Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics.

This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Staphylococcus aureus isolates from children with clinically differentiated osteomyelitis exhibit distinct transcriptomic signatures.

There is substantial genomic heterogeneity among Staphylococcus aureus isolates of children with acute hematogenous osteomyelitis (AHO) but transcriptional behavior of clinically differentiated strains has not been previously described. This study evaluates transcriptional activity of S. aureus isolates of children with AHO that may regulate metabolism, biosynthesis, or virulence during bacterial growth and pathogenesis. In vitro growth kinetics were compared between three S. aureus clinical isolates from children with AHO who had mild, moderate, and severe illness. Total RNA sequencing was performed for each isolate at six separate time points throughout the logarithmic phase of growth. The NASA RNA-Sequencing Consensus Pipeline was used to identify differentially expressed genes allowing for 54 comparisons between the three isolates during growth. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment pathways were used to evaluate transcriptional variation in metabolism, biosynthesis pathways and virulence potential of the isolates. The S. aureus isolates demonstrated differing growth kinetics under standardized conditions with the mild isolate having higher optical densities with earlier and higher peak rates of growth than that of the other isolates (p<0.001). Enrichment pathway analysis established distinct transcriptional signatures according to both sampling time and clinical severity. Moderate and severe isolates demonstrated pathways of bacterial invasion, S. aureus infection, quorum sensing and two component systems. In comparison, the mild strain favored biosynthesis and metabolism. These findings suggest that transcriptional regulation during the growth of S. aureus may impact the pathogenetic mechanisms involved in the progression of severity of illness in childhood osteomyelitis. The clinical isolates studied demonstrated a tradeoff between growth and virulence. Further investigation is needed to evaluate these transcriptional pathways in an animal model or during active clinical infections of children with AHO.

What's New in Pediatric Septic Arthritis? A Review of Pertinent Clinical Questions.

BACKGROUND: The evaluation and treatment of children with septic arthritis (SA) is challenging and requires an organized approach to address the spectrum of pathogens which appear to aggregate in age-specific groups. Although evidence-based guidelines have recently been published for the evaluation and treatment of children with acute hematogenous osteomyelitis, there is a relative dearth of literature devoted exclusively to SA. METHODS: Recently published guidance for the evaluation and treatment of children with SA was reviewed and evaluated with respect to pertinent clinical questions to summarize what is new in this area of practice for pediatric orthopaedic surgeons. RESULTS: Evidence suggests that there is a profound difference between children with primary SA and those who have contiguous osteomyelitis. This disruption of the commonly accepted paradigm of a continuum of osteoarticular infections has important implications in the evaluation and treatment of children with primary SA. Clinical prediction algorithms have been established to help determine the applicability of magnetic resonance imaging during the evaluation of children suspected to have SA. Antibiotic duration for SA has been recently studied with some evidence in favor of short-course parenteral followed by short-course oral therapy may be successful if the pathogen is not methicillin-resistant Staphylococcus aureus . CONCLUSION: Recent studies of children with SA have provided better guidance for evaluation and treatment to improve diagnostic accuracy, processes of evaluation, and clinical outcomes. LEVEL OF EVIDENCE: Level 4.

Comparison of Procalcitonin With Commonly Used Biomarkers and Algorithms for Evaluating Suspected Pediatric Musculoskeletal Infection in the Emergency Department.

