Paediatric bone and joint infection _ efort open reviews

Advances in pharmacology and our understanding of acute paediatric osteoarticular infections have led to significant reductions in associated mortality. Staphylococcus aureus food poisoning 1, 2 These infections are still, however, associated with significant morbidity. Staphylococcus saprophyticus uti This is partly because of increased survival rates, the emergence of new resistant strains, delays in diagnosis and inconsistencies in delivering optimal care.

Staphylococcus virus 3 Osteoarticular infections in children comprise a spectrum of disorders depending on the localisation of infection, such as osteomyelitis, septic arthritis, a combination of both or spondylodiscitis (not discussed here). Staphylococcus aureus gram positive The source of infection may be haematogenous, secondary to contiguous infection or secondary to direct inoculation from trauma and surgery. Staphylococcus aureus causes Most are primarily haematogenous in origin and result from symptomatic or asymptomatic bacteraemia 4 in otherwise healthy individuals. Early diagnosis and prompt treatment are of paramount importance in achieving optimal outcomes and reducing the potentially devastating sequelae of permanent impairment (longitudinal growth arrest with subsequent discrepancy in limb length, angular deformity, chronic infection), septicaemia, multi-organ failure and death. Staphylococcus aureus characteristics Management goals have progressed from survival to limb preservation to maintenance of normal limb development and function. Staphylococcus epidermidis hemolysis 2 Osteomyelitis is the inflammation of bone caused by pyogenic organisms. Symptoms of staphylococcus aureus Various descriptive classification systems have been developed. What is staphylococcus epidermidis A description in terms of timing between onset and diagnosis distinguishes between acute (< 2 weeks), subacute (< 3 months) and chronic (> 3 months). Staphylococcus aureus symptoms 5 The majority of paediatric osteomyelitis cases are secondary to haematogenous spread. Staphylococcus epidermidis treatment The infection seeds in the metaphysis where blood flow is rich but sluggish. Staphylococcus species 6 The femur (27%) and tibia (26%) are the most commonly affected sites. What are the symptoms of staphylococcus 2 In anatomical sites where the bony metaphysis is intracapsular, such as the upper end of the femur, the proximal humerus, the proximal tibia and the distal fibula, there can be subperiosteal spread of infection to the adjacent joint space. Staphylococcus bacteria pictures The epiphyses of children aged less than 18 months are vascularised by transphyseal vessels. Staphylococcus saprophyticus treatment 7 This can facilitate haematogenous spread of bone infection from the metaphysis to the epiphysis and the adjoining joint space, and clinicians should be alert to that possibility. Staphylococcus symptoms 4 The use of appropriate imaging modalities such as magnetic resonance imaging (MRI) is vital in such cases to appreciate the full extent of the pathology, recognise adjacent spread and ensure that optimal treatment is delivered. Septic arthritis is the inflammation of a joint caused by pus-forming organisms, most often by means of haematogenous dissemination of bacteria into the vascular synovium. Staphylococcus aureus prevention In some cases, spread may be from adjacent foci of metaphyseal osteomyelitis as a result of the skeletal vascular anatomy discussed earlier. Staphylococcus epidermidis shape Any joint can be affected but the hip and knee joints are the most common. Define staphylococcus 8 The acute inflammatory response following bacterial infection leads to a potent immune response and the release of cartilage-degrading enzymes, which, together with bacterial toxins, lead to rapid joint destruction. Causes of staphylococcus 4 To optimise outcomes, treatment of septic arthritis requires prompt recognition, rapid and aggressive antimicrobial therapy, and surgical irrigation of the joint in order to clear the factors responsible (bacteria and inflammatory debris) for the potent activation of the immune response. The classic presentation of an infected child with a leucocytosis has become increasingly less common in developed countries. Methicillin resistant staphylococcus aureus treatment This could be attributed to improved host resistance and less virulent pathogens involved which can often lead to a subacute presentation. Gram positive staphylococcus aureus 17 In infants and neonates, immune response is not fully developed, and signs and symptoms may be minimal. Staphylococcus causes 18 Prodromal symptoms and recent minor injury are often part of the acute presentation. A more insidious and variable presentation is common. Staphylococcus aureus images Features and severity may vary greatly depending on the site of infection, age of the child and the responsible pathogen. How to treat staphylococcus 19 In a recent systematic review in acute and subacute osteomyelitis paediatric patients, the most common presenting features were pain (81%), swelling and erythema (70%), fever (62%), reduced joint movement or pseudoparalysis (50%) and reduced weight-bearing or a limp (49%). Staphylococcus saprophyticus cause 2 Pelvic osteomyelitis is especially difficult