The epidemiology of paediatric bone and joint infections from South America is poorly known. We herein report a retrospective study conducted in whole French Guiana from January 2010 to December 2015. Medical charts of 55 previously healthy children were analysed, identifying 27 with osteomyelitis, 22 with septic arthritis and 6 with multifocal infections and/or osteoarthritis. The male:female ratio was 2.2:1, and the mean age was 7.5 years. Eighty percent children were ≥36 months old who had predominantly osteomyelitis related to methicillin-susceptible Staphylococcus aureus (p < 0.05) in the course of neglected skin infections. Five children presented with multi-systemic infections resulting in one fatality, mainly caused by S. aureus producing Panton-Valentine leucocidin (p < 0.01). In contrast, children aged 6–36 months had more likely culture-negative infections (p < 0.05), septic arthritis and mild clinical and biological features. Further prospective studies are required to better guide rational diagnostic and therapeutic strategies.

INTRODUCTION

Bone and joint infections are serious diseases in children that may result in potentially devastating outcomes [1, 2]. Commonly caused by community-acquired methicillin-susceptible Staphylococcus aureus (MSSA) [2, 3], an increased incidence of osteoarticular infections incriminating S. aureus strains producing the Panton-Valentine leucocidin (PVL) has been reported in children over the past decade [4–6]. PVL is a potent necrotizing exotoxin found particularly in primary skin infections [7]. Associated to local extension of deep-seated infections and multisystemic diseases, S. aureus producing PVL is responsible for a substantial morbidity and mortality in paediatrics [4–6, 8].

In contrast, Kingella kingae is a low virulent pathogen recently recognized as the prime cause of osteoarticular infections in children aged 6–36 months in high-income countries [9–11]. Asymptomatically carried in the oropharynx, K. kingae is a significant cause of septic arthritis [12] and less commonly bone infections [13, 14] in young children, who usually display mild to moderate clinical and biological features, making the disease recognition difficult [9, 12]. Reluctant to grow on classical cultures, the detection of this gram-negative bacterium is currently facilitated by the use of specific polymerase chain reaction (PCR) assays [10, 11, 15].

In high-income countries, the reported annual incidence of septic arthritis range from 5 to 37 per 100 000 children [16, 17]. Osteomyelitis account for about 8 of 100 000 children per year [18], but it is substantially more common in low-income areas [18, 19]. Although extensively studied worldwide [11, 16, 19–22], our knowledge of the epidemiology of paediatric bone and joint infections in South America is scarce [23] and this has not been yet studied in French Guiana, a French overseas department located in northeastern Amazonia. Low-income, poor housing communities inhabit this tropical region, especially in wetlands where health infrastructures may be difficult to access and diagnostic microbiology resources are limited. To define the patterns of osteoarticular infections in healthy children living in this tropical area, we conducted a 6 year retrospective study approved by the Andrée Rosemon Hospital institutional review board in Cayenne, French Guiana.

MATERIALS AND METHODS

Inclusion and exclusion criteria. From January 2010 to December 2015, we included all consecutive patients aged 6 months to 18 years old with osteoarticular infections admitted in the three tertiary referral hospitals in French Guiana, localized in Cayenne, Kourou and Saint-Laurent-du-Maroni (Supplemental Figure). Medical records of 74 children with bone and joint infections were gathered, and of those, we excluded patients with underlying illness such as immunodeficiency (n = 2) and sickle cell anaemia (n = 17).

Data extraction. We collected information on patient demographics, clinical presentation, hospital course, laboratory and microbiological findings, radiological studies and clinical follow-up from the medical chart databases using Epidata 3.1.

Statistical analysis. Categorical variables were compared with the Student’s t-test or Fisher exact test. All analyses were two-tailed and p < 0.05 was considered to denote significant differences.

