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成人和兒童化膿性關(guān)節(jié)炎的診斷和治療指南(執(zhí)行摘要)_GEIO、SEIP、SECOT 制定(2024)成人和兒童化膿性關(guān)節(jié)炎的診斷和治療指南(執(zhí)行摘要)_GEIO(SEIMC)、SEIP和SECOT制定(2024)Executivesummary:Guidelinesforthediagnosisandtreatmentofsepticarthritisinadultsandchildren,developedbytheGEIO(SEIMC),SEIPandSECOT?BenitoN,Martinez-PastorJC,Lora-TamayoJ,ArizaJ,BaezaJ,Belzunegui-OtanoJ,CoboJ,Del-ToroMD,FontechaCG,Font-VizcarraL,HorcajadaJP,MorataL,MurilloO,NollaJM,Nunez-CuadrosE,PigrauC,PortilloME,Rodriguez-PardoD,Sobrino-DiazB,Saavedra-LozanoJ.Executivesummary:Guidelinesforthediagnosisandtreatmentofsepticarthritis?inadultsandchildren,developedbytheGEIO(SEIMC),SEIPandSECOT[J].EnfermInfeccMicrobiolClin(EnglEd),2024,42(4):208-214.?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/37919201/轉(zhuǎn)載文章的原鏈接2：https://www.sciencedirect.com/science/article/pii/S2529993X23002551?via%3Dihub?AbstractInfectionofanativejoint,commonlyreferredtoassepticarthritis,isamedicalemergencybecauseoftheriskofjointdestructionandsubsequentsequelae.Itsdiagnosisrequiresahighlevelofsuspicion.Theseguidelinesforthediagnosisandtreatmentofsepticarthritisinchildrenandadultsareintendedforusebyanyphysiciancaringforpatientswithsuspectedorconfirmedsepticarthritis.TheyhavebeendevelopedbyamultidisciplinarypanelwithrepresentativesfromtheBoneandJointInfectionsStudyGroup(GEIO)belongingtotheSpanishSocietyofInfectiousDiseasesandClinicalMicrobiology(SEIMC),theSpanishSocietyofPaediatricInfections(SEIP)andtheSpanishSocietyofOrthopaedicSurgeryandTraumatology(SECOT),andtworheumatologists.Therecommendationsarebasedonevidencederivedfromasystematicliteraturereviewand,failingthat,ontheopinionoftheexpertswhopreparedtheseguidelines.Adetaileddescriptionofthebackground,methods,summaryofevidence,therationalesupportingeachrecommendation,andgapsinknowledgecanbefoundonlineinthecompletedocument關(guān)于背景、方法、證據(jù)摘要、支持每項(xiàng)建議的基本原理以及知識(shí)差距的詳細(xì)描述可以在完整的在線文件中找到。?ResumenLainfeccióndeunaarticulaciónnativa,generalmentedenominadaartritisséptica,constituyeunaurgenciamédicaporelriesgodedestrucciónarticularylasconsecuentessecuelas.Sudiagnósticorequiereunaltoniveldesospecha.Estaguíadediagnósticoytratamientodelaartritissépticaenni?osyadultosestádestinadaacualquiermédicoqueatiendapacientesconsospechadeartritissépticaoartritissépticaconfirmada.LaguíahasidoelaboradaporunpanelmultidisciplinarenelqueestánrepresentadoselGrupodeEstudiodeInfeccionesOsteoarticulares(GEIO)delaSociedadEspa?oladeEnfermedadesInfecciosasyMicrobiologíaClínica(SEIMC),laSociedadEspa?oladeInfectologíaPediátrica(SEIP)ylaSociedadEspa?oladeCirugíaOrtopédicayTraumatología(SECOT);ademáshanparticipadodosreumatólogos.Lasrecomendacionessebasanenlaevidenciaproporcionadaporunarevisiónsistemáticadelaliteraturay,ensudefecto,enlaopinióndelosexpertosquehanelaboradolapresenteguía.Eneltextocompletoonlinesehaceunadescripcióndetalladadelosantecedentes,métodos,resumendelaevidencia,fundamentosqueapoyancadarecomendaciónylaslagunasdeconocimientoexistentes.?KeywordsSepticarthritis?Infectiousarthritis?Bacterial?arthritisNativejointinfection?RecommendationsfordiagnosisI.Whenshouldthediagnosisofsepticarthritis(SA)inchildrenandadultsbeconsidered?1.Allacutearthritisshouldbeconsideredinfectiousuntilprovenotherwise.AhighindexofsuspicionforinfectiousarthritisisrequiredbecauseSAisamedicalemergencyandshouldbediagnosedasearlyaspossible(A-II).2.SuspectadiagnosisofSAinanypatientwithsigns/symptomsofarthritis:jointpain,swelling,effusion,warmth,erythema,and/orrestrictionofmovementinoneormorejoints,?withorwithoutsystemicsigns/symptoms(fever,chills,shivering),and?withorwithoutriskfactorsforSA(previousjointdisorder,immunosuppressiveconditions,recentjointprocedures,bacteraemia)(A-II).3.IncreaseclinicalsuspicionofSAinpatientswithacutemonoarticulararthritisespeciallyoflargeperipheraljoints(kneeandhipinparticular)(A-II).4.AdiagnosisofSAshouldbeconsideredespeciallyinadultswithacutemonoarticularorpolyarticulararthritis(usuallyinvolvingtwoorthreejoints)with:?inflammatoryjointdiseases(mainlyrheumatoidarthritis),?persistentbacteraemia,and/or?immunosuppression(A-II).5.MaintainahighindexofsuspicionforthediagnosisofSAofaxialjoints(sternoclavicular,acromioclavicular,costochondral,symphysispubis,sacroiliacandfacetjoints)becauseoftheirlowerincidenceandoftennon-specificclinicalfeatures(localpainandtenderness)(A-II).6.Inpatientswithsubacuteorchronicjointpainandswelling,consideradiagnosisofinfectiousarthritiscausedbyotherinfrequentorganisms,suchasmycobacteria結(jié)核分枝桿菌orfungi,orinfrequentbacteria(Borreliaburgdorferi,Brucellaspp.布魯氏菌,Coxiellaburnetii,Bartonellaspp.,Legionellaspp.軍團(tuán)桿菌,mollicutes[Ureaplasma/Mycoplasma],Nocardiaspp.,orTropherymawhipplei)(A-II).II.WhatotherpossiblediseasesmaybeimportanttoconsiderinpatientswithsuspectedSA?1.?????InpatientswithsuspectedSA,wesuggestconsideringalternativediagnoses,mainlythefollowing:????Non-infectiousarthritis,suchascrystal-inducedarthritis,post-traumaticarthritis,rheumatoidarthritis,andspondyloarthritis(includingreactivearthritis,axialspondyloarthritis,psoriaticarthritis,andarthritisassociatedwithinflammatoryboweldisease).Inchildrenoradolescents,considerjuvenileidiopathicarthritis.????Infectionsofstructuresadjacenttothejoint,suchasbursitis,mainlyinadults,andosteomyelitisorpyomyositis(typicallyaroundthepelvisandhip),mainlyinchildren.????Variousviralinfectionsthatcanpresentwitharthralgiasand/orarthritismimickingsepticarthritis.????TransientsynovitisandPerthesdiseaseinchildrenwithhipinvolvement(A-II).2.?????InadultswithsuspectedSA,itisrecommendedtoruleoutcrystalarthritis(gout,pseudogout)(A-III).Comment:Itispossibletohaveconcomitantinfectiousandcrystalarthritis.III.WhatistheappropriatediagnosticevaluationandinitialmanagementofpatientswithsuspectedSA?1.AcompletehistoryandphysicalexaminationarerecommendedinallcasesofsuspectedSA(A-III).ThiscanhelptodifferentiatebetweenSAandotherdisordersandtoidentifypathogen-specificriskfactors.2.Adiagnosticalgorithm(Fig.1)showinglaboratoryandimagingtests(B-III)isprovided.Thesearedescribedinfurtherdetailinthefollowingthreesections.??Fig.1.Diagnosticalgorithmofsepticarthritis(SA).??IV.WhatsamplesshouldbecollectedandwhatmicrobiologicaltestsshouldbeperformedifSAissuspected?1.BloodculturesarerecommendedinallpatientswithsuspectedSAandshouldbeobtainedpriortoantibioticadministrationwheneverpossible(A-II).Forbloodculturespositivefororganismsthatcommonlycauseendocarditis(suchasStaphylococcusaureus,viridansgroupstreptococci,orenterococci),wesuggestevaluationforendocarditis(B-III).2.Synovialfluid(SF)samplesshouldbetakenassoonaspossibleinallpatientswithsuspectedSA,preferablybeforeinitiatingantimicrobialtherapy(A-II).3.ItisrecommendedtosendtheSFinasterilecontainerforGramstaining,cultureand,whenindicated,molecularstudies(A-II).Ifthereisenoughfluid(e.g.,morethan2mL)forstaining,culture,possiblemolecularstudiesandleucocytecount,wesuggestbedsideinoculationofbloodculturebottleswithSF(B-II).