Pediatric hospitalists are very comfortable with prescribing steroids for asthma exacerbations and croup; however, whether steroids should be used to treat septic arthritis remains a mystery. The high risk of rapid joint destruction puts pediatric hospitalists on high alert to start treatment urgently and involve a multidisciplinary team. Knowing that early joint destruction is caused by inflammation, the use of steroids to minimize these effects makes intuitive sense; however, there is additional complexity of possibly decreasing the immune response to a bacterial infection and masking symptoms that warrant further intervention.
There is a current paucity of literature to answer this conundrum, and in fact the Pediatric Infectious Disease Society and Infectious Disease Society of America conditionally recommend against using steroids due to lack of research showing definitive benefit. In the article, “Intravenous Dexamethasone Use and Outcomes in Children Hospitalized with Septic Arthritis,” Kern-Golfberger et al. seek to better understand the role of steroids in septic arthritis.
The objectives of this study were to describe variation in intravenous (IV) dexamethasone use and evaluate the association of its use with outcomes. The multicenter retrospective cohort study using the Pediatric Health Information System describes significant variation in dexamethasone use, with 31.5% of the total 3524 patients receiving IV dexamethasone within 0-2 days of admission. Between the 47 hospitals included, practice ranged anywhere from 0 to 60% of cases receiving IV dexamethasone. Data showed a 13.8 hour decrease in hospital length of stay in the group receiving IV dexamethasone with lower cost per admission and without increasing the odds of 30-day readmission, repeat procedures, or repeat imaging. This study argues that there may be benefit of using IV dexamethasone without increasing the risk of rebound infections or short-term complications.
Interestingly, Woods et al. have responded to this study in their commentary emphasizing that joint dysfunction after an episode of septic arthritis cannot fully be evaluated without a 12-month follow-up, and decreasing length of stay without acute complications does not provide information on long-term joint mobility. Authors of this commentary are part of the panel that established the current guideline and discuss why this study does not warrant changing clinical practice that currently limits severe complications to about 1%.
As hospitalists, we should ask ourselves whether this reinforces dexamethasone use for those already prescribing it or potentially changes practice for those of us who do not currently use it. We may agree more with the commentary that benefit does not outweigh the risks and long-term unknown. In either case, further studies will be helpful to provide clarity to optimize the care of septic arthritis and this study has begun to answer this complicated question.