RESULTS

Clinical features

Our case series included 55 previously healthy children who were admitted for osteoarticular infections including 22 children with septic arthritis, 27 with a single site of osteomyelitis and 6 with multifocal infections and/or osteoarthritis (Table 1). There were 38 boys and 17 girls (male:female ratio of 2.2:1). The mean age at the time of onset of symptoms was 7.5 years (range, 6 months to 16 years; Fig. 1). Notably, children with septic arthritis were significantly younger than those from other groups. Fever (rectal temperature >38 °C) and functional impairment were present at admission in all children. A portal of entry for infection was found in 24 (44%) children, including penetrating traumas in 21 (38%), dental abscess in 2 and peritonsillar abscess in 1 (Table 1). Twelve (22%) children had undergone prior antibiotic treatment, including two who were hospitalized in the previous month. All children underwent imaging investigations, including radiography, ultrasonography and/or magnetic resonance imaging. The lower limb was affected in 48 (87%) children, involving mainly hips and knees (Fig. 2).

Fig. 1.

Age distribution of 55 children with bone and joint infections from French Guiana, 2010–2015.

Fig. 1.

Age distribution of 55 children with bone and joint infections from French Guiana, 2010–2015.

Fig. 2

Skeletal distribution of anatomic sites involved in bone and joint infections among 55 children, French Guiana, 2010–2015.

Fig. 2

Skeletal distribution of anatomic sites involved in bone and joint infections among 55 children, French Guiana, 2010–2015.

Table 1

Demographic, clinical and laboratory characteristics of children with bone and joint infections in French Guiana, 2010–2015

Characteristics Septic arthritisa Osteomyelitisa Multifocal infections Osteoarthritis Total p values 
n = 22 n = 27 n = 6 n = 55 
Mean age, years 5.7 ± 4.6 8.4 ± 4.7 10.0 ± 3.1 7.5 ± 4.7 **0.044 
Male, n (%) 15 (68) 20 (74) 3 (50) 38 (69) NS 
Comorbidities 
 Prematurity, n (%) 1 (5) 1 (4) 1 (17) 3 (5) NS 
 Malnutrition, n (%) 1 (5) 0 (0) 0 (0) 1 (2) NS 
Portal of entry 
 Penetrating traumas, n (%) 8 (36) 11 (38) 2 (33) 21 (38) NS 
 ENT, dental infections, n (%) 1 (5) 0 (0) 2 (33) 3 (5) ***0.028 
Laboratory findings 
 Mean CRP level (mg/l)b 129 ±139 126 ± 93 258 ± 122 140 ± 123 **0.048; ***0.006 
 Mean WBC count (cells/µl)b 16,026 ± 5,896 13,072 ± 8,255 13,000 ± 3,021 14,516 ± 6,684 NS 
Standard cultures 
 Blood cultures, n (%) 22 (100) 27 (100) 6 (100) 55 (100)  
 Positive, n (%) 7 (32) 19 (70) 5 (83) 31 (56) *0.019 
 Bone/joint samples, n (%) 14 (64) 11 (41) 5 (83) 30 (56) NS 
 Positive 10 (71) 9 (82) 4 (80) 23 (77) NS 
 Microorganisms identified, n (%) 11 (50) 21 (78) 5 (83) 37 (67)  
 MSSA, n (%) 5 (46) 19 (90) 3 (60) 27 (73) *0.011 
 PVL-MSSA, n (%) 2 (18) 1 (4) 2 (40) 5 (14) NS 
Streptococcus pyogenes 3 (27) 1 (4) 0 (0) 4 (11) NS 
 Group G Streptococcus 1 (9) 0 (0) 0 (0) 1 (3) NS 
Living place 
 Urban areas, n (%) 16 (73) 14 (52) 3 (50) 33 (60) NS 
 Wetlands, n (%) 6 (27) 13 (48) 3 (50) 22 (40) NS 
 Mean length of hospitalization, days 15.5 ± 10.4 14.0 ± 16.7 31.7 ± 31.8 17.2 ± 13.9 **0.047 
Characteristics Septic arthritisa Osteomyelitisa Multifocal infections Osteoarthritis Total p values 
n = 22 n = 27 n = 6 n = 55 
Mean age, years 5.7 ± 4.6 8.4 ± 4.7 10.0 ± 3.1 7.5 ± 4.7 **0.044 
Male, n (%) 15 (68) 20 (74) 3 (50) 38 (69) NS 
Comorbidities 
 Prematurity, n (%) 1 (5) 1 (4) 1 (17) 3 (5) NS 
 Malnutrition, n (%) 1 (5) 0 (0) 0 (0) 1 (2) NS 
Portal of entry 
 Penetrating traumas, n (%) 8 (36) 11 (38) 2 (33) 21 (38) NS 
 ENT, dental infections, n (%) 1 (5) 0 (0) 2 (33) 3 (5) ***0.028 
Laboratory findings 
 Mean CRP level (mg/l)b 129 ±139 126 ± 93 258 ± 122 140 ± 123 **0.048; ***0.006 
 Mean WBC count (cells/µl)b 16,026 ± 5,896 13,072 ± 8,255 13,000 ± 3,021 14,516 ± 6,684 NS 
Standard cultures 
 Blood cultures, n (%) 22 (100) 27 (100) 6 (100) 55 (100)  
 Positive, n (%) 7 (32) 19 (70) 5 (83) 31 (56) *0.019 
 Bone/joint samples, n (%) 14 (64) 11 (41) 5 (83) 30 (56) NS 
 Positive 10 (71) 9 (82) 4 (80) 23 (77) NS 
 Microorganisms identified, n (%) 11 (50) 21 (78) 5 (83) 37 (67)  
 MSSA, n (%) 5 (46) 19 (90) 3 (60) 27 (73) *0.011 
 PVL-MSSA, n (%) 2 (18) 1 (4) 2 (40) 5 (14) NS 
Streptococcus pyogenes 3 (27) 1 (4) 0 (0) 4 (11) NS 
 Group G Streptococcus 1 (9) 0 (0) 0 (0) 1 (3) NS 
Living place 
 Urban areas, n (%) 16 (73) 14 (52) 3 (50) 33 (60) NS 
 Wetlands, n (%) 6 (27) 13 (48) 3 (50) 22 (40) NS 
 Mean length of hospitalization, days 15.5 ± 10.4 14.0 ± 16.7 31.7 ± 31.8 17.2 ± 13.9 **0.047 
a

