Contents

Search

infectious arthritis (septic arthritis)

Generally, inflammation of a joint caused by bacterial invasion. Diagnostic criteria: 1) acute monoarticular arthritis. 2) positive gram stain/culture from synovial fluid (exception Neisseria gonorrhoeae) Etiology: 1) Staphylococcus aureus a) most common cause of septic arthritis [3] b) affects native & prosthetic joints c) medical emergency [3] 2) Neisseria gonorrhoeae - common cause in sexually-active young adults - 3 distinct syndromes - arthritis-dermatitis syndrome - arthritis-urogenital syndrome - purulent gonococcal arthritis 3) Neisseria meningitidis - may produce an arthritis-dermatitis syndrome indistinguishable from Neisseria gonorrhoeae 4) coagulase negative Staphylococcus 5) Streptococcus species - Streptococcus pneumoniae - Streptococcus pyogenes - Streptococcus agalactiae 6) gram negative bacilli a) Escherichia coli b) Salmonella, especially osteomyelitis c) Pseudomonas d) Haemophilus influenzae e) more common in elderly, immunosuppressed, post-op, injection drug users, or patients with recent trauma, GI infection or with intravenous catheters 7) Brucella preferentially involves spine 8) tuberculosis - preferentially involves spine (spondylitis, osteomyelitis) - may also involve hip or knee [3] - concurrent pulmonary tuberculosis in a minority of patients [3] 9) Mycobacterium marinum 10) Borrelia burgdorferi (Lyme disease) a) late-stage manifestation b) generally monoarticular, most commonly involves knee 11) viral arthritis: a) rubella b) parvovirus B19 c) hepatitis B & hepatitis C d) HIV 12) fungus (subacute monoarthritis in a patient with systemic mycosis) a) Sporothrix schenckii b) Histoplasma c) Crytococcus d) Blastomyces 13) prosthetic joint (prosthetic joint infection) or recent joint surgery 14) general risk factors for infectious arthritis [3] - sources of infection - wounds - skin infection - pneumonia - urinary tract infection - injection drug use associated with subacute septic arthritis - septic sacroiliitis, sternoclavicular joint & pubic symphysis involvement - gram-negative bacilli: coverage for Pseudomonas [21] - pre-existing arthritis or joint damage - rheumatoid arthritis - intra-articular glucocorticoid injection - age > 80 or very young children - low socioeconomic status - alcoholism - diabetes mellitus - end-stage renal disease - immunosuppression - sickle cell disease - underlying malignancy [3] Pathology: 1) hematogenous spread from another primary site of infection 2) contiguous spread to joint from soft tissue or adjacent bone Clinical manifestations: 1) acute onset monoarthritis (< 48 hours) a) worsening of chronic inflammatory arthritis in a single joint b) previously damaged joints at increased risk c) onset generally over a few days 2) constitutional symptoms, fever, shaking chills uncommon 3) affected joint may be warm, erythematous, swollen & painful with limited joint mobility 4) loss of active & passive range of motion - pain on passive range of motion in the absence of trauma 5) pain & swelling less in elderly & in patients receiving glucocorticoids 6) joints commonly affected a) knee is involved in 1/2 of the cases b) hips c) shoulders d) wrists e) ankles f) elbows g) spine - involves vertebral body & adjacent intervertebral disk space h) in drug abusers (Staphylococcus aureus, Pseudomonas) 1] sternoclavicular joint [8] & acromioclavicular joint 2] sacroiliac joint 7) migratory arthragia, tenosynovitis (wrist or ankle) & dermatitis (vesiculopustular) = disseminated gonococcal infection - disseminated gonococcal infection may also present as a purulent monoarthritis or oligoarthritis [3] 8) overlying skin infection in a patient who has recently undergone arthroplasty suggests prosthetic joint infection Laboratory: 1) synovial fluid cell count with differential a) appearance: yellow, purulent, or bloody b) 50,000-200,000 WBC/mm3 with > 90% neutrophils - cell count for gonococcal arthritis lower than other types of infectious arthritis, as low as 14,000 WBC/mm3 with 85% neutrophils [3] c) RBCs present 2) synovial fluid Gram stain, culture & sensitivity - gram stain negative in 20% of septic arthritis, especially common with gram-negative organisms - septic arthritis can cause release of calcium pyrophosphate crystals from cartilage [13] 3) serum glucose & synovial fluid glucose - synovial fluid glucose often < 50% fasting serum glucose 4) "string test": normal