INTRODUCTION: It is difficult to distinguish between children with infectious versus noninfectious conditions of the musculoskeletal system during initial evaluation. Clinical predictive algorithms potentially support this effort but not without limitations. Procalcitonin (PCT) has been proposed as a biomarker to help differentiate infection from noninfection. This study evaluates the adoption and utility of PCT during initial infection evaluations and assesses test characteristics of commonly used parameters and algorithms. METHODS: PCT was introduced for initial laboratory evaluation of the suspected musculoskeletal infection. Prospective enrollment occurred from July 2020 to November 2021 with 3 cohorts established after a retrospective review of final diagnoses at the end of treatment: 1) deep infection, 2) superficial infection, and 3) noninfection. Univariate and multivariate logistic regression analysis of parameters and diagnoses was performed. Test characteristics of individual and aggregated parameters were assessed. RESULTS: Among 258 children evaluated, 188 (72.9%) had PCT drawn during the evaluation. An increase of PCT acquisition from 67.8% to 82.4% occurred over the study timeframe. Eighty-five children were prospectively studied, including those with deep infection (n=21); superficial infection (n=10), and noninfection (n=54). Test characteristics of parameters showed accuracy ranging from 48.2% to 85.9%. PCT >0.1 ng/mL independently predicted deep infection in 84.7% of cases, outperforming white blood cell, C-reactive protein (CRP), and absolute neutrophil count. Using study thresholds for CRP, erythrocyte sedimentation rate, PCT, and Temp improved accuracy to 89.4%. CONCLUSIONS: PCT is a potentially useful biomarker during the initial assessment of children suspected to have a musculoskeletal infection. Systematic evaluation using a combination of parameters improves the accuracy of assessment and assists predictive judgment under uncertainty. PCT <0.1 ng/mL, erythrocyte sedimentation rate <18 mm/hr, CRP <3.3 mg/dL, and temperature <37.8°C should reasonably reassure clinicians that deep musculoskeletal infection is less likely, given the high negative predictive value and collective accuracy of these parameters. LEVEL OF EVIDENCE: Level III - Retrospective cohort comparison.

Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries.

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.

Assessment of TB underreporting by level of reporting system in Lagos, Nigeria.

BACKGROUND: Nigeria has an estimated TB prevalence of 219 per 100,000 population. In 2019, Nigeria diagnosed and notified 27% of the WHO-estimated cases of all forms of TB and contributed 11% of the missing TB cases globally. OBJECTIVE: To assess TB underreporting by type and level of health facility (HF), and associated factors in Lagos State, Nigeria. METHODOLOGY: Quantitative secondary data analysis of TB cases was conducted in 2015. χ2 test was used to assess the association between treatment initiation, TB underreporting, local government area (LGA) and HF characteristics. RESULTS: Overall, 2,064 persons with bacteriologically confirmed TB (15.5%) were not matched to patients in sampled TB registers. Treatment status was unknown for 86 cases (IQR 55-97) per LGA. LGAs with higher case-loads had higher proportions of cases with unknown TB status. Discrepant reporting of treated TB was also common (60% HFs). Primary-level TB treatment facilities and unengaged private facilities were less likely to notify. CONCLUSION: There was TB under-reporting across all types and levels of HFs and LGAs. There is a need to revise or strengthen the process of supervision and data quality assurance system at all levels.

CONTEXTE: Le Nigeria a une prévalence de la TB estimée à 219 pour 100 000 habitants. En 2019, le Nigéria a diagnostiqué et notifié 27% des cas estimés par l'OMS de toutes les formes de TB et a contribué à 11% des cas de TB manquants dans le monde. OBJECTIF: Évaluer la sous-déclaration de la TB par type et niveau d'établissement de santé (HF), et les facteurs associés dans l'État de Lagos, au Nigeria. MÉTHODES: Une analyse quantitative des données secondaires des cas de TB a été réalisée en 2015. Le test χ2 a été utilisé pour évaluer l'association entre l'initiation du traitement, la sous-déclaration de la TB, la zone de gouvernement local (LGA) et les caractéristiques des HF. RÉSULTATS: Dans l'ensemble, 2 064 personnes ayant une TB confirmée par épreuve bactériologique (15,5%) n'ont pas été appariées à des patients dans les registres de TB échantillonnés. Le statut de traitement était inconnu pour 86 cas (IQR 55­97) par LGA. Les LGA ayant un plus grand nombre de cas avaient une plus grande proportion de cas dont le statut de traitement était inconnu. La déclaration discrète de la TB traitée était également fréquente (60% des HF). Les établissements de traitement de la TB de premier niveau et les établissements privés non engagés étaient moins susceptibles de faire des déclarations. CONCLUSION: Il y avait une sous-déclaration de la TB dans tous les types et niveaux d'HF et de LGA. Il est nécessaire de réviser ou de renforcer le processus de supervision et le système d'assurance qualité des données à tous les niveaux.

