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Diagnosis and Management of Musculoskeletal Infections - Pediatric - Emergency Department/Inpatient

Diagnosis and Management of Musculoskeletal Infections - Pediatric - Emergency Department/Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Infection and Isolation


1
Diagnosis and Management of
Musculoskeletal Infections – Pediatric –
Emergency Department/Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................................................... 3
SCOPE .................................................................................................................................................................... 4
METHODOLOGY ..................................................................................................................................................... 5
INTRODUCTION ..................................................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................................................ 5
TRIAGE ......................................................................................................................................................................... 5
DIFFERENTIAL DIAGNOSIS ................................................................................................................................................ 6
ULTRASOUND AND MAGNETIC RESONANCE IMAGING (MRI) .................................................................................................. 6
DETECTED EFFUSION AND ASPIRATION ............................................................................................................................... 6
SEDATION/ANESTHESIA FOR PROCEDURES AND MRI ............................................................................................................. 7
DIAGNOSIS OF INFECTION ................................................................................................................................................. 7
ANTIMICROBIAL THERAPY MANAGEMENT ........................................................................................................................... 8
UW HEALTH IMPLEMENTATION ............................................................................................................................. 9
APPENDIX A. EVIDENCE GRADING SCHEME(S) ..................................................................................................... 11
APPENDIX B. PEDS MUSCULOSKELETAL INFECTION EVALUATION AND TREATMENT ALGORITHM ....................... 12
REFERENCES ......................................................................................................................................................... 13
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2
Contact for Content:
Name: Kenneth Noonan, MD – Pediatric Orthopedics
Phone Number: (608) 263-6208
Email Address:Noonan@ortho.wisc.edu
Name: James Conway, MD – Pediatric Infectious Diseases
Phone Number: (608) 265-6488
Email Address:jhconway@pediatrics.wisc.edu
Name: Kara Gill, MD – Pediatric Radiology
Phone Number: (608) 263-8922
Email Address:kgill@uwhealth.org
Contact for Changes:
Name: Katherine Le, PharmD- Center for Clinical Knowledge Management
Phone Number: (608) 890-5898
Email Address: Kle@uwhealth.org
Coordinating Team Members:
Sabrina Butteris, MD- Pediatric Hospital Medicine
Derrick Chen, MD- Laboratory
J. Muse Davis, MD- Pediatric Infectious Diseases
Mary Jean Erschen-Cooke, RN- Pediatric Emergency Medicine
Sheryl Henderson, MD- Pediatric Infectious Diseases
Michael Kim, MD- Pediatric Emergency Medicine
Kirsten Koffarnus, RN- Pediatric Hospital Medicine
Jie Nguyen, MD- Pediatric Radiology
Jodie Ritchie, PharmD- Pharmacy Inpatient Services
Humberto Rosas, MD- Musculoskeletal Radiology
Lucas Schulz, PharmD, BCPA-AQ ID- Pharmacy Inpatient Services
Dan Sklansky, MD- Pediatric Hospital Medicine
Lindsey Spencer, MS- Center for Clinical Knowledge Management
Lianne Stephenson, MD- Pediatric Anesthesiology
Josh Vanderloo, PharmD, BCPS- Drug Policy Program
Review Individuals/Bodies:
Devon Christenson, CPNP- Diagnosis/Therapy Center
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council 06/22/2017
Release Date: June 2017 | Next Review Date: June 2019
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3
Executive Summary
Guideline Overview
This guideline has been developed to assist in the evaluation and management of pediatric
patients with a musculoskeletal infection. The recommendations include what imaging and labs
to obtain, when to consider full magnetic resonance imaging (MRI), and recommended empiric
antibiotic therapy and monitoring parameters.
Key Practice Recommendations
1. A child who presents with limited use of a limb (e.g., joint swelling, localized bony
tenderness, overlying warmth or redness, refusal to bear weight or walk, painful and limited
range of motion in all directions,) malaise, and a fever > 101.3°F (38.5 °C) should be
screened for bony abnormalities and/or fracture with x-ray imaging.
1
(UW Health Moderate
quality of evidence, weak/conditional recommendation)
2. If no significant bony abnormalities or fractures are noted on x-ray, obtain the following labs:
erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), complete blood
count (CBC) with differential, as well as blood culture(s) prior to starting antibiotics.
