Septic arthritis: Difference between revisions
 
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''This page is for <u>adult</u> patients; for pediatric patients see [[septic arthritis (peds)]].''
==Background==
==Background==
* Def: inflammation of a synovial membrane with purulent effusion into the joint capsule
*Most important diagnostic consideration in acute joint pain (can destroy joint in days)
* usually affects monoarticular joints (the knee is most commonly affected in adults and the hip in children)
*Knee most commonly involved in adults; hip most common in pediatric
* Relatively rare disease however because it can quickly destroy the joint or lead to osteomyelitis, fibrous ankylosis, sepsis, or even death it is important to catch and treat promptly
*Most often seen in patients >65yr
* Frequency is ~20,000 cases in USA/year (may be higher in pts with immunologic disorders (RA, SLE))
*Most common causative organisms
* M>F predominance, usually in patients >65 years
**<35 y/o ''[[N. gonorrhoeae]]''
* Etiology is usually bacterial, divided into gonococcal or nongonococcal groups
**>35 y/o ''[[S. aureus]]''
* staph and strep are most common nongonococcal causes
* consider different organisms in children, IV drug users, and those with prosthetic joints
==Diagnosis==
* may be difficult to diagnose in early stages
* patient typically presents with fever and a warm, red, painful, swollen joint with decreased range of motion even passively
* confirm diagnosis with work up


==Work-Up==
==Clinical Features==
* CBC
*Fever
* ESR
*Warm, red, painful, swollen joint
* Blood Cultures
*Decreased range of motion to active and passive movement
* Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
*[[Gonococcal]] arthritis
* Arthrocentesis with synovial fluid analysis
**[[Urethritis]]/[[vaginitis]] may be absent
* infected fluid characteristics:
**May have prodromal phase:
* large amount (>3.5 mL)
***Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
* turbid in appearance
***Macularpapular rash or pustules especially on hands/feet may proceed overt arthritis
* decreased viscosity
*Endocarditis should be considered in the presence of 2 or more affected joints
* 15,000->200,000 leukocytes/cubic cm
* 50-100% PMNs
* Poor mucin clot
* glucose >40mg/100mL less than plasma glucose
* Positive culture
* Plain films (often normal but may show widening of joint space or evidence of osteomyelitis)
* Ultrasound (can show joint effusion, extent of disease, and may help differentiate from other conditions)


==DDx==
==Differential Diagnosis==
* toxic synovitis
*[[Transient (Toxic) Synovitis]]
* abscess
*Abscess
* cellulitis
*[[Cellulitis]]
* primary rheumatologic disorder (i.e. vasculitis)
*Primary rheumatologic disorder (i.e. vasculitis)  
* iatrogenic
*Iatrogenic
* reactive arthritis (post infectious)  
*[[Reactive Arthritis (Poststreptococcal)]]
*Consider if patient has Sickle Cell (fever '''and''' limited joint ROM)
**Osteomyelitis typically has neither


==Gonococcal Arthritis==
{{Differential Diagnosis Monoarthritis}}
Healthy, young sexually active adults


Women > men
==Evaluation<ref>Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18(8):781-96.</ref>==
[[File:SepticJointFluid.jpg|thumb|Synovial fluid from a septic knee]]
Suppurative monoarthritis (may be preceded by polyarthralgias)
===Work-Up===
*Arthrocentesis with synovial fluid analysis
**cell count with differential
**glucose
**protein
**bacterial culture and sensitivity (not 100% sn)
**polarized light microscopy for crystals
*CBC
*ESR - Sn 94% (with 15mm/h cut-off)<ref>Hariharan, H, et al. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients. J of Emerg Med. 2010; 40(4):428–431. http://dx.doi.org/10.1016/j.jemermed.2010.05.029</ref>
*CRP - Sn 92% (with 20mg/L cut-off)
*Blood Culture
*Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
*Imaging (may be helpful for excluding other diagnoses - e.g. trauma, osteo, etc)
*Immunocompromised
**Consider mycobacterial or fungal arthritis
**Leukemia history: predisposed to Aeromonas infections
*Periprosthetic infection
**Non-emergent: acute microbiological diagnosis is more important than rapid antibiotics
**Diagnose with two synovial fluid cultures (avoid collection from a draining sinus)
**CRP >100mg/L during first 6 weeks post-op warrants aspiration and may be used to differentiate from superficial skin infection


