Clin Infect Dis. 2009 Peltola 1201 121

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Simplified Treatment of Septic Arthritis • CID 2009:48 (1 May) • 1201

M A J O R A R T I C L E

Prospective, Randomized Trial of 10 Days versus 30Days of Antimicrobial Treatment, Including a Short-Term Course of Parenteral Therapy, for ChildhoodSeptic Arthritis

Heikki Peltola,1 Markus Paakkonen,2 Pentti Kallio,1 and Markku J. T. Kallio,1 for the Osteomyelitis–Septic Arthritis(OM-SA) Study Groupa

1Helsinki University Central Hospital, Hospital for Children and Adolescents, Helsinki, and 2Kuusankoski Regional Hospital, Kuusankoski, Finland

(See the editorial commentary by Bradley, on pages 1211–2)

Background. The standard treatment for septic arthritis in children is antimicrobials for several weeks (initially administered intravenously) and arthrotomy (at least for the hip and shoulder joints). No sufficiently poweredstudy has examined the true need for these treatments.

Methods. In a randomized, multicenter prospective trial in Finland, children aged 3 months to 15 years whohad culture-positive septic arthritis were randomized to receive clindamycin or a first-generation cephalosporinfor 10 days or 30 days (intravenously for the first 2–4 days). The number of surgical procedures was kept to aminimum. Illness was monitored with preset criteria. Antimicrobial therapy was discontinued when the clinicalresponse was good and the C-reactive protein level decreased to р20 mg/L. The primary end point was fullrecovery without need for further administration of antimicrobial therapy because of an osteoarticular indicationduring the 12 months after therapy.

Results. Of the total 130 cases, 88% were caused by Staphylococcus aureus, Haemophilus influenzae, or Strep-tococcus pyogenes; 63 patients were in the short-term treatment group, and 67 were in the long-term treatmentgroup. The median durations of antimicrobial treatment were 10 days and 30 days, respectively. Surgical proceduresthat were more extensive than percutaneous joint aspiration were performed for 12% of patients, with no pre-

ponderance to hip or shoulder arthritis. Two late-onset infections occurred in 1 child in the long-term treatmentgroup; however, all patients recovered without sequelae.Conclusions. Large doses of well-absorbed antimicrobials for !2 weeks (initially administered intravenously)

and only 1 joint aspiration are sufficient for treatment of most cases of childhood septic arthritis, regardless of the infecting pathogen or anatomical site, if the clinical response is good and the C-reactive protein level normalizesshortly after initiation of treatment.

No consensus prevails on the duration of antimicrobial

therapy for childhood septic arthritis (SA). The lack of

sufficiently powered studies [1–5] is surprising, because

the duration of treatment is equally as important as the

choice of agent [6]. Recommendations, based on per-

Received 19 October 2008; accepted 12 December 2008; electronically published

26 March 2009.a Members of the study group are listed at the end of the text.

Reprints or correspondence: Dr. Heikki Peltola, HUCH Hospital for Children and

Adolescents, P.O. Box 281, 11 Stenback St., 00029 HUS, Helsinki, Finland

([email protected]).

Clinical Infectious Diseases 2009;48:1201–10

ᮊ 2009 by the Infectious Diseases Society of America. All rights reserved.

1058-4838/2009/4809-0007$15.00

DOI: 10.1086/597582

sonal experience and retrospective case analyses, reit-

erate that after an intravenous treatment phase of ∼1

week [6–8], oral treatment may be possible [1–4, 9] if

serum bactericidal activity is assayed [10] and treatment

compliance is guaranteed. The total treatment course

should last weeks, depending on patient age, causative

agent, and localization of the infection [5, 11, 12]. Therole of surgery is underlined by many clinicians, es-

pecially if the shoulder or hip joint is involved.

Data showing that many severe infections can be

treated safely with short-term, mostly oral regimens

[13, 14] are proof against long-term hospital stays and

bacterial resistance and provide a way to reduce the

overall cost of treatment. By conducting a large com-

parative trial in Finland, we sought to determine



1202 • CID 2009:48 (1 May) • Peltola et al.

whether the treatment of SA could be simplified by shortening

the duration of treatment and maintaining strict criteria for

surgical procedures. Because SA in Scandinavia is rare (inci-

dence among persons aged 0–14 years, !5 cases per 100,000

persons per year [15, 16]), long-term enrollment was expected.

