Neonatal Septic Arthritis

Transcription

1 Neonatal Septic Arthritis Ahmad Elgadra,* Huda Elnaji,* Introduction: Infection of the bones & joints occurring in the first 4 weeks of life are uncommon even in intensive care nurseries, despite an increasing problem with fungal infection ((Candida osteo_arthritis)). 1 The over all rate of nosocomial bone & joint infection remined low.6 or less per thousand admission. -4 Infection associated with procedures such as placement of IV catheters may not appear or recognized until after the newborn period, some times several days or weeks after catheter removed. Premature babies, in whom there is also a high incidence of sepsis, acquire bone & joint infections with relatively greater frequency than do term babies Because most cases of neonatal septic arthritis arise as a consequence of an early bacteremia, so the bacteria responsible for septic arthritis are changing from time to time. ew decades ago hemolytic Streptococci were the predominant organisms responsible for sepsis & septic arthritis in the newborn period. As septicemia caused by hemolytic streptococcus became less common, the incidence of staph aureus & group B Strepto septicemia rose. 11,1 Gram negative enteric bacilli has remain an important cause of sepsis in the newborn period. Septic arthritis caused by group B streptococcus has a distinctive clinical picture. ost cases are caused by type III strepto & the infection presents as a late onset illness during the third & fourth week of life, babies infected by these organisms have no sign of systemic toxicity or involvement of other organ systems & usually the infection involves a single joint. Predisposing factors commonly seen with septic arthritis caused by Staph aureus or gram negative bacteria such as maternal obstetric complications, difficulties in the early neonatal period,use of IV lines are unusual with group B Strepto. Syphilitic osteitis & osteochondrtis used to be a frequent problem in the former years. 1 Nowadays it has been eliminated through screening of pregnant women & treatment of infected mothers. Tuberculous septic arthritis is extremely rare in the neonatal period even in the presence of disseminated congenital TB. aterial & ethods: This is retrospective analysis of neonatal pts with septic arthritis who were admitted to neonatal department of Alfatah hospital in Benghazi. The study was done over a period of eight months ((from 1\8\004 to 1\\005)) Purpose: To reveal the epidemiological changes of neonatal septic arthritis according to age; sex; joint involvement ; pattern of presentation; risk factor; most common organism & antimicrobial therapy which were used in our department. Results: Incidence: 15 patients was diagnosed as neonatal septic arthritis out of 954 pts ((total admission)) during the study period so incidence 1. 5 %. Age: mean of age at diagnosis 1 days. Sex: 15 patients; 6\15 male; 9\15 female. i.e m : f ratio : i.e 1: 1.5 Joint Involvement: 10\15 of cases hip joint. \15 knee joint. \15 multiple joint involvement. \15 joint. 1\15 elbow joint. \15 wrist joint. ode of Infection: 9\15 of patient had history of previous admission to hospital. 5\9 transfer from other hospital as case of 4\9 previous admission due to other problems ((hospital acquired)). 6\15 had no history of previous admission ((home acquired)). Risk actors: 5\15 premature. \15 mother had H\O premature rupture of membrane((leaking)). 1\15 H\O abruption placenta. \15 diabetic mother. \15 meconium aspiration. *) Neonatal department Alfatah children hospital, Benghazi - Libya 4 Sebha University Journal of edical Sciences, 005, Vol. 4()