Early Transition to Oral Antimicrobial Therapy Among Children With Staphylococcus aureus Bacteremia and Acute Hematogenous Osteomyelitis.

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is a frequent complication of acute hematogenous osteomyelitis (AHO) in children, but data on the optimal duration of parenteral antibiotics prior to transition to oral antibiotics remains sparse. We examined clinical outcomes associated with early transition to oral antimicrobial therapy among children admitted to our institution with AHO and SAB, and evaluated the utility of a severity of illness score (SIS) to guide treatment decisions in this setting. METHODS: Children with AHO and SAB admitted to our institution between January 1, 2009, and December 31, 2018, were retrospectively reviewed and stratified according to a previously validated SIS into mild (0-3), moderate (4-7) and severe (8-10) cohorts. Groups were assessed for differences in treatment (eg, parenteral and oral antibiotic durations, surgeries) and clinical response (eg, bacteremia duration, acute kidney injury, length of stay and treatment failure). RESULTS: Among 246 children identified with AHO and SAB, median parenteral antibiotic duration differed significantly between mild (n = 80), moderate (n = 98) and severe (n = 68) cohorts (3.6 vs. 6.5 vs. 14.3 days; P ≤ 0.001). SIS cohorts also differed with regard to number of surgeries (0.4 vs. 1.0 vs. 2.1; P ≤ 0.001), duration of bacteremia (1.0 vs. 2.0 vs. 4.0 days; P ≤ 0.001), acute kidney injury (0.0% vs. 3.0% vs. 20.5%; P ≤ 0.001), hospital length of stay (4.8 vs. 7.4 vs. 16.4 days; P ≤ 0.001) and total duration of antibiotics (34.5 vs. 44.7 vs. 60.7 days; P ≤ 0.001). Early transition to oral antimicrobial therapy among mild or moderate SIS cohorts was not associated with treatment failure despite SAB. CONCLUSIONS: SAB is associated with a wide range of illness among children with AHO, and classification of severity may be useful for guiding treatment decisions. Early transition to oral antimicrobial therapy appears safe in children with mild or moderate AHO despite the presence of SAB.

Demographics and outcomes of laboratory-confirmed COVID-19 cases during the first epidemic wave in Senegal.

BACKGROUND: Few studies have focused on the effects of COVID-19 on African populations. During the first epidemic wave in Senegal (May 1 to July 31, 2020), COVID-19 cases were isolated in treatment centers of epidemics (TCEs). We described the demographics and outcomes of COVID-19 cases in TCEs. PATIENTS AND METHODS: All cases with laboratory-confirmed COVID-19 in Thiès medical region of Senegal were included. RESULTS: COVID-19 was confirmed in 600 cases. Median age of cases (men: 357, 59.5%; women: 243, 40.5%) was 34.0years. The incidence was 12 per 100,000 inhabitants per month. Overall, 46 (7.7%) cases had a severe or critical form of the disease, and nine of them died. Of 455 cases quarantined in non-hospital TCEs, 340 (74.7%) had no symptom and 115 (25.3%) had mild or moderate symptoms. CONCLUSION: In this African retrospective cohort, COVID-19 cases were young and mostly asymptomatic with a low case fatality rate.

Primary Septic Arthritis in Children Demonstrates Presumed and Confirmed Varieties Which Require Age-specific Evaluation and Treatment Strategies.

