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 Pediatrics Test 1: Pediatric Hip and Spine
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The Journal of Bone and Joint Surgery (American) 85:994-999 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Scientific Article

A Clinical Practice Guideline for Treatment of Septic Arthritis in Children

Efficacy in Improving Process of Care and Effect on Outcome of Septic Arthritis of the Hip

Mininder S. Kocher, MD, MPH, Rahul Mandiga, BS, Jane M. Murphy, RN, MS, Donald Goldmann, MD, Marvin Harper, MD, Robert Sundel, MD, Kirsten Ecklund, MD and James R. Kasser, MD

Investigation performed at the Children's Hospital, Boston, Massachusetts

Mininder S. Kocher, MD, MPH
Rahul Mandiga, BS
Jane M. Murphy, RN, MS
Donald Goldmann, MD
Marvin Harper, MD
Robert Sundel, MD
Kirsten Ecklund, MD
James R. Kasser, MD
Departments of Orthopaedic Surgery (M.S.K., R.M., and J.R.K.), Nursing (J.M.), Infectious Disease (D.G.), Emergency Medicine (M.H.), Rheumatology (R.S.), and Radiology (K.E.), Children's Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail address for M.S. Kocher: mininder.kocher{at}tch.harvard.edu

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Background: The development of clinical practice guidelines is a central precept of the evidence-based-medicine movement. The purposes of this study were to develop a guideline for the treatment of septic arthritis in children and to evaluate its efficacy with regard to improving the process of care and its effect on the outcome of septic arthritis of the hip in children.

Methods: A clinical practice guideline was developed by an interdisciplinary expert committee using evidence-based techniques. Efficacy was evaluated by comparing a historical control group of thirty consecutive children with septic arthritis of the hip managed before the utilization of the guideline with a prospective cohort group of thirty consecutive children treated with use of the guideline. Benchmark parameters of process and outcome were compared between groups.

Results: The patients treated with use of the guideline, compared with those treated without use of the guideline, had a significantly higher rate of performance of initial and follow-up C-reactive protein tests (93% compared with 13% and 70% compared with 7%), lower rate of initial bone-scanning (13% compared with 40%), lower rate of presumptive drainage (13% compared with 47%), greater compliance with recommended antibiotic therapy (93% compared with 7%), faster change to oral antibiotics (3.9 compared with 6.9 days), and shorter hospital stay (4.8 compared with 8.3 days). There were no significant differences between the groups with regard to other process variables, and there were no significant differences with regard to outcome variables, including readmission to the hospital, recurrent infection, recurrent drainage, development of osteomyelitis, septic osteonecrosis, or limitation of motion.

Conclusions: Patients treated according to the septic arthritis clinical practice guideline had less variation in the process of care and improved efficiency of care without a significant difference in outcome.

Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.



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