2 ode of Presentation: 8\15 present with joint swelling & restriction of ; \8 had H\O previous admission to our unit with other medical problems & had IVcannula inserted. 5\15 transfer from other hospital as case of 1\15 presented with systemic manifestations of sepsis. 1\15 developed septic arthritis during hospitalization for other reasons. Joint Aspiration & Organism: 4\15 of cases underwent joint aspiration by orthopedic surgeon. \4. 1\4 E coli. Antimicrobial Agent: 8\15 used only: CLAORAN GENTAICIN at least for 1 days. 4\15 used: CLAORAN GENTAICIN + TIENTIN. 1\15 used: CLAORAN GENTAICIN+TIENTIN +ERONE. \15 used: CLAORAN GENTAICIN + AZACTA. Discussion: Neonatal septic arthritis is a rapidly destructive joint disease that may cause significant morbidity &mortality if not treated early & efficiently. The infection may be primary ((hematogenous)), following septicemia or bacterimia or arise secondary to an adjacent metaphyseal osteomyelitis, which has burst through in to the joint. Also infection can happen as a direct inoculation from puncture wound such as a heel prick or femoral vein puncture. Direct extension through the epiphyseal center is most likely to occur in babies when there are still vessels in the metaphyseal plexus penetrating the growth plate. Rupture of subperiosteal abscess directly in to the joint can take place where the metaphyses is intracapsular eg: hip & joints. In older child, the growth plate provide an effective barrier & the epiphyses is usually not involved. If septic arthritis not recognized early, dislocation of the joint may follow within a few days as a result of distension of the capsule by pus. Later changes include destruction of the joint space & resorption of epiphyseal cartilage. Large joint such as the hip, ankle, &elbow joints are particularly vulnerable. Discussion: The initial signs &symptoms of neonatal septic arthritis are non specific which may lead to a delay in the diagnosis. The baby may presents with symptoms of septicemia & after few days the disease becomes localized to the joints. Typical symptoms of joint involvement include limitation of spontaneous s of the involved extremity ((pseudoparalysis)). Erythema with swelling &tenderness of the affected joint also noted. Prolonged episodes of crying during nappy changing are common early manifestation of septic arthritis involving the hip joint. Babies usually appear less ill than would be expected due to persistence of maternal antibodies, they have less fever, leukocytosis &elevation of ESR than older children with These babies are generally feeding well, gaining weight & have no evidence of infection other than local swelling of the infected joint, so seeking medical advice by the parents might be delayed for few weeks until bone destruction occurs. Even in hospital nurseries where babies are under continuous professional observation, Joint infection may be missed. Babies with multiple joint involvement are usually more ill than babies presenting with only one site of infection. In neonatal septic arthritis diagnostic imaging examinations are done to provide evidence of the severity of the disease with in the joint structure. Ultrasound examination has an important role in determine the presence of fluid in the articular cavity. Radiological examination show osteolytic foci & periosteal proliferation after the first week. CT scan & RI may be helpful to provide reliable evaluation of the joint structure & long term affects of the infection. Neonatal septic arthritis is a medical &surgical emergency &the key to excellent management include : 1. early recognition.. Appropriate antimicrobial therapy. 5 Sebha University Journal of edical Sciences, 005, Vol. 4()

3 . Joint drainage by puncture or surgical incision of the joint to provide better exploration of the joint cavity & removal of pus. Arthotomy seems to be more efficient than joint puncture. Neonatal septic arthritis requires long duration of antibiotic therapy 4-6 weeks. Close co operation between the pediatrician & orthopedic surgeon is vital in management of neonatal Prognosis: The prognosis of septic arthritis in newborn is excellent if the joint is drained early, before damage to the articular cartilage has occurred. Poor Prognostic actor Include: Young age. Infection with Staph aureus, gram negative or fungal pathogens If the baby has associated osteomyelitis. Delayed therapy ((more than 5-7 days)) after symptoms are apparent carries a poor prognosis. Usually there is no mortality &few residual deficits occur if the infection is recognized & treated early. Conclusion: rom our study we found out that the incidence of neonatal septic arthritis is quite high ((15 per 1000 admission)) to our unit compared to other studies ((.6 per 1000 admission)) & this can be only explained by: 1) The poor standard of hygiene at our unit due to lack of cleaning facilities such as hand washing & the improper disposable of used needles & syringes. ) The acute shortage of trained nursing staff plays a major role in spreading of infection in the unit, some times especially at night we have only four nurses to look after 40 babies, just imagine the nurse who give the antibiotics, put the drips up &feeds the babies also changes the soiled nappies without washing her hands. ) Lack of diagnostic facilities such as blood culture, CS culture & urine culture, which are not available most of the time. We treated most of our patients blindly without knowing the causative organisms &this lead to emerge of resistant bacteria in the unit. 4) Lack of incubators is another problem some times we put three babies in one incubator & this leads to spreading of infection from one baby to another. 5) The visitor make life a hell for every body at the unit, they want to come any time to visit, touching & kissing the babies with out washing their hands. All the above factors are directly responsible for the high incidence of sepsis in our special care baby unit. Recommendations: 1) Providing enough number of highly trained nurses to look after sick babies. ) Providing cleaning facilities. ) Proper disposable of used syringes & needles. 4) Providing diagnostic facilities such as blood culture bottle, CS culture media. 5) Providing good laboratories facilities 6) Providing enough & continuous supply of broad spectrum antibiotics 7) Providing enough number of incubators. 8) Putting strict restrictions on the number of people who are visiting the unit. ig 1: Xray of Rt knee show osteolytic area of distal femure of NN pt with ig : xray of Lt elbow show periosteal reaction of humerus of NNpt with septic arthritis. 6 Sebha University Journal of edical Sciences, 005, Vol. 4()

