Clinical Epidemiology and Outcomes of Pediatric Musculoskeletal Infections


      To understand the epidemiology of acute hematogenous osteomyelitis and septic arthritis, including clinical and demographic features, microbiology, treatment approaches, treatment-associated complications, and outcomes.

      Study design

      Retrospective cohort study of 453 children with acute hematogenous osteomyelitis and/or septic arthritis from 2009 to 2015.


      Among the 453 patients, 218 (48%) had acute hematogenous osteomyelitis, 132 (29%) had septic arthritis, and 103 (23%) had concurrent acute hematogenous osteomyelitis/septic arthritis. Treatment failure/recurrent infection occurred in 41 patients (9%). Patients with concurrent acute hematogenous osteomyelitis/septic arthritis had longer hospital stays, longer duration of antibiotic therapy, and were more likely to have prolonged bacteremia and require intensive care. Staphylococcus aureus was identified in 228 (51%) patients, of which 114 (50%) were methicillin-resistant S aureus. Compared with septic arthritis, acute hematogenous osteomyelitis and concurrent acute hematogenous osteomyelitis/septic arthritis were associated with higher odds of treatment failure (OR, 8.19; 95% CI, 2.02-33.21 [P = .003]; and OR, 14.43; 95% CI, 3.39-61.37 [P < .001], respectively). The need for more than 1 surgical procedure was also associated with higher odds of treatment failure (OR, 2.98; 95% CI, 1.18-7.52; P = .021). Early change to oral antibiotic therapy was not associated with treatment failure (OR, 0.64; 95% CI, 0.24-1.74; P = .386). Most (73%) medically attended treatment complications occurred while on parenteral therapy.


      Musculoskeletal infections are challenging pediatric infections. S aureus remains the most common pathogen, with methicillin-resistant S aureus accounting for 25% of all cases. Concurrent acute hematogenous osteomyelitis/septic arthritis is associated with more severe disease and worse outcomes. Fewer treatment-related complications occurred while on oral therapy. Early transition to oral therapy was not associated with treatment failure.


