Septic arthritis: Difference between revisions

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== Background ==
== Background ==
 
*Most important diagnostic consideration in acute joint pain (can destroy joint in days)
*Inflammation of synovial membrane with purulent effusion into the joint capsule
*Knee most commonly involved in adults; hip most common in peds  
*Knee most commonly involved in adults; hip most common in peds  
*Most often seen in pts >65yr  
*Most often seen in pts >65yr  
*Most commonly bacterial (gonococcal vs nongonococcal)
*Gonococcal arthritis is commonest cause in adolescents and young adults


== Clinical Features ==
== 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 may have prodromal phase:
**Migratory arthritis and tenosynovitis predominate before pain and swelling occurs


== Diagnosis ==
== Diagnosis ==
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<br>
== DDx ==
#Toxic synovitis
#Abscess
#Cellulitis
#Primary rheumatologic disorder (i.e. vasculitis)
#Iatrogenic
#Reactive arthritis (post-infectious)


== Work-Up ==
== Work-Up ==
#Arthrocentesis with synovial fluid analysis
#Arthrocentesis with synovial fluid analysis
##Synovial fluid culture only
#CBC  
#CBC  
#ESR/CRP
#ESR
##Sn 96% (with 30mm/h cut-off)
#Blood Culture
#Blood Culture
#Gonorrhea culture (urethral/cervical/pharyngeal/rectal)  
#Gonorrhea culture (urethral/cervical/pharyngeal/rectal)  
#Plain films (often normal but may show widening of joint space or evidence of osteomyelitis)  
#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)
#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
^^cell counts are as low as 20,000 in MRSA Cx + synovial fluid


== Treatment ==
== Treatment ==
 
#Joint drainage
#drainage of the joint
#Abx
#IV Antibiotics
##Gram stain can be used to guide treatment
#generally Oxacillin or Nafcillin with a cephalosporin (ceftriaxone, feotaxme, ceftizoxime) will cover
###Gram+: vancomycin IV
#add vancomycin if you suspect MRSA
###Gram- OR gonococcus suspected: Ceftriaxone IV
#in IVDA patients use IV aminoglycoside + antipseudomonal cephalosporin
#Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection
#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 ==
 
*Admit all to ortho
*All patients should be admitted with Ortho consult and continued on IV antibiotics


== See Also ==
== See Also ==
*[[Arthrocentesis]]  
*[[Arthrocentesis]]  
*[[Monoarticular Arthritis]]  
*[[Monoarticular Arthritis]]  
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== Source ==
== Source ==
 
*Tintinalli
http://emprocedures.com/arthrocentesis/analysis.htmEmedicine


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

Revision as of 20:37, 27 February 2012

Background

  • Most important diagnostic consideration in acute joint pain (can destroy joint in days)
  • Knee most commonly involved in adults; hip most common in peds
  • Most often seen in pts >65yr
  • Gonococcal arthritis is commonest cause in adolescents and young adults

Clinical Features

  • Fever
  • Warm, red, painful, swollen joint
  • Decreased range of motion to active and passive movement
  • Gonococcal arthritis may have prodromal phase:
    • Migratory arthritis and tenosynovitis predominate before pain and swelling occurs

Diagnosis

  • Arthrocentesis for synoval fluid
Normal Noninflammatory Inflammatory Septic
Clarity Transparent Transparent Cloudy Cloudy
Color Clear Yellow Yellow Yellow
WBC <200 <200-2000 200-50,000 >25,000
PMN <25% <25% >50% >90%
Culture Neg Neg Neg >50% positive
Crystals None None Multiple or none None

DDx

  1. Toxic synovitis
  2. Abscess
  3. Cellulitis
  4. Primary rheumatologic disorder (i.e. vasculitis)
  5. Iatrogenic
  6. Reactive arthritis (post-infectious)

Work-Up

  1. Arthrocentesis with synovial fluid analysis
    1. Synovial fluid culture only
  2. CBC
  3. ESR
    1. Sn 96% (with 30mm/h cut-off)
  4. Blood Culture
  5. Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
  6. Plain films (often normal but may show widening of joint space or evidence of osteomyelitis)
  7. Ultrasound (can show joint effusion, extent of disease, and may help differentiate from other conditions)

Treatment

  1. Joint drainage
  2. Abx
    1. Gram stain can be used to guide treatment
      1. Gram+: vancomycin IV
      2. Gram- OR gonococcus suspected: Ceftriaxone IV
  3. Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection

Disposition

  • Admit all to ortho

See Also

Source

  • Tintinalli
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