Septic arthritis overview

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Differentiating Septic Arthritis from other Diseases

Epidemiology and Demographics

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayesha A. Khan, MD[2] Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [3]

Overview

Septic arthritis is the one of the most serious medical emergency of a patient present with one or more hot and swollen joints.[1] It is the most rapidly destructive joint disease.[2] It is most common in patients with longstanding rheumatoid arthritis and it is a an important consideration in adults presenting with monoarticular arthritis in 80 to 90% of patients. It can involve any joint, but most commonly involves knee > hip > shoulder > ankle.[3] Other joints such as sacroiliac joint, sternoclacicular or costoclavicular joints may be involved in patient with history of intravenous drug abuse (IVDA), penetrating trauma, animal or human bites and local steroid injections. Septic arthritis is joint inflammation secondary to an infectious etiology, usually bacterial, but occasionally fungal, mycobacterial, viral, or other uncommon pathogens. Septic arthritis is usually monoarticular involving one large joint such as the hip or knee; however, polyarticular septic arthritis involving multiple or smaller joints may also occur. Though uncommon, septic arthritis is an orthopedic emergency that can cause significant joint damage leading to increased morbidity and mortality.

Historical Perspective

  • First case of septic arthritis described in literature by Walter Whitehead in 1902, as "The open method of treating exceptional cases of septic arthritis of the knee".[4]
  • An experimental and clinical Study on arthritis deformans described by Nathan PW in 1917.[5]
  • Surgical management of septic arthritis by By Captain W. Rankin in 1917.[6]

Classification

Septic arthritis broadly classified based on the etiology as gonococcal or non-gonococcal arthritis and based on the clinical presentation it is classified as mono articular septic arthritis or poly articular septic arthritis.[7][8]

Pathophysiology

Septic arthritis most commonly develop as a result of hematogenous spreading of bacteria into the synovial membrane, that induces inflammatory reactions. Eventually, release of cytokines and activation of both host humoral and immunological response along with bacterial virulence factors cumulatively damages articular surface and cartilage.[9][10]

Causes

Septic arthritis caused by bacteria or tiny disease-causing microorganisms that spread through the bloodstream to a synovium. It may also occur when the joint is directly infected with a microorganism from an injury or during surgery. The most common sites for this type of infection are the knee and hip. Most cases of acute septic arthritis are caused by bacteria such as staphylococcus or streptococcus. Chronic septic arthritis (which is less common) is caused by organisms such as Mycobacterium tuberculosis and Candida albicans.

Differential Diagnosis

Patient present with septic arthritis should be differentiate from other causes of acute monoarticular arthritis.

Differential diagnosis of acute monoarticular arthritis
Infectious Crystal induced Hemorrhagic Systemic rheumatological

disorders

Intra-articular derangement

Epidemiology and Demographics

  • Incidence of septic arthritis approximately varies between 2 to 10 cases per 100,000 per year in the general population.[11]
  • Incidence of septic arthritis in patients with history of rheumatoid arthritis and patients with joint prostheses is ~30–70 cases per 100,000 per year.[12]
  • Incidence of septic arthritis in patients with joint prostheses is 40-68 cases per 100,000 per year.
  • The case-fatality rate of septic arthritis is estimated to be 10-25%.[13]
  • Even after survival from septic arthritis, 25-50% of the patients suffer from irreversible loss of joint function.[14][15]

Risk Factors

Most common risk factors that predisposes septic arthritis are rheumatoid arthritis, prosthetic joint or joint replacement and skin infections. Other common risk factors includes:

Natural History, Complications & Prognosis

Septic arthritis commonly present with either mono articular involvement associate with tenosynovitis and dermatitis (gonococcal) or polyarticular involvement (non gonococcal).[13] It is more common in patients in extreme age groups with pre existing joint disorders such as rheumatoid arthritis or predisposing factors such as skin infection.[16] Prompt diagnosis. rapid initiation of treatment, early physical therapy and mobilization are crucial for the outcome of septic arthritis. Complications of septic arthritis mainly depends on the pre existing joint disease and treatment of current infection. Common complications include Joint degeneration (~ 40%) bacteremia (5-20%) osteomyelitis and growth retardation (in children)[17] Prognosis of septic arthritis depends on various factors such host immune response, pre existing joint disease, presence of risk factors, virulence of the pathogen and the duration between onset of symptoms and diagnosis.[18]