1
(UW
Health Moderate quality of evidence, strong recommendation.) Antibiotics can be withheld until
specimens are obtained with the exception of toxic/unstable and ill-appearing children where
clinical judgement suggests immediate antibiotics are indicated.
3. If there is suspicion of joint involvement but the joint is difficult to assess/appreciate for
effusion (i.e., hip) quick MRI is the preferred imaging modality. If the hip is not suspected
(e.g., shoulder, elbow, wrist) and/or the patient is not a candidate for quick MRI (e.g., has
metal implant) use ultrasound.
2
(UW Health Moderate quality of evidence, strong
recommendation)
4. Quick MRI is preferred over ultrasound in patients with a suspected hip infection because it
yields more diagnostic information and can rule out infection of muscle or adjacent bone
(such as pyomyositis which can present with similar symptoms as a septic hip.) Quick MRI is
advised before a full MRI since it requires no sedation (although an anxiolytic such as
midazolam may be given, if needed), may be done on the same day as ED presentation,
and allows for better resource planning (i.e., scheduling surgery, PICC line placement, and
sedation if full MRI is needed.)
3-5,14
(UW Health Very low quality of evidence, weak/conditional
recommendation)
5. Joints that appear swollen and that are easily palpated (e.g., knee or ankle) may be
aspirated may be aspirated without specialty consultation and intervention, if the physician is
capable and comfortable in doing so.(UW Health Low quality of evidence, weak/conditional
recommendation)
6. Joint aspirate specimens should be sent to the lab for synovial fluid cell count and body fluid
culture aerobic/anaerobic with gram stain.
6
(UW Health Moderate quality of evidence,
weak/conditional recommendation) If the child is less than 5 years and Kingella kingae is
possible or if the patient has been previously treated with antibiotics, the lab should be
requested to keep the cultures active for at least 10 days and 16s ribosomal PCR testing
should be ordered to be done as soon as the laboratory runs them.
7. If a sick patient with severe infection is in surgery for the infected joint, age ≤ 8 years old,
and resources are available, consider placing a peripherally inserted central catheter (PICC)
line in while the patient is in the operating room (OR). If PICC will delay case or resources
unavailable, do not place in OR.
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4
8. It is recommended to initially contact the Pediatric Anesthesia service versus the Pediatric
Sedation Clinic if sedation is needed for a full MRI to ensure timely evaluation of infection.
(UW Health Very low quality of evidence, weak/conditional recommendation)
9. It is recommended to initiate empiric antibiotic therapy as follows in any patient who meets
the following criteria
7
(UW Health Moderate quality of evidence, weak/conditional recommendation):
a. Non-toxic, clinically stable – initiate oxacillin 50mg/kg every 6 hours.
b. Non-toxic, clinically stable with concern for Methicillin-resistant Staphylococcus
aureus (MRSA) – initiate vancomycin 15 mg/kg every 6 hours.
c. Toxic, ill-appearing – initiate oxacillin + vancomycin.
d. If there is concern for Kingella kingae (i.e., age 3 months-3 years), Strep
pneumoniae, Haemophilus influenzae (i.e., non-immunized) or Neiserria
gonorrhoae (i.e., sexually active adolescent) – add ceftriaxone 37.5 mg/kg twice
a day.
Companion Documents
1. Pediatric Suspected Musculoskeletal Infection Evaluation and Treatment Algorithm
Scope
Disease/Condition(s): Osteomyelitis, Septic Arthritis
Clinical Specialty: Pediatric Emergency Medicine, Emergency Medicine, Pediatric Hospital
Medicine, Pediatric Orthopedics, Pediatric Radiology, Musculoskeletal Radiology, Pediatric
Anesthesiology, Infectious Diseases, Laboratory, Pharmacy
Intended Users: Physicians, Advanced Practice Providers, Nurses, Pharmacists
Objective(s): To provide an evidence-based guideline to assist in the assessment and
management of pediatric patients who present with a possible septic arthritis or osteomyelitis
infection.
Target Population: Pediatric patients age 17 years or younger who present to the emergency
department with suspected osteomyelitis or septic arthritis infection and who do not have one or
more of the following criteria/conditions: immunocompromised, known rheumatologic disease,
prosthesis, age less than 56 days old, recent orthopedic procedure involving affected joint,
penetrating injury, Sickle cell disease, Thrombocytopenia or coagulopathy, and/or possible
sepsis.
