Musculoskeletal Infection Care Process Model

Musculoskeletal Infection Care Process Model Musculoskeletal infections are serious and potentially life-threatening. Musculoskeletal infections include necrotizing fasciitis, septic arthritis, osteomyelitis, and pyomyositis. The prompt recognition and treatment of children with these conditions is important in improving their outcomes. The Initial Work Up The first step in identifying a musculoskeletal infection is having a high index of suspicion. Subtle signs such as fever with a slight limp or joint swelling in the absence of trauma may be the initial presentation for a severe musculoskeletal infection. Signs and symptoms that should alert the clinician to a possible musculoskeletal infection and lead to an initial workup for these conditions include children who present with the following signs or symptoms, with or without fever > 38.3 C (100.9 F): 1. Limb pain 2. Joint effusion 3. Reluctance to bear weight or use an extremity 4. Pain out of proportion to the exam 5. Fixed joint (pseudoparalysis) 6. Point tenderness over the bony metaphysis 7. Hip rests in a position of flexion, abduction, and external rotation 8. Previous health care visit for the same problem In patients where there is a concern based on the signs and symptoms listed above or the clinician suspects a musculoskeletal infection, an initial workup should be performed. The workup for a child with a possible musculoskeletal infection is the following: 1. Thorough history and physical exam 2. Plain radiographs of the affected area 3. CBC with differential 4. Blood culture 5. Inflammatory markers (CRP and ESR) 6. Ultrasound of a suspected septic hip joint Following the initial workup children will fall into one of four categories: 1. High likelihood of a musculoskeletal infection with sepsis 2. High likelihood of musculoskelteal infection without sepsis 3. Possible musculoskeletal infection- Non-septic child with two findings including exam and labs but not definitive 4. Unlikely to be a musculoskeletal infection The probability of a septic hip joint based on a clinical decision rule has been studied in 3 different publications. See Table 1. 1

Factor Fever or History of Fever Nonweight bearing status Previous Health Care Visit C- reactive protein > 2.0 mg/dl S. WBC > 12.0 X10 9 /L ESR > 40 mm/hr Percent Probability Kocher, Zurakowski, & Kasser, 1999 x x x x 4 factors 99.3 % 3 factors 93.1 % 2 factors 40% 1 factor 3% 0 factors >0.2% Luhmann et al., 2004 x x x Caird et al., 2006 x x x x x 3 factors 71% 2 factors DNR* 1 factor DNR 0 factors DNR 5 factors 97.5 % 4 factors 93.1 % 3 factors 82.6 % 2 factors 62.4% 1 factor 36.0% 0 factors 16.9% Based on the above studies a high likelihood of septic hip joint would equate to having >3 factors present in the Kocher study (probability >93%) or > 3 factors from the Caird study (probability > 82%). While the studies have evaluated only septic hip joints, we suggest using these factors in determining the probability of osteomyelitis, pyomyositis, and necrotizing fasciitis. 2

High Likelihood of Musculoskeletal Infection In cases where the diagnosis is very likely based on the ED/General Peds diagnostic acumen and laboratory findings, the primary goal is to coordinate treatment to optimize outcomes. Recommendations are broken down into two groups (a) the child with high likelihood of musculoskeletal infection and sepsis and (b) the child with high likelihood of musculoskeltetal infection, BUT not showing signs and symptoms of sepsis. High Likelihood Of Musculoskeletal Infection And Septic Initiate antibiotics (vancomycin, clindamycin and cefepime) immediately in the toxic appearing child with hemodynamic instability, leukopenia, or thrombocytopenia. Refer to the ED sepsis protocol for specific criteria concerning for sepsis. Additionally, Orthopedics should be consulted immediately as the workup is being performed and completed to help in expediting the care of the child. 1. Initiate workup including history, exam, & labwork (This should have already been done) 2. Initiate antibiotics immediately: a. Vancomycin 15mg/kg/dose every 6 hours (unless needing renal adjustment) b. Clindamycin 10mg/kg/dose every 6 hours c. Cefepime 50mg/kg/dose every 8 hours (unless needing renal adjustment) 3. Consult Orthopedics 4. *Following the Orthopedic resident s evaluation of the patient, the ED/Gen Pediatrics attending should speak with the Orthopedic attending and ID attending to discuss the following: (*Huddle) a. MRI immediately? Yes/No b. Surgery immediately? Yes/No c. Joint aspiration immediately? Yes/No d. Patient placement? General team or PICU 5. If the patient requires immediate surgery, then anesthesia should be notified by Orthopedics so that the MRI and surgery can be potentially coordinated. 6. After the MRI and/or Surgery, the child will be admitted to a General Pediatrics team and Orthopedics and ID will be consulted. 7. ID will see as soon as possible. 8. ID will discuss the patient with Orthopedics and general pediatrics immediately after seeing the patient to help in establishing the plan *Huddle- A discussion will occur among the General Pediatric and/or ED attending and ED fellow/resident (if applicable), Orthopedic resident and attending, and Infectious Diseases Attending/fellow. Everyone will be on the call or meet in person to discuss the case and answer the questions in #5 above. We realize it is not always possible to get everyone on the line in a timely manner and if this is not possible we believe all parties need to at least be aware and discuss the case. 3