synovial fluid when gently pushed from syringe will form a 5-10 cm "string". With infection, the "string" will be shorter 5) polarized microscopy of joint fluid for crystals a) septic arthritis can develop in patients with crystalline arthritis b) crystals in synovial fluid does not exclude infection 6) complete blood count (CBC) may show leukocytosis 7) blood cultures (obtain specimens prior to empiric antibiotics) 8) if disseminated gonococcal infection is suspected, also wound culture (skin pustule), urethral culture or cervical culture, rectal culture, throat culture - Neisseria gonorrhoeae DNA vs culture - synovial fluid cultures tend to be negative [1]* 9) CH50 assay screen for complement deficiency: - all patients with recurrent disseminated gonorrhea - family history of disseminated Neisseria infection [3] 10) see ARUP consult [5] * septic arthritis caused by N gonorrhoeae (vs disseminated gonococcal infection) is monoarticular or pauciarticular, & is more commonly associated with positive synovial fluid cultures & negative blood cultures [11] Special laboratory: - arthrocentesis for synovial fluid - synovial biopsy for tuberculous arthritis Radiology: 1) plain films of joint (rarely helpful [3]) a) soft tissue swelling & distension of joint capsule early b) joint destruction may be observed as a late manifestation c) evidence of co-existing osteomyelitis may be present 2) bone scan may be useful, but is non-specific 3) magnetic resonance imaging (MRI) Differential diagnosis: - rheumatoid arthritis monoarticular flare Management: 1) joint aspiration & drainage daily from bacterial infection of native joint until fluid ceases to accumulate [3] 2) arthroscopic or open drainage may be necessary if joint fluid cannot be completely evacuated by aspiration - early orthopedic consultation recommended [3,9,10] - multiple procedures may be necessary in 50% of patients especially patients with diabetes mellitus [10] 3) antibiotic therapy (after synovial fluid & blood collection) a) determined by clinical condition & laboratory studies b) empiric antibiotic therapy 1] no organisms seen on gram stain a] vancomycin or linizolid + 3rd generation cephalosporin or cefepime or ceftazidime (Pseudomonas, IVDA) [3] b] narrow spectrum of antibiotic coverage based on culture & sensitivity c] antibiotic coverage for 7-14 days even if cultures negative [3] d] vancomycin + ceftazidime if low risk for gonorrhea 2] gram positive cocci a] always initiate therapy with coverage for MRSA b] vancomycin or linizolid for MRSA [3]; teicoplanin 2nd line c] nafcillin or oxacillin +/- gentamicin for MSSA; cefazolin 2nd line 3] gram negative bacilli a] ceftriaxone or cefotaxime; fluoroquinolone 2nd line b] include ceftazidime + gentamicin, cefepime, or Zozyn if Pseudomonas - injection drug use [3,4] c] if gonococcal arthritis, treat for co-infection with Chlamydia (doxycycline or azithromycin) [3] 4] suspect tuberculous arthritis or fungal arthritis if empiric antibacterial therapy is unsuccessful [3] c) duration of therapy: 1] 2 weeks [3] or 3 weeks if post-Chlamydia arthritis 2] some patient may require 6 weeks or more of therapy [3] 3] 2 weeks non-inferior to 4 weeks [18] d) oral antibiotics non-inferior to IV antibiorics [16,18] 4) amphotericin B, echinocandin or azole (itraconazole, fluconazole, voriconazole, posaconazole) for fungal arthritis 5) standard 3-4 drug treat of tuberculosis for tuberculous arthritis 6) acute viral arthritis is generally self-limiting & may be managed symptomatically 7) surgery + antibiotics for infected prosthesis - removal of hardware is generally required [3] - consult orthopedic surgery if prosthetic joint infection is suspected [3] 8) splinting of joint may provide symptomatic relief 9) passive range of motion exercises once pain has diminished followed by active exercise to restore strength & joint mobility 10) bony fusion may be required with severely damaged weight-bearing joints 11) poor outcomes are common even with aggressive management 12) glucocorticoids a) persistent synovitis & effusion after cure of infection may respond to a single intra-articular glucocorticoid injection b) document negative cultures after completion of antibiotics prior to glucocorticoid injection c) administration of dexamethasone 0.2 mg/kg IV every 8 hours for 12 doses improved outcomes in children [4]; 1st dose administered 15-20 minutes before 1st dose of parenteral antibiotics [4]