However, we believe that the goal was reached; most cases of

childhood SA responded to relatively uncomplicated treatment.

METHODS

Study design. This randomized, multicenter, open-label, par-

allel-group, noninferiority trial was performed at 7 referral hos-

pitals in Finland during 1983–2005. The study protocol was

approved by the relevant ethical committees, and the inclusion

of a child required the consent of a legal guardian. The trial

was designed, conducted, and analyzed independently of any

medical companies or manufacturers. Only previously healthy

children were included. The study is registered as International

Standard Randomized Controlled Trial ISRCTN38832979.

When acute SA (marked by fever, painful and swollen jointwithout trauma, restriction of motion, and often tenderness

and warmth [11]) was suspected in a child aged 3 months to

15 years, the clinician contacted (by telephone) a special ward

of the Children’s Hospital (Helsinki, Finland) 24 h/day. Each

patient obtained a computer-generated number that random-

ized him or her to receive antimicrobial treatment for 10 or

30 days; the information was immediately recorded in the chart.

If involvement of an adjacent bone was detected during the

first few days of treatment, the case was deemed to be a com-

bination of SA and osteomyelitis. These cases were excluded

from this analysis, which focused only on SA.

Treatment. Because SA in industrialized countries is most

frequently caused by gram-positive agents [2, 5–7, 11, 12, 15,

17], clindamycin [1, 18–20] (40 mg/kg per day every 6 h) [4,

20] or a first-generation cephalosporin (see below; 150 mg/kg

per day every 6 h) [4, 21] was used. This randomization was

performed by birthday (odd or even). Because Haemophilus

influenzae type b was previously the second-most common

causative agent of SA [15, 22], ampicillin or amoxicillin (both

200 mg/kg per day every 6 h [4]) was also given to children

aged 0–4 years until the causative pathogen was identified; the

treatment course was completed with only 1 antimicrobial. Af-

ter vaccination eliminated the H. influenzae type b etiology in1997, ampicillin and amoxicillin were no longer used for treat-

ment of SA [22].

Of the first-generation cephalosporins, cephradine [4, 23–

25] was our first choice, because it was available for parenteral

and oral use. Later, withdrawal of cephradine from Scandinavia

forced a change to intravenous cephalothin and oral cephalexin

[3, 21] or cephadroxil (all administered in the same manner

as cephradine). The switch was not deemed critical for the

study, because the properties of all first-generation cephalo-

sporins are very similar [26].

Antimicrobial treatment was instituted intravenously for 2–

4 days, and the course was then completed orally with the same

high doses. Serum or joint fluid concentrations were not as-

sayed, and adjuvant dexamethasone [27] was not used. Instead,

nonsteroidal antiinflammatory drugs were given at the discre-

tion of the attending clinician (a pediatrician or a pediatric ororthopedic surgeon).

Identification of the causative agent, role of surgery, and

monitoring of patients. Blood cultures were performed invar-

iably. The only recommended surgical procedure was needle as-

piration to obtain a representative sample for bacterial culture;

otherwise, the number of surgical procedures was kept to a min-

imum. Repeated aspirations or routine arthrotomy with or with-

out lavage were not recommended even for shoulder or hip

arthritis, unless the clinical response was unsatisfactory or the

orthopedic surgeon felt that such an operation was mandatory.

The preset laboratory and radiographic investigations com-

prised plain radiograph at hospital admission and on days 10

and 19 and basic blood analysis at presentation and on days 5

and 10. Serum C-reactive protein (CRP) level and erythrocyte

sedimentation rate (ESR) were measured sequentially [28, 29]

during the entire follow-up period (figures 1 and 2). A CRP

level у20 mg/L and an ESR у20 mm/h were considered to be

increased. CT and MRI were performed only on demand. Spe-

cial forms were used for recording. All data were then com-

puterized and analyzed in Helsinki with use of Statview (SAS

Institute). A researchers’ meeting was held yearly.

