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Osteoarticular Infections Following Open or Penetrating Trauma in Children in the Post-Community-Acquired Methicillin-resistant Staphylococcus aureus Era

The Impact of Enterobacter cloacae

McNeil, J. Chase, MD; Vallejo, Jesus G., MD; Hultén, Kristina G., PhD; Kaplan, Sheldon L., MD

The Pediatric Infectious Disease Journal: December 2018 - Volume 37 - Issue 12 - p 1204–1210
doi: 10.1097/INF.0000000000001991
Original Studies

Background: Most cases of pediatric osteoarticular infections (OAIs) are hematogenous in nature and caused by Staphylococcus aureus. OAI in children can also occur through direct inoculation of microorganisms secondary to penetrating or open trauma. No studies in the United States have evaluated the microbiology or outcomes of trauma-related OAI (TROAI) in children in the era of community-acquired methicillin-resistant S. aureus (CA-MRSA).

Methods: Cases were identified from the inpatient infectious diseases consultation database at Texas Children’s Hospital from January 2011 to December 2016. TROAI cases were those in which OAI developed following a clear history of penetrating trauma, open fracture, crush injury or traumatic amputation. Only cases with radiographic evidence of bone abscess, gross appearance of infection at the time of surgery and/or positive cultures from bone or joint were included. Complications included recurrence of infection, pathologic fracture or chronic osteomyelitis.

Results: During the study period, 692 consultations for OAI were performed, with 34 meeting inclusion criteria. In 68%, at least 1 organism was isolated, and the most commonly isolated organisms were S. aureus (32% overall, 21% MRSA) and Enterobacter cloacae (24%). Polymicrobial infections occurred in 38% of patients. Eighty-five percentage of patients had at least 1 surgical procedure, and 38% underwent ≥ 2 procedures. Eighty-two percentage of patients were discharged on oral therapy. Complications developed in 15% of patients and were more commonly associated with E. cloacae (80% vs. 14%, P = 0.007) and fungi (P = 0.03).

Conclusion: TROAI are relatively uncommon in children but cause significant morbidity. While MRSA contributes substantially to TROAI, the highly diverse microbiology emphasizes the importance of obtaining cultures for microbiologic diagnosis and management. Clinicians should be aware of the frequency of E. cloacae in TROAI and its high risk for sequelae.

From the Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX.

Accepted for publication December 2, 2017.

Dr. McNeil is supported through NIAID K23AI099159. Dr. Kaplan is PI on a phase 2/3 study of ceftaroline in acute osteomyelitis; Drs. Vallejo and McNeil are co-investigators on this study.

The authors have no funding or conflicts of interest to disclose.

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Address for correspondence: J Chase McNeil, MD, Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. E-mail:

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