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Septic Arthritis
From WikiSM
Contents
Other Names
- Infectious Arthritis
- Bacterial Arthritis
- Infected Joint
Background
- This page refers to septic arthritis (SA) of all joints
History
Epidemiology
- Estimated case fatality rate of 11%[1]
- More than 50% of cases involve the knee (need citation)
- Incidence ranges widely, between 4 and 29 cases per 100,000 person-years [2]
Pathophysiology
- Etiology
- Bacteremia and hematogenous spread most common[3]
- Direct inoculation from trauma, surgery
- Local contiguous spread such as osteomyelitis
- Etiology
- Penetrating trauma can seed the joint, causing SA[4]
- Affected joint
- Effects on joint
- Irreversible cartilage destruction begins as early as 8 hours
Organisms
- Staphylococci aureus, streptococcus pyogenes (group A)
- Account for up to 91% of cases[8]
- Gram negative organisms (E. coli, klebsiella, enterobacter)
- More common in older adults, immunocompromised patients
- Neisseria Gonorrhea
- Accounts for about 20%, seen in young sexually active adults, may have associated dermatitis
- Tenosynovial, seen in hands, wrists and ankles
- Associated with terminal complement deficiency
- Propionibacterium acnes
- Can be seen following shoulder surgery
- Sickle Cell Disease
- Consider Salmonella or Streptococcus pneumoniae
- Bartonella henselae
- Associated with HIV
- Eikenella corrodens
- Seen in human bites
- Fungal/candida
- Consider in immunocompromised host
- Cat or dog bite
- Typically hands, fingers
- Bugs: Pasteurella multocida or Capnocytophaga species
- Mycobacterium marinum
- Seen in small joints such as hand, fingers.
- Associated with cleaning fish tank[9]
- Brucella species
- Associated with consumption of unpasteurized dairy products[10]
- Often monoarticular, affects sacroiliac joint
- Pseudomonas aeruginosa
- Associated with IV drug abuse (IVDA), nail through shoe
- Coccidioides immitis
- Regional: Southwestern United States, Central and South America
- Patients typically have a primary respiratory illness, knee most commonly affected
- Blastomyces dermatitidis
- Found in soil, dust containing decomposed wood
- Regional: north-central and southern United States
- Monoarticular: knee, ankle, or elbow
- Systemic Lupus Erythematosus
- Consider: N. gonorrhoeae, Proteus species, Salmonella species
Risk Factors
- Social/ Demographic risks
- Alcoholism and liver cirrhosis
- Low socioeconomic status
- Intravenous drug abuse (IVDA)
- Age > 80
- Systemic risks
- Diabetes Mellitus
- HIV
- Immune suppression medications
- Sexual activity
- Inflammatory/ Autoimmune
- Dermatologic
- Skin and soft tissue infections[11]
- Cutaneous ulcers
- Orthopedic
- Osteoarthritis
- Recent intra-articular surgery[12]
- History of intra-articular Corticosteroid Injection[13]
- History of prosthetic joint
Differential Diagnosis
- Extra-articular
- Degenerative
- Autoimmune/ Inflammatory
- Gout
- Psuedogout
- Rheumatoid Arthritis
- Behçet syndrome
- Sarcoid
- Systemic Lupus Erythematosus
- Still disease
- Seronegative spondyloarthropathy (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis, inflammatory bowel disease–related arthritis)
- Systemic vasculitis
- Systemic Infection
- Bacterial Endocarditis]]
- Human Immunodeficiency Virus
- Other
- Pigmented Villonodular Synovitis
- Amyloidosis
- Avascular Necrosis
- Coagulopathy
- Familial Mediterranean fever
- Foreign body
- Fracture
- Hemarthrosis
Clinical Features
- History
- Classically, patients will present with a hot, swollen and tender joint
- Range of motion is restricted
- Duration of symptoms is typically <2 weeks
- Longer more insidious presentations can be seen with low virulence organisms, tuberculosis, prosthesis infection[14]
- Large joints are more commonly affected than small joints
- Constitutional symptoms (sensitivity): fever (57%), chills (27%), or rigors (19%)[15]