Diagnosis

Patients with history of chronic joint disease and concurrent septic arthritis can be misdiagnosed as acute flareup of underlying chronic disease which often delays the treatment for septic arthritis. So, patients with acute flare of one or two new inflamed joints with underlying chronic joint diseases or with another connective tissue disease, it should be assumed that the joint is septic until proven otherwise, should always rule out concurrent septic arthritis with appropriate diagnostic studies.[2] In patients with acute effusion of unknown etiology, might have concurrent crystal-induced arthritis and septic arthritis. So, the synovial fluid should always be cultured and examined for crystals in the evaluation of an acute effusion.[19]

History and Symptoms

Septic arthritis commonly present with joint pain (knee> hip>shoulder>ankle) associate with fever, malaise and local joint symptoms such as swelling, erythema and decreased range of motion at the level of joint. In children, hip is commonly affected. Abrupt onset of a single hot, swollen, and painful joint indicate non gonococcal arthritis.[13] It can involve any joint, but most commonly knee is the site of infection in 50% of cases of adults and elderly patients. Hip infection is the most common site in children.[11] Disseminated gonococcal infection(DGI) often present initially with migratory polyarthralgias, tenosynovitis, dermatitis, and fever. Less commonly, patients with DGI will present with purulent joint effusion, most often of the knee or wrist.[20] Often present with inflamed and tender tendons of the wrist, ankles, and small joints.

Physical Examination

  • Swelling of the joint that involved
  • Decreased range of motion such as pseudo paralysis
  • Patient hold the hip in flexed and externally rotated position if SA involving hip.
  • If child, unwillingness to bear weight on the affected joint (antalgic gait)

Diagnostic Evaluation

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hot, swollen joint suspecting septic arthritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Joint aspiration
send synovial fluid for Gram stain, culture and cell count
 
 
 
 
 
 
 
 
 
 
 
If dry tap:
Do image guided joint apiration with ultrasound or CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inflammatory/Purulent joint fluid
Presence of PMN 50,000-150,000 cells and mostly neutrophils
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-inflammatory fluid/Crystals
Suspect non bacterial arthritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gram positive cocci
Start empiric Vancomycin or Nafcicillin
 
 
 
 
 
Gram negative bacilli
Start empiric 3rd generation cephalosporins + aminoglycosides
 
 
 
 
 
Negative Gram stain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow-up with synovial fluid culture results
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If culture positive
❑ Treat for septic arthritis
❑ Change antibiotics according to the culture results
❑ Joint drainage
 
 
 
 
 
If culture negative
❑ Assess for true or false positivity of Gram stain
❑ Assess for clinical response
 
 
Immunocompromised
start empiric Vancomycin and 3rd generation cephalosporins
 
 
 
 
 
Immunocompetent
start empiric vancomycin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wait for culture results
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If culture positive,
❑ Treat for septic arthritis
❑ Change antibiotics according to the culture results
❑ Joint drainage
 
 
 
 
 
 
 
 
If culture negative
Confirmed non bacterial arthritis and look for alternative diagnosis
 
 
 
 
 
 
 
 
 
 

Imaging Studies

X-ray

X-ray of the joint with septic arthritis are usually normal in the first few days of infection as there is no joint destruction seen usually or may show a preexisting joint disease such as rheumatoid arthritis or osteoarthritis. So, the initial x-ray may be useful to determine pre-existing conditions, such as osteoarthritis or simultaneous osteomyelitis, or may be useful as a baseline image in monitoring the treatment response. However, in the late stages of septic arthritis, X-ray film may show: swelling of the joint capsule and soft tissue around the joint, fat pad displacement, and joint space widening due to localized edema and effusion.[21]

