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Three Part Question

In [children with septic arthritis] does [the addition of corticosteroids] reduce [the clinical severity or the duration of the symptoms]?

Clinical Scenario

A 3-year-old child presents to the emergency department with High fever and pain in his right knee. You perform a diagnostic arthrocentesis and the stat gram is positive. You start the IV antibiotic treatment and you wonder if the addition of a corticosteroid would be appropriate.

Search Strategy

A. No BestBETs or critical appraisal were found on this topic.
B. There was no Cochrane review found on the subject.
C. www.clinicaltrials.gov was searched for an ongoing trial on the topic, and none was found.

D. Medline 1900 to September 6 2011 via Pub med :

1. "Arthritis, Infectious"[Mesh] = 11 695
2. "Glucocorticoids"[Pharmacological Action] = 147 730
3. 1 AND 2 = 180
4. Children = 1 676 598
5. 3 AND 5 = 17

2 relevant papers

E. Embase >1946 to September 8 2011 :

1. "Septic Arthritis" = 7 340
2. "Infectious Arthritis" = 25 249
3. "Bacterial Arthritis" = 5 765
4. 1 OR 2 OR 3 = 26 256
5. "Glucocorticoid" = 520 783
6. 4 AND 5 = 1 221
7. "Children" = 2 051 602
8. 6 AND 7 = 143

2 relevant papers

Search Outcome

The two revelant papers from Pubmed and Embase were the two same RCT

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Odio C. and al 2003 Costa Rica	123 children from 3 months to 13 years old with suspected hematogenous bacterial arthritis received, with antibiotics, Dexamethasone 0,2mg/kg/dose q 8h or saline for 4 days. 100 were evaluable (50 in each group)	Double-blind randomized-control trial	Residual dysfunction of the articulation at the End of the therapy	4% (Dex) vs 32% (placebo) p = 0,00068	No primary outcome identified 23 patients not evaluated (5 met exclusion criteria and 18 were considered non bacterial synovitis) No mention of the side effects
			Residual dysfunction of the articulation at the 6 months	2% (Dex) vs 37% (placebo) p = 0,00007
			Residual dysfunction of the articulation at the 12 months	2% (Dex) vs 26% (placebo) p = 0,00053
			Time to resolution of symptoms	2.34 ± 5.06 d (Dex) vs 7.81 ± 2.04 d (placebo) p = 0,001
Harel, L. and al 2011 Israel	49 children aged 6 months to 18 years with hematogenous bacterial arthritis received, with antibiotics, Dexamethasone 0,15mg/kg/dose q 6h (24 patients) or saline (25 patients) for 4 days.	Double-blind randomized-control trial	First day <37°C (primary outcome)	1.68 ± 2.57 d (Dex) vs 2.83 ± 2.41 d (placebo) p= 0.021	Multiple primary outcomes 20 patients lost to follow-up for late sequelae Small study No mention of the side effects
			First day pain free (primary outcome)	7.18 ± 6.46 d (Dex) vs 10.76 ± 7.20 d (placebo) p= 0.021
			First day pain free (primary outcome)	7.00 ± 6.42 d (Dex) vs 12.24 ± 11.34 d (placebo) p=0.03
			Presence of late sequelae (Secondary outcome)	None in the two groups

Comment(s)

There are two RCT, with methodological limitation, showing benefit of giving a Dexamethasone regimen to children with septic arthritis. The first study shows a clear reduction of residual limitation at one year and reduction of the time to resolution of the symptoms. The second RCT is a smaller study that also shows a quicker resolution of the symptoms. However, this study didn’t show difference between the two groups in the presence of late sequelae (none in each group). The potential side effects of the treatment were not reported in those two RCT.

Clinical Bottom Line

In children with septic arthritis, a regimen of dexamethasone for four days appears to reduce the duration of symptoms and could reduce the residual dysfunction of the articulation. However, a large multicentre RCT should be done to confirm the outcomes found in those two small studies with a lot of methodological weaknesses.

References

1. Odio, C. M. Ramirez, T. Arias, G. Abdelnour, A. Hidalgo, I. Herrera, M. L. Bolanos, W. Alpizar, J. Alvarez, P. Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children Pediatric Infectious Disease Journal 2003/10/11 ;883-888
2. Harel, L. Prais, D. Bar-On, E. Livni, G. Hoffer, V. Uziel, Y. Amir, J. Dexamethasone therapy for septic arthritis in children: results of a randomized double-blind placebo-controlled study Journal of Pediatric Orthopedia March 2011; 211-215