Septic (Infectious) Arthritis
Original Editors - Amy Bramble & Kayla Klope from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Top Contributors - Amy Bramble, Kelli House, Kim Jackson, Lucinda hampton, Admin, Elaine Lonnemann, WikiSysop, 127.0.0.1, Jill Thompson, Wendy Walker, Lauren Lopez, Khloud Shreif and Nupur Smit Shah
Definition/Description[edit | edit source]
Septic arthritis is also commonly referred as bacterial or infectious arthritis. Septic arthritis is an intensely painful infection in a joint. [1] Bacteria, viruses and fungi may invade the joint through various routes which cause inflammation of the synovial membrane.[2] With the onset of inflammation, cytokines and proteases are released, thus resulting in potential joint destruction. [3] The infection is located in the synovial or periarticular tissues and is most commonly bacterial. [4] Bacteria or other foreign pathogens can infect either one joint or, if left untreated, can spread and cause further systemic damage. Septic arthritis may occur at any age but is more likely in children and older adults. The most commonly targeted joins in the body are the knee, hip, shoulder, ankle and wrists. [5]
Prevalence[edit | edit source]
In the United States, there are approximately 20,000 cases of septic arthritis reported each year. The most common strain is the staphyloccoccus aureus which is found in 60% of positive cultured joint aspirations. In non gonococcal strains, which includes staphylococcus, this incidence can increase to 28-38 cases per 100,000 in individuals also diagnosed with Rheumatoid Arthritis. [5]
Characteristics/Clinical Presentation[edit | edit source]
Typical presentation of septic arthritis in children and adults includes:
- Acute, rapid onset of pain
- Unable to move the joint through active and passive range of motion
- Typically only one joint (can be bilateral or more than one joint depending on the type of infection)
- Unable to bear any weight on the joint
- Effusion
- Joint warmth
- Skin rash
- Low grade fever
- Lymphadenopathy
- The joints of the arms and legs are the most commonly affected in adults (especially the knees)
- The hip joint is most commonly affected in children
Symptoms in Newborns/Infants
- Cries when infected joint is moved
- Fever
- Unable to move the limb
- Irritability
Note: A patient may be taking medications for other types of arthritis that may mask the original signs and symptoms of septic arthritis. Early diagnosis for proper treatment is critical. [9]
Prognosis:
The best outcome for individuals with septic arthritis is immediate treatment. Mortality ranges from 19-25% and permanent joint disability occurs in 25-50% of the cases.[10] Fifty percent of adults with septic arthritis have significant decreased range of motion or chronic pain after the infection.[11] Poor outcome predictors in prognosis of septic arthritis include the following: Age older than 60, infection of the hip or shoulder joints, underlying rheumatoid arthritis, positive findings on synovial fluid cultures after 7 days of therapy, delay of 7 days or longer in beginning treatment.[12]
Associated Co-morbidities[10][edit | edit source]
• Systemic corticosteroid use
• Radiation therapy
• Preexisting arthritis
• Arthrocentesis: joint aspiration
• Human Immunodeficiency virus
• Diabetes Mellitus
• Alcohol or drug use
• Trauma
• Other infectious diseases
Medications
[edit | edit source]
Needle joint aspiration is often the initial choice of treatment. Floroscopy is used at the sacroiliac joint and hip due to the difficulty of performing needle aspiration. Following the results of the cultures, antibiotics are chosen.[10]
www.cmaj.ca/content/176/11/1605.full.pdf+html
Common Antibiotic Used:[12]
- Ceftriaxone (Rocephin)- Effective against gram-negative enteric rods
- Ciprofloxacin (Cipro) - Treat N gonorrhoeae and gram-negative enteric rods.
- Cefixime (Suprax) –Broad activity against gram-negative bacteria, by binding to one or more of the penicillin-binding proteins. Arrests bacterial cell wall synthesis and inhibits bacterial growth.