to diagnose, causing significant delays in treatment. Staphylococcus aureus sepsis 20 Joint sepsis may present with the typical features of an effusion, local erythema, warmth, tenderness, reduced range of movement and systemic features of sepsis. What causes staphylococcus This can be variable, however, with cases often presenting with minimal local symptoms, irritability, reluctance to weight-bear, pseudoparalysis and malaise. Staphylococcus aureus treatment and prevention 1 A systematic review on acute osteomyelitis found a leucocytosis in 36% of children on presentation, raised erythrocyte sedimentation rate (ESR) in 91% and raised C-reactive protein (CRP) in 81%. Staphylococcus epidermidis morphology 2 The sensitivity is highest (98%) when both the ESR and CRP are raised. Types of staphylococcus 21 A similar review in paediatric joint infections highlights the variable inflammatory marker response. Staphylococcus epidermidis characteristics 1 White cell count (WCC) response is age-related, with infants and neonates rarely producing a leucocytosis. Staphylococcus epidermidis infections ESR in isolation has been shown to have a variable sensitivity and is most useful in combination with other parameters, such as those set in Kocher’s criteria. Define staphylococcus aureus 22 CRP has been shown to have a high predictive value, 23 and a more conservative approach is advocated in the presence of normal values as sepsis is unlikely. Staphylococcus aureus mrsa 24, 25 Significant leucocytosis should alert the physician to the possibility of rare or very virulent pathogens. Staphylococcus aureus gram negative 26 CRP values > 100 mg/L are particularly significant in osteomyelitis patients for concomitant septic arthritis and are also the best predictor of a complicated course and the need for prolonged intravenous antibiotics. Morphology of staphylococcus aureus 23 CRP has a short half-life and hence is useful for monitoring response to treatment. Prevention of staphylococcus aureus 27 Serum procalcitonin has recently been advocated as a potential highly specific marker for bacterial infection that could assist in the diagnosis of osteoarticular infections. Diseases caused by staphylococcus aureus 28 The British Orthopaedic Association (BOA) and British Society for Children’s Orthopaedic Surgery (BSCOS) guidelines recommend that microbiology specimens be taken prior to antibiotic therapy administration but state that this should not delay treatment in unwell children. Staphylococcus pneumoniae 29 Samples should be sent for urgent microscopy and gram stain. How to prevent staphylococcus aureus Synovial fluid WCC > 50 000 with > 80% polymorphs is often seen in joint sepsis but clinical correlation is required as similar results can be seen in inflammatory arthropathi
es. Antibiotics for staphylococcus aureus Gram stain sensitivity has been reported as variable (30% to 80%). Staphylococcus aureus treatment natural 1 Blood cultures should be sent prior to antibiotic treatment despite their low yield as they are occasionally the only samples to provide a positive yield. What are the symptoms of staphylococcus aureus Reported overall rates of positive organism identification in blood/tissue samples vary in the literature from 34% to 82%. Staphylococcus aureus food poisoning 1 Recent studies suggest that tissue and fluid sampling in aerobic media increases their microbiology yield and should be routinely employed. Staphylococcus saprophyticus uti 30 Recently, the addition of polymerase chain reaction and other molecular diagnostics recently has significantly increased positive results. Staphylococcus virus 31 Specimens should also be sent for histopathology as childhood malignancies can present similarly. Staphylococcus aureus gram positive 29 Plain radiographs should be obtained on admission in order to rule out other pathologies. Staphylococcus aureus causes 29 Skeletal changes of osteomyelitis are generally not visible before day five as periosteal ossification. Staphylococcus aureus characteristics 32 MRI is the modality with the highest sensitivity (82% to 100%) and specificity (75% to 99%). Staphylococcus epidermidis hemolysis 32 It offers excellent tissue delineation and allows for detailed evaluation and surgical planning while avoiding radiation hazards. Symptoms of staphylococcus aureus It is not, however, always available and it often requires sedation in the paediatric patient. Computed tomography (CT) has a limited role in the acute setting due to poor soft-tissue contrast and excessive radiation. What is staphylococcus epidermidis It may be employed when MRI is not available or contraindicated. Staphylococcus aureus symptoms Bone scans can be useful to assist localisation in younger children who cannot verbalise the site of pain. Staphylococcus epidermidis treatment They offer a valid alternative to MRI with sensitivity of 73% to 100% and specificity 73% to 79%. Staphylococcus species They involve radiation exposure. What are the symptoms of staphylococcus They have a limited role in neonates due to the decreased sensitivity and they lack sensitivity and specificity in distinguishing septic arthritis from nearby osseous or soft-tissue infections. Staphylococcus bacteria pictures 33 Ultrasound is very sensitive (95%) in identifying hip effusions, 34 but despite