BACKGROUND: There is uncertainty involved in the evaluation and treatment of children suspected to have septic arthritis particularly when no causative pathogen is confirmed. This study evaluates children with primary septic arthritis to refine the processes of evaluation and treatment and improve the rate of pathogen confirmation. METHODS: Children suspected to have septic arthritis from 2009 to 2019 were retrospectively studied. Diagnosis of primary septic arthritis, defined as hematogenous joint infection without associated osteomyelitis, was established by clinical evaluation, radiology and laboratory results, including joint fluid analysis. Excluded cases were categorized by etiology. Children with primary septic arthritis were divided into confirmed and presumed cohorts for statistical comparison. RESULTS: A total of 355 children (average age 4.4 y, range 0.05 to 18 y) were initially treated as septic arthritis. Eighty-seven (24.5%) were excluded due to other conditions, including 34 (9.6%) with noninfectious conditions. Among 268 children with primary septic arthritis, 134 were confirmed and 134 were presumed. A higher rate of 16S polymerase chain reaction (PCR) acquisition (71.6% vs. 45.5%) occurred in the confirmed cohort. Overall yield for various methods of pathogen identification were 27 of 239 (11.3%) by blood culture, 83 of 268 (31.0%) by joint fluid culture and 85 of 157 (54.1%) by PCR. PCR identified a pathogen in 87.5% of children with confirmed septic arthritis. Antibiotic pretreatment was associated with a lower rate of joint fluid culture positivity. Pathogens aggregated within specific age groups. The 4 to 9-year-old age group displayed the widest spectrum of pathogens with limited predictability. CONCLUSIONS: This study emphasizes the need for systematic processes of evaluation and treatment for children suspected to have primary septic arthritis, including minimization of antibiotic pretreatment, age-based empiric antibiotic selection, and sufficient follow-up to ensure noninfectious conditions are distinguished in culture-negative cases. Extended observation, before intervention, may be appropriate for some children. LEVEL OF EVIDENCE: Level III-retrospective control study.

Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics.

This clinical practice guideline for the diagnosis and treatment of acute hematogenous osteomyelitis (AHO) in children was developed by a multidisciplinary panel representing Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with AHO, including specialists in pediatric infectious diseases, orthopedics, emergency care physicians, hospitalists, and any clinicians and healthcare providers caring for these patients. The panel's recommendations for the diagnosis and treatment of AHO are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of AHO in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Children with Primary Septic Arthritis Have a Markedly Lower Risk of Adverse Outcomes Than Those with Contiguous Osteomyelitis.

BACKGROUND: It is widely believed that septic arthritis poses a risk of joint destruction and long-term adverse outcomes for children if not treated emergently. In the present study, children who had primary confirmed septic arthritis were compared with those who had septic arthritis and adjacent osteomyelitis to evaluate differences that affect the relative risk of adverse outcomes. METHODS: Children who underwent multidisciplinary treatment for septic arthritis with or without contiguous osteomyelitis between 2009 and 2019 were retrospectively studied. Clinical, laboratory, treatment, and outcome data were compared between cohorts of children with primary confirmed septic arthritis and children with septic arthritis and contiguous osteomyelitis. RESULTS: One hundred and thirty-four children had primary confirmed septic arthritis, and 105 children had septic arthritis with contiguous osteomyelitis. Children with osteomyelitis were older (median, 7.4 versus 2.4 years), had higher initial C-reactive protein (median, 15.7 versus 6.4 mg/dL), and had a higher rate of thrombocytopenia (21.0% versus 1.5%). They also had a higher rate of bacteremia (69.5% versus 20.2%) for a longer duration (median, 2.0 versus 1.0 days). Detected pathogens in children with osteomyelitis as compared with those with primary septic arthritis were more likely to be Staphylococcus aureus (77.1% versus 32.1%) and less likely to be Kingella kingae (2.9% versus 32.1%). Children with contiguous osteomyelitis had longer hospitalizations (median, 8.0 versus 4.0 days), a higher rate of intensive care (21.0% versus 1.5%), a higher readmission rate (17.1% versus 5.2%), and a higher complication rate (38.1% versus 0.7%). CONCLUSIONS: Primary septic arthritis in children is dissimilar to septic arthritis associated with osteomyelitis. The present study demonstrates that long-term adverse outcomes in children with septic arthritis are likely due to the contiguous osteomyelitis. Children with primary septic arthritis are sufficiently distinguishable from those who have contiguous osteomyelitis to guide decisions for magnetic resonance imaging acquisition, duration of antibiotic therapy, and length of outpatient follow-up in order to recognize and address adverse outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) through non-specialist providers and telemedicine: a study protocol for a non-inferiority randomized controlled trial.