Discontinuation of antimicrobial therapy, management of

special problems, and control visits. Antimicrobial therapy was discontinued when the patient was clinically recovering

(i.e., when fever was improving and the majority of local symp-

toms and signs were subsiding) and the CRP level had decreased

to !20 mg/L, regardless of the ESR. If the clinical signs were

still prominent or the CRP level remained elevated or notably

increased again, therapy was continued until 2 normal CRP

levels were obtained. In cases of likely drug allergy, the med-

ication was switched to an alternative drug.

Because osteoarticular infections have some tendency to

reoccur [5, 30] and long-term sequelae may develop slowly

[31], control visits were scheduled at 2 weeks, 3 months, and

у1 year after hospitalization. The liaison performed all inves-tigations, paying special attention to potential sequelae. Radi-

ographs were performed, and ESRs and CRP levels were

checked routinely.

Outcome measures and statistical analysis. To maximize

the reliability of results, only culture-positive cases were in-

cluded. The primary end point was full recovery (i.e., having

no symptoms or signs of SA at the end of the follow-up period,

with no readministration of antimicrobial therapy for an os-




Figure 1. Serum C-reactive protein (CRP) level ( SEM) and erythrocyte sedimentation rate (ESR; SEM) in 16 children who underwent arthrotomy

or joint lavage by arthroscopy or with needles, compared with those in the 110 children who underwent diagnostic aspiration only. Data from 2 weeks,

3 months, and 1 year were collected after hospitalization.

teoarticular indication since the primary treatment). Secondary

outcomes included all potential sequelae and the absence of

disease after discontinuation of antibiotic therapy.The 95% CI for the difference in success rates was calculated

on the basis of normal approximation to the binomial distri-

bution. This noninferiority test was based on the lower bound

of the 95% CI being within a prespecified noninferiority margin

of 15% and the upper bound containing 0%. Assuming 90%

efficacy in both groups, 80% power, and a 1-sided significance

level of , 63 patients in each group were needed toP p .025

test the null hypothesis (at least 15% difference in treatment

results).

RESULTS

Participants. SA was diagnosed in 200 children (figure 3),

154 of whom had an organism isolated. Adjacent bone was

affected in 23 cases (excluded), but of importance, this was

never a consequence of short-term treatment. Because 1 child

refused follow-up, 130 cases of SA (table 1) were analyzed.

All age groups were affected; however, children aged !2 years

preponderated (figure 4). The mean age was 6.5 years (median,

5.7 years). Medical attention was sought within 3 days after

the onset of symptoms by 85 patients (65%) and within 6 days

by 121 (93%). No association prevailed between the duration

of time from symptom onset to presentation and the presenting

status. The lower extremities were most frequently affected: thehip was affected in 48 patients (37%), the knee was affected in

32 (25%), and the ankle (tibiotalar joint) was affected in 30

(23%). With the exception of the hip and knee, among which

the affects of SA were distributed somewhat unevenly (although

nonsignificantly) between groups, the distribution of the affects

of SA among joints was similar.

Bacteria grew on cultures of synovial fluid and blood spec-

imens from 41 patients (32%; only synovial fluid specimens

from 60 patients [46%] and only blood specimens from 29

patients [22%]). Staphylococcus aureus (all methicillin suscep-

tible) caused 76 cases, H. influenzae type b caused 23 cases,

Streptococcus pyogenes caused 16 cases, Streptococcus pneumo -niae caused 11 cases, and other agents caused 4 cases (table 1,

figure 4). Sixty-three children (48%) were randomized to the

10-day treatment group, and 67 (52%) were randomized to the

30-day treatment group. Clindamycin was administered to 43

children, cephalosporin was administered to 26 children, and

ampicillin or amoxicillin was administered to 20 children; the

other children received medication preferred by the attending

physician.




Figure 2. Serum C-reactive protein (CRP) level ( SEM), erythrocyte sedimentation rate (ESR), and WBC count in the 67 patients in the 30-day

treatment group, compared with those in the 63 patients in the 10-day treatment group. Data from 2 weeks, 3 months, and 1 year were collected

after hospitalization.

The initial mean CRP level was slightly higher in the 10-day

treatment group than in the 30-day treatment group (93 mg/

L vs. 83 mg/L) (table 1). The mean ESR was similar between

groups (54 mm/h vs. 56 mm/h).