Knee, wrist, ankle
{{Arthrocentesis diagnostic chart}}


==Arthritis-Dermatitis Syndrome==
==Management==
===Diagnosis===
===[[Antibiotics]]===
-Triad: dermatitis, tenosynovitis, migratory polyarthritis (hematogenous spread of bacteria and immune complexes)
{{Septic Arthritis Antibiotics}}


-Skin lesions: scattered small painless erythematous macules or petechiae-->pustular -->necrotic lesions
===Consultation===
 
*Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection
-Transient painful extensor tenosynovitis (writs, hands, ankles)
**Benefit of serial aspirations vs arthroscopy vs irrigation and debridement is unclear
 
-Asymmtric polyarthralgia of extremity joints
 
DiagnosisCx everything - jt, mucosal surfaces, lesions
 
===Treatment===
CTX 1gIV qd OR
 
Cefotax 1g q8
 
Empirically treat Chlamydia
 
==Nongonococcal Arthritis==
===Background===
Fulminant presentation (abrupt, swelling, toxicity and fever) unless elderly
 
-Hematogenous
 
-Contiguous
 
-Direct traumatic implantation
 
-Postop
 
===Causes===
Bacterial
 
Mycobacterial
 
Spirochete (lyme, syphilis)
 
Fungal
 
VIral (HIV, Hep B, Rubella, etc)
 
Postinfectious
 
===Diagnosis===
Synovial fluid aspiration
 
Cx - if only one test, use BCx bottles (may enhance yield)
 
Grm stain - 80% positive in gram-positive infxn; less sens in gram-negative
 
Cell count with dif - >50,000-150,000; PMN > 90%
 
===Treatment===
PCN-ase resistant synthetic PCN:
 
Nafcillin 1-2g
 
Cefazolin 1-2g
 
AND
 
3rd gen ceph
 
OR
 
Vanc^
 
^new evidence suggests significantly increased rate of MRSA septic arthritis
 
^^cell counts are as low as 20,000 in MRSA Cx + synovial fluid
 
==Treatment==
* drainage of the joint
* IV Antibiotics
* generally Oxacillin or Nafcillin with a cephalosporin (ceftriaxone, feotaxme, ceftizoxime) will cover
* add vancomycin if you suspect MRSA
* in IVDA patients use IV aminoglycoside + antipseudomonal cephalosporin
* patients with prosthetic joints are at higher risk of MRSA, MRSE, Enterobacteriaceae, and Pseudomonas
* consider gonococcal infection in young sexually active patients (treat with ceftriaxone)
* Open drainage and lavage in the OR


==Disposition==
==Disposition==
* All patients should be admitted with Ortho consult and continued on IV antibiotics
*Admit all


==See Also==
==See Also==
*[[Arthrocentesis]]
*[[Arthrocentesis]]  
*[[Monoarticular Arthritis]]
*[[Monoarticular arthritis]]
*[[Septic Arthritis (Hip)]]
*[[Septic arthritis of the hip (peds)]]
*[[Septic arthritis (peds)]]
*[[Knee diagnoses]]
 
==External Links==
*[http://www.mdcalc.com/kocher-criteria-septic-arthritis/ MDCalc - Kocher Criteria for Septic Arthritis]


==Source==
==References==
http://emprocedures.com/arthrocentesis/analysis.htmEmedicine
<references/>


[[Category:ID]]
[[Category:ID]]
[[Category:Ortho]]
[[Category:Orthopedics]]

Latest revision as of 03:31, 11 December 2019

This page is for adult patients; for pediatric patients see septic arthritis (peds).

