Delay to diagnosis in childhood bone and joint infection

To determine the proportion of delayed diagnosis among cases of acute childhood bone and joint infection (BJI) and examine the impact of delayed diagnosis on illness trajectory.

A retrospective review was undertaken of patients <16 years with acute haematogenous osteomyelitis (AHO) or septic arthritis (SA) treated in the Auckland region from 2018-2023. Electronic case information was used to identify any alternative diagnosis given prior to identification of BJI (delayed disease recognition). Cases were grouped into the following subtypes: multifocal sepsis or shock, "isolated" AHO or SA, or contiguous local infection such as pyomyositis and subperiosteal abscess. Primary outcomes included length of stay (LOS) and hospitalisation cost.

A total of 563 cases of childhood BJI were identified, of whom 512 had clearly documented presenting complaint. A high proportion received an alternative initial diagnosis (43%). Alternatively diagnosed children were more likely to have attended primary or urgent care (82% vs 38%, p=0.00001) and have a recent viral illness (46% vs 34%, p=0.008). Receiving alternative diagnosis was associated with greater delay to treatment (7.8 vs 4 days, p=<0.00001). Contiguous local infection was more likely in children with >1 week of symptoms (34% vs 17%, p=0.002). Contiguous infection required more surgical intervention, longer LOS and higher hospitalisation cost when compared to isolated AHO.

Delayed recognition of childhood AHO and SA is common and is associated with delayed treatment. Symptoms present for >1 week are associated with contiguous infection, which, compared with isolated AHO, requires more surgery with increased hospitalisation costs.