Single infection site.

b

Data available for 52 children.

ENT, ear, nose, throat; NS, not significant.

The Student’s t-test or Fisher exact test was used to compare the following categorical variables:

*

septic arthritis and osteomyelitis;

**

septic arthritis and multifocal infections;

***

osteomyelitis and multifocal infections. p values <0.05 were considered to denote significant differences.

Laboratory findings

On admission, serum C-reactive protein (CRP) level and white blood cell (WBC) count were available in 52 children. The CRP level averaged 140 mg/l (range, 0–580 mg/l), was >80 mg/l in 31 (56%) of the children and significantly higher among those with multifocal infections (p < 0.05) (Table 1). The WBC count averaged 14 516 cells/µl (range, 3400–44 000 cells/µl) and was >14 000 cells/µl in 26 (47%) children. CRP level and WBC count were within the normal range in only three (6%) children.

Microbiological results

At least one aerobic and one anaerobic blood culture bottles were obtained for every child. Open or percutaneous surgical drainage, followed by culturing of bone and/or joint specimens, was carried out in 14 (64%) children with septic arthritis, in 11 (41%) with osteomyelitis and in 5 (83%) with multifocal infections (Table 1). The pathogen was identified from classical cultures in 37 (67%) children: in 30 (55%) children from blood cultures and in 23 (77%) from bone and joint specimens. When osteoarticular material was available, the diagnostic yield was improved by identifying the causative microorganism in 7 (64%) of the 11 children with negative blood cultures. The responsible organism isolated was MSSA in 32 (87%) children, Streptococcus pyogenes in 4 and group G Streptococcus in 1. Of the 32 MSSA strains isolated, at least 5 (16%) produced PVL (PVL-MSSA) as detected by immunoprecipitation assays. MSSA was statistically more often isolated from children with osteomyelitis than from those with septic arthritis (p < 0.005).

