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From the Centers for Disease Control and Prevention
July 7, 2004

Brief Report:

JAMA. 2004;292(1):34. doi:10.1001/jama.292.1.34

MMWR. 2004;53:244

Kingella kingae is recognized increasingly as a cause of skeletal infections in children.1 Recent studies indicate that direct inoculation of clinical specimens into aerobic blood culture bottles (ABCBs), instead of direct plating of specimens on solid media, might improve recovery of the fastidious bacteria.2,3 Prompted by a report of a possible cluster of osteoarticular infections caused by K. kingae among children, the Infectious Diseases Society of America Emerging Infections Network (IDSA-EIN) surveyed pediatric infectious disease consultants (PIDCs) about their experiences in diagnosing K. kingae and other skeletal infections in children. This report summarizes the findings of that survey, which identified 23 K. kingae pediatric cases and indicated that 35% of responding PIDCs did not use ABCBs in diagnosing skeletal infections. Efforts to increase use of ABCBs among clinicians and laboratorians might lead to increased detection of K. kingae cases.

In November 2002, a questionnaire was distributed to PIDCs in IDSA-EIN. This query aimed to (1) identify the diagnostic approaches of PIDCs in evaluating skeletal infections in children and (2) determine the number of cases and types of infections attributed to K. kingae diagnosed by these physicians during June 2001–November 2002. Of 254 PIDCs surveyed, 156 (61%) responded.

During June 2001–November 2002, PIDCs diagnosed skeletal infections, including septic arthritis, osteomyelitis, diskitis, tenosynovitis, and dactylitis, in 1,908 patients aged <5 years. For these cases, 56 (43%) PIDCs reported no organism found in ≤25% of their cases, 43 (33%) in ≤50% of their cases, and 24 (18%) in >50% of their cases. Eighteen (12%) PIDCs diagnosed 23 cases of K. kingae infection: septic arthritis (12), osteomyelitis (nine), endocarditis (one), and bacteremia (one). Median age of patients was 2.3 years (range: 0.5-10.0 years); no K. kingae case clusters were reported. At diagnosis, four persons had upper respiratory tract infections, and one had stomatitis.

When diagnosing skeletal infections, the majority (97 [62%]) of PIDCs requested that specimens be inoculated into ABCBs for some (55 [35%]) or all (42 [27%]) of their cases; 55 (35%) PIDCs never made that request. The most common specimens inoculated into ABCBs were synovial fluid (78 [80%]) and bone aspirate (49 [51%]). Of those using ABCBs, 53 (54%) had been making this request for <5 years. Of all respondents, 89 (57%) were aware that use of ABCBs might improve isolation of this organism and subsequent identification. PIDCs reported several barriers to use of ABCBs in diagnosing skeletal infections, including (1) specimens obtained for diagnosis commonly being taken before consulting PIDCs and (2) laboratories being unwilling to perform requested tests.

This survey identified 23 K. kingae pediatric cases; the majority (91%) of infections were either septic arthritis or osteomyelitis. When diagnosing skeletal infections, 43% of PIDCs reported that no organism was found in <25% of cases; 38% of PIDCs did not use ABCBs for recovery of K. kingae. Several studies have indicated that commercial blood-culture systems improve the recovery of K. kingae from synovial fluid.2,3 Increased use of ABCBs might reveal K. kingae to be a more common cause of skeletal infections. Educational efforts to improve the selection of diagnostic methods for infectious diseases should be targeted not only to infectious disease consultants but also to clinical microbiology laboratorians and those physicians most likely to obtain specimens (e.g., orthopedic surgeons for skeletal infections).

Reported by:

Infectious Diseases Society of America Emerging Infections Network. L Strausbaugh, MD, L Liedtke, MS, Veterans Affairs Medical Center and Oregon Health and Science Univ, Portland, Oregon. J Hageman, MHS, A Khaw, MD, D Jernigan, MD, Div of Healthcare Quality Promotion, National Center for Infectious Diseases, CDC.

References
1.
Lundy DW, Kehl DK. Increasing prevalence of Kingella kingae in osteoarticular infections in young children.  J Pediatr Orthop.1998;18:262-7.
2.
Yagupsky P, Dagan R, Howard CW, Einhorn M, Kassis I, Simu A. High prevalence of Kingella kingae in joint fluid from children with septic arthritis revealed by the BACTEC blood culture system.  J Clin Microbiol.1992;30:1278-81.
3.
Host B, Schumacher H, Prag J, Arpi M. Isolation of Kingella kingae from synovial fluids using four commercial blood culture bottles.  Eur J Clin Microbiol Infect Dis.2000;19:608-11.
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