Septic arthritis is inflammation of a joint due to a bacterial or fungal infection. Septic arthritis that is due to the bacteria that cause gonorrhea has different symptoms and is called gonococcal arthritis. Septic arthritis develops when bacteria or other tiny disease-causing organisms microorganisms spread through the blood to a joint. It may also occur when the joint is directly infected with a microorganism from an injury or during surgery.
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Prompt diagnosis and treatment of infectious arthritis can help prevent significant morbidity and mortality. The acute onset of monoarticular joint pain, erythema, heat, and immobility should raise suspicion of sepsis. Constitutional symptoms such as fever, chills, and rigors are poorly sensitive for septic arthritis. In the absence of peripheral leukopenia or prosthetic joint replacement, synovial fluid white blood cell count in patients with septic arthritis is usually greater than 50, per mm 3.
Isolation of the causative agent through synovial fluid culture is not only definitive but also essential before selecting antibiotic therapy. Synovial fluid analysis is also useful to help distinguish crystal arthropathy from infectious arthritis, although the two occasionally coexist.
Almost any microorganism can be pathogenic in septic arthritis; however, septic arthritis is caused by nongonococcal pathogens most commonly Staphylococcus species in more than 80 percent of patients.
Gram stain results should guide initial antibiotic choice. Vancomycin can be used for gram-positive cocci, ceftriaxone for gram-negative cocci, and ceftazidime for gram-negative rods.
If the Gram stain is negative, but there is strong clinical suspicion for bacterial arthritis, treatment with vancomycin plus ceftazidime or an aminoglycoside is appropriate. Evacuation of purulent material with arthrocentesis or surgical methods is necessary. Special consideration should be given to patients with prosthetic joint infection.
In this population, the intraarticular cutoff values for infection may be as low as 1, white blood cells per mm 3 with a neutrophil differential of greater than 64 percent. Septic arthritis is a key consideration in adults presenting with acute monoarticular arthritis. Failure to initiate appropriate antibiotic therapy within the first 24 to 48 hours of onset can cause subchondral bone loss and permanent joint dysfunction.
Because of the lack of a limiting basement plate in synovial tissues, the most common route of entry into the joint is hematogenous spread during bacteremia.
Suspicion of septic arthritis should be pursued with arthrocentesis, and synovial fluid should be sent for white blood cell count, crystal analysis, Gram stain, and culture. In addition to antibiotic therapy, evacuation of purulent material is necessary in patients with septic arthritis; arthrocentesis and surgical methods are appropriate.
Intraarticular white blood cell cutoff values for infection as low as 1, per mm 3 1. Patients presenting with acute joint swelling, pain, erythema, warmth, and joint immobility should be screened for risk factors associated with septic arthritis Table 1 8 — A prospective study in the Netherlands of patients diagnosed with septic arthritis found that 84 percent of adults had an underlying medical condition and 59 percent had a previous joint disorder.
Skin infection, cutaneous ulcers 8 , 9. Previous intraarticular injection 8 , Prosthetic joint: early and delayed 8 Table 6. Recent joint surgery 8 , Diabetes mellitus 8 , Human immunodeficiency virus infection Immunosuppressive medication 9 , Intravenous drug abuse Other cause of sepsis 9.
Prosthetic joint: late 8 Table 6. Rheumatoid arthritis 8 , 9. Sexual activity specifically for gonococcal arthritis Age older than 80 years 8. Information from references 8 through Constitutional symptoms such as fever, chills, or rigors may be present in patients with septic arthritis, although their sensitivities are 57, 27, and 19 percent, respectively. Information from references 6 and The physical examination should determine if the site of inflammation is intraarticular or periarticular, such as a bursa or skin.
Generally, intraarticular pathology results in severe limitation of active and passive range of motion, and the joint is often held in the position of maximal intraarticular space. For example, a septic knee will be extended fully. Conversely, pain from periarticular pathology occurs only during active range of motion, and swelling will be more localized. Although septic arthritis is usually monoarticular, up to 20 percent of cases are oligoarticular. Serum markers, such as white blood cell WBC count, erythrocyte sedimentation rate, 10 , 17 and C-reactive protein levels, 9 are often used to determine the presence of infection or inflammatory response.
Patients with confirmed septic arthritis have been found to have normal erythrocyte sedimentation rates and C-reactive protein levels. Because pathogenesis may be hematogenous, blood cultures are positive in 25 to 50 percent of patients with septic arthritis. Because the clinical presentation of septic arthritis may overlap with other causes of acute arthritis Table 2 6 , 16 , arthrocentesis is needed to identify the causative infectious agent.
Many parameters vary widely and must be interpreted in the clinical context. Three bedside observations color, transparency, and viscosity are quick and easy to assess. With normal transparent fluid, words can be read clearly through the fluid. The words become less crisp and gradually obscured with increasing turbidity.