Antibiotic treatment

Children received an empirical combination antibiotic regimen depending on the local policies including intravenous third-generation cephalosporin, aminoglycosides and fosfomycin for a mean of 10 days (range, 7–14 days) until the time of microbiological results. Then, oral antibiotic treatment with amoxicillin-clavulanate, with or without rifampicin, was administered in the majority of children for a mean of 5 weeks (range, 4–6 weeks).

Multisystemic infections

Five children with a mean age of 7.4 years (range 3–12 years) presented with multisystemic infections (Table 2). Of these, PVL-MSSA strains were isolated in three (60%) children, resulting in local extension of deep-seated infections and higher mean CRP level. When compared with isolates from children of the same age group, PVL-MSSA strains were significantly more often isolated in children with multisystemic infections (p < 0.01). Children with diseases caused by PVL-MSSA were more likely to have multiple sites of bone and joint infections (67%). All presented with cardio-pulmonary complications including severe pleuropneumonia, pericarditis and septic shock, resulting in one fatal case 8 days after the admission. One child presented with bilateral pleuropneumonia and multiple osteomyelitis caused by S. pyogenes in the course of neglected dental infection.

Table 2

Comparative analysis between children with multisystemic infections and those from the same age group (from 3 to 12 years old)

Characteristics Multisystemic infections Same age group p values 
n = 5 n = 40 
Mean age, years 7.4 ± 4.0 9.32 ± 3.88 NS 
Male, n (%) 3 (60) 28 (70) NS 
Systemic manifestations    
 Septic shock, n (%) 2 (40) 0 (0) 0.01 
 Cardio-pulmonary complications, n (%) 4 (80) 0 (0) <0.0001 
 Deep-seated infections, n (%) 3 (60) 0 (0) <0.001 
 Multifocal infections, n (%) 2 (40) 3 (8) NS 
 Aseptic meningitis, n (%) 1 (20) 0 (0) NS 
Portal of entry   NS 
 Penetrating traumas, n (%) 4 (80) 14 (40) NS 
 ENT, dental infections, n (%) 1 (20) 2 (5) NS 
Laboratory findings    
 Mean CRP level (mg/l)a 300 ± 193 143 ± 102 0.006 
 Mean WBC count (cells/µl)a 13,280 ± 6,351 13,625 ± 5,458 NS 
 Microorganisms identified, n (%) 5 (100) 27 (68) NS 
 MSSA, n (%) 1 (20) 22 (82) 0.015 
 PVL-MSSA, n (%) 3 (60) 2 (7) 0.008 
Streptococcus pyogenes 1 (20) 2 (7) NS 
 Group G Streptococcus 0 (0) 1 (4) NS 
Complications   NS 
 Death, n (%) 1 (20) 0 (0) NS 
 Orthopaedic sequelae, n (%) 1 (20) 1 (3) NS 
Lifeplace   NS 
 Urban areas, n (%) 4 (80) 24 (60) NS 
 Wetlands, n (%) 1 (20) 16 (40) NS 
 Mean length of hospitalization, days 34.8 ± 33.4 16.3 ± 9.2 0.006 
Characteristics Multisystemic infections Same age group p values 
n = 5 n = 40 
Mean age, years 7.4 ± 4.0 9.32 ± 3.88 NS 
Male, n (%) 3 (60) 28 (70) NS 
Systemic manifestations    
 Septic shock, n (%) 2 (40) 0 (0) 0.01 
 Cardio-pulmonary complications, n (%) 4 (80) 0 (0) <0.0001 
 Deep-seated infections, n (%) 3 (60) 0 (0) <0.001 
 Multifocal infections, n (%) 2 (40) 3 (8) NS 
 Aseptic meningitis, n (%) 1 (20) 0 (0) NS 
Portal of entry   NS 
 Penetrating traumas, n (%) 4 (80) 14 (40) NS 
 ENT, dental infections, n (%) 1 (20) 2 (5) NS 
Laboratory findings    
 Mean CRP level (mg/l)a 300 ± 193 143 ± 102 0.006 
 Mean WBC count (cells/µl)a 13,280 ± 6,351 13,625 ± 5,458 NS 
 Microorganisms identified, n (%) 5 (100) 27 (68) NS 
 MSSA, n (%) 1 (20) 22 (82) 0.015 
 PVL-MSSA, n (%) 3 (60) 2 (7) 0.008 
Streptococcus pyogenes 1 (20) 2 (7) NS 
 Group G Streptococcus 0 (0) 1 (4) NS 
Complications   NS 
 Death, n (%) 1 (20) 0 (0) NS 
 Orthopaedic sequelae, n (%) 1 (20) 1 (3) NS 
Lifeplace   NS 
 Urban areas, n (%) 4 (80) 24 (60) NS 
 Wetlands, n (%) 1 (20) 16 (40) NS 
 Mean length of hospitalization, days 34.8 ± 33.4 16.3 ± 9.2 0.006 
a

