Question:
In children with septic arthritis, does the addition of dexamethasone to antibiotic therapy improve clinical and laboratory outcomes?
Design:
Randomized (allocation concealed), blinded (clinicians and patients), controlled trial with twelve-month follow-up.
Setting:
Schneider Children's Medical Center of Israel.
Patients:
Forty-nine children who were six months to eighteen years of age (mean age, thirty-three months) with septic arthritis. The diagnosis was based on acute onset of swelling, pain, local warmth, and severe limitation of motion in any joint other than hip or shoulder; aspiration on admission of all involved joints considered septic (turbid purulent appearance and ≥50,000 white blood cells [WBC] per mm3); and elevated levels of acute phase reactants. Exclusion criteria were a history of chronic arthritis, autoimmune disease, immune deficiency, or arthritis secondary to a puncture wound. All patients completed the study.
Intervention:
In addition to antibiotic therapy with intravenous (IV) cefuroxime (150 mg/kg per day in three doses), patients were allocated to IV dexamethasone (0.15 mg/kg per dose every six hours for sixteen consecutive doses) (n = 24) or the same volume of placebo (n = 25).
Main outcome measures:
The primary outcomes were time to clinical (fever, local inflammatory signs, pain, range of movement, and function) and laboratory (erythrocyte sedimentation rate [ESR], WBC count, and C-reactive protein [CRP] concentration) normalization and duration of hospitalization.
Main results:
Compared with the placebo group, patients in the dexamethasone group had shorter durations of fever, local heat, pain, and time until full range of movement (Table). The patients receiving dexamethasone had a shorter time until erythrocyte sedimentation rate and CRP normalization, but the groups did not differ in terms of WBC count (Table). Patients in the dexamethasone group spent a shorter time on IV treatment (Table). The groups were similar in terms of days on oral and antibiotic treatment (Table).
Conclusion:
In children with septic arthritis, the addition of dexamethasone to antibiotic therapy led to less fever, local inflammatory signs, elevated acute phase reactants, and intravenous treatment.
In this small but well-designed randomized trial, Harel and colleagues reported that the addition of IV dexamethasone to antibiotic therapy in the management of septic arthritis in children led to measurably earlier improvements in both laboratory (ESR and CRP) and clinical (fever, pain, and restricted motion) markers of inflammation, with clinically important shorter duration of symptoms, earlier conversion to oral antibiotics, and shorter hospital stays. This study flies in the face of clinicians’ concerns about the known immunosuppressive effects of corticosteroids and the possibility of long-term complications. Rather, the study corroborates the findings of an earlier randomized trial1 and adds to the body of evidence that suggests that the use of corticosteroids might indeed have some benefits in the management of many types of microbial infections2,3. Whether similar benefits might be observed with the use of adjuvant nonsteroidal anti-inflammatory drugs is unknown.
Are these data then sufficient to alter current practice, when comparable outcomes have been demonstrated with shorter (less-than-two-week) courses of antibiotics alone4? This trial was small and the duration of the follow-up was too short to completely reassure clinicians about serious side effects in the shorter or longer term. However, systematic reviews of adjuvant corticosteroid use for microbial infections suggest that short courses of corticosteroids are remarkably safe2. While geographic differences in the bacteriology of septic arthritis, including increasing rates of methicillin-resistant Staphylococcus aureus, might give clinicians some pause, corticosteroids may have their greatest benefits for severe infections with high morbidity2,3.
In conclusion, the addition of parenteral corticosteroids to antibiotic therapy deserves serious consideration for septic arthritis in children.
References
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