High Likelihood Of Musculoskeletal Infection Without Sepsis 1. Initiate workup including history, exam, & labwork 2. Consult Orthopedics** 3. Determine need for MRI or ultrasound or diagnostic/therapeutic joint aspiration a. If an MRI is recommended by Orthopedics or felt necessary by the ED attending, the ED attending will order the test and determine the best timing for this test based on need for sedation, MRI availability, etc. b. If the patient is determined to require immediate surgery, then anesthesia should be notified by Orthopedics so that the MRI and surgery can be potentially coordinated. c. If a joint aspiration is recommended to be done by IR, orthopedics will discuss with the ED or admitting team on who will contact IR for coordination. 4. Initiate antibiotics: Clindamycin 10mg/kg/dose every 6 hours 5. The child will be admitted to a General Pediatrics team and Orthopedics and ID will be consulted. 6. ID will see the patient as soon as possible 7. ID will discuss the patient with Orthopedics and General Pediatrics immediately after seeing the patient to help in establishing the plan **Communication is paramount in the effective management in children with high likelihood of musculoskeletal infection. It is expected and required that the ED team and Orthopedic team will communicate on the best management plan for the child. If concerns exist regarding the decision making at any time by either team, communication should occur between the ED attending and Orthopedic Surgery attending. Infectious Diseases can also be included in this discussion if necessary. A huddle is NOT required for these children. Moderate Likelihood of Musculoskeletal Infection Some children will present with clinical findings and/or laboratory results suggestive of a musculoskeletal infection but also with a reasonable probability that a musculoskeletal infection is NOT present (2 factors from both Kochar and Caird studies). These cases are the hardest diagnostically for the providers and require the most effort in making sure the child is cared for appropriately. Management of moderate likelihood of musculoskeletal infection. 1. Initiate workup including history, exam, & labwork (This should have already been done) 2. Consult the Orthopedics 3. Determine need for MRI or ultrasound or diagnostic/therapeutic joint aspiration 4

a. If an MRI is recommended by Orthopedics or felt necessary by the ED attending, the ED attending will order the test and determine the best timing for this test based on need for sedation, MRI availability, etc. 4. Admit to a General Pediatric Team and consult ID and Orthopedics 5. The initiation of antibiotics will be determined based on the history, exam, lab and imaging findings A huddle with the Orthopedic resident and attending is NOT required. Musculoskeletal Infection- Unlikely Following the initial workup, laboratory results within the acceptable range from the above table and a reassuring exam as noted from the initial criteria (either 0 or one factor from Kocher or Caird) can reassure the clinicians that a musculoskeletal infection is unlikely. In this situation, the providers must assure that follow up will occur within 48 hours by their PCP or a healthcare provider. A huddle with the Orthopedic resident and attending is not required. Adele Hall Direct Admits and Emergency Department Providers will perform the evaluation and work up and institute the management plan as outlined above. South Emergency Department Once the provider has performed the initial workup and it is determined that the patient has a High or Moderate likelihood of a musculoskeletal infection the following should occur: 1. Consult Orthopedic nurse practitioner or PA 2. If available at South at the time of the patient visit obtain MRI if indicated 3. The Orthopedic nurse practitioner or PA will discuss the case and potential imaging findings with the Orthopedic surgery attending. If a surgical intervention is necessary or anticipated the patient will be transferred to the Adele Hall campus. 4. For patients determined to have a musculoskeletal infection that does NOT require a surgical intervention, they can be admitted to South if the following occurs: a. Infectious Diseases is available to do an initial consult (Currently ID is available Mon-Fri at South) b. ED, Orthopedic and ID attendings discuss the case and agree the patient is suitable for South CMH Urgent Care Clinics Once the provider has performed the initial workup and a child has a high or moderate likelihood of musculoskeletal infection, the patient must be transferred to the Adele Hall campus. In cases determined to be unlikely to have a musculoskeletal infection followup must occur within 48 hours by their PCP or a healthcare provider. 5

Direct Admits Any direct admits from outside hospitals, emergency departments or clinics with confirmed or a possible musculoskeletal infection must be admitted to the Adele Hall campus. Admission For patients admitted with a high likelihood or moderate likelihood musculoskeletal infection, ID should be consulted in addition to Orthopedics. Infectious Diseases will see the patient as soon as possible and will discuss the patient and any additional recommendations with Orthopedics and the general team. These discussions are important to help facilitate care and to avoid prolong delays in the care of these patients. Note: In patients with cellulitis or other skin and soft tissue infections that are not considered to be a musculoskeletal infection, ID and Orthopedics do not have to be consulted unless the general team feels this would aid in the care of the patient. 6