Treatment. Antimicrobial therapy was given intravenously

for a mean duration of 3 days. The median duration of the

entire medication was 10 days (interquartile range, 10–15 days)

in the short-term treatment group and 30 days (with no de-

viation) in the long-term treatment group. Treatment was pro-

longed only if there was a slow decrease in CRP level or if the

attending physician deemed the response to be suboptimal.

Adjacent osteomyelitis was suspected in 1 patient but was not

confirmed later.

Four children did not undergo a surgical procedure. Per-

cutaneous aspiration was performed for 110 patients; needle

lavage was performed for 7 of these patients (2 with hip in-

volvement, 2 with knee involvement, and 1 each with ankle,

elbow, and shoulder involvement). Knee arthroscopy was per-




Figure 3. Trial profile. Patients who did not fulfill the criteria for septic

arthritis (SA) were those with culture-negative cases.

formed for 1 patient. Arthrotomy, occasionally with drilling of

adjacent bone, was performed for 15 patients (12% overall).

Hip arthrotomy was performed 3 times in the short-term treat-

ment group and 4 times in the long-term treatment group,

whereas operations on the shoulder (6 cases) were never per-

formed. As shown in figure 1, CRP levels and the ESR nor-

malized more slowly in the children who underwent surgical

procedures than in the children who did not undergo surgicalprocedures (the curves for CRP level joined on day 12, and

the curves for ESR joined on day 19).

Outcomes. Most patients recovered quickly, and there were

no statistically significant differences between the groups with

regard to any follow-up index. Figure 2 shows a comparison

of the CRP levels, ESRs, and blood leukocyte counts in the

short-term and long-term treatment groups. Of importance,

no marker in the 10-day treatment group deviated after dis-

continuation of antimicrobial treatment.

Two weeks after hospitalization, 10 children in the short-

term treatment group and 21 in the long-term treatment group

were still recovering; the most common complaints were jointswelling, restricted mobility, and pain. Soft-tissue swelling was

found by radiography in 5 children.

At 3 months, 3 patients had minor joint symptoms; a 9-

year-old boy still had a swollen knee, a 6-year-old boy recov-

ering from hip arthritis complained of groin pain, and a 15-

year-old boy had local pain during exercise after having had

sacroiliacal arthritis. At 1 year, these children had no symptoms,

whereas an 11-year-old boy with perinatal Erb palsy and left

elbow arthritis showed mild extension deficit, likely related to

previous palsy. A 14-year-old boy with hip arthritis showed a

1-cm limb shortening; this normalized within 12 months. Ra-

diography detected mild coxa magna in a 2-year-old boy and

narrow hip joint space in a 5-year-old boy.

Problem cases and adverse events. Treatment was changed

for 8 children (table 2), all of whom recovered without further

problems. A 10-year-old boy in the 30-day treatment group

experienced 2 late reoccurrences of infection. Initially, S. aureus

arthritis of the ankle responded to cephradine so well that

treatment was discontinued on day 28. Seventeen months later,

the same joint was affected, S. aureus was isolated, and cephra-

dine treatment was administered again. This time, suboptimal

clinical response led to a change to clindamycin for 30 days.

Recovery seemed uneventful; however, of surprise, the same

ankle was affected again 8 months later, and coagulase-negative

staphylococci were identified. Clindamycin therapy for 30 days

led to full recovery. Since 1990, the child has remained symp-

tomless. No surgical procedure other than aspiration was per-

formed, and scintigram findings were normal. Immunodefi-ciency and bacterial resistance were not found.

Four children developed rash, likely caused by medication

(2 during amoxicillin therapy and 1 during cephradine or clin-

damycin therapy). Change of the agent led to full recovery

without prolonged treatment. Loose stools were reported in 7%

of the children who received cephalosporin and in 1% of pa-

tients who received clindamycin, but a causal association was

disputable.

Final outcomes. One hundred fifteen (88%; 86% from the

10-day treatment group and 91% from the 30-day treatment

group) of the 130 children attended the 1-year follow-up visit.

One child in the 10-day treatment group was documented asfully recovered 7 months after hospitalization. The remaining

patients refused additional follow-up visits after full recovery

at 3 months. With the exception of the patient who had late

reoccurrences of infection (table 2), none of the patients ex-

perienced relapse, recrudescence, residual dysfunction, growth

disturbance, or other clinically significant sequelae.

