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Pablo Yagupsky, Kingella kingae and the Empiric Antibiotic Therapy for Skeletal System Infections, Journal of the Pediatric Infectious Diseases Society, Volume 8, Issue 3, July 2019, Page 284, https://doi.org/10.1093/jpids/piy078
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To the Editor—In a recent report, Shahrestani et al [1] described the rather unusual occurrence of Kingella kingae arthritis of the shoulder in an otherwise healthy 11-year-old child. The case widens the current concept of septic arthritis caused by this emerging pediatric pathogen and shows that, similar to cases of endocarditis, K kingae can invade the skeletal system of a child with no predisposing factors beyond the traditional age group (6 months to 4 years).
The case is also interesting in that the initial clindamycin therapy, administered to cover a presumptive staphylococcal infection, was switched to trimethoprim-sulfamethoxazole once K kingae infection was identified and resulted in full recovery and no functional sequelae. The report suggests that non–β-lactam antimicrobial agents in general, and co-trimoxazole in particular, to which the species is almost always susceptible [2, 3], can be used successfully for management of the disease in an outpatient setting.
However, I am concerned by the authors’ suggestion that amoxicillin can be used empirically for the treatment of children with septic arthritis to cover both K kingae and methicillin-susceptible Staphylococcus aureus in regions in which the incidence of methicillin-resistant S aureus (MRSA) infection is low. Although β-lactamase production is uncommon among invasive strains of K kingae and, thus, the organism is usually susceptible to amoxicillin, the prevalence of the hydrolytic enzyme has been shown to vary widely depending on geographic location; the trait is detected frequently in isolates obtained in Minnesota and Reykjavik (Iceland) and has also been found in France [4, 5]. Because of the fastidious nature of the bacterium, most K kingae infections are diagnosed nowadays by nucleic acid amplification assays without culture isolation; thus, no information on the antibiotic susceptibility of the infecting organism is usually available. Amoxicillin should not be used to treat K kingae infection unless the infecting strain is isolated and the production of β-lactamase is ruled out. Moreover, the prevalence of β-lactamase production in strains of S aureus, disregarding the presence of methicillin resistance (i.e., MRSA strains), approaches 100% worldwide; therefore, amoxicillin is clearly contraindicated for the empiric management of skeletal system infections in children.