      CRP (C-reactive protein), ESR (Erythrocyte sedimentation rate), ICU (Intensive care unit), MRSA (Methicillin-resistant S aureus), MSSA (Methicillin-susceptible S aureus), PICC (Peripherally inserted central catheter)
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        • Arnold J.C.
        • Bradley J.S.
        Osteoarticular infections in children.
        Infect Dis Clin North Am. 2015; 29: 557-574
        • Carrillo-Marquez M.A.
        • Hulten K.G.
        • Hammerman W.
        • Mason E.O.
        • Kaplan S.L.
        USA300 is the predominant genotype causing Staphylococcus aureus septic arthritis in children.
        Pediatr Infect Dis J. 2009; 28: 1076-1080
        • Harik N.S.
        • Smeltzer M.S.
        Management of acute hematogenous osteomyelitis in children.
        Expert Rev Anti Infect Ther. 2010; 8: 175-181
        • Sutter D.E.
        • Milburn E.
        • Chukwuma U.
        • Dzialowy N.
        • Maranich A.M.
        • Hospenthal D.R.
        Changing susceptibility of Staphylococcus aureus in a US pediatric population.
        Pediatrics. 2016; 137: e20153099
        • Hulten K.G.
        • Mason E.O.
        • Linda B.L.
        • Forbes A.R.
        • Revell P.A.
        • Kaplan S.L.
        Analysis of invasive community-acquired methicillin-susceptible Staphylococcus aureus infections during a period of declining community acquired methicillin-resistant Staphylococcus aureus infections at a large children's hospital.
        Pediatr Infect Dis J. 2018; 37: 235-241
        • Weiss L.
        • Lansell A.
        • Figueroa J.
        • Suchdev P.S.
        • Kirpalani A.
        Declining prevalence of methicillin-resistant Staphylococcus aureus septic arthritis and osteomyelitis in children: implications for treatment.
        Antibiotics (Basel). 2020; 9: 101
        • Whitney C.G.
        • Pilishvili T.
        • Farley M.M.
        • Schaffner W.
        • Craig A.
        • Lynfield R.
        • et al.
        Effectiveness of seven-valent pneumococcal conjugate vaccine against invasive pneumococcal disease: a matched case-control study.
        Lancet. 2006; 368: 1495-1502
        • Nuorti J.P.
        • Whitney C.G.
        • Centers for Disease Control and Prevention
        Prevention of pneumococcal disease among infants and children—use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine: recommendations of the advisory committee on immunization practices (ACIP).
        MMWR Recomm Rep. 2010; 59: 1-18
        • Moore M.R.
        • Link-Gelles R.
        • Schaffner W.
        • Lynfield R.
        • Lexau C.
        • Bennett N.
        • et al.
        Effect of use of 13-valent pneumococcal conjugate vaccine in children on invasive pneumococcal disease in children and adults in the USA: analysis of multisite, population-based surveillance.
        Lancet Infect Dis. 2015; 15: 301-309
        • Olarte L.
        • Romero J.
        • Barson W.
        • Bradley J.
        • Lin P.L.
        • Givner L.
        • et al.
        Osteoarticular infections caused by Streptococcus pneumoniae in children in the post-pneumococcal conjugate vaccine era.
        Pediatr Infect Dis J. 2017; 36: 1201-1204
        • Wood J.B.
        • Thomsen I.P.
        • Creech C.B.
        • Newland J.G.
        Best practices for treatment of invasive methicillin-susceptible Staphylococcus aureus infections: the case for oxacillin.
        J Pediatric Infect Dis Soc. 2016; 5: 480-482
        • Gutierrez K.
        Bone and joint infections in children.
        Pediatr Clin North Am. 2005; 52: 779-794
        • Wood J.B.
        • Fricker G.P.
        • Beekmann S.E.
        • Polgreen P.
        • Buddy Creech C.
        Practice patterns of providers for the management of Staphylococcus aureus bacteremia in children: results of an emerging infections network survey.
        J Pediatric Infect Dis Soc. 2018; 7: e152-e155
        • Keren R.
        • Shah S.S.
        • Srivastava R.
        • Rangel S.
        • Bendel-Stenzel M.
        • Harik N.
        • et al.
        Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children.
        JAMA Pediatr. 2015; 169: 120-128
        • Zaoutis T.
        • Localio A.R.
        • Leckerman K.
        • Saddlemire S.
        • Bertoch D.
        • Keren R.
        Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children.
        Pediatrics. 2009; 123: 636-642
        • Paakkonen M.
        • Kallio P.E.
        • Kallio M.J.
        • Peltola H.
        Does bacteremia associated with bone and joint infections necessitate prolonged parenteral antimicrobial therapy?.
        J Pediatric Infect Dis Soc. 2015; 4: 174-177
        • Peltola H.
        • Paakkonen M.
        • Kallio P.
        • Kallio M.J.T.
        • Grp O-SS
        Prospective, randomized trial of 10 days versus 30 days of antimicrobial treatment, including a short-term course of parenteral therapy, for childhood septic arthritis.
        Clin Infect Dis. 2009; 48: 1201-1210
        • Peltola H.
        • Paakkonen M.
        • Kallio P.
        • Kallio M.J.T.
        • Osteomyelitis-Septic Arthritis Study Group