- Oxacillin - Oxacillin is useful against methicillin-sensitive S aureus (MSSA).
- Vancomycin (Vancocin) - An anti-infective agent used against methicillin-sensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients allergic to penicillin.
- Linezolid (Zyvox) - An alternative antibiotic that is used in patients allergic to vancomycin and for the treatment of vancomycin-resistant enterococci.
Diagnostic Tests/Lab Tests/Lab Values[13][edit | edit source]
- Arthrocentesis with synovial fluid examination and culture
- Increased White blood cell count
- Increased Erythrocyte sedimentation rate (ESR)
- Increased Temperature
- Increased C-Reactive Protein (CRP)
- Imaging studies are used to rule out other conditions
www.vumc.nl/afdelingen-themas/41463/27797/2089686/2090082/1608664/8.pdf
Etiology/Causes[edit | edit source]
Septic arthritis is caused by invasion of bacteria, viruses, or fungi into the synovial membrane of a joint. This occurs most commonly by direct inoculation, penetrating wound, or direct extension. [15]The most common mechanism of infection is via hematogenous. [10]
www.merckmanuals.com/media/professional/pdf/Table_039-2.pdf
The most important risk factors to consider include age (children and older adults are at greatest risk), diabetes mellitus, IV drug use, indwelling catheters, immunocompromised condition, rheumatoid arthritis, osteoarthritis, alcohol abuse, or a recent history of joint damage. [15]An additional risk factor is recent ACL reconstruction with a contaminated bone-tendon-bone allograft.[15] This is not a common occurrence secondary to advances in medicine.
Risk Factors for Acquiring Septic Arthritis |
---|
Age (Neonates, children, older adult) |
Alcoholism |
Anemia |
Arthrocentesis or joint surgery |
Bacteremia |
Cancer |
Diabetes |
Hemodialysis |
Hemophilia |
History of previous joint infection |
Immunodeficiency |
Immunosuppressive therapy |
IV drug use |
Joint Replacement |
RA |
Risk for sexually tramitted disease |
Sickle cell disease |
Skin infection |
SLE |
Any other chronic illness not listed |
Systemic Involvement[edit | edit source]
Septic arthritis presents with a multitude of signs and symptoms affecting visceral systems. Joint symptoms may present in conjunction with a skin rash, low-grade fever, chills, and lymphadenopathy. [15]Bilateral joint involvement is common in the fingers, knees, shoulders, and ankles. The classic signs of infection may be present including increased temperature, swelling, redness, and loss of function. [10] Acute symptoms of an arthritic joint in the presence of fever should alert the health care provider of potential septic arthritis and should be treated as a medical emergency.
Medical Management (current best evidence)[edit | edit source]
Antibiotic Treatment- Septic arthritis is best treated immediately with antibiotics. There is no one antibiotic better than another; rather it is based on the organism involved. Antibiotics will need to be chosen based on the culture.[16]
Joint Drainage and Surgical options- Removal of infected joint material is imperative in improving a patient’s status. One systematic review found “the results suggested that needle aspiration appeared, in general, to be preferable to surgical treatment as an initial mode of treatment of joint sepsis, although the results did not reach statistical significance (and there was a trend towards higher mortality in the needle aspiration group)".[16]
Management regarding antibiotic choice, dosage, route of administration, and duration of treatment is unknown in the treatment of septic arthritis. In addition, no evidence has shown if closed aspiration or open arthroscopy is better at removing materials from a joint that’s infected.[16]
Physical Therapy Management (current best evidence)[12][edit | edit source]
It is important to first immobilize the joint. This will control the patient’s pain because it is often too painful to bear weight. Gentle mobilization of the infected joint can begin if the patient is responding well following 5 days of gentle treatment. Patients will usually respond better to aggressive PT to allow maximum post infection functioning. PT needs to consists of allowing the joint to be in its functional position and positioning the joint to allow passive range of motion activities.
