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Bone and joint infections in children. Bone and joint infections in children are diagnostic and therapeutic emergencies. The most frequently isolated bacteria are Staphylococcus aureus and Kingella kingae. The latter gives few clinical symptoms with slightly abnormal biological signs. Improved bacteriological sampling techniques and analysis (PCR) have allowed to isolate fragile germs. The clinical examination is fundamental completed by bone scintigraphy and MRI for early diagnosis. Actual shorter antibiotic treatment protocols are currently used and shorten the duration of hospitalization. Surgical treatment with the evacuation of a collection and/ or washing of a joint is still a key point in the management of such infections. Currently, severe forms of bone and joint infections have appeared due to staphyloccocus aureus resistant to methicillin., Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts.

The epidemiology of acute paediatric osteoarticular infections (OAI) has recently evolved, mainly due to the improvement of microbiological diagnosis. We conducted a prospective study to analyse the recent epidemiology and the clinical evolution of paediatric OAI in order to validate the adequacy of our probabilistic first-line antibiotic treatment (intraveinous cefamandole + gentamicin). All children suspected of community acquired OAI were included and followed-up for 3 years. The etiologic diagnosis was based on blood cultures, joint aspirations and bone punctures. All osteoarticular (OA) samples were systematically inoculated into blood culture bottles. Real-time universal 16S rRNA and PCR targeted on Staphylococcus aureus, Kingella kingae, Streptococcus pneumoniae and Streptococcus pyogenes were performed twice a week. From 17 March 2007 to 26 February 2009, 98 septic arthritis, 70 osteomyelitis, 23 osteoarthritis and six spondylodiscitis were analysed. A portal of entry was suspected in 44% of cases, including 55% of otorhinolaryngological infections. C reactive protein was the most sensitive inflammatory marker. PCR increased by 54% the performance of bacteriological diagnosis. Among the patients completely investigated (blood culture and OAI samples), there were 63% documented OAI. The main pathogens found were K. kingae (52%), S. aureus (28%), S. pyogenes (7%), S. pneumoniae (3%) and Streptococcus agalactiae (2%). All isolated bacteria were sensitive to the probabilist treatment and outcome was favorable. PCR has significantly improved the performance and the delay of IOA diagnosis in children, for which K. kingae turned out to be the first causative agent. The probabilistic treatment was active against the main bacteria responsible for paediatric OAI., (© 2012 The Authors Clinical Microbiology and Infection © 2012 European Society of Clinical Microbiology and Infectious Diseases.)

Streptococcus pneumoniae is an uncommon cause of osteoarticular infections (OAI) in children. The objective of this study was to investigate the clinical and laboratory characteristics of pneumococcal OAI before and after the introduction of the heptavalent pneumococcal conjugate vaccine (PCV7). Data were retrospectively collected from children aged <16 years who were hospitalized for pneumococcal OAI between 1997 and 2007 in four Parisian teaching hospitals. Forty-three children were included (32 with arthritis and 11 with osteomyelitis) and the median age of these children was 12.5 months (range 3 months to 14 years). Serotypes were available for 19/43 strains (44 %) from 1997 onwards and for 12/13 strains (92 %) from 2005 onwards. Seven unvaccinated children were infected with vaccine serotypes and we observed only one vaccine failure. After the introduction of PCV7, we noted an increase in short-term complications and the emergence of serotype 19A, which was penicillin-intermediate in 86 % of cases. After PCV7 introduction, serotype 19A was the most frequent serotype implicated in pediatric pneumococcal OAI. The 13-valent pneumococcal conjugate vaccine introduced in France in June 2010 should cover the emerging serotype.

The broad-range PCR has been successfully developed to search for fastidious, slow-growing or uncultured bacteria, and is mostly used when an empirical antibiotic treatment has already been initiated. The technique generally involves standard PCR targeting the gene coding for 16S ribosomal RNA, and includes a post-PCR visualisation step on agarose gel which is a potential source of cross-over contamination. In addition, interpretation of the presence of amplified products on gels can be difficult. We then developed a new SYBR Green-based, universal real-time PCR assay targeting the gene coding for 16S ribosomal RNA, coupled with sequencing of amplified products. The real-time PCR assay was evaluated on 94 articular fluid samples collected from children hospitalised for suspicion of septic arthritis, as compared to the results obtained with bacterial cultures and conventional broad-range PCR. DNA extraction was performed with the automated MagNa Pure system. We could detect DNA from various bacterial pathogens including fastidious bacteria (Kingella kingae, Streptococcus pneumoniae, Streptococcus pyogenes, Salmonella spp, Staphylococcus aureus) from 23% of cases of septic arthritis giving negative culture results. The real-time technique was easier to interpret and allowed to detect four more cases than conventional PCR. PCR based molecular techniques appear to be essential to perform in case of suspicion of septic arthritis, provided the increase of the diagnosed bacterial etiologies. Real-time PCR technique is a sensitive and reliable technique, which can replace conventional PCR for clinical specimens with negative bacterial culture.