        Short-versus long-term antimicrobial treatment for acute hematogenous osteomyelitis of childhood prospective, randomized trial on 131 culture-positive cases.
        Pediatr Infect Dis J. 2010; 29: 1123-1128
        • Ruebner R.
        • Keren R.
        • Coffin S.
        • Chu J.
        • Horn D.
        • Zaoutis T.E.
        Complications of central venous catheters used for the treatment of acute hematogenous osteomyelitis.
        Pediatrics. 2006; 117: 1210-1215
        • Tice A.D.
        • Rehm S.J.
        • Daloviso J.R.
        • Bradley J.S.
        • Martinelli L.P.
        • Graham D.R.
        • et al.
        Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines.
        Clin Infect Dis. 2004; 38: 1651-1672
        • Moumile K.
        • Merckx J.
        • Glorion C.
        • Pouliquen J.C.
        • Berche P.
        • Ferroni A.
        Bacterial aetiology of acute osteoarticular infections in children.
        Acta Paediatr. 2005; 94: 419-422
        • Arnold S.R.
        • Elias D.
        • Buckingham S.C.
        • Thomas E.D.
        • Novias E.
        • Arkader A.
        • et al.
        Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus.
        J Pediatr Orthop. 2006; 26: 703-708
        • Vicetti Miguel C.P.
        • Mejias A.
        • Leber A.
        • Sanchez P.J.
        A decade of antimicrobial resistance in Staphylococcus aureus: a single center experience.
        PLoS One. 2019; 14: e0212029
        • Spaulding A.B.
        • Thurm C.
        • Courter J.D.
        • Banerjee R.
        • Gerber J.S.
        • Newland J.G.
        • et al.
        Epidemiology of Staphylococcus aureus infections in patients admitted to freestanding pediatric hospitals, 2009-2016.
        Infect Control Hosp Epidemiol. 2018; 39: 1487-1490
        • An T.J.
        • Benvenuti M.A.
        • Mignemi M.E.
        • Martus J.
        • Wood J.
        • Thomsen I.
        • et al.
        Similar clinical severity and outcomes for methicillin-resistant and methicillin-susceptible Staphylococcus aureus pediatric musculoskeletal infections.
        Open Forum Infect Dis. 2017; 4: ofx013
        • Davis W.T.
        • Gilbert S.R.
        Comparison of methicillin-resistant versus susceptible Staphylococcus aureus pediatric osteomyelitis.
        J Pediatr Orthop. 2018; 38: e285-e291
        • Martinez-Aguilar G.
        • Avalos-Mishaan A.
        • Hulten K.
        • Hammerman W.
        • Mason Jr., E.O.
        • Kaplan S.L.
        Community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children.
        Pediatr Infect Dis J. 2004; 23: 701-706
        • Hawkshead 3rd, J.J.
        • Patel N.B.
        • Steele R.W.
        • Heinrich S.D.
        Comparative severity of pediatric osteomyelitis attributable to methicillin-resistant versus methicillin-sensitive Staphylococcus aureus.
        J Pediatr Orthop. 2009; 29: 85-90
        • Gafur O.A.
        • Copley L.A.
        • Hollmig S.T.
        • Browne R.H.
        • Thornton L.A.
        • Crawford S.E.
        The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines.
        J Pediatr Orthop. 2008; 28: 777-785
        • Saavedra-Lozano J.
        • Falup-Pecurariu O.
        • Faust S.N.
        • Girschick H.
        • Hartwig N.
        • Kaplan S.
        • et al.
        Bone and joint infections.
        Pediatr Infect Dis J. 2017; 36: 788-799
        • Benvenuti M.A.
        • An T.J.
        • Mignemi M.E.
        • Martus J.E.
        • Thomsen I.P.
        • Schoenecker J.G.
        Effects of antibiotic timing on culture results and clinical outcomes in pediatric musculoskeletal infection.
        J Pediatr Orthop. 2019; 39: 158-162
        • Barrier A.
        • Williams D.J.
        • Connelly M.
        • Creech C.B.
        Frequency of peripherally inserted central catheter complications in children.
        Pediatr Infect Dis J. 2012; 31: 519-521
        • Alhinai Z.
        • Elahi M.
        • Park S.
        • Foo B.
        • Lee B.
        • Chapin K.
        Prediction of adverse outcomes in pediatric acute hematogenous osteomyelitis.
        Clin Infect Dis. 2020; 71: e454-e464
        • Branson J.
        • Vallejo J.
        • Flores A.
        • Hulten K.
        • Mason E.O.
        • Kaplan S.
        • et al.
        The contemporary microbiology and rates of concomitant osteomyelitis in acute septic arthritis.
        Pediatr Infect Dis J. 2017; 36: 267-273

      Linked Article

      • Traditional culture methods consistently overlook Kingella kingae osteoarticular infections
        The Journal of PediatricsVol. 236
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          Yi et al reported that Staphylococcus aureus was the most common pediatric joint and bone infection etiology in 2 large US hospitals.1 Although this concept was widely accepted in the past, the increasing use of sensitive nucleic acid amplification tests has demonstrated that Kingella kingae is the leading agent of skeletal system infections in the 6- to 48-month-old population, causing 30%-93% of the cases in this age group.2,3 Yi et al, however, isolated the bacterium in only 1% of the 453 patients.
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