DISCUSSION

Although SA is no longer associated with significant mortality

[32], deaths still occur [9, 33]. Therefore, there is an abundance

of advice on how aggressive the treatment should be, bothmedically and surgically. The relevance of those recommen-

dations has been questioned; however, studies have found that

clinicians continue to use long durations of therapy (25–29

days in the United States [8, 34] and 31 days in Australia [35]).

A recent guideline [36] states that empirical therapy comprises

administration of antimicrobials for 4–6 weeks, starting intra-

venously for at least 3–4 weeks. To our knowledge, our study

is the first sufficiently powered randomized trial to document

the efficacy and safety of a considerably shorter duration of

treatment. Because all of our cases were culture positive, many

interpretation problems (e.g., the case definition) were avoided.

Most children presented within a week after symptom onsetin our study, similar to other studies [5, 33, 34]. Differences

prevail between countries [5–9, 15, 17, 37–39], but we believe

that our series is representative of SA in the industrialized

world. Whether our results apply to the developing countries,

such as those where Salmonella arthritis is common [37, 38],

remains to be shown, but we expect at least some relevance. If

so, our data should also be good news for those settings.

We used high doses of antimicrobials, as has been previously




Table 1. Characteristics patients with septic arthritis (SA).

Variable

Patients

All

(n p 130)

Short-term

treatment group

(n p 63)

Long-term

treatment group

(n p 67)

Sex, M:F 75:55 32:31 43:24

Age, median years (IQR) 6.2 (2.0–10.2) 6.2 (1.8–9.9) 6.6 (3.1–10.3)

Time f rom sy mp tom o ns et t o pr ese nt at ion , m edian d ay s ( IQ R) 2.0 (1.0– 4.0) 3 .0 (1.0– 4.0) 2.0 (1.0– 4.0)Localization of SA

Hip 48 19 29

Knee 32 21 11

Ankle (tibiotalar) 30 14 16

Elbow 8 3 5

Shoulder 6 4 2

Sacroiliac joint 2 1 1

Multiple joint involvement 3 1 2

Other 1 … 1a

Causative agent

Staphylococcus aureus 76 35 41

Haemophilus influenzae type b 23 12 11

Streptococcus pyogenes 16 9 7

Streptococcus pneumoniae 11 4 7Other 4 3

b1c

Site from which the pathogen was cultured

Joint only 60 28 32

Joint and blood 41 18 23

Blood onlyd

29 17 12

Initial laboratory value

CRP level, mean mg/L SEM 88 5 93 7 83 6

ESR, mean mm/h SEM 55 3 54 4 56 4

WBC count, mean cells/mm3 SEM 14,100 600 13,877 1000 14,472 1000

Duration of antimicrobial therapy, median days (IQR) 25 (10–30) 10 (10–15) 30 (30–30)e

Relapse 0 0 0

Late-onset reinfection 2 0 2f

Full recovery at last follow-up visit 130 (100) 63 (100) 67 (100)

NOTE. Data are no. or no. (%) of patients, unless otherwise indicated. CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IQR,

interquartile range.a

The metatarsophalangeal joint was affected.b

One infection each was caused by Neisseria meningitidis group W135, b-hemolytic streptococcus type G, and Streptococcus viridans.c

Infection was caused by Neisseria meningitidis group B.d

Includes all patients with compatible symptoms and signs of acute SA and objective documentation of joint involvement.e

No deviation.f

One patient who initially received cephradine experienced reinfection twice, with 17 and 8 months between infections.

recommended elsewhere [2–4, 20, 21, 40]. Serum concentra-

tions were not assessed [34], because oral clindamycin [18–20],

first-generation cephalosporins [3, 4, 10, 21, 23–25], and am-

picillin and amoxicillin [3] absorb well and penetrate joints

effectively and large doses are surprisingly well tolerated [20,

21, 40]. The reasonable cost of these drugs adds to their use-

fulness. Our positive experience with treatment staphylococcal

osteomyelitis [41] has provided a good reason to maintain the

same policy.