being useful in the visualisation of subperiosteal collections, has a limited role in the diagnosis of osteomyelitis. Staphylococcus saprophyticus treatment It is less sensitive than MRI in differentiating sepsis from other causes of hip effusion. Staphylococcus symptoms 35 The key role of ultrasonography is to support the suspected clinical diagnosis. Staphylococcus aureus prevention 29 It is cheap, safe, non-invasive and portable. Positron emission tomography with CT has been described as superior to MRI in monitoring response to treatment for osteomyelitis. Staphylococcus epidermidis shape It is better at distinguishing between ongoing infection and reparative activity and has faster scanning times. Define staphylococcus 36 Exposure to radiation and limited availability reduce its practical use. In up to 55% of cases no organism is identified. Causes of staphylococcus 19 Staph. Methicillin resistant staphylococcus aureus treatment aureus is the most common pathogen in acute osteoarticular infections, being identified in 70% to 90% of culture-positive cases, followed by streptococcal ( S. Gram positive staphylococcus aureus pyogenes and S. Staphylococcus causes pneumoniae) and gram-negative organisms. Staphylococcus aureus images 37 Salmonella is an important pathogen in sickle-cell patients. How to treat staphylococcus Haemophilus influenzae has become rare following worldwide vaccination programmes. Community-acquired methicillin-resistant Staph. Staphylococcus saprophyticus cause aureus (MRSA) is on the increase in many parts of the world and has been reported as a causative agent in 9% to 30% of children with osteomyelitis. Staphylococcus aureus sepsis Panton-Valentine Leukocidin MRSA (PVL-MRSA), an extremely virulent strain, has been increasingly reported in the paediatric population. What causes staphylococcus 38 PVL is a toxin that destroys white blood cells and is associated with increased morbidity and mortality. Staphylococcus aureus treatment and prevention 38 In the context of osteoarticular infections, when presentation is associated with increased systemic and local complications, clinicians should have a high index of suspicion for this emerging strain necessitating more aggressive antibiotic regimes and surgical management. Staphylococcus epidermidis morphology 39, 40 The Health Protection Agency has recently published guidance on the diagnosis and management of these infections. Types of staphylococcus 41 Kingella kingae (a gram-negative bacillus) is a significant cause of osteomyelitis and septic arthritis in young children, with recent studies suggesting that it is the most common pathogen in children under the age of four years. Staphylococcus epidermidis characteristics 42 Despite its identification in the 1960s, this organism has until recently not been fully understood. Staphylococcus epidermidis infections It is a common coloniser of the oropharynx that can be easily transmitted. Define staphylococcus aureus Recent advances in laboratory investigations have enabled easier isolation from samples and it has now been recognised as a common pathogen in osteoarticular infections. Staphylococcus aureus mrsa The mild symptoms and limited increases in acute phase reactants associated with it can lead to diagnostic failures as other clinical conditions may have similar presentations. Staphylococcus aureus gram negative 43, 44 It is important to maintain a high index of suspicion in this age group presenting with joint inflammation, especially if indices of infection are mild. Morphology of staphylococcus aureus It appears likely that children historically treated with antibiotics for ‘culture-negative’ septic arthritis were infected with K. Prevention of staphylococcus aureus kingae. Diseases caused by staphylococcus aureus 39 Optimal outcomes are achieved through the prompt administration of antibiotics of appropriate sensitivities and dosages. Staphylococcus pneumoniae Culture results are desirable but often not available. How to prevent staphylococcus aureus Empirical treatment is therefore commonly employed based on local guidelines and patient factors. Antibiotics for staphylococcus aureus 37 Management should involve early input from a microbiologist. The BOA/BSCOS guidelines recommend flucloxacillin or a cephalosporin as first-line treatment owing to the dominance of Staph. Staphylococcus aureus treatment natural aureus while benzylpenicillin or a cephalosporin should be added in children not immunised against H. What are the symptoms of staphylococcus aureus influenzae. Staphylococcus aureus food poisoning Gentamicin is advocated for gram-negative cover in children aged less than one year. Staphylococcus saprophyticus uti Clindamycin is the drug of choice in penicillin-allergic patients. Staphylococcus virus Broad spectrum combinations should be employed early in high-risk patients for atypical organisms. Staphylococcus aureus gram positive Local protocols should have provisions for MRSA infections based on local sensitivities. Staphylococcus aureus causes There is wide geographical variation with regard to pathogen prevalence and doctors should be aware of these when considering the underlying pathogens to determine the most appropriate regime. Staphylococcus aureus characteristics First-line antibiotics may need to be adjusted upon this basis.