Updated: 9/7/2018

Septic Arthritis - Adult

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https://upload.orthobullets.com/topic/1058/images/sc joint septic arthritis_moved.jpg
https://upload.orthobullets.com/topic/1058/images/staph aerues  (reference.medscape).jpg
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https://upload.orthobullets.com/topic/1058/images/faber (aafp.org).jpg
https://upload.orthobullets.com/topic/1058/images/ultrasound knee (gcus.com).jpg
https://upload.orthobullets.com/topic/1058/images/lateral mri (ajronline.org).jpg
Introduction
  • Epidemiology
    • body location
      • most commonly affected joints in descending order
        • knee (~ 50% of cases) >
        • hip >
        • shoulder >
        • elbow  >
        • ankle >
        • sternoclavicular joint 
          • found in IV drug users
          • pseudomonas aeruginosa was most common pathogen in 1980's
          • staphylococcus aureus is now the most common pathogen in all patients, including IV drug users
    • risk factors
      • age > 80 years
      • medical conditions
        • diabetes
        • rheumatoid arthritis
        • cirrhosis
        • HIV
      • history of crystal arthropathy
      • endocarditis or recent bacteremia
      • IV drug user
      • recent joint surgery
  • Pathophysiology
    • pathoanatomy
      • 3 etiologies of bacterial seeding of joint
        • bacteremia
        • direct inoculation
          • from trauma or surgery
        • contiguous spread
          • from adjacent osteomyelitis
    • cellular biology
      • septic arthritis causes irreversible cartilage destruction in an involved joint
        • cartilage injury can occur by 8 hours
      • caused by release of proteolytic enzymes from inflammatory cells (PMNs)
    • microbiology
      • most common pathogens is staphylococcus aureus (accounts for >50% of cases) 
      • see Classification below
  • Associated conditions
    • prosthetic implant infection topic
  • Prognosis
    • delayed diagnosis can lead to profound, extensive cartilage damage within hours
Classification
  • By organism
    • staphylococcus species 
      • staphylococcus aureus 
        • most common and accounts for >50% of cases
      • MRSA
      • staphylococcus epidermis
    • neisseria gonorrhea  
      • account for ~20% of cases
      • most common organism in otherwise healthy sexually active adolescents and young adults
      • manifests as a bacteremic infection
        • arthritis-dermatitis syndrome in ~60% of cases
        • localized septic arthritis in ~40% cases
    • gram-negative bacilli
      • account for 10-20% of cases
      • pathogens include
        • E coli, proteus
        • klebsiella
        • enterobacter
      • risk factors
        • neonates
        • IV drug users
        • elderly
        • immunocompromised patients with diabetes
    • streptococcus
      • streptococcus pyogenes (Group A)
        • most common
      • Group B streptococcus (e.g., agalactiae
        • predilection for infants, elderly and diabetic patients
    • propionibacterium acnes
      • associated with shoulder surgery
    • salmonella or streptococcus pneumoniae
      • seen in patients with sickle cell disease
    • bartonella henselae
      • seen in patients with HIV
    • pseudomonas aeruginosa
      • seen in patients with history of IV drug abuse
    • pasteurella multocida
      • seen in patients after dog or cat bite
    • eikenella corrodens
      • seen in patients after human bite
    • fungal/candida
      • found in immunocompromised host
Presentation
  • Symptoms
    • pain in affected joint
    • fevers (only present in 60% of cases)
    • may appear toxic
  • Physical exam 
    • inspection
      • erythema 
      • effusion
      • extremity tends to be in position of maximum joint volume
        • hip would be in FABER position (flexed, abducted, externally rotated)
    • palpation
      • warmth
      • tender
    • motion
      • inability to bear weight
      • inability to tolerate PROM 
Imaging
  • Radiographs 
    • recommended views 
      • AP and lateral of the joint in question 
    • findings
      • may show joint space widening or effusion 
      • periarticular osteopenia
  • Ultrasound 
    • indications
      • may help in confirming joint effusion in large joint such as hip 
        • can be used in guiding aspirations
  • MRI 
    • indications
      • detects joint effusion, and may detect adjacent bone involvement such as osteomyelitis 
Studies
  • Serum labs
    • WBC >10K with left shift
    • ESR >30
      • ESR is often elevated but may be normal early in process
        • rises within 2 days of infection and can rise 3-5 days after initiation of appropriate antibiotics, and returns to normal 3-4 weeks
    • CRP >5
      • most helpful
      • best way to judge efficacy of treatment, as CRP rises within few hours of infection, and may normalize within 1 week of treatment
  • Joint fluid aspirate
    • gold standard for treatment and allows directed antibiotic treatment
    • should be analyzed for
      • cell count with differential
      • gram stain
      • culture
      • glucose level
      • crystal analysis
        • septic arthritis occurs concurrently with gout or pseudogout in < 5% of cases
    • characteristic findings
      • joint fluid appears cloudy or purulent
      • cell count with WBC > 50,000 is considered diagnostic for septic arthritis, however lower counts may still indicate infection
        • prosthetic joint with WBC >1,100 is considered septic
      • gram stains only identifies infective organism 1/3 of time
      • glucose less than 60% of serum level
  • Saline load test 
    • utilized to determine if wound near a joint communicates with the joint
    • for the knee
      • 155 mL of saline is needed to reach 95% sensitivity 
      • 175 mL of saline is needed to reach 99% sensitivity 
Differential
  • Crystal arthropathy
    • gout 
    • pseudogout 
  • Cellulitis
  • Bursitis
    • prepatellar bursitis 
Treatment
  • Operative
    • IV abx, operative irrigation and drainage of the joint
      • indications
        • considered an orthopaedic surgical emergency
      • IV antibiotic therapy
        • initiate empiric therapy prior to definitive cultures based on patient age and or risk factors
          • young, healthy adults
            • staphylococcus aureus and neisseria gonorrhea
          • immunocompromised patients
            • staphylococcus aureus and pseudomonas aeruginosa
        • transition to organism-specific antibiotic therapy based once obtain culture sensitivities
      • outcomes
        • treatment can be monitored by following serum WBC, ESR, and CRP levels during treatment
Technique
  • Operative irrigation and drainage of the joint
    • approach
      • can be performed open or arthroscopically (depending on joint)
    • irrigation
      • remove all purulent fluid and irrigate joint
    • debridement
      • synovectomy can be performed as needed
    • cultures
      • obtain joint fluid and tissue for culture
Complications
  • Arthritis
  • Fibrous ankylosis
  • Osteomyelitis
 

