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Infectious Arthritis Clinical Pathway – Emergency Department and Inpatient

Emergency Department and Inpatient Clinical Pathway for the Evaluation/Treatment of Children with Suspected Infectious Arthritis

 
 

Triage

  • Analgesia as indicated
  • Consider X-ray RN Standing Order
 
 
 
 
 
 
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

 
 
 
 
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
 
 
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
Inadequate Treatment Response
48–96 hrs
  • Fever resolution
  • Decreased pain, swelling, increased mobility
  • Persistent fever
  • Continued pain, swelling,
    no change/rising 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

 

 

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