Differential Diagnosis[edit | edit source]
Septic arthritis presents as many associated arthropathies, these must be ruled out in order for a definitive diagnosis to be made. With the immediacy of joint destruction with septic arthritis, the differential diagnosis must be performed with urgency to initiate proper treatment immediately. Conditions that must be considered include: rheumatoid arthritis, osteoarthritis, HIV infection, Lyme disease, and gout. Patients with these diagnoses often have a poor prognosis secondary to delays in the proper diagnosis of septic arthritis. Clinicians often attribute the signs and symptoms to the preexisting conditions. Other conditions that must be ruled out include: infective endocarditis, reactive arthritis, and viral arthritis.[11]
Case Reports/ Case Studies[edit | edit source]
- Septic arthritis of the hip:
www.ncbi.nlm.nih.gov/pmc/articles/PMC2485040/
- Pneumococcal polyarticular septic arthritis after a single infusion of infliximab in a rheumatoid arthritis patient:
www.jmedicalcasereports.com/content/6/1/81
- Cervical facet joint septic arthritis:
ukpmc.ac.uk/articles/PMC2958294/
Resources
[edit | edit source]
Mayo Clinic www.mayoclinic.com/health/bone-and-joint-infections/DS00545
Medscape emedicine.medscape.com/article/236299-overview
Merck Manual
PubMed www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001466/
Recent Related Research (from Pubmed)
[edit | edit source]
Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1-khLOXmKonNtxktOeWstA4_W9E4uKQ_vkm-r66-5MuEhn1Y0j|charset=UTF-8|short|max=10: Error parsing XML for RSS
References[edit | edit source]
see adding references tutorial.
- ↑ Cite error: Invalid
<ref>
tag; no text was provided for refs namedmayo Clinic
- ↑ 2.0 2.1 Cite error: Invalid
<ref>
tag; no text was provided for refs namedpatho Book
- ↑ Cite error: Invalid
<ref>
tag; no text was provided for refs namedddx book
- ↑ http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/infections_of_joints_and_bones/acute_infectious_arthritis.html#v907387
- ↑ 5.0 5.1 http://emedicine.medscape.com/article/236299-overview#aw2aab6b2b3aa
- ↑ Cite error: Invalid
<ref>
tag; no text was provided for refs namedmerck manual
- ↑ Cite error: Invalid
<ref>
tag; no text was provided for refs namedDdx book
- ↑ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001466/
- ↑ Cite error: Invalid
<ref>
tag; no text was provided for refs namedMayo Clinic
- ↑ 10.0 10.1 10.2 10.3 10.4 Goodman CC, Fuller KS. Pathology: implications for the physical therapist. 3rd ed. St. Louis: Saunders Elsevier; 2009.
- ↑ 11.0 11.1 Goldenberg DL, Cohen AS. Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med. Mar 1976;60(3):369-77.
- ↑ 12.0 12.1 12.2 Cite error: Invalid
<ref>
tag; no text was provided for refs namedMedscape
- ↑ Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg. 2011 July; 93(11): 1556-61.
- ↑ Goldenberg DL. Septic arthritis. The Lancet. 1998 [cited 2012 March 22]; 351: 197-202. Available from VUMC with Full Text: http://www.vumc.nl/afdelingen-themas/41463/27797/2089686/2090082/1608664/8.pdf
- ↑ 15.0 15.1 15.2 15.3 Goodman CC, Snyder TEK. Differential diagnosis for physical therapists: screening for referral. 4th ed. St. Louis: Saunders Elsevier; 2007.
- ↑ 16.0 16.1 16.2 Matthews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007 [cited 2012 March 2]; 66: 440-45. Available from NCBI with Full Text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856038/pdf/440.pdf
- ↑ YouTube. Septic arthritis of the knee arthroscopic debridement. Available at: http://www.youtube.com/watch?v=0AOv06XWCps. (Accessed 2012 April 3).