New Clinical Pathway for Musculoskeletal Infections

Seattle Children’s has developed a new Musculoskeletal Infections Pathway. The purpose of the pathway is to develop and standardize an evidence-based approach for the evaluation and care of patients with musculoskeletal infections, including septic arthritis and osteomyelitis.

Pathway Recommendations:

1. Order CBC with differential, CRP and ESR for all patients undergoing diagnostic evaluation for septic arthritis and/or osteomyelitis.
2. Order two blood cultures (aerobic + anaerobic) for all patients undergoing diagnostic evaluation for septic arthritis and/or osteomyelitis with moderate/high likelihood of disease. Consider ordering two blood cultures (aerobic + anaerobic) for all patients undergoing diagnostic evaluation for osteomyelitis with low likelihood of disease. Blood cultures (aerobic + anaerobic) should be drawn prior to initiating antibiotics for patients with confirmed musculoskeletal infections.
3. Order X-ray of the suspected involved bone(s)/joint(s) for all patients undergoing diagnostic evaluation for septic arthritis and/or osteomyelitis.
4. Order ultrasound of the suspected involved joint(s) for all patients undergoing diagnostic evaluation for septic arthritis, particularly ultrasound of the hip in any patient at risk for septic arthritis of the hip joint.
5. Empiric first-dose antibiotics for septic arthritis and/or osteomyelitis should include:
   a) Nontoxic; low risk for MRSA: cefazolin 50 mg/kg IV × 1 (max dose: 2000 mg)
   b) Nontoxic; cefazolin allergy or MRSA risk factors present: clindamycin 13.3 mg/kg IV × 1 (max dose: 600 mg)
   c) Systemically/critically ill and MRSA not yet ruled out by culture: vancomycin 15 mg/kg IV × 1 (max dose: 2000 mg)

For more information or questions, please contact the pathway team.