CT

Computerised tomography is used to diagnose ambiguous cases of septic arthritis to differentiate it from other causes of acute arthritis or to determine the extent of bone and soft tissue infections. But, it is less sensitive in the early stages of the disease. In the late stages of septic arthritis, CT shows: visualization of joint effusion, soft tissue swelling, para-articular abscesses, joint space widening due to localized edema, bone erosions, foci of osteitis, and scleroses.[22][7]

MRI

The role of MRI in the diagnosis of septic arthritis has been increasing in recent years in an effort to detect this entity earlier.[23] Findings are usually evident within 24 hours following the onset of infection and include: synovial enhancement, perisynovial edema and joint effusion. Signal abnormalities in the bone marrow can indicate a concomitant osteomyelitis.[24] The sensitivity and specificity of MRI for the detection of septic arthritis has been reported to be 100% and 77% respectively.

Treatment

Medical Therapy

Acute nongonococcal septic arthritis is a medical emergency which causes severe joint destruction and may increase both morbidity and mortality. So prompt diagnosis and treatment with antibiotic therapy and prompt drainage which reduces long-term complications. Vancomycin is recommended as either empirical therapy for patients with Gram-positive cocci on a synovial fluid Gram stain or as a component of regimen for those with a negative Gram stain if methicillin-resistant Staphylococcus aureus (MRSA) is prevalent. If Gram-negative bacilli are observed, an anti-pseudomonal Cephalosporin (e.g., Ceftazidime, Cefepime) should be administered. Carbapenems should be considered in conditions such as colonization or infection by extended-spectrum β-lactamase–producing pathogens. The optimal duration of therapy for septic arthritis remains uncertain. A minimum 3- to 4 week course is suggested for septic arthritis caused by S. aureus or Gram-negative bacteria. The use of Corticosteroids or intraarticular antibiotics is not advisable.[25][26]

Surgical Therapy

Successful treatment of septic arthritis include both anti microbial therapy and removal of intra-articular pus with surgical management. Surgical or arthroscopic management will increase the risk of infections when compared to diagnostic athroscopic procedures without further procedures. Infection rate depends on the type of procedure (open procedures ~17% and arthroscopic procedures 1~1%), duration of the procedure and prior joint disease.[27] Surgical management options include:

  • Closed needle aspiration
  • Open drainage
  • Tidal irrigation
  • Arthroscopy
  • Arthrotomy

Primary Prevention

Prevention of septic arthritis is possible by intensive treatment of risk factors such as old age patients having rheumatoid arthritis, diabetes mellitus, joint prostheses or joint surgery and skin infection.[12]