4 No Age D17 D1 D14 D8 D8 D0 D11 D6 D5 D11 D10 D10 Sex joint ultiple Lt elbow Lt knee Rt knee Rt ultiplert Rt wrist B\L hip multiple Lt knee Rt wrist B\L hip ode of presentation Refuse feeding fever irritability ((sepsis)) case of ID hypoglycemia Risk factor& H\O admission H\o leaking PT Abruption placenta TVD TVD T vaccum delivery meconium aspiration H\O admission & receive AB TVD TVD Tc\s H\Oadmission & receive AB other diabetic TVD PT H\O leaking PTc\s econium aspiration receive AB TVD mother had H\O UTI during prgnancy PTc\s ((twin)) H\O admission ID developesa During hospitalization PT breech delivery H\O admission & Receive AB organism E coli antibiotic eronim 7 Sebha University Journal of edical Sciences, 005, Vol. 4()

5 Joint Involvement Risk actors hip premature. knee multiple elbow wrist 1 10 PRO vaginal bleeding diabetic mother. meconium aspiration. 1 5 Reference: 1. Youset Zadeh, D. K. & Jackson, J. H.: Neonatal & infantile candidal arthritis with or with out osteomyelitiis: a clinical & radiographical review of 1 cases. Skeletal Radiol. 1980, 5:77.. Brill, P.W., Winchester, P., Krouss, A. N., et al.: Osteomyelitis in a neonatal intensive care unit. Radiology, 1979, 1:8.. Goldmann, D. A., Durbin, W. A., Jr. & reewan, J.: Nosocomial infection in a neonatal intensive care unit. J. Infect. Dis. 1981, 144: ox, L. & Sprunt, K.: Neonatal osteomyelitis. Pediatrics 1978, 6: Bergdahl, S., Ekengren, K. & Eriksson,.: Neonatal hematogenous osteomyelitis: risk factor for long term sequelae. J. Pediotr. Orthose. 1985, 5: ok, P.., Peilly, B. J. & Ash. J..: Osteomyelitis in the neonatal with cerebral abscess. Radiology, 198, 145: Jorvis, W. R.: Epidemiology of nosocomial infections in Pediatric patients Pediatr. infect. Dis. 1987, 6: Ross, D. W.: Acute suppurative arthritis of the hip in premature infants. J. A.. A. 1954, 156:0. 9. Edwards,. S., Baker, C. J., Wogner,. L., et al.: An etiologic shift in infantile osteomyelitis: the emergence of the group B. Streptococcus. J. Pediatr. 1978, 9: Howard, J. B. & c Cracken, G. H. Jr.: The spectrum of group B. Streptococcal infection in infancy. Am. J. Dis. child. 1974, 18: emon, I. A., Jacols, N.., Yeh, T.., et al.: Group B. strptococcal osteomyelitis & its occurrence in infants less than months old. Am. J. Dis. Child. 1979, 1: Omene, J. A. & Odita, J. C.: Clinical & radiological features of neonatal septic arthritis. Trop. Geogr. ed. 1979, 1 : Scoles, PV, Aronoff SC: Antimicrobial therapy of childhood skeletal infections: Current concepts review. J. Bone. Joint. Surg ((Am)), 1984; 66: Barton LL, Dunkle L, Habib H: septic arthritis in childhood. A. J. Dis. Child. 1987, 141: Lefrock J, ader J, Smith B, Car B: bone &joint infections caused by gram positive bacteria: treatment with cefotoxime. Infection. 1985; 1: (S1) Lefrock JL, Carr BB: Clinical experience with cefotaxime in the treatment of serious bone & joint infections. Rev Infect Dis. 198; 4(Suppl): ader JT, Ortiz : Update on the diagnosis &management of osteomyelitis. Clin Podiatr ed Surg. 1996; 1(4): Sebha University Journal of edical Sciences, 005, Vol. 4()