BACKGROUND: Depression and anxiety impact up to 1 in 5 pregnant and postpartum women worldwide. Yet, as few as 20% of these women are treated with frontline interventions such as evidence-based psychological treatments. Major barriers to uptake are the limited number of specialized mental health treatment providers in most settings, and problems with accessing in-person care, such as childcare or transportation. Task sharing of treatment to non-specialist providers with delivery on telemedicine platforms could address such barriers. However, the equivalence of these strategies to specialist and in-person models remains unproven. METHODS: This study protocol outlines the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) randomized trial. SUMMIT is a pragmatic, non-inferiority test of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a brief, behavioral activation (BA) treatment for perinatal depressive and anxiety symptoms. Specialists (psychologists, psychiatrists, and social workers with ≥ 5 years of therapy experience) and non-specialists (nurses and midwives with no formal training in mental health care) were trained in the BA protocol, with the latter supervised by a BA expert during treatment delivery. Consenting pregnant and postpartum women with Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10 (N = 1368) will be randomized to one of four arms (telemedicine specialist, telemedicine non-specialist, in-person specialist, in-person non-specialist), stratified by pregnancy status (antenatal/postnatal) and study site. The primary outcome is participant-reported depressive symptoms (EPDS) at 3 months post-randomization. Secondary outcomes are maternal symptoms of anxiety and trauma symptoms, perceived social support, activation levels and quality of life at 3-, 6-, and 12-month post-randomization, and depressive symptoms at 6- and 12-month post-randomization. Primary analyses are per-protocol and intent-to-treat. The study has successfully continued despite the COVID-19 pandemic, with needed adaptations, including temporary suspension of the in-person arms and ongoing randomization to telemedicine arms. DISCUSSION: The SUMMIT trial is expected to generate evidence on the non-inferiority of BA delivered by a non-specialist provider compared to specialist and telemedicine compared to in-person. If confirmed, results could pave the way to a dramatic increase in access to treatment for perinatal depression and anxiety. TRIAL REGISTRATION: ClinicalTrials.gov NCT04153864 . Registered on November 6, 2019.

Modelling and predicting the spatio-temporal spread of COVID-19, associated deaths and impact of key risk factors in England.