Interventions and Practices Considered:
1. Antimicrobial therapy
2. Joint aspiration
3. Imaging (i.e., x-rays, ultrasound, MRI)
Major Outcomes Considered:
1. Patient mortality
2. Hospital length of stay
3. Peripherally Inserted Central Catheter (PICC) complications
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5
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Recognition of Potential Health Care Disparities:
Acute osteoarticular infections such as osteomyelitis and septic arthritis are relatively rare in
high-income settings compared to developing countries. The annual incidence in a high-income
country like the United States varies between 10 and 25 per 100000 population.
8

Introduction
Musculoskeletal infections such as osteomyelitis (OM) and septic arthritis (SA) can have long
term, devastating consequences for children and adolescents if they are not diagnosed and
promptly treated.
9,10
The classic presentation for these infections is a child with a fever and
difficulty bearing weight or refusal to walk (“limping”).
6
The clinical challenge then begins in
determining what particular type of infection the child has (e.g., septic arthritis versus
osteomyelitis versus Lyme arthritis).
10
To further complicate matters, the evaluation and
management of the patient involves a number of hospital services including laboratory,
orthopedics, radiology and anesthesiology, which can present a separate systems challenge for
the clinicians involved.
11

Recommendations
Triage
1. A child who presents with a clinical impression of infection (e.g., swollen red joint, limited
use of joint, refusal to bear weight with fever, toxic appearance) should be considered
suspect for a musculoskeletal infection.
2. A child who presents with limited use of a limb (e.g., joint swelling, localized bony
tenderness, overlying warmth or redness, refusal to bear weight or walk, painful and
limited range of motion in all directions,) malaise, and a fever > 101.3°F (38.5 °C) should
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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6
be screened for bony abnormalities and/or fracture with x-ray imaging.
1
(UW Health
Moderate quality of evidence, weak/conditional recommendation)
a. X-ray imaging should be done prior to collecting labs related to musculoskeletal
suspicion.
b. In a limping child with localized pathology on clinical presentation,
anteroposterior and lateral radiography of affected areas should be performed,
especially frog-leg lateral radiographs when evaluating the hip.
2,6
(UW Health
Moderate quality of evidence, strong recommendation)
Differential Diagnosis
1. If no significant bony abnormalities or fractures are noted on x-ray, obtain the following
labs: erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), complete
blood count (CBC) with differential, as well as blood culture(s) prior to starting
antibiotics.
1
(UW Health Moderate quality of evidence, strong recommendation.) Antibiotics can
be withheld until specimens are obtained with the exception of toxic/unstable and ill
appearing children where clinical judgement suggests immediate antibiotics are
indicated. Refer to UWHC Clinical Laboratory Policy 1507.P014- Blood Culture
Collection for additional guidance on blood culture collection.
2. A Lyme Antibody, IgG w/Reflex to Immunoblot should be ordered if a joint is involved
and the patient is a resident of Wisconsin or has traveled to an endemic region.
12,13
(UW
Health Moderate quality of evidence, weak/conditional recommendation)
Ultrasound and Magnetic Resonance Imaging (MRI)
1. If the joint is difficult to assess/appreciate for effusion (i.e., hip) quick MRI is the
preferred imaging modality. If patient is not a candidate for quick MRI (e.g., shoulder,)
use ultrasound
2
imaging. (UW Health High quality of evidence, weak/conditional
recommendation)
2. Quick MRI is preferred over ultrasound in patients with a suspected hip infection
because it yields more diagnostic information and can rule out infection of muscle or
adjacent bone (such as pyomyositis which can present with similar symptoms as a
septic hip.) Quick MRI is advised before a full MRI since it requires no sedation
(although an anxiolytic such as midazolam may be given, if needed), may be done on
the same day as ED presentation, and allows for better resource planning (i.e.,
scheduling surgery, PICC line placement, and sedation if full MRI is needed.)
3-5,14
(UW
Health Very low quality of evidence, weak/conditional recommendation)
Detected Effusion and Aspiration
1. Joints that appear swollen and erythematous by physical exam may be aspirated without
pediatric orthopedic or radiology consultation and intervention, if the physician is capable
and comfortable in doing so.
15
(UW Health Low quality of evidence, weak/conditional
recommendation)
2. If effusion is detected on imaging of a difficult joint (e.g., shoulder), consider consulting
pediatric orthopedics and/or pediatric radiology for aspiration with or without ultrasound
guidance.
