Successful treatment of Septic arthritis in childrens depends on early diagnosis and prompt treatment. The standard of care for acute septic arthritis and osteomyelitis is prompt surgical drainage of any collection [1–4] followed by a 6-week course of antibiotics [5,6]. A debate about the duration of antibiotics has been raised in last few years [7].
REVIEW
Kim and Alman [8] reviewed 20 consecutive patients with culture-proven acute septic arthritis of the hip who were treated with a shortened course of parenteral antibiotic therapy, followed by oral antibiotics based on the patient’s response. They concluded that such a treatment plan was associated with no recurrence and a good clinical outcome. Blockey and Watson [9] stated that intravenous antibiotics could be stopped after 10 days if the erythrocyte sedimentation rate was decreasing and in the absence of radiologic cortical bone erosion or new bone formation. Nelson et al. [10,11] showed that a short duration of parenteral therapy followed by oral therapy was not associated with recurrence of infection. Tetzlaff et al. [12,13] reported on 30 patients with acute hematogenous septic arthritis and osteomyelitis who were treated by surgery and oral chemotherapy. Oral therapy provided increased patient comfort and decreased the risk of nosocomial infection associated with prolonged intravenous therapy. They stated that this mode of treatment should be carried out only under carefully monitored conditions in the hospital to ensure compliance and adequacy of serum bactericidal activity.
SHORT TERM THERAPY
Short term intravenous antibiotic therapy followed sequentially by oral antibiotics has been studied by two prospective trials by Jaberi et al[14] and Jagodzinski et al [15]. Jaberi et al had 33 patients in there series which they randomized. The septic arthritis patients received 1 week of v antibiotics in one group and 2 weeks of IV antibiotics in second group. Both the groups were then followed up with 4 weeks of oral antibiotics. Overall, excellent or good results were found in both groups with respect to eradication of infection, radiological and functional scores. The average hospital cost for a patient in second group was twice that for a patient in first group.
Jagodzinski et al studied 70 children’s prospectively. Their hypothesis stated that the majority of children with acute septic arthritis and osteomyelitis could be treated with 3 days of intravenous antimicrobial therapy, after prompt surgical drainage, followed by 3 weeks of oral therapy. Results showed that 59% of patients can be successfully converted to oral therapy by day 3 and 86% can be converted by day 5. Only 14% of patients in our study required intravenous therapy for 6 days or more.
HOW TO IDENTIFY WHICH PATIENT WILL REQUIRE PROLONGED THERAPY
Thus short term therapy is been backed up with good evidence, however the question remains of how to identify patients who will need prolonged therapy. Both the above studies have provided with their own guidelines. Jaberi et al used a scoring system that was based on clinical, laboratory and radiological criteria’s
Any patient with scores less than 4 were switched from intravenous to oral antibiotics and vice versa
In study by Jagodzinski et al, after 3 full days of intravenous antibiotics the patients were assessed with regard to converting to oral therapy. An improvement in symptoms (pain, movement), normalization of temperature, and stabilizing CRP were defined as prerequisites for conversion. Persistent pain, fever, and rising inflammatory markers dictated that therapy should continue and that surgical exploration could be indicated.
CONCLUSION
Thus in conclusion it can be said that present evidence points towards short term therapy for septic arthritis guided by the patients response to be quite effective in treatment.
USEFUL TIP-
Kocher et al [16,17] predicted that 99.6% of children who were non-weight bearing with a fever (defined as temperature above 38.41C), ESR greater than 40 mm/h, and WCC greater than 12000/cmm would have septic arthritis of the hip as opposed to transient synovitis.
REFERENCES
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