COVID-19 caseloads in England have passed through a first peak, and at the time of this analysis appeared to be gradually increasing, potentially signalling the emergence of a second wave. To ensure continued response to the epidemic is most effective, it is imperative to better understand both retrospectively and prospectively the geographical evolution of COVID-19 caseloads and deaths at small-area resolution, identify localised areas in space-time at significantly higher risk, quantify the impact of changes in localised population mobility (or movement) on caseloads, identify localised risk factors for increased mortality and project the likely course of the epidemic at high spatial resolution in coming weeks. We applied a Bayesian hierarchical space-time SEIR model to assess the spatiotemporal variability of COVID-19 caseloads (transmission) and deaths at small-area scale in England [Middle Layer Super Output Area (MSOA), 6791 units] and by week (using observed data from week 5 to 34 of 2020), including key determinants, the modelled transmission dynamics and spatial-temporal random effects. We also estimate the number of cases and deaths at small-area resolution with uncertainty projected forward in time by MSOA (up to week 51 of 2020), the impact mobility reductions (and subsequent easing) have had on COVID-19 caseloads and quantify the impact of key socio-demographic risk factors on COVID-19 related mortality risk by MSOA. Reductions in population mobility during the course of the first lockdown had a significant impact on the reduction of COVID-19 caseloads across England, however local authorities have had a varied rate of reduction in population movement which our model suggest has substantially impacted the geographic heterogeneity in caseloads at small-area scale. The steady gain in population mobility, observed from late April, appears to have contributed to a slowdown in caseload reductions towards late June and subsequent start of the second wave. MSOA with higher proportions of elderly (70+ years of age) and elderly living in deprivation, both with very distinct geographic distributions, have a significantly elevated COVID-19 mortality rates. While non-pharmaceutical interventions (that is, reductions in population mobility and social distancing) had a profound impact on the trajectory of the first wave of the COVID-19 outbreak in England, increased population mobility appears to have significantly contributed to the second wave. A number of contiguous small-areas appear to be at a significant elevated risk of high COVID-19 transmission, many of which are also at increased risk for higher mortality rates. A geographically staggered re-introduction of intensified social distancing measures is advised and limited cross MSOA movement if the magnitude and geographic extent of the second wave is to be reduced.

Primary Septic Arthritis Among Children 6 to 48 Months of Age: Implications for PCR Acquisition and Empiric Antimicrobial Selection.

INTRODUCTION: Primary septic arthritis requires unique evaluation and treatment considerations for children in the 6- to 48-month age range because of the spectrum of identified pathogens and high rate of negative cultures. The purpose of this study is to evaluate primary septic arthritis in this age group in order to differentiate children with infection caused by Kingella kingae from those with other confirmed pathogens and those with no identified pathogen. METHODS: Preschool children who underwent multidisciplinary evaluation and treatment for septic arthritis between 2009 and 2019 were retrospectively studied. Three cohorts were established for comparison of clinical and laboratory features of primary septic arthritis: (1) confirmed K. kingae, (2) confirmed other pathogen, and (3) presumed (without identified pathogen). RESULTS: Among 139 children with septic arthritis, 40 (29%) were confirmed K. kingae, 29 (21%) other pathogen, and 70 (50%) presumed. Children with Kingella and those with presumed septic arthritis had significantly lower initial C-reactive protein (4.8 and 4.5 vs. 9.3 mg/dL) and fewer febrile hospital days (0.2 and 0.4 vs. 1.3 d) than children with other confirmed pathogens. Children with other pathogens had higher rates of bacteremia (38% vs. 0%) and positive joint fluid cultures (86% vs. 15%) than that of children with Kingella. The rate of polymerase chain reaction (PCR) acquisition was 38 of 40 (95.0%) Kingella cases, 18 of 29 (62.1%) other pathogen cases, and 33 of 70 (47.1%) presumed cases. CONCLUSIONS: K. kingae was the most commonly identified pathogen among 6-month to 4-year-old children. The Kingella and other identified pathogens in this study serve to guide empiric antimicrobial recommendations for this age range. Because of similarities between children with septic arthritis because of K. kingae and those with no identified pathogen, it is likely that an unrecognized burden of Kingella resides in culture negative cases, particularly if no PCR is sent. Systematic evaluation, including PCR acquisition, and a high index of suspicion for K. kingae are recommended to thoroughly evaluate septic arthritis in preschool children. LEVEL OF EVIDENCE: Level III-Retrospective cohort comparison.

Pediatric Type II Supracondylar Humerus Fractures: Factors Associated With Successful Closed Reduction and Immobilization.