We report here a case of osteoarticular infection associated with Panton-Valentine leukocidin-producing Staphylococcus aureus. The 3-year-old child presented osteoarthritis associated with toxic shock syndrome, which was complicated by thrombosis, pneumonia, and diaphysitis, despite appropriate antibiotic treatment. Osteitis associated with toxinogenic S. aureus is rarely described. This case highlights the need of early and aggressive surgical treatment, in addition to appropriate antimicrobial therapy.

Aim: To study the bacterial aetiology of acute osteoarticular infections in children and to analyse the efficiency of culture methods., Methods: Bacteriological data of 407 cases of clinically suspected osteoarticular infections affecting 406 children hospitalized in an orthopaedic surgery department between 1999 and 2002 were retrospectively reviewed., Results: Bacterial cultures from clinical specimens were positive in 74 cases (18%): 38 cases of septic arthritis and 36 cases of bone infections (osteitis, osteomyelitis or osteoarthritis). The use of liquid medium bottles to grow bacteria from articular fluids increased the rate of positive cultures compared to the use of standard solid media (p = 0.0001). The most commonly recovered pathogen was Staphylococcus aureus (44%) followed by Kingella kingae (14%), Streptococcus pyogenes (10%) and Streptococcus pneumoniae (10%). K. kingae was most frequently isolated among children under 36 mo of age (p = 0.0003), whereas S. aureus was most frequently isolated among children over 36 mo (p = 0.0015)., Conclusion: By improving our culture method, we observed a recrudescence of isolation of K. kingae, but S. aureus remains the main pathogen isolated from osteoarticular infections in children. This finding is useful for the adaptation of a probabilistic antibiotic treatment of these infections.

To describe bacteriologic epidemiology of bone and joint infections, a total of 52 osteomyelitis, 52 arthritis and 20 osteoarthritis of children aged one month to 15 years during a one-year period (2001) were included in a retrospective unicentric review. The mean age was 3,9 +/-3,6 years. Fever and pain were the most common clinical symptoms. The site of infection was single in 95%, involving lower extremities in 80%. Bone scintigraphy was abnormal in 71% of osteomyelitis. Positive cultures was obtained in 29% of all cases (blood cultures: 20%, aspiration cultures: 29%), but in 42% of cases which have both blood and aspiration cultures. Thirty-six bacteria were identified: 19 Staphylococcus (14 aureus), ten Streptococcus (four pneumoniae), three Salmonella, three Kingella kingae, one Moraxella. All the isolates were susceptible to the empiric antibiotic therapy. Outcome was good in 100% of osteomyelitis and in 96% of arthritis.

Septic arthritis is a synovial infection of bacterial origin. Such a diagnosis, suggested by pain and diminished resistance to infection, should be confirmed by puncture of the joint effusion. The condition calls for emergency hospitalisation and treatment in a surgical unit. Treatment should include draining and cleaning of the joint, immobilization at least in the early stages, and double parenteral antibiotic administration. Clinical, radiological and laboratory follow-up (CRP and ESR) should be pursued. Detection of the responsible germ is often difficult and requires great care in sampling and analysis. The frequency of Haemophilus in children under 4 years of age requires adaptation of antibiotic therapy. In newborns, diagnosis is often difficult and delayed, explaining the frequency of sequelae in this age group. The only important prognostic factor is the interval before beginning treatment.

The purpose of this paper was to evaluate the results after acute septic arthritis of the knee in children and to discuss the method of treatment. 51 cases records of septic arthritis of the knee in children were studied with an average follow-up of 5 years. The etiology was hematogenous in 42 cases, penetrating wounds in 7 cases and osteomyelitis in 2 cases. Treatment was chiefly joint washing by arthrotomy 36 times, arthroscopy 4 times, with a needle 8 times; 3 synovectomies were necessary. Patients underwent systematic joint immobilization and parenteral antibiotics. The results were excellent in 35 cases, good in 10 cases, fair in 6 cases. Prognosis was good for hemategenous arthritis, but much less so for arthritis secondary to penetrating wounds and osteomyelitis. The essential factor for a good result was an early diagnosis and treatment. Apart from 2 arthrodeses, functional results were good. One of the noteworthy facts of our series was the great number of negative cultures (68 per cent). Treatment is discussed according to literature. Joint washing by arthroscopy has the double advantage of being simple and innoculous, and enables synovial biopsy. Immobilization at first seems necessary but its duration can be shortened to encourage articular cartilage nutrition. Antibiotics must be given parenterally at first, to be continued by oral administration as soon as their efficiency is proven. To evaluate this, CRP seems to be an efficient test.