12,16
(UW Health High quality of evidence, strong recommendation)
3. Joint aspirate specimens should be sent to the lab for synovial fluid cell count and body
fluid culture aerobic/anaerobic with gram stain.
6
If the child is less than 5 years and
Kingella kingae is possible or if the patient has been previously treated with antibiotics,
the lab should be requested to keep the cultures active for at least 10 days and 16s
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7
ribosomal PCR testing should be ordered to be done as soon as the laboratory runs
them. (UW Health Moderate quality of evidence, weak/conditional recommendation)
4. If synovial fluid interpretation yields white blood cell (WBC) count < 50 K/µL, a full MRI
may be needed to continue diagnostic work-up. (UW Health Moderate quality of evidence,
weak/conditional recommendation)
5. If synovial fluid interpretation yields white blood cell (WBC) count ≥ 50 K/µL, an
interdisciplinary discussion between relevant services (e.g., pediatric orthopedics,
pediatric anesthesia, pediatric radiology, pediatric hospital medicine and pediatric
infectious disease) should occur to determine how to best proceed with treatment (e.g.,
debridement surgery, MRI, or whether empiric antibiotic is needed.) (UW Health Low
quality of evidence, weak/conditional recommendation)
6. It is recommended to consider planning admission for a patient who has undergone joint
aspiration, as the patient may be started on empiric antibiotics or may require additional
treatment due to the severity of the infection or for pain management from the
procedure. (UW Health Very low quality of evidence, weak/conditional recommendation)
Sedation/Anesthesia for procedures and MRI
1. It is recommended to assess whether or not anesthesia is required for the patient to
undergo a full MRI evaluation, given some older patients do not require it. (UW Health
Very low quality of evidence, weak/conditional recommendation)
2. It is recommended that providers try to minimize the number of instances the pediatric
patient is sedated or undergoes general anesthesia during the encounter or admission.
Some scenarios to consider include : (UW Health Moderate quality of evidence,
weak/conditional recommendation)
a. If a patient is sedated to undergo a full MRI and the full MRI indicates patient will
need surgery, it is best if the patient can remain sedated and proceed to the
operating room once the MRI is completed.
b. If a sick patient with severe infection is in surgery for the infected joint, age ≤ 8
years old, and resources are available, consider placing a peripherally inserted
central catheter (PICC) line in while the patient is in operating room (OR). If PICC
will delay case or resources unavailable, do not place in OR.
3. If sedation is needed for a full MRI, it is recommended to initially contact the Pediatric
Anesthesia service versus the Pediatric Sedation Clinic to ensure timely evaluation of
infection. (UW Health Very low quality of evidence, weak/conditional recommendation)
Diagnosis of infection
1. Septic arthritis of the hip should be suspected over transient synovitis if 3 or more of the
following Kocher criteria are met: inability to bear weight, oral temperature > 101.3°F
(38.5°C), ESR > 40 mm/hr, white blood cell count > 12 K/µL
1
or CRP > 2 mg/dL.
17
These criteria are not applicable to any other joint or osteomyelitis. (UW Health Moderate
quality of evidence, weak/conditional recommendation)
2. A WBC > 50 K/µL from synovial fluid interpretation strongly suggests a bacterial infection
and surgical debridement and antibiotic therapy should be considered.
10
(UW Health
Moderate quality of evidence, strong recommendation)
3. If the patient is diagnosed with osteomyelitis, orthopedics, pediatric infectious diseases
and musculoskeletal radiology should be consulted to determine if the patient requires a
full MRI, PICC line placement and whether the patient should proceed to surgery and/or
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8


have a biopsy done. (UW Health Very low quality of evidence, weak/conditional
recommendation)
Antimicrobial Therapy Management
1. Placement of a peripherally inserted central catheter (PICC) line should be considered
once the patient is diagnosed with a musculoskeletal infection, given that the
recommended antibiotic duration for septic arthritis can be 3-4 weeks and 4-5 weeks for
osteomyelitis. Antibiotic therapy is also initially given by intravenous (IV) route.
18,19
(UW
Health Moderate quality of evidence, weak/conditional recommendation)
2. Antibiotics with activity against Staph aureus and Group A streptococci should be
selected for empiric therapy because these pathogens are typically the primary causes
of osteomyelitis and septic arthritis.