The risk of reoccurrence is not known. Among 168 US cases

[5], there were no reoccurrences of infection, whereas 1 child

in our study experienced 2 reoccurrences of infection. Second

episodes of osteomyelitis caused by different strains were re-

cently reported in 3 patients [30]. Obviously, a previously in-

fected site remains a focus of diminished resistance to infection;

an analogy to endocarditis is evident. However, these aberra-

tions from the usual pattern should not dictate the general

treatment guidelines, which are determined only from large

randomized trials such as ours. We are confident in the effec-

tiveness of our short-term treatment regimen, without claiming

that it works in 100% of cases. In clinical medicine, exceptions

always exist.

Enrollment of 130 patients in Finland required a long period,

but we had to decide whether to only include patients with

proven cases, leaving little space for misdiagnosis, or to also

include patients with unconfirmed cases. We selected the for-




Figure 4. Age distribution (top) and localization and proportional dis-

tribution of the causative agents (bottom) among the 130 children with

acute septic arthritis. Hib, Haemophilus influenzae type b; GAS, group A

streptococcus (Streptococcus pyogenes); Pnc, pneumococcus (Streptococ-

cus pneumoniae).

mer alternative; thus, the enrollment time was long. However,

the data were not significantly biased for this reason, because

the researchers’ yearly meetings kept standards the same. With-

drawal of cephradine from Scandinavia was unwelcome news

but did not significantly skew the results, because all first-gen-

eration cephalosporins perform almost identically [26].

There were, however, also limitations in our study. The pro-

tocol advised how to cope with problem cases; however, wecould not always understand why treatment was prolonged or

another agent was used. On the other hand, a responsible cli-

nician makes the final decision, and this ethical view has few

counterarguments. Despite these deviations from protocol, we

believe that the goal of the study was achieved.

Although 12% of the patients did not have a 1-year follow-

up visit, undetected reoccurrences almost certainly did not ex-

ist. Patient care in Finland is virtually free of cost, and the

doorstone to revisit a health care facility is low if any problems

during convalescence from such a serious disease as SA arise.

We are convinced that the nonattendees also recovered entirely.

Five lessons were learned. First, pyogenic arthritis can often

be treated with antimicrobials for ∼10 days without notable

risk of recrudescence or sequelae. Some cases might have im-

proved with an even shorter course of treatment; however,

because our treatment relied on the normalization of CRP level,

we cannot comment further on this likely possibility (except

that, currently, we do not necessarily wait for the CRP level to

decrease to !20 mg/L if recovery seems otherwise likely). It is

evident that the antimicrobial has to be well chosen and that

large doses are probably needed [40]. Clindamycin and first-

generation cephalosporins (and ampicillin or amoxicillin)

worked well in our study. Methicillin resistance was not a prob-

lem, but fortunately, methicillin-resistant staphylococci usually

retain their susceptibility to clindamycin [42].

Second, intravenous therapy (if needed at all) can be ad-

ministered for only a few days. When shifting to the oral route,

serum assays are not mandatory [34], but compliance shouldbe guaranteed. Oral administration is gaining a footing for

several community-acquired infections, including severe pneu-

monia [13, 14], and a swift switch to the oral route simplifies

the treatment in many respects. Oral antimicrobials (except

vancomycin) are also considerably cheaper than their parenteral

forms.

Third, routine joint decompression and debridement are

usually not indicated for treatment of SA, at least not childhood

SA. In fact, most patients in our study recovered uneventfully

after having only the diagnostic joint aspiration performed. Our

results are in good accordance with prospective [39] and ret-

rospective studies [1, 33, 35, 43, 44] that suggest that aggressive

surgery sometimes worsens the outcome [43, 44]. We cannot

exclude the possibility that the children who underwent surgical

procedures were more ill, but no prospectively recorded data

supported this assumption. Because the initial CRP levels were

also essentially the same in the children who underwent surgical

procedures and in those who did not, we view that surgical

interventions, per se, provoked greater inflammatory reactions,

and for this reason, CRP levels and ESRs decreased more slowly

when arthrotomy or arthroscopy was performed. The CRP

curve joined at 14 days, which is approximately the same du-

ration of antimicrobial therapy that the short-term treatmentgroup received, whereas the ESR curve joined 1–2 weeks after

that. Extinction of inflammation (whatever the cause) was thus

shown sooner by CRP level.

Fourth, sequential CRP measurements proved to be very

useful in the diagnosis and monitoring of the course of illness.