Data available for 38 children.

ENT, ear, nose, throat; NS, not significant. Categorical variables were compared with the Student’s t-test or Fisher exact test. Only p values ≤0.05 were considered to denote significant differences.

Possible K. kingae infections

Strikingly, we found a statistically significant higher incidence of culture-negative osteoarticular infections among children aged 6–36 months (p < 0.05) (Table 3). Of the 11 children from this age group, culture-negative bone and joint infections were observed in 7 (64%), whereas in the 44 older children, cultures failed to detect the pathogen in only 11 (25%). Of the seven children aged 6–36 months with unidentified pathogen, five (71%) presented with septic arthritis involving the knee in two children and the hip, the glenohumeral joint and the wrist in one each. The two remaining children presented with uncomplicated L4-L5 spondylosdiscitis and osteomyelitis of the tibia in one each. At initial presentation, the CRP level averaged 36 mg/l (range, 8–76 mg/l), which was drastically lower compared with that of our series (p < 0.01) and that of the same age group infected by MSSA and S. pyogenes (Table 3). All experienced a benign clinical course with classical empirical antibiotic therapy regimens.

Table 3

Comparative analysis between children aged 6–36 months and older patients in our study population, French Guiana, 2010–2015

Characteristics <36 months with culture- negative infections <36 months with culture- positive infections ≥36 months p values 
n = 7 n = 4 n = 44 
Mean age 14.6 ± 6.5a 14.3 ± 9.6a 9.1 ± 3.9b  
Male, n (%) 3 (43) 4 (100) 31 (71) ##0.018 
Comorbidities 
 Prematurity, n (%) 0 (0) 1 (25) 2 (5) NS 
 Malnutrition, n (%) 0 (0) 0 (0) 1 (2) NS 
Portal of entry 
 Penetrating traumas, n (%) 1 (14) 3 (75) 17 (39) NS 
 ENT, dental infections, n (%) 0 (0) 0 (0) 3 (68) NS 
Laboratory findings 
 Mean CRP level (mg/l) 36 ± 27 83 ± 104 163 ± 125* ##0.007 
 Mean WBC count (cells/µl) 15,814 ± 2,710 21,000 ± 16,561 13,680 ± 5,510* NS 
Standard cultures 
 Blood cultures, n (%) 7 (100) 4 (100) 44 (100) NS 
 Positive, n (%) 0 (0) 3 (75) 27 (61) NS 
 Bone/joint samples, n (%) 1 (14) 3 (75) 26 (59) NS 
 Positive 0 (0) 1 (33) 20 (77) NS 
 Microorganisms identified, n (%) 0 (0) 4 (100) 33 (75) ##0.028 
 MSSA, n (%) 0 (0) 3 (75) 24 (74) #0.024 
 PVL-MSSA, n (%) 0 (0) 0 (0) 5 (15) NS 
Streptococcus pyogenes 0 (0) 1 (25) 3 (9) NS 
 Group G Streptococcus 0 (0) 0 (0) 1 (3) NS 
Living place 
 Urban areas, n (%) 4 (57) 2 (50) 3 (61) NS 
 Wetlands, n (%) 3 (43) 2 (50) 17 (39) NS 
 Mean length of hospitalization, days 9.7 ± 7.2 14.5± 5.8 18.5 ± 14.8 NS 
Characteristics <36 months with culture- negative infections <36 months with culture- positive infections ≥36 months p values 
n = 7 n = 4 n = 44 
Mean age 14.6 ± 6.5a 14.3 ± 9.6a 9.1 ± 3.9b  
