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Peds MSK Infection Evaluation and Management Algorithm

Peds MSK Infection Evaluation and Management Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Infection and Isolation, Related


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