Pediatric emergency medicine trisk 595

puncture wound

Pseudomonas

Crepitance,
subcutaneous air on
XR, or gangrene

Clostridium species or
other anaerobes

Immunocompromised
hosts

Pseudomonas, other
GNRs, anaerobes

Pseudomonas accounts
for up to 70–90% of
plantar puncture–
associated
osteomyelitis; the
benefit of postpuncture
prophylactic antibiotics
is unclear
Broad-spectrum
antibiotics covering
anaerobes and aerobes +
early surgical
consultation if concern
exists for necrotizing

fasciitis
If neutropenic, a child may
not have redness,
induration, or pus, but
will have tenderness;
examination findings
may not correlate with
the extent of disease

GAS, group A streptococcus (S. pyogenes ); Hib, Haemophilus influenzae type b; PCN, Penicillin; GNRs,
gram-negative rods; XR, radiograph.


e-TABLE 94.13
CLINICAL AND LABORATORY FEATURES DIFFERENTIATING
PYOGENIC SEPTIC ARTHRITIS FROM LYME ARTHRITIS
Variable

Pyogenic

Lyme disease

Clinical

Swollen, exquisitely
tender
Refusal to bear weight
Range of motion
severely limited
Fever is common

Joint erythema is
common

Swollen, less tender than with
pyogenic arthritis
Usually can walk without difficulty
Range of motion diminished, but can
still flex and extend to some degree
Fever is uncommon
Joint erythema is less common

Laboratory a

ESR/CRP elevated
ESR/CRP normal or elevated
Synovial fluid WBC Synovial fluid—variable, and over ½
>100,000 cells/mm3
have synovial fluid WBC >100,000
cells/mm3
Does not improve
Can have spontaneous resolution after
without treatment
several weeks

Outcome
a Data

from Dart AH, Michaelson KA, Aronson PL, et al. Hip synovial fluid cell counts in children from a
Lyme disease endemic area. Pediatrics 2018;141(5):e20173810.
ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; WBC, white blood cell count.

e-TABLE 94.14
TREATMENT OF LYME DISEASE SEPTIC ARTHRITIS
Age
Type

<8 yrs of age

≥8 yrs of age

Initial

Amoxicillin 50 mg/kg/day in
three divided doses
(maximum 500 mg/dose)
for 28 days

Recurrent or
persistent

Ceftriaxone 50–75 mg/kg
(maximum dose 2 g/day) as
a single daily dose for 14–
28 days
14–28 days
or
Same regimen as above for
initial treatment of arthritis

Doxycycline 2.2 mg/kg/dose
twice daily (maximum 100
mg/dose) for 28 days
or
Amoxicillin 50 mg/kg/day in
three divided doses
(maximum 500 mg/dose)
for 28 days
Same as for younger children

Data from Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention
of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the
Infectious Diseases Society of America. Clin Infect Dis 2006;43:1089–1134. Newer guidelines to be
published in the winter of 2020.


e-TABLE 94.15
EPIDEMIOLOGY AND COMPLICATIONS OF MALARIA