Septic Arthritis

Pujan Parikh

Definition
Inflammation of a synovial membrane with purulent effusion into the joint capsule, often due to bacterial infection

Epidemiology
1:1 M:F Mean Age=55 85%=Monoarticular Patients with Damaged Joints are at Increased Risk

Most are hematogenously spread

Fever present in only 60% of non-GC septic arthritis

Crystalline arthritis is 4x as common as septic arthritis; fevers/rigors non-specific

Route of infection
dissemination of pathogens via the blood, from distant site. IV Drug Injection: Most Common

dissemination from an acute osteomylitic focus

dissemination from adjacent soft tissue infection : cellulitis, abscess, bursitis, tenosynovitis entry via penetrating trauma entry via iatrogenic means

Route of Infection
75% have extra-articular source: Look for skin, respiratory, or GU sources

50% have known portal of entry

Etiology
Staph aureus Streptococci In all age groups, 80% due to grampositive aerobes, 20% due to gramnegative anaerobes Neonates and infants < 6mos -- S aureus and gram-negative anaerobes
Incidence of H. influenzae has decreased due to the vaccine

Pathophysiology
There is an acute synovitis with a purulent joint effusion and Synovial membrane becomes edematous, swollen and hyperemic, and produces increase amount of cloudy exudates contains leukocytes and bacteria As infection spread through the joint, articular cartilage is destroyed by bacterial and cellular enzymes. If the infection is not arrested the cartilage may be completely destroyed. Pus may burst out of the joint to form abscesses and sinuses. The joint may be become pathologically dislocated.

Pathophysiology
Adults
Knee 40-50 % Hip 20-25 % Infants and young children
Hip 95 %

Groups at Risk
Rheumatoid Arthritis: Account for up to 50% of cases Immunosuppressed Host, especially Organ Transplant Patients Advanced Age: Greater than 60, especially with Prosthetic Joints: May result in Osteomyelitis Diabetes

Neoplasm
IV Drug Use: Repetitive transitory Bacteremia: Staphylococci (MRSA)>Enterobacter, Serratia, and Pseudomonas Hemodialysis: Recurrent Vascular Infections, especially Staphylococci

Clinical Presentation
Typical features are acute pain and swelling in a single large joint ,commonly the hip in children and the knee in adults, however any joint can be affected.

The most commonly involved joint is the knee (50% of cases), followed by the hip (20%), shoulder (8%), ankle (7%), and wrists (7%). interphalangeal, sternoclavicular, and sacroiliac joints each make up 1-4% of cases.

Symptoms in newborns or infants:

The emphasis is on septicemia rather than joint pain. Irritability ,Fever, refuses to feed, rapid pulse.

Unable to move the limb with the infected joint (pseudoparalysis) .

Cries when infected joint is moved (diaper changing) Infection is usually suspected ,but it could be anywhere so the joints should be carefully felt and moved to elicit the local signs of warmth ,tenderness and resistance to movement. Umbilical cord or the site of injection should be examined for possible source of infection. If the baby is distressed and wont move his/her leg think of hip infection.

In Children

Acute pain in single large joint. The joint is swollen (if superficial), warm and tender. Fever. All movements are restricted due to muscle spasm (Pseudoparesis). Differentiation from transient synovitis important: 4 independent variables
History of fever Non-weight-bearing ESR > 40mm/h WBC > 12,000/uL

In Adults

Intense joint pain . Joint swelling . Joint redness . Unable to move the limb with the infected joint . Low-grade fever. Young sexually active pts: + fever, tenosynovitis, migratory polyarthralgia and dermatitis ( papular rash over trunk and distal extremity extensor surfaces that may turn hemorrhagic ) = Suspect N gonorrheae IVDU = Pseudomonas

Gonococcal Arthritis
Emerging Trends in Resistance: Up to 30% resistant to PCN: Ceftriaxone or Imipenem or Ciprofloxacin in PCN resistant cases Migratory Polyarthralgias/Polyarthritis/Tenosynovitis = 66%; Knee>hand>wrist

Dermatitis=sparse peripheral necrotic pustules in 40%

83%=female, mean age=23, GU involvement in 63%, often asymptomatic Check VDRL and HIV and Co-treat Chlamydia

Gram (+) Arthritis

Staphylococcus: 50% of culture (+) cases; assume penicillinase producing, possible MRSA, use Vancomycin, otherwise Nafcillin

Streptococcus, non-Group A, Beta-hemolytic: Second most common cause of septic arthritis (10 to 20%); Diabetics often infected with Group B (watch for SC, MS, and SI joints and fasciitis and myositis); use Vancomycin or Cefotaxime if resistant to PCN Pneumococcus, up to 10% of septic arthritis, check for PCN resistance, use Vancomycin if resistant to PCN
Enterococcus, rare cause of native and prosthetic joint infections

Gram Negative Arthrits

10 to 20% of septic arthritis, mostly in immunosuppressed hosts

SLE/Sickle: Salmonella, watch for resistance

IV drug abuse: Pseudomonas, watch for SC, SI, and spine locations; Serratia and Enterobacter

Decubitus Ulcers, often gram (-) organism after prior antibiotic use
Animal Bites: Cats/Dogs: Pasturella multocida, usually PCN sensitive; Rats: Rat Bite Fever

Physical Examination
1. 2.

