Delphi Method Approved Statements July 21

Background and Justification

Musculoskeletal infection in children can be life threatening or lead to long term disability, so necessitates prompt diagnosis and timely management. There needs to be an awareness of the spectrum of disease, which includes osteomyelitis, septic arthritis, spinal discitis, pyomyositis, fasciitis, panniculitis and cellulitis. Several adjacent tissue types can be infected concurrently.

Paediatric Orthopaedic networks and hospitals require the appropriate pathways and infrastructure to manage these children, enable optimum recovery, and minimise the sequelae of infection.

For the background behind the Delphi method used to reach this consensus please click here.

Section 1: Assessment, Investigation and Diagnosis

1. All children suspected to have musculoskeletal infection should be considered for joint management by orthopaedic surgeons and paediatricians, especially in cases of diagnostic uncertainty.
2. In addition to examination of the affected limb and spine, a full systematic examination including upper respiratory tract and ears should be performed and documented by a paediatrician or other appropriate professional.
3. In cases of cellulitis that do not settle with standard treatment, deeper infection should be considered.
4. No single clinical algorithm for detecting MSK infection has been proven to be completely reliable, so should be considered in conjunction with history and examination.
5. FBC, CRP, ESR and blood cultures are the minimum baseline laboratory investigations in suspected cases of MSK infection.
6. Plain radiographs of the affected bone/joint should be performed in all cases.
7. MRI is the gold standard second line imaging investigation if the child’s condition allows.
8. Ultrasound of the affected bone/joint should be considered when MRI is not possible.
9. Where a joint is aspirated, the fluid should be sent to the laboratory in both plain universal culture pot and also in blood culture bottles.
10. The majority of uncomplicated cases of osteomyelitis do not require biopsy nor surgery, with biopsy reserved for cases of diagnostic uncertainty or where symptoms are not settling with treatment.
11. Empirical intravenous antibiotics should be started immediately in any child who meets the Sepsis 6 criteria, even if prior to a diagnosis of MSK Infection.
12. Antibiotics can be delayed to take adequate samples if a child’s condition is stable and surgery can be performed in a timely fashion.
13. A raised CRP or ESR in a child with an appropriate history and examination findings is suspicious for MSK infection.
14. A normal CRP or ESR does not exclude MSK infection if early on in the disease course.
15. Isotope bone scan should be avoided where MRI is available, to reduce radiation to children

Section 2: Treatment

16. In septic arthritis, urgent irrigation and drainage of the joint is the accepted standard, repeated if necessary.
17. Osteomyelitis in bones adjacent to the joint should be considered in cases of septic arthritis.
18. In acute haematogenous osteomyelitis, intravenous antibiotics are first line treatment, with surgical intervention indicated when response is sub optimal.
19. Empiric antibiotics for osteomyelitis should be guided by local guidelines and the Sepsis 6 pathway.
20. In osteomyelitis a large collection of pus on imaging should be surgically drained, especially in non-responders.
21. Every effort should be made to protect growth plates during surgery for osteomyelitis.
22. In surgery for osteomyelitis, adjacent joint effusions should be aspirated, and joint washout performed if pus is present.
23. In both septic arthritis and osteomyelitis, consider long line access at the earliest opportunity, particularly in the younger child.
24. Convert to oral antibiotics when the child is clinically improving and inflammatory markers are falling.
25. Temperature, CRP, ESR, and clinical improvement are all important to monitor response, guide treatment and exclude chronic osteomyelitis.
26. Clinical examination and x-ray imaging are both necessary to assess medium and long term complications including fracture in osteomyelitis, joint contracture, growth arrest, hyaline cartilage loss, and Brodie Abscess formation.
27. Total antibiotic duration should be guided with local MDT discussion, and continued at least until inflammatory markers are normal.
28. Pyomyositis can present similarly to septic arthritis or osteomyelitis, especially around the hip, and MRI is the investigation of choice.
29. Pyomyositis can often be treated successfully without surgery, with clinical examination and blood tests helpful for monitoring response.

Section 3: Service, Pathways and Networks

30. Children should be treated at their local hospital if the local expertise is sufficient for the nature of the infection present.
31. Each child should be treated by a multidisciplinary team, with a minimum of 2 disciplines (a surgeon and a paediatrician or microbiologist) with further input from an infectious diseases team where required.
32. Admit all children with musculoskeletal infection for initial management.
33. Each region must agree pathways in which specialist hospitals and supra-regional centres support district general hospitals in managing children with bone and joint infections (see definitions below).
34. Complex cases should be transferred promptly to specialist centres.
35. The receiving team in specialist centre should be defined – paediatrician, or paediatric orthopaedic surgeon, or both.
36. Clinicians managing children with MSK infection at local hospitals should have a low threshold for discussing cases with a specialist unit.
37. If a child is well enough for discharge, but cannot be converted to orals and requires long term IV antibiotics for their treatment, then there should be provision for IV treatment as an outpatient or in the community.
38. Consider repatriation of complex cases from a specialist hospital to their local hospital when treatment plan is finalised.
39. Each child should have a discharge plan including dates, location and duration of outpatient appointments according to predicted complications.
40. Follow-up should be under an interested specialist who anticipates bone fragility in osteomyelitis, monitors growth, and can manage consequences of growth disturbance and joint damage.

Definitions

Local Hospital: interested orthopaedic surgeon and paediatrician/microbiologist. Paediatric inpatient beds.

Specialist Hospital: interested paediatric orthopaedic surgeon and interested paediatrician/microbiologist. May be limited by anaesthetic provision and out of hours radiology provision.

Supra-regional Centre: team of paediatric orthopaedic surgeons, specialist infectious disease paediatricians, and anaesthetic/paediatric critical care support. Able to provide 7 days a week specialist care.

Therefore, by these definitions any hospital where a BSCOS consultant member works will be either a specialist hospital or supra-regional centre.

BSCOS MSK Infections Consensus Group

Chair and Point of Contact:
Piers Mitchell (email)

Consensus group members:
Alwyn Abraham
Clare Carpenter
Jo Dartnell
Laura Deriu
Philip Henman
Colin Holton
Mark Latimer
Janet McCaul
Rajan Natarajan
Anish Sanghrajka
Krishna Vemulapalli