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(OBQ06.249) Which of the following is true regarding the use of the saline injection load test to diagnose traumatic knee arthrotomies? Review Topic

QID: 260
1

Addition of methylene blue to the saline load test increases the sensitivity of the test

22%

(188/867)

2

Injection of 110ml of saline will diagnose 95% of knee arthrotomies

13%

(113/867)

3

Injection of 175ml of saline will diagnose 99% of knee arthrotomies

57%

(490/867)

4

A superomedial injection location requires significantly less fluid than a inferoeromedial injection location

1%

(10/867)

5

A history and physical exam by an orthopaedic surgeon has equivalent sensitivity to saline load test at detecting a traumatic arthrotomy

7%

(62/867)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ10.114) When performing a saline load test to evaluate for a traumatic arthrotomy of the knee, a mininum of how much saline should be utilized? Review Topic

QID: 3208
1

30 mL

1%

(32/2490)

2

50 mL

5%

(134/2490)

3

75 mL

5%

(134/2490)

4

100 mL

10%

(249/2490)

5

155 mL

78%

(1931/2490)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ04.24) A 45-year-old IV drug abuser has sternoclavicular (SC) joint pain for the past 2 weeks. He is afebrile and physical exam findings include point tenderness and swelling. He most likely has septic arthritis of the sternoclavicular joint. If so, what is the most likely infecting organism? Review Topic

QID: 135
1

Streptococcus pneumoniae

1%

(4/316)

2

Staphylococcus aureus

80%

(254/316)

3

Pseudomonas aeruginosa

8%

(26/316)

4

Staphylococcus epidermis

8%

(26/316)

5

Propionibacterium acnes

1%

(4/316)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ06.63) A 20-year-old man presents with erythema, swelling, and pain at the left sternoclavicular joint shown in Figure A. His temperature is 38.9 degress Celsius, serum WBC is 14,000, and his C-reactive protein is elevated. He reports that he uses IV heroin. A coronal 3D CT scan of the left clavicle is shown in Figure B. Joint aspiration shows many grams stain positive organisms. Which of the following organisms is the most likely pathogen? Review Topic

QID: 174
FIGURES:
1

Propionibacterium acnes

1%

(11/812)

2

Staphylococcus aureus

93%

(757/812)

3

Group B streptococcus

3%

(25/812)

4

Neisseria gonorrhea

1%

(10/812)

5

Enterococcus coli

0%

(3/812)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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