PURPOSE: The debate on the treatment of type IIa supracondylar humerus fractures has yet to be resolved. The purpose of this study was to assess the factors associated with successful closed reduction and immobilization and to assess the efficacy of a novel radiographic "hourglass" angle measurement in the management of type IIa supracondylar humerus fractures within the pediatric population. METHODS: An institutional review board-approved retrospective review of all children who underwent closed reduction and casting or splinting of an isolated type IIa supracondylar humerus fractures treated at 2 pediatric hospitals from January 1, 2009 to August 31, 2016. Analyzed radiographic parameters included Baumann angle (BA), humerocondylar angle (HCA), perpendicular distance (PD) from the anterior humeral line to the capitellum, and the hourglass angle (HGA). These parameters were measured on injury radiographs (XR), postreduction XR, and at the first and final follow-up XR. The success of closed reduction was defined as maintenance of an acceptable reduction without a secondary procedure. The interobserver reliability was calculated. RESULTS: There were 77 elbows treated with closed reduction and long-arm cast or splint immobilization. Of those closed reductions, 76.62% of elbows (59/77) maintained their reduction alignment and did not require surgical treatment for percutaneous pinning. In this series, the BA was not significantly different following closed reduction ([INCREMENT]1.04 degrees; P=0.081); however, the PD ([INCREMENT]1.89 mm), HGA ([INCREMENT]7.38 degrees), and HCA ([INCREMENT]5.07 degrees) had significant improvement following closed reduction (P<0.001 for all). The use of procedural sedation during reduction was strongly associated with success, 83.05% (49/59) with sedation compared with 55.56% (10/18) success without sedation (P=0.025). Furthermore, fractures that underwent a secondary procedure had 6.20 degrees less HGA following a closed reduction (P=0.016) and required additional follow-up visits (P=0.0037). The success of type IIa supracondylar humerus fractures did not significantly differ based on sex (P=0.5684), laterality (P=0.6975), mechanism of injury (P>0.9999), location of care-emergency department versus clinic (P=0.1160), or type of fracture immobilization (P=0.7411). The mean HGA in normal elbows was 177.8 degrees. The interobserver reliability for HCA was poor [intraclass correlation coefficient (ICC)=0.342]; fair for BA (ICC=0.458); and excellent for both PD and HGA (ICC=0.769 and 0.805, respectively) (P<0.001 for all). CONCLUSIONS: Improved and acceptable radiographic parameters were achieved by a closed reduction in the majority of minimally displaced type IIa fractures treated by closed reduction and immobilization in this series. HCA upon presentation was significantly greater in successful cases, and failure to improve and maintain HGA and PD following closed reduction was associated with loss of reduction. Procedural sedation during reduction was strongly associated with success. The HGA and PD were consistent parameters used to determine effective management of type IIa fractures. This study adds support for a nonoperative closed reduction under sedation with immobilization of selected type IIa supracondylar humerus fractures.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States.

OBJECTIVE: Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. STUDY DESIGN: Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. RESULTS: 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. CONCLUSION: At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Team Approach: Pediatric Musculoskeletal Infection.

A team approach is optimal in the evaluation and treatment of musculoskeletal infection in pediatric patients given the complexity and uncertainty with which such infections manifest and progress, particularly among severely ill children. The team approach includes emergency medicine, pediatric intensive care, pediatric hospitalist medicine, infectious disease service, orthopaedic surgery, radiology, anesthesiology, pharmacology, and hematology. These services follow evidence-based clinical practice guidelines with integrated processes of care so that children and their families may benefit from data-driven continuous process improvement. Important principles based on our experience in the successful treatment of pediatric musculoskeletal infection include relevant information gathering, pattern recognition, determination of the severity of illness, institutional workflow management, closed-loop communication, patient and family-centered care, ongoing dialogue among key stakeholders within and outside the context of direct patient care, and periodic data review for programmatic improvement over time. Such principles may be useful in almost any setting, including rural communities and developing countries, with the understanding that the team composition, institutional capabilities or limitations, and specific approaches to treatment may differ substantially from one setting or team to another.

Quality Improvement of Magnetic Resonance Imaging for Musculoskeletal Infection in Children Results in Decreased Scan Duration and Decreased Contrast Use.

