Septic (Infectious) Arthritis
Original Editors - Amy Bramble & Kayla Klope from Bellarmine University's Pathophysiology of Complex Patient Problems project.
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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 infect the joint which will invade and cause inflammation of the synovial membrane.[2] With the onset of inflammation, cytokines and proteases are released thus, resulting in cartilage destruction.[3] The infection is located in the synovial or periarticular tissues and is most commonly bacteria.[4] Bacteria can spread from other infected areas in your body to a joint.[1] Sometimes bacteria will only infect one joint, leaving other areas of your body unharmed. Septic arthritis is common at any age. It most commonly occurs in children under the age of three. [4] The sites that are most common for developing septic arthritis include the hip and the knee.[5]
Prevalence[edit | edit source]
In the United States, there are approximately 20,000 cases of septic arthritis reported each year. Europe reports a similar incidence.[6] Most common is the staphyloccoccus aureus which is found in 60% of positive cultured joint aspirations. Bactermia is not as common as staphylococcus but it can lead to polyarticular involvement in 15% of the cases with septic arthitits.[7]
Characteristics/Clinical Presentation[edit | edit source]
Septic arthritis can present with acute symptoms of joint pain, swelling, tenderness and loss of motion.[4] The symptoms usually come on quick and a fever may be present. The patient may be unable to weight bear through the joint.[3]
Symptoms in Newborns/Infants[5]
- Cries when infected joint is moved
- Fever
- Unable to move the limb
- Irritability
Symptoms in Children and Adults[5]
- Unable to move the limb
- Intense joint pain
- Joint swelling
- Joint redness
- Low fever
- Chills may occur
- Possible Tachycardia
Patient who has another type of arthritis will likely be taking medication and septic arthritis pain may be masked by that medication so being aware of the other signs and symptoms are very important. In adults, the joints of the arms and legs are usually affected. The knees are most commonly affected by septic arthritis. The hip is most commonly affected in children. Children will usually hold their hip in a fixed position and try to avoid any movement. [1]
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.[2] Fifty percent of adults with septic arthritis have significant decreased range of motion or chronic pain after the infection.[8] 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.[6]
Associated Co-morbidities[2][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.[2]
www.cmaj.ca/content/176/11/1605.full.pdf+html
Common Antibiotic Used:[6]
- 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[9][edit | edit source]
- Arthrocentesis with synovial fluid examination and culture
- White blood cell count
- Erythrocyte sedimentation rate (ESR)
- Temperature
- C-Reactive Protein (CRP)
- Imaging studies are used to rule out other conditions
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. [3]The most common mechanism of infection is via hematogenous. [2]
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. [3]An additional risk factor is recent ACL reconstruction with a contaminated bone-tendon-bone allograft.[3] This is not a common occurrence secondary to advances in medicine.
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. [3]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. [2] 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]
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Physical Therapy Management (current best evidence)[edit | edit source]
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Alternative/Holistic Management (current best evidence)[edit | edit source]
There are no significant recommendations from an alternative medicine perspective on this subject.
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.[8]
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
- Computer assisted knee arthrodesis in a primary case of septic arthritis
www.sciencedirect.com/science/article/pii/S0968016010001390
- Cervical facet joint septic arthritis
ukpmc.ac.uk/articles/PMC2958294/
Resources
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ 1.0 1.1 1.2 Mayo Clinic [Internet]. Mayo Foundation for Medical Education and Research; 2012 [cited 2012 March 22]. Availablefrom: http://www.mayoclinic.com/health/bone-and-joint-infections/DS00545
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Goodman CC, Fuller KS. Pathology: implications for the physical therapist. 3rd ed. St. Louis: Saunders Elsevier; 2009.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Goodman CC, Snyder TEK. Differential diagnosis for physical therapists: screening for referral. 4th ed. St. Louis: Saunders Elsevier; 2007.
- ↑ 4.0 4.1 4.2 The Merck Manual [Internet]. Whitehouse Station: Merck Sharp & Dohme Corp.; 2010 [cited 2012 March 22]. Available from: http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/infections_of_joints_and_bones/acute_infectious_arthritis.html#v907387
- ↑ 5.0 5.1 5.2 Pub med [Internet]. Bethesda: National Center for Biotechnology Information; 2012 [cited 2012 March 22]. Available from : http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001466/
- ↑ 6.0 6.1 6.2 Brusch, J. Medscape [Internet]. Septic Arthritis; 2011 [updated 2011 July 18; cited 2012 March 22] Available from: http://emedicine.medscape.com/article/236299-overview#aw2aab6b2b3aa
- ↑ Raz Guy, Elisha Ofiram, Izhar Arieli, Shaul Savig Disseminating Septic Arthritis Following Hip Hemiarthroplasty Case Communications 2009; 11:317-318
- ↑ 8.0 8.1 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.
- ↑ 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.
