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Evaluation and Treatment of Musculoskeletal Infections in Children
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Posted on: 10/29/2009
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According to Dr. Lawson Copley, a professor of orthopedic surgery at the University of Texas Southwestern (Dallas, Texas), serious bone and soft tissue infections in children are on the rise and have become more serious and more complex than ever before. In this article, Dr. Copley takes us down the path of evaluation, diagnosis, and treatment of deep infections involving the musculoskeletal system in children.
He stresses the importance of a team approach involving a full complement of health care professionals. Parents/family head the list along with physicians from a variety of specialties (emergency, infectious disease, pediatricians, radiologists, emergency doctors), nursing, and laboratory staff. The most successful results come when all members of the team participate in the decision-making process. Communication is key to efficient and effective treatment.
That sounds all very serious and it is because these pediatric musculoskeletal infections can be deep, wide spread, and deadly. What has changed to bring this all about? MRSA-- methicillin-resistive staphylococcus aureus infection. MRSA is a staph infection that has become resistant to all but one antibiotic. And there's evidence that the bacteria is continuing to mutate (change) with at least one strain now resistant to all antibiotics. Children who are infected with MRSA are more likely to develop blood clots that can travel to the lungs, a potential cause of death.
Early, accurate diagnosis is very important. Recognizing telltale symptoms gets the process started. Pain, tenderness, swelling, redness, loss of motion, and a distinct limp or difficulty walking are common first symptoms. The diagnosis can be delayed when medical staff is fooled into thinking the child has a superficial (skin deep) infection called cellulitis. Or it may look like an isolated and contained abscess when, in fact, there is a deeper, more widespread and invasive infection. Sometimes it goes clear to the bone as in the case of osteomyelitis (bone infection). Areas affected most often include the spine, pelvis, and arms or legs. In some cases, it isn't until a bone fracture or visible deformity occurs that the diagnosis is made.
The use of MRIs today has helped identify the full extent of these infections. Other imaging studies with X-rays, CT scans, ultrasonography, and bone scans provide vital details about the location, size, and depth of infection. Any part of the soft tissues can be affected including skin, muscle, joint, and/or bone. Antibiotics and surgery remain the mainstay of treatment.
Lab studies are done to identify the specific bacteria and help direct which antibiotic to use. Blood is drawn and studied. Blood tests help reveal the presence and type of infection and show which children are at risk for blood clot formation. One study has shown that children nine years old and older who have MRSA-related osteomyelitis have a 40 per cent incidence of blood clots when the C-reactive protein (CRP) level is more than 6 mg/dL. CRP is a protein found in the blood. CRP levels rise in response to inflammation. Whenever possible, fluid is also removed from the affected joint or a bit of the affected tissue is taken for laboratory analysis. The information gained from these tests also helps aid in selecting an antibiotic that will be most effective.
Hospitalization is almost always required for these infections. When the specific bacteria present can be identified, then antibiotic treatment usually begins. At first, antibiotics are delivered intravenously (directly into the bloodstream) with follow-up treatment using oral (pill form) antibiotics.
The author presents a table with antibiotic recommendations with type, dose, route of administration, and frequency based on age. Timing and duration of antibiotic administration is still more difficult to figure out. There are no evidence-based guidelines published yet. It has been suggested that the physician can change the child from an intravenous antibiotic to an oral form when symptoms improve and CRP levels drop. Repeat blood cultures may also help determine when this change can take place. Usually the child can be released from the hospital when the intravenous antibiotic is discontinued. Oral antibiotics are often continued at home for at least another six weeks, depending on the child's response, any adverse side effects of the medication, and lab values.
Surgery may be needed to clean out pockets of infection and pus. This procedure is referred to as debridement. Abscesses don't always clear up even with antibiotics. Surgical drainage helps the antibiotic get into the area of infection once the abscess is removed. Joints that are affected by infection may respond to a procedure called aspiration and lavage. The infected fluid is drawn out of the joint and a saline solution is used to flush out any remaining infection and bacteria.
Bone infections require a different surgical technique. The surgeon may have to cut out a window in the outer surface of the bone to gain access to the infection. Debridement must be done carefully to avoid damage to the area of bone that is still growing. Drains are put in place to continue removing blood and infected fluids that accumulate in the area. The author suggests removing the drains when fluid output is five milliliters or less.
No matter what type of surgery is performed, failure to improve may mean a second surgery to repeat the process. Time in the hospital can range anywhere from three days to three weeks. With successful treatment, the final step is hospital discharge. The child is carefully followedas an outpatient to make sure the infection is truly gone and doesn't come back.
The authors conclude by saying doctors must work with hospital staff and administrators to establish guidelines for the evaluation and treatment of children with musculoskeletal infections of this type. Every effort should be made to follow the guidelines in order to reduce trauma to the child, speed up recovery, and limit hospitalization. When MRSA infection is recognized and treated early, complications can be reduced. Deformities, damage to musculoskeletal tissues, and disruption of the growth plates can be minimized.
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References:
Lawson A. B. Copley, MD, MBA. Pediatric Musculoskeletal Infections: Trends and Antibiotic Recommendations. In Journal of the American Academy of Orthopaedic Surgeons. October 2009. Vol. 17. No. 10. Pp. 618-626.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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