BACKGROUND: Magnetic resonance imaging (MRI) is a heavily utilized resource to evaluate children suspected to have a musculoskeletal infection. Complex interdisciplinary workflows are involved with decision-making with regard to indications, anesthesia, contrast use, and procedural timing relative to the scan. This study assesses the impact of a quality improvement endeavor on MRI workflows at a tertiary pediatric medical center. METHODS: A registry of consecutively enrolled children for a multidisciplinary musculoskeletal infection program identified those evaluated with MRI from 2012 to 2018. Annual MRI process improvement feedback was provided to the key stakeholders. Demographic characteristics, laboratory parameters, MRI indications, anesthesia use, MRI findings, final diagnoses, scan duration, imaging protocol, surgical intervention following MRI, and length of stay were retrospectively compared between the 3 cohorts (initial, middle, and final) representing 2-year increments to assess the impact of the initiative. RESULTS: There were 526 original MRI scans performed to evaluate 1,845 children with suspected musculoskeletal infection. Anesthesia was used in 401 children (76.2%). When comparing the initial, middle, and final study period cohorts, significant improvement was demonstrated for the number of sequences per scan (7.5 sequences for the initial cohort, 5.8 sequences for the middle cohort, and 4.6 sequences for the final cohort; p < 0.00001), scan duration (73.6 minutes for the initial cohort, 52.1 minutes for the middle cohort, and 34.9 minutes for the final cohort; p < 0.00001), anesthesia duration (94.1 minutes for the initial cohort, 68.9 minutes for the middle cohort, and 53.2 minutes for the final cohort; p < 0.00001), and the rate of contrast use (87.6% for the initial cohort, 67.7% for the middle cohort, and 26.3% for the final cohort; p < 0.00001). There was also a trend toward a higher rate of procedures under continued anesthesia immediately following the MRI (70.2% in the initial cohort, 77.8% in the middle cohort, and 84.6% in the final cohort). During the final 6-month period, the mean scan duration was 24.4 minutes, anesthesia duration was 40.9 minutes, and the rate of contrast administration was 8.5%. CONCLUSIONS: Progressive quality improvement through collaborative interdisciplinary communication and workflow redesign led to improved utilization of MRI and minimized contrast use for suspected musculoskeletal infection. There was a high rate of procedural intervention under continued anesthesia for children with confirmed musculoskeletal infection. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Electronic Medical Record Use and Satisfaction Among Pediatric Orthopaedic Surgeons.

INTRODUCTION: Electronic medical record (EMR) use among pediatric orthopaedic surgeons has evolved substantially within the past decade. In response to the Patient Protection and Affordable Care Act, large hospitals and tertiary pediatric medical centers rapidly acquired and implemented EMRs with uncertainty as to the potential impact on patient care and operational efficiency of subspecialists. This study reviews the background and regulatory framework for Meaningful Use of EMR and assesses the current landscape of EMR utilization by pediatric orthopaedic surgeons. METHODS: In 2015, the Practice Management Committee distributed a survey regarding EMR use and satisfaction to members of the Pediatric Orthopaedic Society of North America. Survey responses from 324 members were used to analyze levels of satisfaction by EMR platform and practice type and to consider drivers of satisfaction or dissatisfaction of end users. RESULTS: Although there were no differences in overall satisfaction based on vendor or practice type, significant differences were noted for 5 specific parameters of satisfaction, including: usefulness of templates, efficiency of practice workflow, information services support, number of logon events, and speed of the system. A user/vendor map is provided to facilitate networking among providers and groups utilizing common EMR platforms to help bring about rational improvements in EMR functionality for the future. CONCLUSIONS: Substantial effort needs to be made to improve subspecialty-specific EMR documentation, order entry, research tools, and clinical workflows to enhance the processes of care for children with orthopaedic conditions in the era of EMR. LEVEL OF EVIDENCE: Level IV.