Viscosity is assessed by observing the fluid dropping from the syringe. Normal viscosity has a long, stringy tail. A positive result does not exclude infection. Information from references 19 through 21 , and 24 through Measuring synovial fluid glucose or protein is not useful because results are neither sensitive nor specific for septic arthritis. The sensitivities of synovial fluid, Gram stain, and culture vary by pathogenic organism.
There are no data on imaging studies that are pathognomonic for acute septic arthritis. Plain films establish a baseline and may detect fractures, chondrocalcinosis, or inflammatory arthritis.
Ultrasonography is more sensitive for detecting effusions, particularly in difficult-to-examine joints, such as the hip. Almost any microorganism may be pathogenic in septic arthritis. Bacterial causes of septic arthritis include staphylococci 40 percent , streptococci 28 percent , gram-negative bacilli 19 percent , mycobacteria 8 percent , gram-negative cocci 3 percent , gram-positive bacilli 1 percent , and anaerobes 1 percent.
Clinical presentations can be broadly grouped into three categories: nongonococcal, gonococcal, and other e. Cleaning fish tank 7 , Dog or cat bite 7 , Capnocytophaga species, Pasteurella multocida. Ingestion of unpasteurized dairy products 7 , Intravenous drug use 7 , 18 , Nail through shoe Sexual activity Nocardia species, Pantoea agglomerans, Sporothrix schenckii.
Soil or dust exposure containing decomposed wood north-central and southern United States. Systemic lupus erythematosus particularly if functional hyposplenism Terminal complement deficiency 7. Distinctive presentations may occur with certain organisms or historical background.
Information from references 7 , 18 , 20 , and 31 through Septic arthritis is caused by nongonococcal pathogens in more than 80 percent of patients. Gram-positive staphylococci and streptococci are the causative agents in the majority of bacterial arthritis cases in which an organism is identified, 3 and are associated with drug abuse, cellulitis, abscesses, endocarditis, and chronic osteomyelitis.
Although data are mostly limited to case reports, the incidence of MRSA ranges between 5 and 25 percent of bacterial arthritis cases, and tends to affect older persons, involve the shoulder, and the health care—associated MRSA strain. Gram-negative bacilli represent approximately 14 to 19 percent of septic arthritis cases 12 , 18 and are associated with invasive urinary tract infections, intravenous drug use, older age, compromised immune system, and skin infections. Patients with disseminated Neisseria gonorrhoeae infection are usually young, healthy, and sexually active.
Patients typically display a migratory pattern of arthralgias, tenosynovial inflammation, or nonerosive arthritis. Fungal arthritis usually has an insidious onset and indolent course. Mycobacterial infectious arthritis is also indolent, which can cause a considerable delay in diagnosis, although joint damage does not occur as rapidly as it does in bacterial infections.
Borrelia burgdorferi infection initially causes viral-like migratory arthralgias of Lyme disease. Late disease is characterized by an intermittent oligoarthritis that usually involves the knee or other large joints. Empiric intravenous antibiotic treatment of septic arthritis should be based on the organism found in the Gram stain of the synovial fluid, or on the suspicion of a pathogen from the patient's clinical presentation Table 4 7 , 18 , 20 , 31 — Treatment options include vancomycin for gram-positive cocci, ceftriaxone Rocephin for gram-negative cocci, and ceftazidime Fortaz for gram-negative rods Table 5 If the Gram stain is negative but there is suspicion of bacterial arthritis, vancomycin plus either ceftazidime or an aminoglycoside is appropriate.
It includes dosing options for patients with renal insufficiency and drug allergies, and lists common drug interactions. If patient is allergic to penicillin or cephalosporins: aztreonam Azactam or fluoroquinolones.
Information from reference The duration of therapy in patients with nongonococcal septic arthritis is typically three to four weeks.
Therapy for disseminated gonococcal infection involves a third-generation cephalosporin, such as ceftriaxone, for 24 to 48 hours after improvement begins, followed by oral therapy. Treatment then may be switched to oral cefixime Suprax , or ciprofloxacin Cipro if quinolone resistance is not a concern, for at least one week. In addition to antibiotic therapy, evacuation of purulent material is necessary.
Guidelines from do not distinguish between arthrocentesis and surgical methods. Open or arthroscopic techniques can be used to surgically drain the infected joint. Arthroscopic drainage is associated with rapid recovery and low morbidity. Before antibiotics were available, two-thirds of patients died from septic arthritis.
Acute Septic Arthritis
Acute septic arthritis may develop as a result of hematogenous seeding, direct introduction, or extension from a contiguous focus of infection. The pathogenesis of acute septic arthritis is multifactorial and depends on the interaction of the host immune response and the adherence factors, toxins, and immunoavoidance strategies of the invading pathogen. Neisseria gonorrhoeae and Staphylococcus aureus are used in discussing the host-pathogen interaction in the pathogenesis of acute septic arthritis. While diagnosis rests on isolation of the bacterial species from synovial fluid samples, patient history, clinical presentation, laboratory findings, and imaging studies are also important.
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