Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics
Publication Date: November 6, 2023
Last Updated: December 14, 2023
Lab Testing
In children with suspected ABA, we recommend performing blood culture prior to administration of antimicrobial therapy. (S, M )
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In children with suspected ABA, we suggest measuring serum C-reactive protein (CRP) on initial evaluation. (C, VL )
Comment: Serum CRP has a low accuracy to establish the diagnosis of ABA given the variability between pathogens, but in situations where the initial CRP is elevated, this result can serve as the baseline value for sequential monitoring that may guide decision-making regarding duration of antimicrobial therapy.
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Imaging
In children with suspected ABA, we recommend obtaining plain radiography of the affected joint and adjacent bones rather than not performing plain radiographs. (S, M )
Comment: Despite the low sensitivity of plain radiography for detecting presence of joint effusion or adjacent osteomyelitis on initial presentation, other important etiologies of acute musculoskeletal pain may be identified.
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In children with suspected ABA in whom further imaging studies are required to detect the presence of joint effusion, particularly of the hip or the shoulder, we recommend performing ultrasonography of the affected joint before performing more complex and less widely available imaging tests. (S, M )
Comment: Ultrasonography documenting the absence of joint effusion suggests that ABA is not present.
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In children with suspected ABA in whom further imaging studies are required to assess the extent of inflammation and infection, including adjacent osteomyelitis and pyomyositis, we suggest performing a magnetic resonance imaging (MRI) study rather than other imaging modalities (e.g., computerized tomography (CT) or bone scintigraphy). (C, VL )
Comment: Children with ABA at high risk of adjacent osteomyelitis include those with more than 3 or 4 days of symptoms prior to presentation, S. aureus infection, and marked elevation of CRP, but these risk factors require further validation.
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Invasive Diagnostic Procedures
In children with suspected ABA, we suggest collecting synovial fluid from the affected joint by arthrocentesis prior to starting empiric antimicrobial therapy. (C, M )
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On joint fluid obtained by arthrocentesis, we recommend performing white blood cell count and differential and routine microbiological cultures (aerobic bacterial culture and Gram stain). (S, M )
Comment: Further diagnostic testing may be beneficial in certain situations: 1) molecular testing for specimens from which no pathogen has been identified by Gram stain and aerobic bacterial culture, (particularly in preschool-aged children at higher risk of K. kingae infection); and 2) more extensive scope of microbial testing, beyond aerobic bacterial culture (e.g., anaerobic, fungal, and/or mycobacterial cultures and stains; molecular testing, which may include metagenomic next-generation sequencing), in children who are immunocompromised or who have a history of penetrating injury. Additional molecular tests may be performed on synovial samples held in the laboratory, or for additional cultures, a repeat arthrocentesis may be required.
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Initiating Treatment
In children with presumed ABA who are ill-appearing or have rapidly progressive infection, we recommend immediately starting empiric antimicrobial therapy (after blood cultures are obtained if possible) rather than withholding antibiotics until invasive diagnostic procedures are performed. (S, M )
Comment: Invasive diagnostic procedures should occur as soon as feasible, even if antibiotics have already been administered.
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In children with presumed ABA who do not appear clinically ill, we suggest withholding antimicrobial therapy, while under careful observation, until an initial joint aspirate is collected for diagnostic purposes. (C, VL )
Comment: The decision to initiate antimicrobials prior to invasive diagnostic procedures depends on the severity of the clinical presentation, local accessibility to experts and resources or, if appropriate, the time required for transport to a higher level of care for additional diagnostic or debridement procedures. The ability to diagnose pathogens by molecular diagnostic techniques suggests that critical information on pathogen identity is now less dependent on obtaining bacterial cultures prior to starting antimicrobial therapy.
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Empiric Antimicrobial Agents
In children with suspected ABA, we recommend using empiric antimicrobial therapy active against S. aureus. (S, M )
Comment: Antimicrobials with activity against community-acquired MRSA (CA-MRSA) should be considered based on local susceptibility data and severity of disease. Adding empiric antimicrobial coverage for pathogens in addition to coverage for S. aureus may be warranted when other pathogens are suspected based on relevant aspects of immunization, exposure history, clinical presentation, or physical examination.
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In infants and preschool aged children (6 to 48 months of age) with suspected ABA, we suggest selecting empiric therapy to include activity against K. kingae rather than only targeting S. aureus. (C, VL )
Comment: With K. kingae reported as the most frequent pathogen in this age group in recent studies, additional therapy is suggested if empiric therapy used for S. aureus is not active against K. kingae.
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Repeat Imaging and Diagnostic Procedures
In children with presumed or confirmed ABA who demonstrate a poor clinical and laboratory response within 48-96 hours (continued fever, persistent bacteremia and/or rising CRP) after initial invasive procedures (open or arthroscopic) and initiation of appropriate antimicrobial therapy, we suggest performing MRI if not previously obtained. (C, VL )
Comment: MRI is performed to evaluate for adjacent AHO, pyomyositis, or abscess as potential indications of ineffective source control to provide a basis to determine whether additional invasive procedures should be considered.
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In children with presumed or confirmed primary ABA who demonstrate a poor clinical and laboratory response within 48-96 hours (continued fever, persistent bacteremia and/or rising CRP) after initial invasive procedures, and evidence to suggest persisting foci of infection (ineffective source control), we suggest additional invasive procedures to ensure adequate source control. (C, VL )
Comment: When ABA is associated with adjacent osteomyelitis, management should follow the osteomyelitis guideline.
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Surgery
In children with presumed or confirmed ABA who require a surgical procedure, we recommend against the routine use of intra-articular antimicrobial agents. (S, VL )
Comment: This recommendation places a high value on avoiding unnecessary harms and costs associated with this intervention.
