Abstract & Commentary
Synopsis: Short-course (4 days) adjunct dexamethasone therapy for hematogenous suppurative arthritis in children shortened the duration of symptoms during the acute phase and reduced residual dysfunction at the end of therapy, and at 6 and 12 months.Source: Odio CM, et al. Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children.Pediatr Infect Dis J. 2003;22:883-888.
A randomized, double-blind, placebo-controlled trial of short-course dexamethasone therapy as an adjunct to antimicrobial therapy was conducted among children 3 months to 11 years of age with hematogenous suppurative arthritis in Costa Rica from 1998 to 2000. After enrollment, children were randomized 1:1 to receive dexamethasone 0.2 mg/kg/dose intravenously every 8 hours for 12 doses (4 days), or saline of the same volume and regimen. Of 123 children who were enrolled, 50 patients in the control group and 50 patients in the treatment group were evaluable. A pathogen was isolated from all evaluable subjects: Staphylococcus aureus accounted for 67% of isolates, Haemophilus influenzae type b for 13%, and Streptococcus pneumoniae for 9%. All H influenzae type b were susceptible to ampicillin, and all S pneumoniae were susceptible to penicillin. (The study was initiated 2 months before the conjugate H influenzae type b vaccine was available for all of Costa Rica.)
Dexamethasone and placebo patients had a normal CRP at 2.04 ± 1.25 days and 4.68 ± 6.23 days of therapy, respectively (P = .01), and resolution of fever, pain, and limitation of range of motion of the joint at 2.3 ± 6.1 days and 7.8 ± 2.0 days, respectively (P = .001). The duration of intravenous/oral antibiotics was 7.2 ± 1.2/7.2 ± 2.5 days for dexamethasone patients, and 10 ± 5.6/9 ± 2.6 days for placebo patients. The number of arthrocenteses and arthrotomies was similar. Bone involvement documented by bone scan was documented in 6 dexamethasone and 6 placebo patients.
At the end of antimicrobial treatment, 2 dexamethasone patients had residual dysfunction, compared to 16 placebo patients with dysfunction (P < .001). At 12 months, 1 dexamethasone patient had residual hip dysfunction with impaired angles of movement, limping, and shortening (2 cm) of the affected extremity. In contrast, 13 placebo patients (P < .001) had residual joint dysfunction—12 patients with hip involvement with impaired angles of movement including 6 with limping and 5 with shortening of the affected extremity, and 1 patient with impaired angles of movement, limping, and pain.
Comment by Hal B. Jenson, MD, FAAP
A short course of dexamethasone, combined with traditional antibiotic treatment, significantly shortened the duration of inflammatory symptoms associated with microbiologically confirmed hematogenous suppurative arthritis and reduced residual joint dysfunction in children at the end of treatment, at 6 months, and at 12 months. The incidence of residual dysfunction in the placebo patients was 26%, similar to the incidence of 23% that has been previously reported.
The short-term benefits of dexamethasone in reducing signs of inflammation, especially fever, and in facilitating symptomatic improvement is not unexpected. More importantly, the long-term (at least at 12 months) benefit of adjunct dexamethasone in reducing residual joint dysfunction is an important new finding. This study suggests a benefit of early anti-inflammatory treatment to mitigate the additional damaging effects of inflammation, reducing inflammation until the bactericidal effect of the antibiotic therapy becomes established. The actual mechanism of this effect, if confirmed, remains to be elucidated.
This was a small study of 100 patients among children all younger than 12 years of age. The benefits suggested by this study need to be replicated among a larger group of children and also among adults. Additional studies of hematogenous suppurative arthritis should include measurements of cytokines in serum and synovial fluid as a marker of the inflammatory response. Nevertheless, this study poses an interesting finding that may have an effect, if confirmed in larger trials, on the routine management of hematogenous suppurative arthritis in children.
Dr. Jenson, Chair, Department of Pediatrics, Director, Center for Pediatric Research, Eastern Virginia Medical School and Children’s Hospital of the King’s Daughters, Norfolk, VA