References

  1. Mathews CJ, Weston VC, Jones A, Field M, Coakley G (2010). "Bacterial septic arthritis in adults". Lancet. 375 (9717): 846–55. doi:10.1016/S0140-6736(09)61595-6. PMID 20206778.
  2. 2.0 2.1 Goldenberg DL (1998) Septic arthritis. Lancet 351 (9097):197-202. DOI:10.1016/S0140-6736(97)09522-6 PMID: 9449882
  3. Barton LL, Dunkle LM, Habib FH (1987) Septic arthritis in childhood. A 13-year review. Am J Dis Child 141 (8):898-900. PMID: 3498362
  4. Whitehead W (1902) Observations ON THE "OPEN METHOD" OF TREATING EXCEPTIONAL CASES OF SEPTIC ARTHRITIS OF THE KNEE. Br Med J 1 (2164):1523-4. PMID: 20760321
  5. Nathan PW (1917) Arthritis Deformans as an infectious Disease : An experimental and Clinical Study from the Carnegie Laboratory (University and Bellevue Medical College) and the Montefiore Home and Hospital for Chronic Diseases. J Med Res 36 (2):187-224.11. PMID: 19972362
  6. Rankin W (1917) ON THE TREATMENT OF CERTAIN SELECTED CASES OF SEPTIC ARTHRITIS OF THE KNEE. Br Med J 2 (2957):287-9. PMID: 20768715
  7. 7.0 7.1 Shirtliff ME, Mader JT (2002) Acute septic arthritis. Clin Microbiol Rev 15 (4):527-44. PMID: 12364368
  8. Dubost JJ, Fis I, Denis P, Lopitaux R, Soubrier M, Ristori JM et al. (1993) Polyarticular septic arthritis. Medicine (Baltimore) 72 (5):296-310. PMID: 8412643
  9. Klein RS (1988) Joint infection, with consideration of underlying disease and sources of bacteremia in hematogenous infection. Clin Geriatr Med 4 (2):375-94. PMID: 3288326
  10. Atcheson SG, Ward JR (1978) Acute hematogenous osteomyelitis progressing to septic synovitis and eventual pyarthrosis. The vascular pathway. Arthritis Rheum 21 (8):968-71. PMID: 737020
  11. 11.0 11.1 Morgan DS, Fisher D, Merianos A, Currie BJ (1996) An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect 117 (3):423-8. PMID: 8972665
  12. 12.0 12.1 Kaandorp CJ, Van Schaardenburg D, Krijnen P, Habbema JD, van de Laar MA (1995) Risk factors for septic arthritis in patients with joint disease. A prospective study. Arthritis Rheum 38 (12):1819-25. PMID: 8849354
  13. 13.0 13.1 13.2 Goldenberg DL, Reed JI (1985) Bacterial arthritis. N Engl J Med 312 (12):764-71. DOI:10.1056/NEJM198503213121206 PMID: 3883171
  14. Kaandorp CJ, Krijnen P, Moens HJ, Habbema JD, van Schaardenburg D (1997) The outcome of bacterial arthritis: a prospective community-based study. Arthritis Rheum 40 (5):884-92. <884::AID-ART15>3.0.CO;2-6 DOI:10.1002/1529-0131(199705)40:5<884::AID-ART15>3.0.CO;2-6 PMID: 9153550
  15. Bengtson S, Knutson K (1991) The infected knee arthroplasty. A 6-year follow-up of 357 cases. Acta Orthop Scand 62 (4):301-11. PMID: 1882666
  16. Esterhai JL, Gelb I (1991) Adult septic arthritis. Orthop Clin North Am 22 (3):503-14. PMID: 1852426
  17. Nelson JD, Koontz WC (1966) Septic arthritis in infants and children: a review of 117 cases. Pediatrics 38 (6):966-71. PMID: 5297142
  18. Goldenberg DL, Cohen AS (1976) Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med 60 (3):369-77. PMID: 769545
  19. Ilahi OA, Swarna U, Hamill RJ, Young EJ, Tullos HS (1996). "Concomitant crystal and septic arthritis". Orthopedics. 19 (7): 613–7. PMID 8823821.
  20. O'Brien JP, Goldenberg DL, Rice PA (1983) Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. Medicine (Baltimore) 62 (6):395-406. PMID: 6415361
  21. Jaramillo D, Treves ST, Kasser JR, Harper M, Sundel R, Laor T (1995) Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol 165 (2):399-403. DOI:10.2214/ajr.165.2.7618566 PMID: 7618566
  22. Seltzer SE (1984) Value of computed tomography in planning medical and surgical treatment of chronic osteomyelitis. J Comput Assist Tomogr 8 (3):482-7. PMID: 6725696
  23. Modic MT, Pflanze W, Feiglin DH, Belhobek G (1986) Magnetic resonance imaging of musculoskeletal infections. Radiol Clin North Am 24 (2):247-58. PMID: 3714999
  24. Tehranzadeh J, Wang F, Mesgarzadeh M (1992) Magnetic resonance imaging of osteomyelitis. Crit Rev Diagn Imaging 33 (6):495-534. PMID: 1476623
  25. Mathews, Catherine J.; Weston, Vivienne C.; Jones, Adrian; Field, Max; Coakley, Gerald (2010-03-06). "Bacterial septic arthritis in adults". Lancet. 375 (9717): 846–855. doi:10.1016/S0140-6736(09)61595-6. ISSN 1474-547X. PMID 20206778.
  26. Sharff KA, Richards EP, Townes JM (2013) Clinical management of septic arthritis. Curr Rheumatol Rep 15 (6):332. DOI:10.1007/s11926-013-0332-4 PMID: 23591823
  27. Armstrong RW, Bolding F, Joseph R (1992) Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors. Arthroscopy 8 (2):213-23. PMID: 1637435


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