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Adjuvant Corticosteroids
In children with presumed or confirmed ABA, we suggest against using adjunctive corticosteroid therapy. (C, VL )
Comment: This recommendation places a high value on avoiding potential serious harms despite providing potential minimal beneficial effects.
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Assessing Response to Therapy
In children with presumed or confirmed ABA receiving antimicrobial therapy with or without surgical intervention, in addition to serial clinical evaluation, we suggest performing CRP at initial evaluation followed by sequential monitoring of CRP to assess response to therapy, rather than relying solely on clinical evaluation. (C, L )
Comment: Serial clinical examinations that assess the febrile response, pain and musculoskeletal function remain the primary means of monitoring response to treatment.
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Hospital Discharge
For children with presumed or confirmed ABA who respond to initial intravenous antibiotic therapy, we recommend transition to an oral antibiotic regimen rather than OPAT when an appropriate, well-tolerated oral antibiotic option is available, and that antibiotic is active against the confirmed or presumed pathogen(s). (S, L )
Comment: This recommendation places a high value on avoidance of harms and costs, as well as on considerations of patient’s values and preferences, feasibility, acceptability, and equity.
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For children with presumed or confirmed ABA who respond to initial parenteral antibiotic therapy but for whom oral antimicrobial therapy is not feasible, we suggest transition from the acute-care hospital to OPAT, rather than remaining in the hospital for the total duration of therapy. (C, VL )
Comment: This recommendation places a high value on avoiding harms and costs associated with unnecessary and prolonged hospital stay. The decision to implement this recommendation and the selection of the type of OPAT (home, intermediate care facility, clinic) may be influenced by availability of local resources.
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Duration of Therapy
In children with confirmed primary ABA without adjacent osteomyelitis with rapid clinical improvement and consistent, progressive decrease in CRP by the end of the first week of treatment, we suggest treating for a total duration of antimicrobial therapy (parenteral plus oral) as short as 10 to 14 days for common pathogens (S. aureus, S. pyogenes, S. pneumoniae, and H. influenzae type b), rather than for longer courses of 21 to 28 days. (C, L )
Comment: For children with slower clinical response, inadequate source control, or persistently elevated CRP, courses of therapy of 21 to 28 days may be preferred. Such longer durations may be more commonly required when infection is caused by pathogens with relatively less antibiotic susceptibility or greater virulence, particularly enteric or non-fermenting Gram-negative bacilli and some S. aureus strains (e.g., USA300 or similarly virulent strains, whether MSSA or MRSA). Children with ABA with adjacent osteomyelitis should be treated according to the osteomyelitis guideline.
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In children with presumed primary ABA without adjacent osteomyelitis with rapid clinical improvement and consistent, progressive decrease in CRP by the end of the first week of treatment, we suggest treating for a total duration of antimicrobial therapy (parenteral plus oral) as short as 10 to 14 days rather than for longer courses. (C, VL )
Comment: For children with slower clinical and laboratory responses, longer courses of therapy may be preferred, as noted above.
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Follow Up Imaging
In children with primary ABA with expected improvement during medical management with or without surgical intervention, associated with full clinical recovery, we suggest against routine follow-up imaging. (C, VL )
Comment: In situations where there is any clinical concern for previously undetected adjacent osteomyelitis, a plain film may be considered just prior to cessation of antimicrobial therapy if osteomyelitis was not reasonably excluded by advanced imaging studies (e.g., MRI) earlier in the course.
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Non-Response or Relapse
For children with presumed or confirmed ABA either experiencing primary treatment failure, or early or late recurrence, clinicians should assess adequacy of the antimicrobial regimen (spectrum of activity, dosage, and antibiotic exposure at the site of infection, adherence) and of joint debridement and irrigation before deciding on the need to broaden the spectrum or to restart antimicrobials. (U, U)
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For children with presumed or confirmed ABA either experiencing primary treatment failure, or early or late recurrence, clinicians should assess the need for additional diagnostic evaluation for possible adjacent osteomyelitis, along with any need for surgical intervention for therapeutic and/or diagnostic purposes. (U, U)
Comment: The initial diagnosis of primary ABA may need to be reconsidered.
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Follow Up Examinations
In children with primary ABA, we suggest close follow-up by providers with expertise in management of musculoskeletal infections until the completion of antibiotic therapy and return of function in the infected joint. (C, VL )
Comment: For primary ABA that responds promptly to treatment, follow-up is not routinely required beyond 2-3 weeks from the start of treatment. For children with ABA with adjacent osteomyelitis, see 2021 PIDS/IDSA Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics.
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics
Authoring Organizations
Infectious Diseases Society of America
Pediatric Infectious Diseases Society
Publication Month/Year
November 6, 2023
Last Updated Month/Year
February 14, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics.
Target Patient Population
Children with acute bacterial arthritis
Target Provider Population
Healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics
Inclusion Criteria
Male, Female, Adolescent, Child, Infant
Health Care Settings
Ambulatory, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Management
Diseases/Conditions (MeSH)
D001168 - Arthritis, D001170 - Arthritis, Infectious
Keywords
bacterial arthritis
Source Citation
Charles R Woods, John S Bradley, Archana Chatterjee, Matthew P Kronman, Sandra R Arnold, Joan Robinson, Lawson A Copley, Antonio Arrieta, Sandra L Fowler, Christopher Harrison, Stephen C Eppes, C Buddy Creech, Laura P Stadler, Samir S Shah, Lynnette J Mazur, Maria A Carrillo-Marquez, Coburn H Allen, Valéry Lavergne, Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics, Journal of the Pediatric Infectious Diseases Society, 2023;, piad089, https://doi.org/10.1093/jpids/piad089
Methodology
Number of Source Documents
310
Literature Search Start Date
August 1, 2017
Literature Search End Date
January 1, 2022