13
(UW Health High quality of evidence, strong
recommendation)
3. It is recommended to initiate empiric antibiotic therapy as follows
7
in any patient who
meets the following criteria: (UW Health Moderate quality of evidence, weak/conditional
recommendation):
e. Non-toxic, clinically stable – initiate oxacillin 50mg/kg every 6 hours.
f. Non-toxic, clinically stable with concern for MRSA (e.g. history of MRSA) –
initiate vancomycin 15 mg/kg every 6 hours.
g. Toxic, ill-appearing – initiate oxacillin + vancomycin.
h. If there is concern for Kingella Kingae (i.e. age 3 months-3 years), Strep
Pneumoniae, Haemophilus Influenzae (i.e. non-immunized) or Neiserria
gonorrhoae (i.e., sexually active adolescent) – add ceftriaxone 37.5 mg/kg twice
a day.
4. It is recommended to obtain a baseline creatinine level before initiating vancomycin, and
to discontinue any non-steroidal anti-inflammatory drugs (NSAIDs) once a patient is
started on vancomycin.
20,21
(UW Health Low quality of evidence, weak/conditional
recommendation)
5. Consider using daily CRP and obtaining ESR measurement 1-2 times per week initially
to monitor patient response to antibiotic treatment, along with clinical assessment.
22,23

(UW Health Low quality of evidence, weak/conditional recommendation)
6. If the patient is afebrile, pain has decreased, and CRP has decreased by 50% or CRP ≤
2 mg/dL, clinicians may consider switching the antibiotic administration from intravenous
to oral route for continued antibiotic therapy.
9,11,24,25
(UW Health Low quality of evidence,
weak/conditional recommendation)


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9
UW Health Implementation
Potential Benefits:
• Decrease in number of times a pediatric patient is sedated during visit/admission
• Decrease in hospital length of stay for patients
• Decrease in radiographic imaging costs to patient
• Optimized management and care of pediatric patients with musculoskeletal infection
• Promotes antimicrobial stewardship
Potential Harms:
• Cost-shifting from inpatient to outpatient setting
• Increase in PICC complications due to IV antibiotic therapy
Pertinent UW Health Policies & Procedures
1. UWHC Clinical Laboratory Policy 1507.P014- Blood Culture Collection
2. UWHC Clinical Policy 8.56 Pediatric Sedation Policy
3. UWHC 2.3.5-Magnetic Resonance Imaging (MRI) Safety and Screening
Patient Resources
1. Health Facts for You #7595- Caring for your Child's PICC
2. Health Facts for You #5093- Understanding your Peripherally Inserted Central Catheter
3. Kids Health- A to Z: Septic Arthritis (Pyogenic Arthritis)
4. Kids Health- Osteomyelitis
5. Kids Health- Blood Culture
6. Kids Health- Blood Test: C-Reactive Protein (CRP)
7. Kids Health- Blood Test: Erythrocyte Sedimentation Rate (ESR)
8. Kids Health- Blood Test: Complete Blood Count
9. Kids Health- Joint Aspiration (Arthrocentesis)
10. Kids Health- Magnetic Resonance Imaging (MRI)
11. Kids Health- Anesthesia- What to Expect
12. Kids Health- Anesthesia Basics
13. Kids Health- Preparing Your Child for Anesthesia
Guideline Metrics
1. # of patients with X-ray
2. # of patients with ultrasound
3. # of patients with quick MRI, full MRI
4. Average amount of time from when patient presented to ED to when quick MRI is done
5. Average number of days patient is on IV antibiotic
Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.
Order Sets & Smart Sets
IP- Venous Access Team- PICC Placement Request- Pediatric-Supplemental [1429]
IP- Orthopedics- General – Pediatric- Admission [5589]
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10
IP- Pediatric- General Care- Admission [1325]
Clinical Practice Guidelines
1. Surgical and Interventional Radiology Antimicrobial Prophylaxis- Adult/Pediatric-
Inpatient/Ambulatory
2. Antimicrobial Use Therapeutic Pearls- Adult/Pediatric-Inpatient/Ambulatory
3. Sedation - Nursing Practice Guideline
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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11
Appendix A. Evidence Grading Scheme(s)
Figure 1. GRADE Methodology adapted by UW Health
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate
We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
Strong
The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.