Decreased or absent rang of motion. Signs of inflammation: joint swelling, warmth, tenderness and erythema. Joint orientation as to minimize pain (position of comfort):

3.

Hip: abducted, flexed and externally rotated. Knee, ankle and elbow: partially flexed. Shoulder: abducted and internally rotated

Ask for: gram stain, culture, leukocyte count with differential, and crystal examination leukocyte count:
o

generally higher than 50,000/L, with a predominance of neutrophils more than 75% gram stain:
are positive in approximately 75% of patients with staphylococcal infections; however, results are positive in only 50% of patients with gram-negative infections

Imaging Studies
1-Plain x-ray:
The appearance of significant x-ray findings depends upon the duration and virulence of infection. Plain radiography findings are generally nonspecific and may reveal only soft tissue swelling ,widening of the joint space ( due to the effusion), and periarticular osteoporosis during the first 2 weeks. Later ,when the articular cartilage is attacked ,the joint space is narrowed.(persistent subluxation, destructive arthritis).

Septic Arthritis of Hip

2-Ultrasonography
This study is very sensitive in detecting joint

effusions generated by septic arthritis. Ultrasound can be used to define the extent of septic arthritis and help guide treatment. Ultrasound helps to differentiate septic arthritis from other conditions (e.g., soft tissue abscesses, tenosynovitis) in which treatment may differ.

3-Radio-isotope bone scan: Show increase uptake of the isotope in the region of the joint. (may help in difficult site as sacroiliac & sternoclavicular joints 4- CT scan: This study may help to diagnose sternoclavicular or sacroiliac joint infections. 5-MRI: MRI is most useful in assessing the presence of periarticular osteomyelitis as a causative mechanism.

Complications
Dislocation: a tense effusion may cause dislocation

Epiphyseal destruction: in neglected infants the largely cartilaginous epiphysis may be destroyed ,leaving an unstable pseudarthrosis. Growth disturbance: physeal damage may result in shortening or deformity
Ankylosis: if articular cartilage is eroded healing may lead to ankylosis Secondary osteoarthritis

Septic Arthritis
Despite advances in diagnostic studies, powerful antibiotics, and early drainage, significant joint destruction commonly occurs Why?
Lack of clinical suspicion Delay in definitive diagnostic needle aspiration Failure to adequately drain the joint

Treatment
General Measures:
The first priority is to aspirate the joint and examine the fluid, treatment is then started without further delay.

Analgesics and splinting of the involved joint in the position of maximal comfort alleviate pain. Fluid replacement and nutritional support may be required. Other foci of infection and any coexisting medical conditions must be identified and treated appropriately.

Treatment
Intravenous antibiotics should be given empirically and started as soon as joint fluid and blood sample have been taken for culture.

If gram positive organisms are identified ,Flucloxacillin is suitable . If in doubt ,a third generation cephalosporin will cover both game+ and gram- organisms.
Children less than 4 yr( if suspicion of H.Infl) treated with Ampicillin. Once the bacterial sensitivity is known the appropriate drug is substituted. Intravenous administration is continued for several weeks and is followed by oral antibiotics for a further 2 or 3 weeks.

Drainage
Drainage: Percutaneous Needle: Usually preferred in Patients with Increased Risk of Comorbidity Arthroscopy or Arthrotomy per your Orthopod Indication of Surgical Drainage:

1-Joints that do not respond to antimicrobial therapy and daily arthrocentesis

2-. Any joint with limited accessibility, including the sternoclavicular or the hip joint 3-Patients with underlying disease, including diabetes, rheumatoid arthritis, immunosuppression, or other systemic symptoms, should be treated more aggressively with

Summary of recommendations for initial empirical antibiotic choice in suspected septic arthritis
Patient Group
No risk factors for atypical organisms

Antibiotic Choice
Flucloxacillin 2g qds iv. Local policy may be to add gentamicin iv. If penicillin allergic, Clindamycin 450-600mg qds iv. or 2nd or 3rd generation cephalosporin iv. 2nd or 3rd generation cephalosporin eg cefuroxime 1.5g tds iv. Local policy may be to add flucloxacillin iv to 3rd generation cephalosporin. Discuss allergic patients with microbiology-Gram stain may influence antibiotic choice Vancomycin iv. plus 2nd or 3rd generation cephalosporin iv.

High risk of Gram ve sepsis (elderly, frail, recurrent UTI, recent abdominal surgery)

MRSA risk ( known MRSA, recent inpatient, nursing home resident, leg ulcers or catheters, or other risk factors determined locally) Suspected gonococcus or meningococcus

Ceftriaxone iv. or similar dependent on local policy / resistance

iv drug users
ITU patients, known colonisation of other organs (eg cystic fibrosis)

Discuss with microbiologist

Discuss with microbiologist

Antibiotic choice will need to be modified in the light of results of Gram stain and culture. This table is based on expert opinion, and should be reviewed locally by microbiology IV antibiotics should be used and continued for at least 2 weeks Repeat joint aspiration/surgical intervention may be required all patients should be referred for a rheumatological or orthopaedic opinion Joints should be aspirated to dryness as often as is required Further treatment with oral antibiotics for at least 4 weeks. Do not stop antibiotics until symptoms and signs resolve, and ESR/CRP are returning to normal

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