4.InpatientswithsuspectedSAandnegativeSFcultures,wesuggestobtaininganewsampleofSFformicrobiologicalstainingandculture(includingmycobacteriaandfungi),moleculartesting(seebelow)andhistopathologicalanalysis,especiallyif:?theydonotrespondtoempiricaltherapyagainsttypicalSApathogensand/or?mycobacteriaorfungiaresuspected(B-II).5.Molecularmethods(broad-range,multiplexorspecificpolymerasechainreaction[PCR])forSFanalysisortissuebiopsy:?ThesearenotroutinelyrecommendedforallSFsamplesfrompatientswithsuspectedSA(D-III).?Theiruseshouldbepreviouslydiscussedwithamicrobiologist(A-III)andconsideredwhenSAissuspectedin:-Allchildrenaged6monthsto5years:Kingellakingae-specificPCR(A-II).-PatientswithnegativeSFculturereceivingantibioticsbeforeoratarthrocentesis:broad-rangeormultiplexPCR(A-II).-PatientswithnegativeSFculturewhodonotimprovewithempiricalantibioticsand/orwithclinicaland/orepidemiologicalsuspicionofinfectionwithNeisseriagonorrhoeaeorfastidious/difficult-to-culturemicroorganisms,includingBrucellaspp.,B.burgdorferi,Bartonellaspp.,C.burnetii,Legionellaspp.,Ureaplasmaspp.,Mycoplasmaspp.,andT.whipplei:targetedPCR(B-II).??6.SerologicaltestingforBrucellaspp.B.burgdorferi,Bartonellaspp.,C.burnetii,and/orMycoplasmaspp.issuggestedinpatientswithnegativeSFculture,especiallyinthepresenceofriskfactorsand/orepidemiological,clinicalorradiologicalevidence(B-III).7.Inpatientswithsuspectedmycobacterialorfungaljointinfection,asmuchSFaspossibleshouldbesentinasterilecontainerforculture;synovialbiopsyisalsorecommendedbecauseofitshigheryieldfortheseorganisms(A-III).8.Inpatientswithsuspectedgonococcalarthritis,inadditiontobloodandjointcultures,wesuggestN.gonorrhoeacultureandnucleicacidamplificationtestingofgenitourinaryspecimensand/orfreshlyvoidedurine,and,ifclinicallyindicated,rectalandoropharyngealswabs(A-II).V.Whatadditionalsynovialfluidandblood/serumtestsshouldbeperformedinpatientswithsuspectedSA?1.RecommendedtestsonSF:grossexamination,leucocytecountandpolymorphonuclearpercentage(A-II).IftheamountofSFislow,priorityshouldbegiventomicrobiologicaltests(A-III).Comment:ThereisnothresholdtoaccuratelydiagnoseSAortodifferentiateSAfromotheracutearthritis,althoughthelikelihoodofSAriseswithincreasingleucocytecountandPMNpercentage.SFleucocytecount>100,000/mm3or50,000–100,000/mm3with>90%PMNaresuggestiveofinfection.2.Additionalmarkers:determinationofSFglucose,lactatedehydrogenase(LDH),serumprocalcitonin(PCT)and/orlactate(ifavailable)aresuggested,especiallyifpreviousinitialdata(includingGramstain)areinconclusive(C-III).Comment:LowglucoselevelsandelevatedLDH,lactateandPCTlevelsarecommoninSA.TheseSFabnormalitiesarenotreliablydiagnosticofSAbutmaybeusefulincombinationwithotherdata.3.UseofleucocyteesteraseandglucosereagentstriptestsinSFmaybeofvalueasarapidscreeningtool(B-II).4.SFshouldbeexaminedforcrystalstoexcludemicrocrystallinearthritisinadults(A-II).5.Recommendedblood/serumtestsatinitialassessment:C-reactiveprotein(CRP),erythrocytesedimentationrate,whitebloodcell(WBC)countandPMNpercentage(A-III).Comment:Thesetestsarenon-specificandcannotdiagnoseSAordifferentiateitfromotherformsofarthritis,buttheirperformancecanbeimprovedinconjunctionwithclinicaldataandotherSFanalyses.Theycanalsobeusedasabaselineforserialmonitoringoftreatmentresponse,particularlyCRP.6.Inadults,considerthedeterminationofserumprocalcitoninlevels,ifavailable.Comment:Althoughserumprocalcitoninlevelsshowlowsensitivity,theirhighspecificitymayhelpdifferentiatebetweenSAandotherformsofarthritis