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Fever >38.5
0
C, Malaise,
limited use of limb?
Patient afebrile,
CRP ≤ 2 or decreased by
50%, pain decreased?
Child presents with
clinical impression of
infection
A
Off guideline, treat as clinically indicated
If discharged, close follow up within 48 hours
Bony abnormality,
fracture (+)
ESR > 40, WBC > 12, or
CRP >2?
Aspirate sample
WBC>50k?
Effusion?
Labs: CRP, ESR, CBC w/differential,
blood culture
B
Quick MRI (i.e. hip)
If not candidate for MRI, Ultrasound
(e.g. shoulder, wrist, elbow)
C
Consider: Surgery/debridement
Full MRI
Start IV antibiotic
F
Consider PICC line
G
Consult Peds Infectious Disease
MRI
Assess whether
sedation is needed
If needed, contact
Peds Anesthesia
Effusion?
Aspirate w/ultrasound if needed
D
Labs
E
Consider whether patient needs sedation
for aspiration
Plan for possible admission
IV antibiotic started
Consider initial daily CRP and ESR 1-2x/week
to monitor, along with clinical assessment
Consider:
switch to oral
antibiotic discharge
Continue IV therapy
and treat as indicated
Imaging: X-rays
Off guideline,
treat as clinically
indicated
Pediatric Musculoskeletal Infection Evaluation and Treatment Algorithm
Aspirate and send
fluid to lab for
analysis
E
YES
Aspirate sample
WBC>50k?
YES
NO
YES
YES
NO
If discharged, close follow
up within 48 hours
Treat as clinically indicated
Consider ortho consult or
possible admission
NO
Difficult to assess for
effusion?
YES
YES
Osteomyelitis?
Consult MSK Radiology
During day: Carrie Adamany 263-6871,
pgr 9585
After hours: page Radiology Resident on call
Consult Peds ID
Consult Ortho
Consider Full MRI
PICC placement
Surgery vs biopsy
NO
YES
NO
NO
YES
Exclusion Criteria:
 Immunocompromised
 Known rheumatologic disease
 Prosthesis
 Age < 56 days
 Recent orthopedic procedure involving
affected joint
 Penetrating injury
 Sickle cell disease
 Thrombocytopenia, coagulopathy
 Possible sepsis
A. Clinical impression of infection examples
including but not limited to:
 Swollen red joint
 Limited use of joint
 Refusal to bear weight with fever, toxic
appearance
B. If joint involved obtain Lyme IgG lab
C. Quick MRI should be done with no sedation
however patient may receive anxiolytic (i.e.,
midazolam)
If effusion noted on exam and joint easily
aspirated (i.e. knee, ankle), routine US is not
recommended.
D. Consider consulting Orthopedics or
Pediatric Radiology for aspiration in difficult
joint.
Daytime: Peds Radiology 263-0671 or 263-0670.
After hours: Page Radiology Resident on call
If aspiration by radiology, contact Peds
Anesthesia for procedural sedation if needed.
E. Labs for fluid analysis: synovial fluid cell
count, body fluid aer/ana culture with gram
stain.
If pt <5 yrs and Kingella possible, request lab
to keep culture active for at least 10 days and
do 16s ribosomal PCR as soon as lab runs.
F. Empiric Antibiotic suggestions
Non-toxic appearing:
IV Oxacillin 50mg/kg every 6 hours
Non-toxic appearing w/risk for MRSA (incl. hx
of MRSA): IV Vancomycin 15 mg/kg every 6
hours
Toxic appearing or known (+) blood culture:
IV Vancomycin + Oxacillin
*Obtain baseline Creatinine if starting
vancomycin and stop NSAIDs
*If Penicillin allergy, consult Peds ID for
antibiotic therapy recommendations.
Add Ceftriaxone 37.5 mg/kg twice a day if:
 suspect Kingella kingae (i.e., pt is 3
months-3 yrs)
 suspect Strep. pneumo or Haemophilus
influenzae. (i.e., non-immunized pt.)
 suspect Neiserria gonorrhoae (i.e.,
sexually active teen)
G. Assess if child will need PICC line and
sedation for PICC line.
If child is sick, age ≤ 8 yrs and resources
available, consider placing PICC in OR during
surgery.
If PICC line placement will delay case or
resources unavailable, do not place in OR.
YES
NO
NO
YES
NO
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

13
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org