- When septic arthritis is a consideration, risk factors should be careful considered
- Physical Exam
- Important to distinguish peri-articular (i.e. prepatellar bursitis) vs intra-articular
- Inspection: erythema, effusion, extremity in position of comfort
- Palpation: warmth, tenderness
- ROM: restricted
- Gait: unable to ambulate or bear weight
- Special Tests
Evaluation
Arthrocentesis and Synovial Fluid Analysis
- Arthrocentesis of the affected joint should be performed promptly
- Gold standard for diagnostic evaluation
- Synovial fluid labs which should routinely be ordered when evaluating for SA
- Culture and gram stain
- Culture
- Cell count
- Protein and glucose
- Crystal analysis
- Synovial lactate
- General
- Fluid may appear cloudy or even purulent
- See also: Synovial Fluid Analysis
- Gram stain
- Only positive in 50% of cases
- Culture
- More sensitive than gram stain alone
- Neisseria Gonnorrhea organisms do not culture well
- Strongly consider injecting synovial fluid into blood culture bottles
- Synovial white cell count
- Coutlakis et al: >50,000/mm3: 47% of cases; >100,000/mm3: 76% of cases[16]
- < 50,000/mm3 have a low likelihood of infection, but it is not entirely excluded
- >1,100/mm3 in prosthetic joint is considered SA
- PMN > 90% often seen
- Low WBC seen with: gonococcal disease, peripheral leukopenia, or joint replacement[17]
- Glucose
- Reportedly less than 60% of normal
- Diagnostic value has been called into question[18]
- Crystal analysis
- SA can co-exist with crystal arthropathies, presence of crystals does not exclude SA[19]
- PCR
- May be useful to isolate uncommon organisms
Serology
- WBC
- Typically elevated with left shift
- Bands may be present
- ESR (erythrocyte sedimentation rate)
- Typically elevated, can be normal
- Can trend with treatment
- CRP (C reactive protein)
- Typically elevated, can be normal, more useful than ESR
- Can trend with treatment
- Blood culture
- Positive in 25-50% of patients with SA[20]
- No evidence for diagnostic value
- Tumour necrosis factor a </ref name="ref1">
- Interleukin 6
- Interleukin 8
Saline Load Test
- Can be used to determine if wound communicates with joint
- 175 mL is 99% sensitive (need citation)
Radiography
- Obtain radiographs of affected joint
- Mainly useful to exclude other pathology
- Potential findings
- Joint space widening
- Effusion
- Periarticular osteopenia
Ultrasound
- Helpful to confirm presence or absence of joint effusion
- Useful to guide arthrocentesis
MRI
- Potential findings
- Joint effusion
- Involvement of bone (osteomyelitis)
Classification
- No formal classification system
- Sometimes broken down into Nongonococcal and gonococcal arthritis
Management
Prognosis
- Outcomes
- Predictors of poor prognosis[22]
- Older age
- Pre-existing joint disease
- Presence of synthetic material within the joint
- Post antibiotics
- Patients with S. aureus SA regain 46% - 50% of their baseline joint function[23]
- Patients with Pneumococcal SA regain 95% of their baseline joint function
Nonoperative
- Antibiotic therapy
- Broad coverage early
- Tapered to organisms found on culture, gram stain
- Antibiotic choices
- Gram positive: vancomycin
- Gram negative cocci: ceftriaxone
- Gram negative rods: Ceftazidime (Fortaz), cefepime (Maxipime), piperacillin/tazobactam (Zosyn), or carbapenems
- Negative gram stain: Vancomycin plus either ceftazidime or an aminoglycoside
Operative
- Indications
- Virtually all cases
- Technique
- Irrigation and drainage of the joint
Rehab and Return to Play
Rehabilitation
- Needs to be updated
- Likely no formal rehabilitation guidelines
Return to Play
- Needs to be updated
- Likely no formal return to play guidelines
Complications
- Osteoarthritis
- Fibrous Ankylosis
- Osteomyelitis
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford) 2001;40:24–30.