(B-II).7.Wesuggestacompletebloodcountandassessmentofliverandkidneyfunctionaspartoftheevaluationofpatientseverityatpresentation,astheycouldinfluencethechoiceanddoseofantibiotics(B-III).VI.WhatistheroleofimaginginpatientswithsuspectedSA?1.Plainradiographsoftheaffectedjointatbaselinearesuggestedinallpatients(B-II).Comment:AlthoughnotusuallyhelpfulforaSAdiagnosis,theycanshowpre-existingjointorbonedisease,ruleoutotherdiagnoses,andcanbeusedasareferenceimagetoassessfuturejointdamage.Additionalimagingisnotusuallynecessary(D-III).2.Ultrasoundisrecommendedtodetecteffusionswhenthephysicalexaminationisunclear,andtoguidejointaspirationinjointsthataredifficulttoexamine,suchasthehiporsacroiliacjoint(A-II).Inchildrenwithhipinvolvementandsuspectedtransientsynovitis,ultrasoundofbothjointsissuggested,asbilateralhipeffusionisatypicalfindingoftransientsynovitisofthehipthatmaysupportthisdiagnosis(B-II).3.Magneticresonanceimaging(MRI)isrecommendedforasuspecteddiagnosisofSAofaxialjoints(A-III),andwhenfurtherimagingisneededforsuspectedspreadofinfectionfromthejointtoadjacentsofttissues,and/orosteomyelitis(morecommoninchildren'sjoints)(A-II).Inchildren,MRImaybeindicatedtodifferentiatetransientsynovitisofthehipfromSAifthediagnosisremainsindoubtaftertheinitialevaluationandinvestigation(A-III).4.Computedtomography(CT)maybeanalternativetoMRIwhenthelatterisnotreadilyavailable(A-II),althoughCTshouldgenerallybeavoidedinchildrenduetoitshighradiationindex.CTmaybeanalternativetoultrasoundtoguidejointaspiration(B-III).5.NuclearmedicineexaminationsarenotrecommendedforthediagnosisofSA(D-III).?RecommendationsfortreatmentVII.GeneralprinciplesofmanagementofSA1.Asageneralrule,patientswithsuspectedordocumentedSAshouldbeadmittedtohospital(A-II).Somestudiesinchildrentreatedexclusivelywithoraloutpatientantibioticsshowedafavourableoutcomewhenspecificcriteriaweremet(BII).2.Jointdrainageisrecommendedforperipheralbacterialarthritis(exceptforgonococcalandearlymycobacterialinfections,whichdonotusuallyrequirejointdrainage)andforfungalarthritis(A-II).3.Werecommendjointdrainageoflargeperipheraljointswithpyogenicarthritisassoonaspossible(A-II).4.Whilemostpatientswithearlydiagnosisofaxialjointinfectiondonotrequiresurgery(B-III),drainageofadjacentabscessesandvarioustypesofsurgeryforconcomitantosteomyelitismaybenecessary,especiallyifdiagnosisisdelayed(A-II).MRIisrecommendedtoassessthepresenceofthesecomplications(A-III).5.Inhaemodynamicallystablepatientswithoutsepsisorsepticshockandwithclinicalandlaboratoryfindingsofperipheralpyogenicarthritis,werecommendstartingempiricalantimicrobialtherapyafterobtainingbloodculturesandSFaspirate,aswellasintraoperativespecimensifthepatientisundergoingurgentsurgery(A-II).6.Inpatientswithhaemodynamicinstability,sepsisorsepticshock,wesuggestobtainingbloodandSFforculturebeforestartingantimicrobialtherapy,ifthisdoesnotsignificantlydelayinitiationofantimicrobialtherapy(<45min)(B-III).7.Werecommendthatthedefinitiveantibioticregimenbebasedontheidentifiedpathogenanditsantimicrobialsusceptibilityor,ifnopathogenisidentified,onthemostlikelycausativeorganism(s),tobediscussedwithaninfectiousdiseasespecialistorclinicalmicrobiologistwheneverpossible(A-II).8.Wesuggeststartingantimicrobialtherapyintravenously(B-III).9.Itisrecommendedtoswitchtooralantibioticsafterafewdays(e.g.,2–7days)ofintravenousantibioticsinadultswithoutendocarditis,withnegativebloodculturesandwithclinicalandlaboratoryimprovement(providedthatappropriateoralantimicrobialscanbeadministered)(A-II).Inchildrenwithafavourableclinicalandanalyticalevolutionafter2–4daysofintravenousantibiotics,switchingtotheoralrouteisstronglyrecommended(A-I).10.Totaldurationofantimicrobialtreatmentinadultswithoutendocarditis:?Forlargeperipheraljointsafterdrainage,wesuggest3–4weeksforS.aureus(SA)andgram-negativebacilli(GNB),2–3weeksforstreptococcalarthritisand1–2weeksforgonococcalarthritis(B-III).?AlongerdurationisrecommendedforSAofaxialjoints(6weeks)andSAwithadjacentosteomyelitis(A-III)andisalsosuggestedforpatientswithimmunosuppressionoraslow/inadequateresponsetoinitialtreatment(B-III).?TwoweeksarerecommendedforSAofthewristorhandjointsaftersurgicaldrainage(thisrecommendationmaynotapplytoSAcausedbymethicillin-resistantS.aureus[MRSA])(A-I).11.Totaldurationofantimicrobialtreatmentinchildren:?Werecommend2–3weeksforalluncomplicatedSAinchildren,and3–4weeksforSAwithosteomyelitis(A-I).?Longertherapy(4–6weeks)mayberequiredin:°InfectionscausedbyMRSA(B-II),Salmonella,EnterobacteralesorPseudomonasaeruginosa(B-III)°SAofaxialjoints(A-III)°Newbornsandyounginfants(<3months)(B-III)°Immunocompromisedchildren(B-III)?EmpiricalantimicrobialtherapyVIII.WhatistherecommendedinitialempiricalantimicrobialtherapyforSA?1.EmpiricaltherapyactiveagainstS.aureusisalwaysrecommendedinanypatient(adultsandchildren)withsuspectedSAandnegativeSFGramstain(A-II).Additionalempiricalantimicrobialcoveragemaybenecessaryforotherpathogens(A-III).2.InadultswithnegativeSFGramstainandnospecificriskfactorsforspecialpathogensorresistantbacteria,wesuggestcoverageofS.aureus,streptococciandthemorecommonGNBwith:?Cloxacillinplusceftriaxoneormonotherapywithamoxicillin–clavulanate(B-III).?Aglycopeptideordaptomycincombinedwithaztreonamorafluoroquinoloneincaseofbeta-lactamallergy(B-III).Otheroptionsshouldbeconsideredinthepresenceofcertainriskfactorsorclinicalcontexts(B-III).3.InchildrenwithoutspecificriskfactorsforspecialpathogensorresistantbacteriaandwithanegativeSFGramstain,werecommendtreatmentasfollows(A-II):?<3months:cloxacillinorcefazolin+cefotaximeorgentamicin(avoiding2cephalosporinstogether).?3monthsto2years:cefuroxime;alternatively,cloxacillin+cefotaximeoramoxicillin–clavulanate.?2–4years:cefazolin;alternatively,cefuroximeforcoverageofHaemophilusinfluenzaeandStreptococcuspneumoniaeinunder-vaccinatedchildren.??>4years:cefazolinorcloxacillin.?TargetedantimicrobialtherapyIX.WhatisthedefinitiveantimicrobialtherapyforS.aureusSA?a)Inadults1.Formethicillin-susceptibleS.aureus,intravenouscloxacillinorcefazolinisrecommended(A-II).Initialadditionofdaptomycinmaybeconsidered(C-III).Patientsallergictobeta-lactamscanbetreatedwithvancomycinordaptomycin(A-II).2.PatientswithMRSASAcanbetreatedwithvancomycinordaptomycin(A-II)(initialcombinationofdaptomycinplusabeta-lactammaybeconsidered,C-III).3.Sequentialoraltreatmentwithbeta-lactams,levofloxacin,clindamycinorlinezolidarepossibleoptions,dependingonisolatesusceptibilityandbeta-lactamallergy(B-III).4.TheuseofrifampinforpureSAisnotsupportedbypathogenesisorevidence.Itcouldbeconsideredincomplicatedcaseswithconcomitantosteomyelitis(A-III).b)Inchildren1.Formethicillin-susceptibleS.aureus,initialintravenouscefazolinorcloxacillinisrecommended(A-II).Sequentialoraltreatmentwithabeta-lactam(i.e.,cefadroxil)isrecommended(A-II).Clindamycin(A-I),linezolid,levofloxacin(children>6months),daptomycin(children>1year)orvancomycinarealternativesforbeta-lactamallergy(B-III).2.ForMRSA,initialintravenousclindamycinisrecommendediftheisolateissusceptible(A-I).Otherwise,themostappropriateantibioticsarelinezolidordaptomycin;aglycopeptidewouldbeavalidbutlesssuitableoption(B-III).Forsequentialoraltreatment,clindamycin(children>6–8years)(AI),cotrimoxazole(B-II),levofloxacin(>6months),orlinezolid(B-III)aresuggested,dependingonisolatesusceptibility.X.WhatisthedefinitiveantimicrobialtherapyforstreptococcalSA?a)Inadults1.ForSAcausedbysusceptiblestreptococci,penicillinisthedrugofchoice.Third-generationcephalosporins(ceftriaxone,cefotaxime)orampicillinaregoodalternatives(A-II).Incasesofallergyorreducedsusceptibility,vancomycin,clindamycin,afluoroquinolone,orlinezolidmaybeused(B-III).2.Fortheoraltreatmentphase,amoxicillin,cefuroxime,levofloxacin,ormoxifloxacinareallgoodoptions(A-III).b)Inchildren1.ForgroupAandgroupBstreptococci,andpenicillin-susceptibleS.pneumoniae,initialintravenouspenicillinorampicillinaretherecommendeddrugsofchoice(A-III).2.Sequentialoraltreatmentwithamoxicillinisrecommended(A-III).3.Third-generationcephalosporins(ceftriaxone,cefotaxime),levofloxacin(children>6months),clindamycin,linezolidorvancomycinarealternativesdependingonisolatesusceptibilityandbeta-lactamallergies(C-III).XI.WhatisthedefinitiveantimicrobialtherapyforSAcausedbygram-negativebacilli?a)Inadults1.ForSAcausedbysusceptibleGNB,initialtreatmentwithanintravenoussecond-orthird-generationcephalosporinisrecommended(A-III).ForGNBisolatesresistanttothird-generationcephalosporins,consultationwithaninfectiousdiseasespecialistisrecommended(A-III).Initialtreatmentwithaztreonamorafluoroquinoloneissuggestedforbeta-lactamallergies(B-III).2.Sequentialoraltreatmentwithciprofloxacinisrecommendedwheneverpossible(A-III).Oralbeta-lactamsorcotrimoxazolearesuggestedalternativetreatments,dependingonthesusceptibilityoftheGNBidentified(B-III).b)Inchildren1.K.kingaeSAcanbetreatedwithpenicillinorampicillin.First-andsecond-generationcephalosporinsoramoxicillin–clavulanatearegoodalternatives(A-II).2.ForSAcausedbyotherGNB,antimicrobialselectionshouldbebasedonsusceptibility(A-III).XII.WhatisthedirectedtherapyforSAcausedbyotherlesscommonmicroorganisms??Candidaspp.septicarthritis1.Insurgicallytreatedcases,wesuggest6–8-weeksoftherapywithanazole,echinocandinorliposomalamphotericinB(A-III).2.InneonateswithcandidaSA,anextent-of-diseasestudyissuggested,includinglumbarpunctureandretinalexamination(B-II).?Mycobacteriumtuberculosisarthritis1.Inpatientswithearlydiagnosistuberculousarthritis(withoutlargeabscessesorbonesequestration),tuberculostatictreatmentsimilartothatfortuberculosisatothersitesisrecommended.Someexpertsrecommendlongertreatment(9–12months)(B-III).2.Itissuggestedthattreatmentbesupervisedbyanexpert(B-III).?Gonococcalarthritis1.Inadults,werecommendceftriaxone1gevery24h(firstchoice)orcefotaxime1gintravenouslyevery8h(alternative)(A-III).Afterclinicalimprovement,wesuggestswitchingtoanoralagentguidedbyantimicrobialsusceptibilitytesting:ciprofloxacin500mg/12horcefixime400mg/12h(B-III).Patientswithgonococcalarthritisshouldbescreenedforothersexuallytransmittedinfections(A-II).2.Inchildren,wesuggest7daysofcefotaxime(neonates)orceftriaxone(B-III).XIII.Whatisthetreatmentforculture-negativesepticarthritis?1.Wesuggestthatculture-negativeSAbetreatedwithantimicrobialtherapysimilartoempiricaltherapyinpatientswithGramstain-negativeSF(B-III).2.Inpatientswhoarereceivingorhaverecentlyreceivedantibiotics,weadviseconsideringantibioticcoveragetotailorantimicrobialtherapy(B-III).3.Anaccurateepidemiologicalassessmentisrequiredtoruleoutuncommonorfastidiousmicroorganisms(B-II).?AdjuvanttreatmentXIV.IsanyadjuvanttreatmentrecommendedforSA?1.Inchildren,nonsteroidalanti-inflammatorydrugsmaybebeneficialduringtheacutephasewhilethesignsofinflammationarepresent(A-III).2.InchildrenwithconfirmedSA,earlyadministrationofashortcourseofintravenouscorticosteroidsmayaccelerateclinicalrecoveryandreducehospitalstay(B-I).Comment:Thepotentialimpactofdiagnosticdelayonnon-infectiousarthritisandthelong-termeffectsinSAareunclear.3.Inadults,corticosteroiduseisnotrecommendedforSAduetothelackofclinicalevidenceonitseffects(D-III).?JointdrainageXV.WhatjointdrainageproceduresarerecommendedinpatientswithSA?1.JointdrainagetotreatSAcanbeperformedbyclosed-needleaspiration(repeatedasnecessary),arthroscopyorarthrotomy(opensurgery)(A-III).Werecommendtailoringtheoptimaldrainageproceduretoage,affectedjoint,extentofinvolvement,timecourseandotherclinicaldata(A-III).2.Inadults,arthroscopicjointdrainagewithsynovectomyisthesuggestedfirst-lineprocedureforSAoftheknee(B-II).Needleaspirationisanothertreatmentoption(B-II).Fortheankle,elboworwrist,initialjointdrainagemaybebyneedleaspirationorarthroscopy(B-III).Forthehipandshoulder,arthroscopyorarthrotomyisthesuggestedinitialprocedure(B-II).Opensurgeryissuggestedforcaseswithunfavourableevolutionafterrepeatedaspirationorarthroscopicdrainage(B-III).3.Inchildren,thesuggestedinitialtreatmentprocedureforuncomplicatedSAofjointsotherthanthehipisneedleaspiration(B-I).ForSAofthehip,knee,ankle,shoulder,elboworwrist,arthroscopyispreferabletoopensurgery(B-II).WesuggestjointdrainagebyarthrotomyasthefirstoptionforhipandshoulderSAinyoungchildren,andaftermoreconservativeprocedures(needleaspirationorarthroscopy)havefailed(C-III).?AdditionalmeasuresXVI.WhatadditionalmeasuresmaybeusefultoimprovethefunctionaloutcomeofapatientwithSA??Suggestionsinclude:1.Initiatingphysiotherapyaftersurgicaljointdrainage(B-III).2.Earlymobilisationoftheaffectedjoint,initiallywithpassivemovement(B-III).Inchildrenwithhiparthritis,immobilisationinanabductionspicacastisreservedforcasesofsevereinfectionatriskofjointdislocation(B-II).3.Earlyweightbearing–includingpartialweightbearing–isdiscouragedwhenthehipjointisaffected(D-III).4.EarlypartialweightbearingissuggestedforpatientswithkneeSA,oncethepainiscontrolled(B-III).?Recommendationsforclinicalfollow-upXVII.Howshouldpatientsbefollowedupandforhowlong?1.Outpatientfollow-upwithoralantimicrobialtherapy(oroutpatientparenteralantimicrobialtherapyiforaltreatmentisnotpossible)issuggestedonceafavourableclinicalandanalyticalevolutionisestablished(B-III).2.Clinical(jointpain,inflammationandfunction)andanalytical(bloodcount,CRPanderythrocytesedimentationrate)monitoringissuggested(B-III).Whilepatientsarereceivingantibiotics,wesuggestmonitoringforpossibleassociatedadverseeffects(B-III).3.Outpatientfollow-upbyorthopaedicandinfectiousdiseasespecialistsissuggestedat1–2weeks,4–6weeksand3monthsafterdischarge(C-III).Wesuggestafollow-upperiodofatleast1yearinadultsatriskoflong-termadverseoutcomesandsequelae(suchasthosewithimpairedjointfunctionand/orconcomitantosteomyelitis)andinchildren(preferablybyanexperiencedorthopaedicsurgeon)(B-III).Ininfantswithhip/physealinvolvement,longerfollow-upmaybenecessary(B-III).