Background

  • Most important diagnostic consideration in acute joint pain (can destroy joint in days)
  • Knee most commonly involved in adults; hip most common in pediatric
  • Most often seen in patients >65yr
  • Most common causative organisms

Clinical Features

  • Fever
  • Warm, red, painful, swollen joint
  • Decreased range of motion to active and passive movement
  • Gonococcal arthritis
    • Urethritis/vaginitis may be absent
    • May have prodromal phase:
      • Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
      • Macularpapular rash or pustules especially on hands/feet may proceed overt arthritis
  • Endocarditis should be considered in the presence of 2 or more affected joints

Differential Diagnosis

Monoarticular arthritis

Algorithm for Monoarticular arthralgia

Evaluation[1]

Synovial fluid from a septic knee

Work-Up

  • Arthrocentesis with synovial fluid analysis
    • cell count with differential
    • glucose
    • protein
    • bacterial culture and sensitivity (not 100% sn)
    • polarized light microscopy for crystals
  • CBC
  • ESR - Sn 94% (with 15mm/h cut-off)[2]
  • CRP - Sn 92% (with 20mg/L cut-off)
  • Blood Culture
  • Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
  • Imaging (may be helpful for excluding other diagnoses - e.g. trauma, osteo, etc)
  • Immunocompromised
    • Consider mycobacterial or fungal arthritis
    • Leukemia history: predisposed to Aeromonas infections
  • Periprosthetic infection
    • Non-emergent: acute microbiological diagnosis is more important than rapid antibiotics
    • Diagnose with two synovial fluid cultures (avoid collection from a draining sinus)
    • CRP >100mg/L during first 6 weeks post-op warrants aspiration and may be used to differentiate from superficial skin infection


Arthrocentesis of synoval fluid

Synovium Normal Noninflammatory Inflammatory Septic
Clarity Transparent Transparent Cloudy Cloudy
Color Clear Yellow Yellow Yellow
WBC <200 <200-2000 200-50,000

>1,100 (prosthetic joint)

>25,000; LR=2.9

>50,000; LR=7.7

>100,000; LR=28

PMN <25% <25% >50%

>64% (prosthetic joint)

>90%

Culture Neg Neg Neg >50% positive
Lactate <5.6 mmol/L <5.6 mmol/L <5.6 mmol/L >5.6 mmol/L
LDH <250 <250 <250 >250
Crystals None None Multiple or none None
  • Viscosity of synovial fluid may actually be decreased in inflammatory or infectious etiologies, as hyaluronic acid concentrations decrease
  • The presence of crystals does not rule out septic arthritis; however, the diagnosis is highly unlikely with synovial WBC < 50,000[3]

Management

Antibiotics

For adults treatment should be divided into Gonococcal and Non-Gonococcal

Gonococcal

Non-Gonococcal

Pediatrics

Sickle Cell

Coverage for Salmonella and Staphylococcus spp

  • Vancomycin 20mg/kg IV twice daily PLUS
    • Ciprofloxacin 400mg IV three times daily OR
    • Imipenem/cilastatin 1g IV three times daily

Consultation

  • Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection
    • Benefit of serial aspirations vs arthroscopy vs irrigation and debridement is unclear

Disposition

  • Admit all

See Also

External Links

References

  1. ↑ Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18(8):781-96.
  2. ↑ Hariharan, H, et al. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients. J of Emerg Med. 2010; 40(4):428–431. http://dx.doi.org/10.1016/j.jemermed.2010.05.029
  3. ↑ Shah K, Spear J, Nathanson LA, Mccauley J, Edlow JA. Does the presence of crystal arthritis rule out septic arthritis?. J Emerg Med. 2007;32(1):23-6.
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