Male, n (%) 3 (43) 4 (100) 31 (71) ##0.018 
Comorbidities 
 Prematurity, n (%) 0 (0) 1 (25) 2 (5) NS 
 Malnutrition, n (%) 0 (0) 0 (0) 1 (2) NS 
Portal of entry 
 Penetrating traumas, n (%) 1 (14) 3 (75) 17 (39) NS 
 ENT, dental infections, n (%) 0 (0) 0 (0) 3 (68) NS 
Laboratory findings 
 Mean CRP level (mg/l) 36 ± 27 83 ± 104 163 ± 125* ##0.007 
 Mean WBC count (cells/µl) 15,814 ± 2,710 21,000 ± 16,561 13,680 ± 5,510* NS 
Standard cultures 
 Blood cultures, n (%) 7 (100) 4 (100) 44 (100) NS 
 Positive, n (%) 0 (0) 3 (75) 27 (61) NS 
 Bone/joint samples, n (%) 1 (14) 3 (75) 26 (59) NS 
 Positive 0 (0) 1 (33) 20 (77) NS 
 Microorganisms identified, n (%) 0 (0) 4 (100) 33 (75) ##0.028 
 MSSA, n (%) 0 (0) 3 (75) 24 (74) #0.024 
 PVL-MSSA, n (%) 0 (0) 0 (0) 5 (15) NS 
Streptococcus pyogenes 0 (0) 1 (25) 3 (9) NS 
 Group G Streptococcus 0 (0) 0 (0) 1 (3) NS 
Living place 
 Urban areas, n (%) 4 (57) 2 (50) 3 (61) NS 
 Wetlands, n (%) 3 (43) 2 (50) 17 (39) NS 
 Mean length of hospitalization, days 9.7 ± 7.2 14.5± 5.8 18.5 ± 14.8 NS 
*

Data available for 42 children aMean age indicated in months bMean age indicated in years.

ENT, Ear, nose, throat; CRP, C-reactive protein; WBC, White blood cells; MSSA, methicillin-susceptible Staphylococcus aureus; PVL-MSSA, MSSA strains producing the Panton-Valentine leukocidin.

The Student’s t-test or Fisher exact test were used to compare the following categorical variables: #children <36 months with culture-negative and culture-positive infections; ##children <36 months and those ≥36 months. p values  <0.05 were considered to denote significant differences; NS, indicates not significant.

Clinical course

The mean duration of hospital stay was 17 days (range, 1–89 days) and was significantly higher in children with multifocal infections (p < 0.05) (Table 1). The duration of the follow-up was available in 23 (40%) children and averaged 47 days (range, 4 days to 13 months). During this period, no recurrence of infection was reported, but three children experienced orthopaedic sequelae including joint stiffness, chronic joint pain and limb length discrepancy in one each. Of these three, two children presented with infections caused by PVL-MSSA (Table 2).

DISCUSSION

As far as we are aware, this is the first review depicting the spectrum of paediatric bone and joint infections in northeastern South America and Caribbean. Our findings revealed various disease patterns that differ depending on the patient age, the clinical syndrome, the patient living place and the causative pathogen. We herein demonstrated that MSSA was the prime cause of osteomyelitis in French Guiana, especially among children >3 years old who composed 80% of our study population. Paralleling numerous studies, we showed that the lower limbs in boys were most commonly involved.

