Septic arthritis: Difference between revisions

No edit summary
 
(56 intermediate revisions by 13 users not shown)
Line 1: Line 1:
== Background ==
''This page is for <u>adult</u> patients; for pediatric patients see [[septic arthritis (peds)]].''
 
==Background==
*Inflammation of synovial membrane with purulent effusion into the joint capsule
*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 pts &gt;65yr  
*Most often seen in patients >65yr  
*Most commonly bacterial (gonococcal vs nongonococcal)
*Most common causative organisms
 
**<35 y/o ''[[N. gonorrhoeae]]''
== Clinical Features ==
**>35 y/o ''[[S. aureus]]''


==Clinical Features==
*Fever  
*Fever  
*Warm, red, painful, swollen joint  
*Warm, red, painful, swollen joint  
*Decreased range of motion (even passively)
*Decreased range of motion to active and passive movement
 
*[[Gonococcal]] arthritis
== Diagnosis ==
**[[Urethritis]]/[[vaginitis]] may be absent
 
**May have prodromal phase:
*Arthrocentesis for synoval fluid
***Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
 
***Macularpapular rash or pustules especially on hands/feet may proceed overt arthritis
{| width="400" border="1" cellpadding="1" cellspacing="1"
*Endocarditis should be considered in the presence of 2 or more affected joints
|-
|
| Normal
| Noninflammatory
| Inflammatory
| Septic
|-
| Clarity
| Transparent
| Transparent
| Cloudy
| Cloudy
|-
| Color
| Clear
| Yellow
| Yellow
| Yellow
|-
| WBC
| &lt;200
| &lt;200-2000
| 200-50,000
| &gt;25,000
|-
| PMN
| &lt;25%
| &lt;25%
| &gt;50%
| &gt;90%
|-
| Culture
| Neg
| Neg
| Neg
| &gt;50% positive
|-
| Crystals
| None
| None
| Multiple or none
| None
|}
 
<br>
 
== Work-Up ==
 
#Arthrocentesis with synovial fluid analysis
#CBC
#ESR/CRP
#Blood Culture
#Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
#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 ==
 
#Toxic synovitis
#Abscess
#Cellulitis
#Primary rheumatologic disorder (i.e. vasculitis)
#Iatrogenic
#Reactive arthritis (post-infectious)
 
== Gonococcal Arthritis ==
 
Healthy, young sexually active adults
 
Women &gt; men
 
Suppurative monoarthritis (may be preceded by polyarthralgias)
 
Knee, wrist, ankle
 
== Arthritis-Dermatitis Syndrome ==
 
=== Diagnosis ===
 
#Triad: dermatitis, tenosynovitis, migratory polyarthritis (hematogenous spread of bacteria and immune complexes)
#Skin lesions: scattered small painless erythematous macules or petechiae--&gt;pustular --&gt;necrotic lesions
#Transient painful extensor tenosynovitis (writs, hands, ankles)
#Asymmtric polyarthralgia of extremity joints  
#Diagnosis Cx 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 - &gt;50,000-150,000; PMN &gt; 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
==Differential Diagnosis==
*[[Transient (Toxic) Synovitis]]
*Abscess
*[[Cellulitis]]
*Primary rheumatologic disorder (i.e. vasculitis)
*Iatrogenic
*[[Reactive Arthritis (Poststreptococcal)]]
*Consider if patient has Sickle Cell (fever '''and''' limited joint ROM)
**Osteomyelitis typically has neither


^^cell counts are as low as 20,000 in MRSA Cx + synovial fluid
{{Differential Diagnosis Monoarthritis}}


== Treatment ==
==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===
*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


#drainage of the joint
{{Arthrocentesis diagnostic chart}}
#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 ==
==Management==
===[[Antibiotics]]===
{{Septic Arthritis Antibiotics}}


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


== See Also ==
==Disposition==
*Admit all


==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]]


== Source ==
==External Links==
*[http://www.mdcalc.com/kocher-criteria-septic-arthritis/ MDCalc - Kocher Criteria for Septic Arthritis]


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


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


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.
Retrieved from "https://www.wikem.org/w/index.php?title=Septic_arthritis&oldid=239449"