Septic Arthritis and Osteomyelitis (< 30 years)



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Septic Arthritis and Osteomyelitis (< 30 years)

Relative contradictions to arthrocentesis

  • Cellulitis overlying the joint
  • Known bacteremia
  • Adjacent Osteomyelitis
  • Uncontrolled coagulopathy

Patient requires general anesthesia for MRI?

History of tick exposure or travel to lyme endemic area?

Effusion present?

Joint fluid obtained?

Discuss antibiotic choice with Infectious Disease service

Atypical presentation?

Penicillin allergy?

Hip affected?

Consider orthopedic or infectious disease consult

Lyme Disease AB (IGG, IGM), Serum

Urine (or other relevant site) gonococcal testing

GC NAAT

X-ray of affected area

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Blood Culture (Aerobic and Anaerobic), Serum
C-Reactive Protein (CRP), Serum
Erythrocyte Sedimentation Rate (ESR), Serum
Inclusion Criteria
  • Clinical concern for bacterial joint or bone infection
Exclusion Criteria
  • Toxic appearing

Strongly suggest septic arthritis

  • Positive Gram stain
  • Synovial WBC > 50,000 cells/microL
  • left-shift (>90 percent) of leukocytes

MRI of affected area

Ultrasound (US) Hip

Ultrasound of affected area for periosteal abscess

Consider other etiologies OR consult ID if high clinical suspicion

Evaluate Kocher criteria?

Interventional radiology available?

Consult orthopedics if not already involved for possible washout PRIOR TO antibiotics

Consider other etiologies

Abscess?

Obtain MRI if not already done

Obtain MRI if not already done

Discuss antibiotic choice with ID

Admit to Floor

Clinical improvement in 48 hours?

Common Osteomyelitis Pathogens

Common Septic Arthritis Pathogens

Admit to Floor

Clindamycin and Vancomycin do NOT necessarily cover Kingella kingae or H. influenzae. If suspicion for these organisms is high, discuss with an infectious disease specialist

Sexually active or history concerning for GC?

Arthrocentesis

Kocher criteria

  • Non-weight-bearing on affected side
  • Fever > 38.5
  • CRP > 2 mg/dL or ESR > 40 mm/hr
  • Serum WBC > 12k

IR ultrasound guided arthrocentesis

50 mg/kg Q8 hours

Cefazolin injection

Atypical presentation

  • Immunocompromized
  • Age < 3 months
  • Incompletely immunized (2 doses of both PCV and Hib)
  • Fever or pain > 48 hours
  • Axial skeleton involvement (i.e. vertebral)
  • Orthopedic hardware present
  • History of MRSA infection
  • Pacific-Islander ethnicity

13 mg/kg Q8 hours

Clindamycin injection

Concern for joint infection?

Synovial fluid culture and cell count (Inject fluid into blood culture vials to identify Kingella kingae)

Operation

  • Incision and drainage
  • Bone biopsy

Labs

  • Orthopedic aerobic culture with gram stain
  • Orthopedic anaerobic culture
  • AFB and fungal cultures if baseline risk factors
  • Reflex 16S if bacterial cultures negative

Antibiotics

  • Confirm that positive culture results susceptible to antibiotic coverage
  • Discuss long-term and discharge antibiotics with ID service
  • Consider probiotics for patients on long term antibiotics

Antibiotics

  • Confirm that positive culture results susceptible to antibiotic coverage
  • IV Antibiotics x3 days minimum
  • Switch to Cephalexin 25 mg/kg/dose PO Q6 hours PO when CRP downtrending, patient afebrile, clinical improvement of bone or joint use
  • Osteomyelitis = 4-6 weeks depending on severity
  • Septic joint = 3-4 weeks depending on severity
  • Consider probiotics for patients on long term antibiotics

Discharge

  • Outpatient PMD or ID appointment in 1 week
  • CBCD, CRP, Cr, AST/ALT in 1 week




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