arthrotomy Aspiration - frank pus, sent for cultures Frank pus upon arthrotomy Started on Clindamycin q6h

62 Post op course POD1 - afebrile, active ROM LLE Cultures: Kingella Kingae Changed to Ancef with transition to Keflex (3 weeks)

63 Follow up 3 weeks postop ID clinic Doing well, labs normalized Final visit with ortho at 3 months Asymptomatic

elevations Specimen in blood culture bottle

64 Kingella Kingae Gram negative aerobe Patients 6-48 months, often in daycare Labs may only show mild elevations Specimen in blood culture bottle increases probability of identifying PCR most sensitive method

65 Case 5 8 year old female CC: L knee pain ( fall during basketball ) PMH Asthma Recurrent UTIs

66 T 39º C Knee exam: Exam No swelling, ecchymosis, erythema TTP proximal tibia Xrays negative for fracture

67 ED Plan Diagnosed with contusion vs sprain Urinalysis performed to work up fever Positive for UTI Discharge home on Bactrim, Ibuprofen Follow-up PCP

68 Follow up Returned to ED 4 days later with persistent knee pain Unable to ambulate, Temp at home 102º F T 37.3 HR 88 RR24 BP 110/60 Urine cultures from prior visit E coli resistant to bactrim Rocephen administered

69 Orthopaedic consult obtained for knee pain Swelling and TTP proximal tibia, no erythema Minimal pain with ROM of knee Unable to weight bear, NVI

70 Work up? Labs WBC 16 ESR 73 CRP 18.2 Blood cultures pending

71 Diagnosis? Musculoskeletal infection vs untreated UTI with knee injury?

72 Plan? Patient admitted to peds team MRI ordered Infectious disease team consulted Positive Blood culture Gram positive cocci in clusters

73 MRI

74 Surgical Treatment Irrigation and debridement left proximal tibial subperiosteal abscess Extensive purulent material Cultures

75 Surgical Treatment Procedure repeated 2 days later 2º to severity of infection Persistent post-operative fevers

76 Disposition Discharge home 3 days post initial surgery Culture MSSA Cephalexin for 6 weeks Follow-up with ID and Ortho post-operatively TTWB with crutches

77 2 Months Post-op

80 Case 5 7 yo presents with inability to weight bear Knee swelling 4-5 days Noted after playing in bounce house Minimal symptoms Now more swelling, over last 24 hours decreased ability to weight bear

81 Exam T 38.6º C Knee + large effusion Minimal tenderness over knee ROM 0º-110º, pain with flexion

83 Work up? ESR 44 CRP 2.3 WBC 8 Aspiration 55 ml fluid 24,000 WBC

84 Next step? Admitted Exam after aspiration: Painless knee Full ROM Able to weight bear

85 Differential diagnosis Septic knee Transient synovitis: Not aware this exists outside of the hip ID consulted, discussed History: travel across US,? Tick bite in Colorado

86 Diagnosis Went to OR for repeat aspirate & arthrotomy Fluid slightly cloudy + Lyme PCR Completed course of amoxicillin

88 15 yo male Case 6 3 week h/o worsening right thigh/back pain Fell x2 playing volleyball 3 weeks prior Visited PCP twice NSAIDs, Oral Steroid Taper, Flexeril Two episodes of emesis the week Denies fevers, chills, recent illness

89 Exam General: Afebrile, vitals stable In obvious discomfort MSK exam Right hip is flexed, externally rotated Will not allow ROM of RLE Will not bear weight

90 Work up WBC 14.7 ESR 66 CRP 11.8 Blood cultures + Ultrasound moderate right hip effusion with synovial hypertrophy

91 Work up Diagnosis? Additional tests? Right hip aspirate: positive for gram (+) cocci in clusters Admitted to PICU for septicemia

92 Work up Diagnosis? Additional tests?

93 Work up Diagnosis? Additional tests? Right hip aspirate: positive for gram (+) cocci in clusters

94 Work up Diagnosis? Additional tests? Right hip aspirate: positive for gram (+) cocci in clusters Admitted to PICU for septicemia

95 Osteomyelitis & Abscess

96 Osteomyelitis

97 Clinical Course Admitted to PICU for resuscitation Started on clindamycin and ceftriaxone Switched to vancomycin after ID consult Surgery next day with IR and Orthopedics IR percutanous drainage of right thigh abscess Arthrotomy & irrigation right septic hip

98 Clinical Course Stable after surgery Cultures positive for MSSA Treated in hospital with Cefazolin, discharged home on Cephalexin

99 Clinical Course Discharged from ID and Orthopedic clinic after completing 8 week course of Cephalexin 1 month later presented to ED with left lower quadrant pain, nausea, vomiting, fever. WBC 8, CRP 31.7, ESR 54 US showed trace left hip effusion.

100 Osteomyelitis MRI: Pelvic osteomyelitis, deep pelvic abscess

101 Recurrence Left pelvic osteomyelitis with associated abscess. Treatment drainage by IR Cultures grew MSSA Abx 8 weeks of Linezolid. Doing well at last follow-up visit.

102 Follow-up

103 Take-home Messages Consider MSK infection with limb disuse Obtain blood cultures with labs Image early (U/S, MRI) Toddlers may have K. kingae (mild presentation) Adolescents can have infections too! 103

104 Practice Change In addition to local cultures, the learner will obtain a blood culture in any child suspected of having a bone and joint infection 104

105 Thank you! 105

The Limping Child: Differential Diagnosis

The Limping Child: Differential Diagnosis Kathryn A Keeler, MD Assistant Professor University of Missouri-Kansas City School of Medicine, Department of Orthopaedic Surgery and Department of Pediatrics