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antibiotic therapy – IV = intravenous administration, PO = oral administration – $ = Complex disease = if any one of the following features are present: – significant bone destruction – resistant or unusual pathogen – immunocompromised patient – sepsis or shock – venous thrombosis or other major complications (e.g. important abscess). – * = Some studies showed that 10 days of treatment may be enough for non-complicated SA – # = Some symptoms may not be related to infection or inflammatory cause but to sequelae (e.g., limping, pain, limit range of motion). Consultation with Orthopaedics may be considered. 3 Epidemiology Musculoskeletal infections involve bones, muscles and joints and are a significant cause of morbidity, and mortality in certain circumstances or settings, in children worldwide (23,24). Acute haematogenous BJI in children may clinically manifest as osteomyelitis (OM), septic arthritis (SA), both combined (OM-SA), or as pyomyositis. Paediatric spondylodiscitis is uncommon and accounts for 1–2% of all children with OM. It is characterised by infection involving the intervertebral disc and adjacent vertebrae. Pyomyositis may complicate or accompany BJI, and it can also be a primary infection by itself without the coexistence of bone or joint infection. · Acute OM is an inflammatory process in the bone accompanied by bone destruction (25) usually due to bacterial infection (26), and it is most commonly seen in the long bones of lower and, less frequently, upper extremities (8,27). In high-income settings, the time from onset of symptoms to presentation for medical care is usually < 5 years of age (24,29). Vertebral OM is more common in older children and usually involves the anterior body of the vertebra (29). In these instances, infectious agents such as M. tuberculosis and Salmonella should be considered as well. · Pyomyositis is frequently seen with pelvic involvement and may be related to MRSA or PVL production (30–34). 3.1 European guidelines Europe is a group of countries, and as such differs greatly in population, culture, wealth and health services. All variations of disease are impacted by differing epidemiology of pathogens and bacterial resistance, differences in presentation of reported cohorts between regions, medical approaches of infectious diseases, possibilities of medical care, etc. © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 9 Therefore, there may be important differences in terms of epidemiology, diagnosis and treatment in relation to the topic of this guideline. Where possible, this guideline describes regional variations in management. To deal with variations in resource availability, this document aims to provide choices of diagnostic tools, options for treatment and investigation in “best practice order” where, for example, “state of the art” solutions are not available. 3.2 Incidence, prevalence · Acute BJI incidence is higher in children than in adults (24). · In developed countries, recent reports of OM rates are 2 to 13 per 100,000 children/year (35,36) and it is considerably more common in developing countries (37). · Overall, OM is often more common than SA (8,36). · The incidence is increased in immunocompromised patients and those with sickle cell disease (SCD), among others. However, not all immunodeficiencies have the same risk; chronic granulomatous disease (CGD) is a very typical example with increased risk. · Boys are 1.2–3.7 times more likely to be affected by BJI than girls (8,24). Table 3 – BJI incidence in European countries (Author input) Country/region BJI incidence Remarks Finland OM: 4.5/100,000/year SA: < 2 weeks, 2 weeks – 3 months, and > 3 months, respectively. Note – Subacute and chronic are not consistently differentiated in the literature due to clinical and diagnostic similarities. 4.2 Causative agents and bacterial resistance The prevalence of different pathogens encountered in various European countries is the main factor influencing the antibiotic regimen in BJI (see Table 14). As one example, a common pathogen of BJI is community-acquired MRSA (CA-MRSA), which has emerged in some countries. Table 4 illustrates the most common pathogens by age in acute BJI. · OM and SA are most commonly caused by Staphylococcus aureus; then, depending on age and other risk factors, or geographical location, K. kingae or GAS. · Pathogens involved less frequently in these infections are S. pneumoniae, Pseudomonas, Haemophilus influenzae type b (Hib), Salmonella, among others. · Group B Streptococcus (GBS) and Escherichia coli are important pathogens in newborns. · In certain areas, a variable but considerable number of cases are caused by CA-MRSA. · Rates of CA-MRSA in children vary across European countries (see Table 14). A recent European pediatric study of invasive S. aureus disease has shown a prevalence of 8% of MRSA (56). · In many European countries/regions, K. kingae should be considered in young children with culture negative skeletal infections. In some studies, it is the second (or even the first) most common aetiology after S. aureus in children < 5 years where real-time polymerase chain reaction (PCR) has been performed (8,13,40,57–59). Table 4 – Most common pathogens by age in acute BJI. Age group Pathogen Infant =5 yr old S. aureus GAS N. gonorrhoeae (in sexually-active adolescents) Note – References: (26,27,36,37) 5 Clinical features The
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