Corticosteroids for septic arthritis in children

Abstract

Background: Septic arthritis is an acute infection of the joints characterised by erosive disruption of the articular space. It is the most common non-degenerative articular disease in developing countries. The most vulnerable population for septic arthritis includes infants and preschoolers, especially boys. Septic arthritis disproportionately affects populations of low socioeconomic status. Systemic corticosteroids and antibiotic therapy may be beneficial for treatment of septic arthritis. Even if the joint infection is eradicated by antibiotic treatment, the inflammatory process may produce residual joint damage and sequelae.

Objectives: To determine the benefits and harms of corticosteroids as adjunctive therapy in children with a diagnosis of septic arthritis.

Search methods: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, Latin American Caribbean Health Sciences Literature (LILACS), the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/), ClinicalTrials.gov (www.ClinicalTrials.gov), and Google Scholar. We searched all databases from their inception to 17 April 2018, with no restrictions on language of publication.

Selection criteria: We included randomised controlled trials (RCTs) with patients from two months to 18 years of age with a diagnosis of septic arthritis who were receiving corticosteroids in addition to antibiotic therapy or as an adjuvant to other therapies such as surgical drainage, intra-articular puncture, arthroscopic irrigation, or debridement.

Data collection and analysis: Two review authors independently assessed eligibility, data extraction, and evaluation of risk of bias. We considered as major outcomes the presence of pain, activities of daily living, normal physical joint function, days of antibiotic treatment, length of hospital stay, and numbers of total and serious adverse events. We used standard methodological procedures expected by Cochrane. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table.

Main results: We included two RCTs involving a total of 149 children between three months and 18 years of age who were receiving antibiotics for septic arthritis. The most commonly affected joints were hips and knees. These studies were performed in Costa Rica and Israel. In both studies, dexamethasone administered intravenously (ranging from 0.15 to 0.2 mg/kg/dose every six to eight hours) during four days was the corticosteroid, and the comparator was placebo. Trials excluded patients with any degree of immunodeficiency or immunosuppression. The longest follow-up was one year. Trials did not report activities of daily living nor length of hospital stay. Both studies used adequate processes for randomisation, allocation concealment, and blinding, and review authors judged them to have low risk of selection and performance bias. Losses to follow-up were substantive in both studies, and we judged them to have high risk of attrition bias and of selective outcome reporting. We graded all outcomes as low quality due to concerns about study limitations and imprecision.The risk ratio (RR) for absence of pain at 12 months of follow-up was 1.33, favouring corticosteroids (95% confidence interval (CI) 1.03 to 1.72; P = 0.03; number needed to treat for an additional beneficial outcome (NNTB) = 13, 95% CI 6 to 139; absolute risk difference 24%, 95% CI 5% to 43%).The RR for normal function of the affected joint at 12 months of follow-up was 1.32, favouring corticosteroids (95% CI 1.12 to 1.57; P = 0.001; NNTB = 13, 95% CI 7 to 33; absolute risk difference 24%, 95% CI 11% to 37%).We found a reduction in the number of days of intravenous antibiotic treatment favouring corticosteroids (mean difference (MD) -2.77, 95% CI -4.16 to -1.39) based on two trials with 149 participants.Researchers did not report length of hospital stay. One trial (49 participants) reported that treatment with dexamethasone was associated with a shorter duration of IV antibiotic treatment, leading to a shorter hospital stay, and although duration of hospitalisation was a primary outcome of the study, study authors did not provide data on the duration of hospitalisation. We downgraded the quality by one level for concerns about study limitations (high risk of attrition bias and selective reporting), and by another level for imprecision.In one trial of 49 participants, researchers followed 29 children for 12 months, and parents reported that no children demonstrated adverse effects of the intervention.

Authors' conclusions: Evidence for corticosteroids as adjunctive therapy in children with a diagnosis of septic arthritis is of low quality and is derived from the findings of two trials (N = 149). Corticosteroids may increase the proportion of patients without pain and the proportion of patients with normal function of the affected joint at 12 months, and may also reduce the number of days of antibiotic treatment. However, we cannot draw strong conclusions based upon these trial results. Additional randomised clinical trials in children with relevant outcomes are needed.

1

Study flow diagram.

2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

1.1. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 1 Pain ‐ absence of pain.

1.2. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 2 Pain ‐ number of days until pain free.

1.3. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 3 Number of participants with normal physical joint function ‐ number of days until normal function of the joint.

1.4. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 4 Number of participants with normal physical joint function ‐ number of days until full range of movement.

1.5. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 5 Number of participants with normal physical joint function ‐ normal function at the end of treatment (short term).

1.6. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 6 Number of participants with normal physical joint function ‐ normal function at 6 months of follow‐up (medium term).

1.7. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 7 Number of participants with normal physical joint function ‐ normal function at 12 months of follow‐up (long term).

1.8. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 8 Number of participants with normal physical joint function ‐ number of days until resolution of symptoms.

1.9. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 9 Number of days of antibiotic treatment ‐ number of days of intravenous antibiotic treatment.

1.10. Analysis

Comparison 1 Corticosteroids versus placebo, Outcome 10 Number of days of antibiotic treatment ‐ number of total days of antibiotic treatment.