Emergency Department and Inpatient Clinical Pathway for the Evaluation/Treatment of Children with Suspected Infectious Arthritis
- Analgesia as indicated
- Consider X-ray RN Standing Order
- Concern for Sepsis
- Huddle, Sepsis Pathway
| Pediatric Kocher Criteria for Hip Acute Bacterial Arthritis (ABA) | |
|---|---|
| Non weight-bearing | |
| Temp | > 38.5°C |
| WBC | > 12 k/uL |
| CRP | > 2 mg/dL |
| ESR | > 40 mm/hr |
Evaluation
- Assess response to analgesia
- Laboratory Studies as indicated
- CBC, CRP, ESR, Blood Culture
- Imaging: XR, Joint Ultrasound as indicated
- Review Kocher Criteria
Low Concern for Acute Bacterial Arthritis (ABA)
Concern for Acute Bacterial Arthritis (ABA)
- Afebrile or low-grade fever
- Mild pain, improved after analgesia
- +/- Effusion
- Labs reassuring, if obtained
- Fever
- Moderate/severe pain
- Unable to bear weight or move joint
- Effusion
- Elevated inflammatory markers
Review physical exam, labs, imaging, synovial fluid interpretation
Transient Synovitis
Presumptive Lyme Arthritis
Not Consistent with ABA
Equivocal
Consistent with ABA
- Analgesia
- Follow-up with PCP if pain not improving 24–48 hrs
- Lyme IgG/IgM with Reflex ELISA
- Consider empiric antibiotics
- NSAIDs
- Follow-up with PCP and ID Clinic
- Review differential diagnosis
- Consider need for admission, treatment
- Consult Ortho
- Arthrotomy in OR as indicated
- Antibiotic Recommendations
Inpatient Care
- Antibiotic Recommendations
- Follow cultures, sensitivities
- Tailor antibiotics as indicated
- Consult ID
- Consult Ortho, Arthrotomy in OR as indicated
- Monitor fever curve and pain
- Trend CRP every 2–3 days, ESR not necessary
Adequate Treatment Response
48–96 hrs
48–96 hrs
Inadequate Treatment Response
48–96 hrs
48–96 hrs
- Fever resolution
- Decreased pain, swelling, increased mobility
- Persistent fever
- Continued pain, swelling,
no change/rising CRP
- Transition to PO antibiotics
- Consider repeat CRP
- Team review with Ortho, ID to consider:
- Need for additional procedure for source control
- Consider MRI to evaluate for adjacent osteomyelitis, abscess, pyomyositis
Discharge
- Antibiotic Recommendations
- Follow-up with Ortho in 1–2 wks
- Follow-up with PCP and ID Clinic 2–3 wks
- No sports/running until cleared by Ortho
Evidence
- PIDS/IDSA 2023 Guidelines for Diagnosing and Managing Acute Bacterial Arthritis in Pediatrics
- Factors Distinguishing Septic Arthritis from Transient Synovitis of the Hip in Children
- Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease
- The Kocher–Caird Criteria for Pediatric Septic Arthritis of the Hip: Time for a Change in the Kingella Era?
- Novel Uses of Traditional Algorithms for Septic Arthritis
CHOP Program