Overall, we found an excessive rate of children with osteomyelitis and skin infections following prior penetrating traumas, notably in those living in peri-urban areas and wetlands along the Maroni and Oyapock Rivers. These territories concentrate on disadvantaged and poverty-stricken communities [24], in which the access to health services often involves walking or navigating several hours, or in some districts, several days. Together with the poor recognition of osteoarticular infections at an early stage, delays in presentation and neglected skin infections may explain the significant high rates of children who presented with advanced diseases, resulting in increased inflammatory markers and positive blood cultures on admission.

Unexpectedly, this study revealed a significant incidence of children with multisystemic infections associated to community-acquired PVL-MSSA, especially in children from urban areas where close contact may have facilitated the spread of virulent strains [7, 25]. PVL-MSSA, notoriously associated to skin infections, exhibited enhanced virulence and invasiveness that promoted toxic manifestations [5, 6, 8], deep-seated infections, marked inflammatory response and disseminated diseases [4, 6, 7] resulting in one fatality. We point out that no methicillin-resistant S. aureus was isolated, in contrast to emerging trends worldwide [4, 5, 7, 25]. These findings stress the need for revising our current diagnostic method strategies and empirical antibiotic therapy policies in children >3 years old with deep skin infections, for who the systematic search for S. aureus producing PVL and empirical antibiotic regimen including clindamycin should be considered [4, 6, 7].

To date, K. kingae infections have been identified in North America [26, 27], Europe [11, 14, 28], Israel [9, 29], Australia [22] and New Zealand [21], but to the best of our knowledge, none have been reported in South America. During the study period, we discovered that K. kingae is carried asymptomatically in the oropharynx of children from 6 to 36 months originary from French Guiana and Haiti (N. El Houmami, unpublished results), therefore indicating that K. kingae circulates in South America and Caribbean. Paralleling K. kingae infections, we significantly found the highest rates of culture-negative infections and septic arthritis in the youngest children of our series. In addition, these patients displayed subtle clinical manifestations, mild inflammatory response and healed with no sequelae after receiving classical antibiotic regimens [9]. Taken together with the involvement of atypical anatomic sites such as the wrist [12] and lumbar spine [13], we postulate that some of these children have more likely experienced K. kingae infections, usually missed in facilities lacking specific K. kingae real-time PCR assays [9, 14, 15]. Early microbiologically proven diagnosis of K. kingae infections would enable to decrease the length of hospital stay, to provide appropriate antibiotic therapy by amoxicillin [9] or amoxicillin-clavulanate [30], and to drastically reduce the total treatment duration from 10 to 20 days [18]. However, the accurate identification of K. kingae requires expensive diagnostic tools not available in low-income regions, which explains the difficulties to confirm K. kingae infections in these localities. An alternative diagnostic strategy illustrated by the seeding of synovial fluids and bone exudates in blood culture vials showed that this culture method enabled to recover K. kingae in one-half of specimens [16]. Although less efficient than real-time PCR assays [31], this alternative method could be considered in facilities lacking molecular assays.

This study highlights the importance of accurate identification of microorganisms in paediatric bone and joint infections, emphasizing the need for improved diagnostic methods, enhanced awareness of clinicians, as well as better surveillance and reporting systems. Early recognition of diseases associated to S. aureus producing PVL is required to promptly administer appropriate antibiotics and maintain vigilance against possible severe complications or sequelae. Although we failed to confirm K. kingae infections, we found clinical and laboratory evidence suggesting that this organism might also contribute to the burden of bone and joint infections in French Guiana, and that its causative role is probably underestimated in early childhood. Further prospective studies to specify the prevalence of S. aureus producing PVL and K. kingae carriage in children living in French Guiana are required to better help guiding rational diagnostic and therapeutic strategies.

ACKNOWLEDGEMENTS

We thank Dr John Balcaen for his technical support.

FUNDING

This work was partially supported by funding from the Méditerranée Infection Foundation. We also acknowledge the support of the A*MIDEX project (no ANR-11-IDEX-0001-02) funded by the Investments for the the Future programme of the French National Research Agency (ANR).

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Author notes

*
These authors are first co-authors

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