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==
*Most important diagnostic consideration in acute joint pain (can destroy joint in days)
*Most important diagnostic consideration in acute joint pain (can destroy joint in days)
*Knee most commonly involved in adults; hip most common in peds
*Knee most commonly involved in adults; hip most common in pediatric
*Most often seen in patients &gt;65yr  
*Most often seen in patients >65yr  
*Most common causative organisms
*Most common causative organisms
**<35 y/o ''[[N. gonorrhoeae]]''
**<35 y/o ''[[N. gonorrhoeae]]''
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**May have prodromal phase:
**May have prodromal phase:
***Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
***Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
***Macularpapular rash or pustules esp on hands/feet may proceed overt arthritis
***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
*Endocarditis should be considered in the presence of 2 or more affected joints


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{{Differential Diagnosis Monoarthritis}}
{{Differential Diagnosis Monoarthritis}}


==Diagnosis==
==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]]
===Work-Up===
===Work-Up===
*Arthrocentesis with synovial fluid analysis
*Arthrocentesis with synovial fluid analysis
**Synovial fluid culture only (not 100% sensitive)
**cell count with differential
**glucose
**protein
**bacterial culture and sensitivity (not 100% sn)
**polarized light microscopy for crystals
*CBC  
*CBC  
*ESR
*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>
**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)
*CRP
**Sn 92% (with 20mg/L cut-off)
*Blood Culture
*Blood Culture
*Gonorrhea culture (urethral/cervical/pharyngeal/rectal)  
*Gonorrhea culture (urethral/cervical/pharyngeal/rectal)  
*Imaging
*Imaging (may be helpful for excluding other diagnoses - e.g. trauma, osteo, etc)
**Helpful for excluding other diagnoses (e.g. trauma, osteo)
*Immunocompromised
*Immunocompromised
**Consider mycobacterial or fungal arthritis
**Consider mycobacterial or fungal arthritis
**Leukemia history: predisposed to Aeromonas infections
**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 diagnostic chart}}
{{Arthrocentesis diagnostic chart}}


==Management==
==Management==
===[[Arthrocentesis]]===
*Treatment based on diagnostic studies
===[[Antibiotics]]===
===[[Antibiotics]]===
{{Septic Arthritis Antibiotics}}
{{Septic Arthritis Antibiotics}}
===Consultation===
===Consultation===
*Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection
*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==
==Disposition==
*Admit all to ortho
*Admit all


==See Also==
==See Also==
*[[Arthrocentesis]]  
*[[Arthrocentesis]]  
*[[Monoarticular Arthritis]]  
*[[Monoarticular arthritis]]  
*[[Septic Arthritis (Hip)]]  
*[[Septic arthritis of the hip (peds)]]
*[[Septic Arthritis (Peds)]]
*[[Septic arthritis (peds)]]
*[[Knee Diagnoses]]
*[[Knee diagnoses]]


==External Links==
==External Links==
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==References==
==References==
<references/>
<references/>


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

Template:Arthrocentesis diagnostic chart

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
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