- ↑ Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846–855....
- ↑ Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis. 2003;36(3):319–327.
- ↑ Brook I, Frazier EH. Anaerobic osteomyelitis and arthritis in a military hospital: a 10-year experience. Am J Med 1993;94:21–8.
- ↑ Rosenthal J, Bole GG, Robinson WD. Acute nongonococcal infectious arthritis. Evaluation of risk factors, therapy, and outcome. Arthritis Rheum 1980;23:889–97.
- ↑ Dubost JJ, Fis I, Denis P, Lopitaux R, Soubrier M, Ristori JM, et al. Polyarticular septic arthritis. Medicine (Baltimore) 1993;72:296–310.
- ↑ Goldenberg DL. Bacterial arthritis. In: Ruddy S, Harris ED, Sledge CB, Kelley WN, eds. Kelley's Textbook of Rheumatology. 6th ed. Philadelphia, Pa.: Saunders; 2001:1469–1483.
- ↑ Ryan MJ, Kavanagh R, Wall PG, Hazleman BL. Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period. Br J Rheumatol 1997;36:370–3.
- ↑ Gardam M, Lim S. Mycobacterial osteomyelitis and arthritis. Infect Dis Clin North Am. 2005;19(4):819–830.
- ↑ Ohl CA. Infectious arthritis of native joints. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa.: Churchill Livingstone; 2010:1443–1456.
- ↑ Kaandorp CJ, Van Schaardenburg D, Krijnen P, Habbema JD, van de Laar MA. Risk factors for septic arthritis in patients with joint disease. A prospective study. Arthritis Rheum. 1995;38(12):1819–1825.
- ↑ Le Dantec L, Maury F, Flipo RM, et al. Peripheral pyogenic arthritis. A study of one hundred seventy-nine cases. Rev Rhum Engl Ed. 1996;63(2):103–110.
- ↑ Meijers KA, Dijkmans BA, Hermans J, van den Broek PJ, Cats A. Nongonococcal infectious arthritis: a retrospective study. J Infect 1987;14:13–20.
- ↑ Gupta MN, Sturrock RD, Field M. Prospective comparative study of patients with culture proven and high suspicion of adult onset septic arthritis. Ann Rheum Dis 2003;62:327–31.
- ↑ Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478–1488.
- ↑ Coutlakis PJ. In:, Roberts WN, Wise CM, eds. Another look at synovial fluid leukocytosis and infection. J Clin Rheumatol 2002;8:67–71.
- ↑ Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluid tests. What should be ordered? JAMA. 1990;264(8):1009–1014.
- ↑ Soderquist B, Jones I, Fredlund H, Vikerfors T. Bacterial or crystal-associated arthritis? Discriminating ability of serum inflammatory markers. Scand J Infect Dis 1998;30:591–6.
- ↑ Yu KH, Luo SF, Liou LB, et al. Concomitant septic and gouty arthritis—an analysis of 30 cases. Rheumatology (Oxford). 2003;42(9):1062–1066.
- ↑ Bockenstedt LK. Infectious disorders: Lyme disease. In: Klippel JH, Stone JH, Crofford LJ, White PH, eds. Primer on the Rheumatic Diseases. 13th ed. New York, NY: Springer; 2008:282–289.
- ↑ Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK health district 1982–1991. Ann Rheum Dis 1999;58:214–9.
- ↑ 22.0 22.1 Kaandorp CJ, Krijnen P, Moens HJ, Habbema JD, van Schaardenburg D. The outcome of bacterial arthritis: a prospective community-based study. Arthritis Rheum. 1997;40(5):884–892.
- ↑ Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982–1991. Ann Rheum Dis. 1999;58(4):214–219.
Created by:
John Kiel on 13 June 2019 10:36:20
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Last edited:
19 December 2022 19:36:28
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