Interactions

disease interactions

Specific

fungal arthritis HIV-associated arthritis infected prosthesis infectious arthritis ankle/foot infectious arthritis elbow infectious arthritis hand infectious arthritis hip infectious arthritis in the elderly infectious arthritis knee infectious arthritis shoulder infectious arthritis wrist tuberculous arthritis viral arthritis

General

arthritis infection (infectious disease)

References

  1. Harrison's Principles of Internal Medicine, 11th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1987, pg 1462
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 877-78
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Journal Watch 23(23):187, 2003 Odio CM et al Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children. Pediatr Infect Dis J 22:883, 2003 PMID: 14551489
  5. ARUP Consult: Septic Arthritis The Physician's Guide to Laboratory Test Selection & Interpretation https://arupconsult.com/content/septic-arthritis
  6. Garcia-De La Torre I, Nava-Zavala A. Gonococcal and nongonococcal arthritis. Rheum Dis Clin North Am. 2009 Feb;35(1):63-73. PMID: 19480997
  7. Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. Lancet. 2010 Mar 6;375(9717):846-55 PMID: 20206778
  8. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore). 2004 May;83(3):139-48. PMID: 15118542
  9. Sammer DM, Shin AY. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. Surgical technique. J Bone Joint Surg Am. 2010 Mar;92 Suppl 1 Pt 1:107-13. PMID: 20194349
  10. Hunter JG et al. Risk factors for failure of a single surgical debridement in adults with acute septic arthritis. J Bone Joint Surg Am 2015 Apr 1; 97:558 PMID: 25834080
  11. Rice PA Gonococcal arthritis (disseminated gonococcal infection). Infect Dis Clin North Am. 2005 Dec;19(4):853-61 PMID: 16297736
  12. Paakkonen M, Peltola H Bone and joint infections. Pediatr Clin North Am. 2013 Apr;60(2):425-36 PMID: 23481109 - Paakkonen M, Peltola H Treatment of acute septic arthritis. Pediatr Infect Dis J. 2013 Jun;32(6):684-5 PMID: 23439494
  13. Sharff KA, Richards EP, Townes JM. Clinical management of septic arthritis. Curr Rheumatol Rep. 2013 Jun;15(6):332. Review. PMID: 23591823
  14. Garcia-Arias M, Balsa A, Mola EM. Septic arthritis. Best Pract Res Clin Rheumatol. 2011 Jun;25(3):407-21. Review. PMID: 22100289
  15. Wang DA, Tambyah PA. Septic arthritis in immunocompetent and immunosuppressed hosts. Best Pract Res Clin Rheumatol. 2015 Apr;29(2):275-89. Review. PMID: 26362744
  16. Li HK, Rombach I, Zambellas R et al. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med 2019 Jan 31; 380:425. PMID: 30699315 https://www.nejm.org/doi/10.1056/NEJMoa1710926
  17. Kim BN, Kim ES, Oh MD. Oral antibiotic treatment of staphylococcal bone and joint infections in adults. J Antimicrob Chemother. 2014 Feb;69(2):309-22. Review. PMID: 24072167
  18. Expert Panel on Musculoskeletal Imaging:, Beaman FD et al ACR Appropriateness Criteria. Suspected Osteomyelitis, Septic Arthritis, or Soft Tissue Infection (Excluding Spine and Diabetic Foot). J Am Coll Radiol. 2017 May;14(5S):S326-S337 PMID: 28473089
  19. Gjika E, Beaulieu JY, Vakalopoulos K et al. Two weeks versus four weeks of antibiotic therapy after surgical drainage for native joint bacterial arthritis: A prospective, randomised, non-inferiority trial. Ann Rheum Dis 2019 Aug; 78:1114 PMID: 30992295 Free Article https://ard.bmj.com/content/78/8/1114
  20. Earwood JS, Walker TR, Sue GJC. Septic Arthritis: Diagnosis and Treatment. Am Fam Physician. 2021 Dec 1;104(6):589-597. PMID: 34913662
  21. NEJM Knowledge+