孩子膝蓋疼有哪些原因膝蓋疼是兒童青少年常見(jiàn)的癥狀，很多家長(zhǎng)都會(huì)說(shuō)這是“長(zhǎng)個(gè)”，補(bǔ)補(bǔ)鈣就行了，不用去醫(yī)院。然而事實(shí)真的如此嗎？新聞里孩子說(shuō)腿疼，家長(zhǎng)沒(méi)重視，最后病情惡化必須截肢的案例屢見(jiàn)不鮮?？梢?jiàn)“腿疼”這一常見(jiàn)的癥狀背后可不一定是生長(zhǎng)痛，還有不少病因如果不及時(shí)處理確實(shí)會(huì)危及肢體甚至生命，家長(zhǎng)和醫(yī)生都應(yīng)引起足夠的重視。膝蓋疼痛的孩子就診時(shí)，應(yīng)根據(jù)病情緊急程度按照以下順序考慮診斷：威脅肢體甚至生命的疾病、髖關(guān)節(jié)病變、關(guān)節(jié)腔積液相關(guān)病因、勞損、良性骨腫瘤，除外以上疾病后才能考慮生長(zhǎng)痛。面對(duì)孩子主訴膝蓋疼，醫(yī)生首先要判斷有沒(méi)有威脅肢體甚至生命的嚴(yán)重疾病，主要包括細(xì)菌感染和惡性腫瘤。▼化膿性關(guān)節(jié)炎膝關(guān)節(jié)是兒童化膿性關(guān)節(jié)炎最常累及的部位?；撔躁P(guān)節(jié)炎一般表現(xiàn)為突發(fā)的逐漸加重的膝關(guān)節(jié)痛，伴有發(fā)熱，查體可發(fā)現(xiàn)膝關(guān)節(jié)腔積液、皮溫升高、紅腫、活動(dòng)受限。膝關(guān)節(jié)正側(cè)位X線、實(shí)驗(yàn)室檢查可以幫助診斷，MRI能夠發(fā)現(xiàn)附近的骨髓炎?；撔躁P(guān)節(jié)炎一般需要切開(kāi)引流及長(zhǎng)期抗生素治療。▼骨髓炎骨髓炎患兒一般會(huì)因疼痛出現(xiàn)跛行，全身癥狀比化膿性關(guān)節(jié)炎輕。查體可發(fā)現(xiàn)關(guān)節(jié)壓痛和活動(dòng)受限，可能存在反應(yīng)性積液。相關(guān)檢查也是X線、實(shí)驗(yàn)室檢查，如果MRI發(fā)現(xiàn)周?chē)浗M織或骨膿腫，則需要進(jìn)行手術(shù)清創(chuàng)。骨髓炎的治療主要為長(zhǎng)期抗生素。▼惡性腫瘤兒童惡性腫瘤發(fā)病率總體不高，但是有幾種惡性腫瘤可能會(huì)表現(xiàn)為膝蓋疼痛，包括原發(fā)骨腫瘤（尤文肉瘤、骨肉瘤、原發(fā)骨淋巴瘤）、軟組織腫瘤（橫紋肌肉瘤、纖維肉瘤、脂肪肉瘤）和白血病。如果兒童出現(xiàn)膝蓋疼痛、全身癥狀、夜間痛或可觸及腫塊，需要進(jìn)行腫瘤評(píng)估，首先是膝關(guān)節(jié)、股骨、脛腓骨的X線正側(cè)位。尤文肉瘤的特征性表現(xiàn)為骨膜“洋蔥皮樣”改變。骨肉瘤的特征表現(xiàn)為“日光放射狀”，即鈣化的血管從病變向周?chē)派洹０籽】杀憩F(xiàn)為骨質(zhì)減少、干骺板受累、骨膜新骨形成、斑塊狀溶骨、硬化、溶骨硬化混合病變、浸潤(rùn)性破壞等。根據(jù)可疑程度，可以進(jìn)一步進(jìn)行MRI、炎癥免疫指標(biāo)檢查等。除外以上最嚴(yán)重的疾病之后，還需要考慮是不是髖關(guān)節(jié)病變引起的膝關(guān)節(jié)痛。如果髖關(guān)節(jié)或大腿疼痛與膝蓋內(nèi)側(cè)疼痛同時(shí)出現(xiàn)，或者髖關(guān)節(jié)不能屈曲90度、不能內(nèi)旋10度，或關(guān)節(jié)活動(dòng)時(shí)有疼痛，則一定要考慮髖關(guān)節(jié)病變。此時(shí)一定避免讓孩子承重，直到骨盆X線正側(cè)位結(jié)果證明沒(méi)有髖關(guān)節(jié)病變。股骨近端骨骺滑脫是指股骨近端骨骺與干骺端分離，常見(jiàn)于10~16歲兒童。查體發(fā)現(xiàn)或X線明確診斷的患兒嚴(yán)格不能負(fù)重，并進(jìn)行急診外科處理。除外髖關(guān)節(jié)疾病后，其他需要處理的病因還包括外傷后或非外傷（炎癥反應(yīng)和非細(xì)菌性感染）導(dǎo)致的積液。▼外傷后積液如果孩子是在急性外傷之后出現(xiàn)膝關(guān)節(jié)腫脹，查體發(fā)現(xiàn)關(guān)節(jié)積液，則需要高度懷疑關(guān)節(jié)內(nèi)紊亂，具體包括骨折（脛骨、股骨、腓骨、髕骨）、軟骨損傷、交叉韌帶損傷、半月板撕裂、髕骨半脫位或脫位。此時(shí)一定需要進(jìn)行膝關(guān)節(jié)MRI平掃。▼非外傷后積液幼年特發(fā)性關(guān)節(jié)炎是一組特發(fā)的自身免疫病，引起炎癥性關(guān)節(jié)炎。全身型（又稱Still病）表現(xiàn)為間歇熱、皮疹和關(guān)節(jié)炎，每天熱峰1~2次。皮疹為橙紅色移動(dòng)性斑疹，多與發(fā)熱一起出現(xiàn)，也可能出現(xiàn)淋巴結(jié)腫大和肝脾腫大。白細(xì)胞和血小板增多、貧血、ESR升高，ANA和RF多為陰性。全身型治療首先使用NSAIDs，可以升級(jí)為激素、甲氨蝶呤和其他生物藥物。少關(guān)節(jié)型多見(jiàn)于2~5歲女孩，累及不超過(guò)4個(gè)非對(duì)稱大關(guān)節(jié)。一般表現(xiàn)為跛行和關(guān)節(jié)腫脹，沒(méi)有疼痛或全身癥狀。治療一般用NSAIDs和關(guān)節(jié)腔內(nèi)注射激素。多關(guān)節(jié)型至少有5個(gè)對(duì)稱小關(guān)節(jié)受累。另外還有銀屑病關(guān)節(jié)炎和附著點(diǎn)炎相關(guān)關(guān)節(jié)炎。感染性關(guān)節(jié)炎：常見(jiàn)的非化膿性感染性關(guān)節(jié)炎包括萊姆病關(guān)節(jié)炎、淋病性關(guān)節(jié)炎、病毒性關(guān)節(jié)炎。最常見(jiàn)的引起病毒性關(guān)節(jié)炎的病毒為細(xì)小病毒、乙肝病毒、丙肝病毒和風(fēng)疹病毒。病毒感染后關(guān)節(jié)炎和關(guān)節(jié)痛一般作為前驅(qū)癥狀出現(xiàn)，病毒性關(guān)節(jié)炎治療可以使用冰敷和抗炎藥。▼膝關(guān)節(jié)急慢性勞損膝關(guān)節(jié)急慢性勞損根據(jù)關(guān)節(jié)疼痛的部位（膝關(guān)節(jié)前、后、內(nèi)側(cè)、外側(cè)）可鑒別多種不同的病因，一般都是因?yàn)椴涣嫉臋C(jī)械作用導(dǎo)致的膝關(guān)節(jié)骨、軟骨和軟組織損傷。▼良性骨腫瘤大多數(shù)良性骨腫瘤都沒(méi)有癥狀，偶爾會(huì)出現(xiàn)腫物、夜間痛、骨骼壓痛。良性骨腫瘤有時(shí)會(huì)導(dǎo)致病理性骨折、引起疼痛或局部侵襲。良性骨腫瘤X線一般為邊界清楚或硬化，病變和正常骨組織分界明確，沒(méi)有骨皮質(zhì)破壞，不會(huì)侵入軟組織。一些病變（如非骨化性纖維瘤和骨軟骨瘤）可以臨床觀察，而病變較大或出現(xiàn)病理性骨折、局部侵襲性、持續(xù)疼痛則需要評(píng)估手術(shù)切除。▼生長(zhǎng)痛生長(zhǎng)痛是兒童膝蓋疼痛最常見(jiàn)的病因，是一種除外性診斷，病因不明，但是目前認(rèn)為是一種壓力性損傷。其臨床特點(diǎn)包括：見(jiàn)于學(xué)齡前或?qū)W齡兒童；雙側(cè)肢體疼痛；間歇痛；夜間痛；晚上孩子睡覺(jué)時(shí)疼醒，早晨好轉(zhuǎn)，白天無(wú)活動(dòng)受限。生長(zhǎng)痛一般出現(xiàn)于大量運(yùn)動(dòng)后幾天。生長(zhǎng)痛與其他慢性疼痛（例如頭痛或腹痛）和家族生長(zhǎng)痛史相關(guān)。查體無(wú)明顯異常。如果病史和查體符合典型的生長(zhǎng)痛表現(xiàn)，則不需要進(jìn)行其他檢查。但是一旦醫(yī)生懷疑其他可能的病因，則應(yīng)進(jìn)行X線和實(shí)驗(yàn)室檢查。生長(zhǎng)痛的治療可選擇冷敷、熱敷、按摩和抗炎藥。生長(zhǎng)痛是自限性疾病，孩子和家長(zhǎng)都不必過(guò)分擔(dān)心。如果疼痛發(fā)生較頻繁，可以在睡前預(yù)防性使用抗炎藥。