The Changing Epidemiology of Musculoskeletal Infection in Children: Impact on Evaluation and Treatment at a Tertiary Pediatric Medical Center in the Southwest United States

Background: Recent reports illustrate an increased incidence and severity of deep musculoskeletal infections in children. Our purpose was to review the historical experience with deep musculoskeletal infection at a tertiary pediatric medical center in the southwest United States and to compare this past experience with the more recent experience within the same institution. Methods: A retrospective review was performed of children treated for deep musculoskeletal infection at Children's Medical Center of Dallas between January 1, 2002 and December 31, 2004. The review identified children with primary diagnoses of osteomyelitis, septic arthritis, non-tropical pyomyositis, or abscesses requiring surgical intervention. Trends were identified in terms of causative organism, anatomic location of infection, frequency of requirement of surgical debridement, and identification of adverse sequelae. These trends were compared to past experience within the same institution. Results: 554 children were treated for deep musculoskeletal infection. Primary diagnoses were as follows: osteomyelitis - 212; septic arthritis - 118; pyomyositis - 20; and abscess - 204. The incidence of osteomyelitis rose from 11.7 cases per year, reported in 1982, to 70.7 cases per year, representing a six-fold increase. The incidence of septic arthritis rose from the 1982 report of 18.1 cases per year to 39 cases per year, a 2.2-fold increase. Staphylococcus aureus was responsible for the majority of infections, with methicillin resistant S. aureus representing an important cause of infection not identified in the previous study at this institution. The most common anatomic locations of infection occurred around the knee and hip joints. Deep venous thrombosis was identified as the most common major complication associated with musculoskeletal infection, with 13 cases occurring over the course of the review. Discussion: We have demonstrated a change in the epidemiology among children with musculoskeletal infection at our tertiary pediatric medical center. The marked differences that are present in our current practice when compared to the experience at the same institution over twenty years ago have prompted a detailed look into this epidemiology. The emergence of methicillin resistant S. aureus, the association of deep venous thrombosis musculoskeletal infection, and the reported occurrence of non-tropical pyomyositis, were unique finding in our study. Our recent experience demonstrated trends that motivated the development of clinical practice guidelines for the evaluation and treatment of pediatric musculoskeletal infection. Future prospective work will be necessary to study the success of implementation of these evidence based guidelines as well as to ascertain their merit in terms of beneficial clinical outcomes.