Review Faust SN, Clark J, Pallett A, et al. Arch Dis Child (2012). doi:10.1136/archdischild-2011-301089 1 of 9 1 Clinical and Experimental Sciences, University of Southampton, Southampton, UK 2 NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK 3 Paediatric Immunology and Infectious Diseases, Newcastle upon Tyne Hospitals NHS Trust, Newcastle, UK 4 Department of Microbiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK 5 Department of Paediatric Orthopaedics, University Hospital Southampton NHS Foundation Trust, Southampton, UK Correspondence to Saul N Faust, NIHR Wellcome Trust Clinical Research Facility, West Wing, Mailpoint 218, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK; s.faust@soton.ac.uk Received 23 September 2011 Accepted 13 January 2012 ABSTRACT There is little high quality evidence on which to base the management of bone and joint infections in children. This pragmatic practice note aims to provide a consensus framework of best current practice prior to the availability of data from large national randomised controlled trials. For straightforward infection in previously normal children, recent trends suggest that shorter length of intravenous therapy with switch to oral treatment is acceptable, although this is not the case for the management of complex infections including those with multifocal disease, significant bone destruction, resistant or unusual pathogens, sepsis or in immunosuppressed children. Flowsheets for management based on the evidence reviewed are presented. OSTEOMYELITIS AND SEPTIC ARTHRITIS IN CHILDREN Osteomyelitis (OM) is inflammation of the bone accompanied by bone destruction, 1 usually due to bacterial infection. It is an acute process, but if not treated effectively, the inflammation can become chronic, leading to the development of sequestra and fistulae. 2 OM and septic arthritis (SA) can both be divided into three types according to the source of the infection: haematogenous, sec- ondary to contiguous infection and secondary to direct inoculation. Haematogenous OM can pres- ent acutely or as a more indolent, progressive pro- cess subacutely, with symptoms present for more than 2 weeks. 3 In children, OM most often affects long bones (femur 36%, tibia 33%, humerus 10%, pelvis 2.8%). 4 Single site infection is most com- mon, but 5–20% of children have multifocal OM. 5 SA is acute infection of synovial joints, 6 7 usually secondary to bacteraemia. The infec- tion affects the synovial membrane and the joint space. In younger children, the capsule of the joint often extends to the metaphysis, which when the cortex is damaged can lead to SA secondary to OM and vice versa. The epiphysial growth plate can also be affected, causing growth discrepan- cies and long term disability or permanent joint destruction if the acute infection is not treated promptly. 2 The estimated incidence for both OM and SA arthritis in Western populations is between 5 and 12 cases per 100 000 children per year. 2 Half of the children with acute haematogenous OM are under the age of 5. 2 7 Boys are 1.2–3.7 times more likely to be affected by osteoarticu- lar infections (OAI) than girls. 2 The incidence in Southampton from 1979 to 1997 was between 1.4 and 10.5 cases per 100 000 per year 8 and in Newcastle from 1991 to 1999 was 7 per 100 000 Managing bone and joint infection in children Saul N Faust, 1,2 Julia Clark, 3 Ann Pallett, 4 Nicholas M P Clarke 5 for SA and 11 per 100 000 for OM (unpublished data). Recent unpublished national data from England show that the admission rate for OM in children 0–18 years of age has varied between 0.048 and 0.070 per 1000 child years (M Sharland, personal communication, 2008). Subacute OM appears to be increasing over recent years 9 and was reported to be found in 5 per 100 000 chil- dren in Norway. 10 Neonatal infection can occur in preterm or term babies and is associated with a wider range of causative organisms (table 1) 11 and potential complications. Neonatal vascular anatomy allows infection within bone to reach the growth plate or joint in 76% of cases. 12 The pathogens implicated in paediatric bone and joint infections at different ages are shown in table 1. DISCITIS (DISKITIS) Discitis is an infection of the intervertebral disc space, probably arising in one of the contiguous vertebral end plates with secondary disc infec- tion. Discitis forms part of a continuum of spinal infections including vertebral OM and soft tis- sue collections. Lumbar discitis is most frequent in children <5 years of age, 13 probably due to the continuing presence of vascular channels in the cartilaginous region of the disk space that disap- pear later in life. Early in the course of these dis- ease processes, differentiation between discitis and vertebral OM is often difficult. The pathogens implicated in discitis are similar to those impli- cated in SA and OM (table 1). CHRONIC RECURRENT MULTIFOCAL OSTEOMYELITIS Chronic recurrent multifocal osteomyelitis (CRMO) is an infl ammatory condition with recurrent, sterile, lytic lesions often in the clav- icle, humerus and tubular bones. Lesions may occur recurrently in the same site or at different sites at the same time. Diagnosis is by persis- tence or recurrence of lesions despite adequate antibiotic treatment, supported by MRI which provides characteristic imaging in established disease. CLINICAL FEATURES The diagnosis and management of OAI in chil- dren should ideally be multidisciplinary, and involve paediatricians, orthopaedic surgeons, radiologists and microbiologists. The clinical features depend on age and disease type, and are detailed in table 2. The diagnosis of OM or SA is made on the basis of the clinical presentation, laboratory tests, imaging and, where available, microbiology results. ADC Online First, published on March 22, 2012 as 10.1136/archdischild-2011-301089 Copyright Article author (or their employer) 2012. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence. group.bmj.com on March 22, 2012 - Published by adc.bmj.com Downloaded from