Factors associated with subsequent surgery after septic arthritis of the knee in children.

BACKGROUND: Septic arthritis of the knee in children is a challenging problem. Surgical debridement is an established treatment, but there is a paucity of literature on long-term prognosis. AIM: To determine the rates and factors associated with return to surgery (RTS) and readmission after index surgical debridement for septic arthritis of the knee in children. METHODS: This is a retrospective cohort study that utilizes data from the Healthcare Cost and Utilization Project (HCUP). We included patients between ages 0 to 18 years that underwent surgical debridement for septic arthritis of the knee between 2005 and 2017. Demographic data included age, gender, race, hospital type and insurance type. Clinical data including index admission length of stay (LOS) and Charlson Comorbidity Index (CCI) were available from the HCUP database. Descriptive statistics were used to summarize the data and univariate and multivariate analyses were performed. RESULTS: Nine-hundred thirty-two cases of pediatric septic knee were included. This cohort was 62.3% male, with mean age of 9.0 (± 6.1) years. Approximately 46% of patients were white and approximately half had Medicaid insurance. Thirty-six patients (3.6%) required RTS at a minimum of 2 year after index surgery, and 172 patients (18.5%) were readmitted at any point. The mean readmission LOS was 11.6(± 11.3) d. Higher CCI was associated with RTS (P = 0.041). There were no significant associations in age, gender, race, insurance type, or type of hospital to which patients presented. Multivariate analysis showed that both increased CCI (P = 0.008) and shorter LOS (P = 0.019) were predictive of RTS. CONCLUSION: Septic arthritis of the knee is an important condition in children. The CCI was associated with RTS at a minimum of 2 years after index procedure. No association was found with age, gender, race, insurance type, or hospital type. Shorter LOS and CCI were associated with RTS in multivariate analysis. Overall, risk of subsequent surgery and readmission after pediatric septic knee arthritis is low, and CCI and shorter LOS are predictive of RTS.

Surgical Debridement for Acute and Chronic Osteomyelitis in Children.

Background: Osteomyelitis is an infection of the bone that commonly occurs in pediatric populations. First-line treatment most often involves a course of antibiotics. In recent studies, surgical debridement, in addition to antibiotics, has been shown to provide positive clinical and functional outcomes in children. Debridement is most often indicated in patients with an abscess or in those who do not respond to empiric antibiotic therapy; however, there are limited video resources describing this technique in pediatric patients. Description: The key steps of the procedure, which are demonstrated in the present video article, are (1) preoperative planning, (2) positioning, (3) subperiosteal exposure and debridement, (4) cortical window creation, (5) irrigation, (6) adjunctive treatment, (7) drain placement, (8) wound closure, (9) dressing and immobilization, and (10) wound check and drain removal. Alternatives: Nonoperative treatment is usually indicated for acute osteomyelitis in which patients present with little to no necrotic tissue or abscess formation. In these cases, a course of broad-spectrum antibiotics may be sufficient for a cure. Rationale: This procedure allows for the removal of necrotic bone and soft tissue, thus facilitating the recovery process. It also allows for the retrieval of tissue samples that may be used to guide selection of the appropriate antibiotic therapy. Surgical debridement is a safe and reliable technique that has been associated with positive long-term outcomes. Expected Outcomes: We expect that some patients will require repeat surgical debridement procedures to decrease pathogen burden and prevent future complications. However, we expect that the majority of patients who undergo surgical debridement for uncomplicated osteomyelitis will recover full functionality of the affected limb with no associated long-term sequelae10. Important Tips: Understand preoperative imaging to identify areas of infection, localize critical structures and the physis, and plan surgical approaches.Use extensile approaches and preserve vascularity during the approach.Perform subperiosteal dissection and create a cortical window to debride areas of infection, but avoid excessive periosteal stripping.Close the dead space and wound in a layered manner. Acronyms and Abbreviations: MRI = magnetic resonance imagingK-wire = Kirschner wireMRSA = methicillin-resistant Staphylococcus aureusPDS = polydiaxonone.

The Likelihood of Developing a Carbapenem-Resistant Enterobacteriaceae Infection during a Hospital Stay.

Of 1,455 unique patients in U.S. intensive care units (ICUs), 4% were rectally colonized with CRE on admission. A total of 297 patients were initially negative for carbapenem-resistant Enterobacteriaceae (CRE) and remained in the ICU long enough to contribute additional swabs; 22% of these patients had a subsequent CRE-positive swab, with a median time to CRE colonization of 13 days (interquartile range, 7 to 21 days). Patients colonized with carbapenemase-producing CRE were more likely than those colonized with non-carbapenemase-producing CRE to develop CRE infections during their hospitalizations (36% versus 3%; P < 0.05).