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children. [IIA] 10. If MRSA infection is suspected and the patient is not critically ill, empirical therapy should include clindamycin if the rate of clindamycin-resistant S. aureus is less than 10-15%. A glycopeptide or other appropriate antibiotic for MRSA, such as linezolid, should be included if local clindamycin-resistant MRSA rates are high. [IIIB] 11. Septic arthritis (SA) in children should be treated with joint drainage by arthrocentesis, arthrotomy or arthroscopy, depending on the preference and experience of the treating clinicians and surgeons. Arthrocentesis may be appropriate as the only invasive procedure in most uncomplicated cases of SA in children. [IIB] 12. Short intravenous therapy followed by oral therapy is appropriate in most children with uncomplicated BJI based on absence of complications and favourable outcome. [IA] 13. Follow up oral antibiotic therapy should be guided by the antibiotic susceptibilities of the bacteria if isolated; if susceptible, the antibiotics of choice are first-generation cephalosporins and clindamycin. [IIA] 14. The minimum total duration of antibiotic therapy should be 2-3 weeks for septic arthritis and 3-4 weeks for osteomyelitis. [IA] © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 5 15. Complicated or high risk BJI such as those produced by Salmonella, MRSA or PantonValentine leukocidin (PVL)-positive strains, developing in young infants, or with slow clinical improvement, may need to receive longer duration of both intravenous (IV) and oral therapy. [IIB] 16. Risk factors associated with sequelae include young infants and newborns, infections caused by MRSA or PVL-positive strains, longer duration of symptoms before initiation of therapy, and hip involvement. Thus, children with BJI who have any of these risk factors should be followed more closely and for a longer time to rule out or treat sequelae. [IIB] 17. A multidisciplinary team should follow children with BJI until osteoarticular function is restored and sequelae are resolved. If bone growth is the only concern, an orthopaedic specialist will suffice. Infants with BJI in hip or with any physis involvement should be followed for extended periods of time. [IIB] Notes – Quality of evidence o I = Good evidence: Randomised placebo controlled trials; other studies appropriately randomized; good meta-analysis and systematic reviews of randomised controlled trials; o II = Moderate evidence: Well designed but not-randomized studies, cohort and case control studies; o III = Poor evidence: Expert opinion, case series – Strength of recommendation – team consensus based on calculation of votes for A, B, or C by the team members: A = Strong recommendation; B = Moderate recommendation; C = Weak recommendation 2.2 BJI diagnostic recommendations Table 1 – Diagnostic options for childhood BJI Type Tests Notes/remarks LABORATORY TESTS (1–4) C-reactive protein (CRP) – Easy, inexpensive, and rapid test in diagnostics and followup – High sensitivity for diagnosis of BJI (2,5) – Normal rate is reached quickly (in 3-8 days) during recovery of BJI (6,7) Erythrocyte sedimentation rate (ESR) – This test may be more difficult in children: larger sample blood volume needed and possible laboratory errors due to handling problems – Some studies have shown high sensitivity (8). Sensitivity may be higher with measurement of both CRP and ESR. – Low specificity for diagnosis of BJI – Normal rate is reached a long time (2-3 weeks or more) during recovery of BJI (7) Complete blood count (CBC) – Useful in conjunction with ESR and CRP – White blood cell, haemoglobin and platelet count may still be very useful for differential diagnosis of BJI (leukaemia, for example) IMAGING X-ray imaging – Always at baseline (often normal at baseline but useful for later re-imaging comparison and to rule out other diseases) – Plain radiography often misses joint effusion, especially in the hip joint (9) – If clinical presentation is not severe and clinical outcome on therapy is appropriate, an additional imaging study may not always be necessary Ultrasound (US) sonography – Identify joint effusion in septic arthritis (very sensitive) – Subperiostic abscess (low sensitivity for osteomyelitis but may be very useful) © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 6 Type Tests Notes/remarks – Doppler may detect elevated blood flow in osteomyelitis (OM) and help in early diagnosis (10) Scintigraphy/ Tc bone scan – In several European countries, scintigraphy has become unpopular due to high radiation dose* – In others, it is still frequently used in the diagnosis of OM – It may be useful in ill-defined locations or if multiple foci are suspected MRI – MRI is expensive and not always available – Best test for OM, especially if symptoms are localised – Not always needed in every child, especially if the diagnosis is clear and the child improves in a short period (2-3 days) – Provides excellent definition of soft tissues and bone marrow – Whole body MRI for multifocal processes has proven very useful (11), e.g., in cases of severe CA-MRSA CT scan – Reserved for diagnostic dilemma in most centres, although local variation exists even within countries – much higher radiation than any other imaging test* – It may be more frequently used in centres where MRI is not readily available MICROBIOLOGY Blood culture – Should always be obtained despite a possible low yield (10%-
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