For decades [28, 29, 45–47], we have learned to rely on this

simple, quick, easy-to-perform [48], and inexpensive param-

eter, which at the present time, can be performed bedside [49,

50]. We use nephelometry or turbidmetry [48], but whatever

the methodology, CRP can be exploited effectively only if it is

measured quantitatively and the results arrive quickly (our re-

sults are available in a few hours or within 20 min if requested).Normalization of the CRP level is a good sign of recovery not

only in a SA, but also in many invasive bacterial infections [28,

45, 47, 49, 50]. During the follow-up period, an ESR [29, 45,

51] adds nothing to a CRP level [46, 52], except that it may

lead to an unnecessarily long course of therapy.

Fifth, staphylococcal disease, which was responsible for the

majority of cases in our series, does not require an approach

that is different from that against infection caused by other



T a b l e

2 .

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d a y s )

H .

i n fl u e n z a e t y p e b

A r t h r o t o m y

7

F

0 . 6

3 0

H i p

R a d i o l o g i c a l s u s p i c i o n o f o s t e o m y e -

l i t i s ( n o t c o n fi r m e d ) a t 1 m o n t h

T o t a l 5 8 d a y s : I V c e f u r o x i m e p l u s

o r a l c e p h a l e x i n

H .

i n fl u e n z a e t y p e b

A s p i r a t i o n

8

F

6 . 1

3 0

H i p

E l e v a t i o n o f C R P l e v e l a n d E S R o n

d a y 3 0


a n d c l i n d a m y c i n ( 3 5 d a y s )

S .

p y o g e n e s

A s p i r a t i o n

L a t e r e i n f e c t i o n : 9

M

1 0 . 7

3 0

A n k l e ( t i b i o t a l a r )

2 r e i n f e c t i o n s a t i n t e r v a l s o f 1 7 a n d

8 m o n t h s

F o r t h e fi r s t i n f e c t i o n , c e p h r a d i n e

( 2 7 d a y s

) ; f o r t h e s e c o n d i n f e c -

t i o n , c e p

h r a d i n e ( 6 d a y s ) a n d

c l i n d a m y c i n ( 3 0 d a y s ) ; f o r t h e

t h i r d i n f e c t i o n , c l i n d a m y c i n ( 3 0

d a y s )

F i r s t a n d s e c o n d i n f e c t

i o n s ,

S .

a u r e u s ; t h i r d i n f e c t i o n , c o a g -

u l a s e - n e g a t i v e s t a p h y l o c o c c i

A s p i r a t i o n

N O T E .

C R P , C - r e a c t i v e p r o t e i n ; E S R , e r y t h r o c y t e s e d i m e n t a t i o n r a t e .




gram-positive organisms or H. influenzae type b. Salmonella

arthritis might be different [37, 38]. From Thailand, we have

learned that Salmonella meningitis requires a long treatment

course [53].

In summary, treatment with large doses of well-absorbed

antimicrobials for ∼10 days (started intravenously for a few

days only) is not less effective as a 30-day treatment course for

childhood SA, provided that the clinical response is good andthe CRP level normalizes quickly. Staphylococcal or hip or

shoulder arthritis do not warrant a special approach. With

interest, we read about shortened intravenous treatment (7

days) of osteoarticular infections in Iran [54]. We hope that

this information hints toward further studies on this potentially

severe infection elsewhere.

MEMBERS OF THE OSTEOMYELITIS–SEPTIC

ARTHRITIS (OM-SA) STUDY GROUP

Kari Aalto and Eeva Salo (Aurora Hospital and Helsinki Uni-

versity Central Hospital, Hospital for Children and Adolescents,

Helsinki), Juhani Merikanto (Helsinki University Central Hos-

pital, Hospital for Children and Adolescents, Helsinki), Ilkka

Anttolainen and Pentti Lautala (Paijat-Hame Central Hospital,

Lahti), Marja Heikkinen (Kuopio University Hospital, Kuopio),

Anita Hiippala and Niilo Kojo (Etela-Saimaa Central Hospital,

Lappeenranta), Ulla Kaski (Seinajoki Central Hospital, Seina-

joki), and Pekka Ojajarvi (Jorvi Hospital, Espoo).

Acknowledgments

Financial support. Orion Pharma, through the University of Helsinki

(Project Code 34490).

Potential conflicts of interest. All authors: no conflicts.

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