septic arthritis
DESCRIPTION
septic arthritisTRANSCRIPT
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Stick a needle in itDiagnosis and management of septic arthritis in the ED
Dr Sarah Dawson, May 2014
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Why septic arthritis?
• Most dangerous and destructive monoarthritis• Can destroy cartilage within days• Mortality 7-15 % despite antibiotic use
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Aims
• To list the main differentials for acute monoarthritis• To understand the pathogenesis of septic arthritis• To list the main organisms that cause septic arthritis• To recognise the symptoms and signs of septic arthritis• To understand the key risk factors for septic arthritis and
how this affects subsequent investigation• To describe the anatomy and method for needle aspiration• To describe empirical antibiotic therapy and approaches
for joint aspiration
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Differential
• Infection- bacterial, mycobacterial, fungal• Gout• Pseudogout• Reactive arthritis• Osteoarthritis• Haemarthrosis• Lyme disease• SLE• RA
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Incidence
• 2-9 / 100 000 person years• 8-27% patients presenting to ED with acute arthritis
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Defitition
• Joint sepsis• 2ry to pathogenic innoculation of joint• By direct or haematogenous routes
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Pathogenesis
Deposit in synovial
membrane
Enter synovial
fluid
Cause purulent
joint
Bacteria enter joint
Haematogenous spread
Direct innoculation
Bite or trauma
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Organisms
• Can be bacterial, fungal, mycobacterial or viral• Bacterial divided into gonococcal and nongonococcal• Gonococcal more common but less morbidity and mortality• Staphylococcus• Streptococcus
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Risk Factors
• Age over 80 (LR 3.5, 95% CI 1.8-7.0)• DM (LR 2.7, 95% CI 1.0-6.9)• RA (LR 2.5, 95% CI 2.0-3.1)• Recent joint surgery (LR 6.9, 95% CI 3.8-12.0)• Hip or knee prosthesis (LR 3.1, 95% CI 2.0-4.9)• Skin infection (LR 2.8, 95% CI 1.7-4.5)• Skin infection + joint prosthesis (LR 15, 95% CI 8.1-28)• HIV (LR 1.7, 95% CI 1.0-2.8)• IV drug use• Alcoholism• IA steroid injection
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Symptoms
• Pain in affected joint 85%• Swelling in affected joint 78%• Large joint (knee or hip 60%)• Wrists and ankles also common
• Sweats 27%• Rigors 19%• May be subacute- especially TB and
prosthetic joints• More than 1 joint affected in 22%
cases• Underlying RA or overwhelming
sepsis
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Signs
• Fever >37.5 57%• Hot, swollen tender joint (or joints)• Reduced ROM
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Investigations
• Bloods- FBC, CRP, ESR- low specificity• WCC>10 000 LR 1.4 (95%CI 1.1-1.8)• ESR>30 LR 1.3 (95% CI 1.1-1.8)• CRP>100 LR 1.6 (95%CI 1.1-2.5)
• Synovial WCC and PMN• WCC<25000 LR 0.32, >25000 LR 2.9, >50000 LR 7.9, >100000 LR
28• PMN >90% LR 3.4• PMN<90% LR 0.34
• Synovial fluid microscopy (only +ve in 50%) and culture• Blood culture (+ve in 50%)• Imaging plain radiograph- baseline, osteomyelitis, concurrent joint
disease
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Synovial fluid analysis
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Anatomy of the knee
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Arthrocentesis
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Initial Antibiotic choice
• Little evidence comparing different antibiotics• No RCTs, based on likelihood of which organism
Patient group Antibiotic choice
No RF for atypicals Fluclox 2g qds +/- fusidic acid or gentamicin. If pen allergic Clindamycin or 2nd/3rg gen cephalosporin
High risk gram –ve sepsis (elderly, frail, recurrent UTI, recent abdominal surgery)
2nd or 3rd gen cephalosporin eg cefuroxime
MRSA risk Vancomycin plus 2nd or 3rd gen cephalosporin
Suspected gonococcus or meningococcus Ceftriaxone
IV drug users d/w micro
ITU patients d/w micro
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Duration of therapy
• No controlled trials• Usually IV abs at least 2 weeks in duration followed by at
least two weeks oral therapy• May need longer for particular organisms- P. aeruginosa,
Enterobacter spp. or S. Aureus with septicaemia
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Joint drainage
• Aim to remove pus from joint space- i.e. drain abscess• Surgically- arthroscopy or arthrotomy• Closed needle aspiration
• No randomised controlled studies comparing the two, needle aspiration may be preferable
• If adequate aspiration not possible by needle, surgery may be necessary
• May be indicated initially for hips, shoulders and prosthetic joints
• Arthroscopy usually for knee shoulder and wrist- hips may have arthrotomy
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Outcomes
• The prognosis of bacterial arthritis has not improved significantly in the last few decades
• Outcome related to:• host factors- prior joint disease, old age• Virulence of infecting organism• Speed of initiating effective treatment
• Inflammation and destruction of joint may continue even in sterile joints with effective antimicrobial therapy
• Mortality 10-15% dependent on co-morbidities
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Summary
• Non gonococcal bacterial arthritis is a dangerous and destructive form of acute arthritis
• Risk factors include pre-existing joint disease, joint replacement, old age, immunosuppression and overlying infection or ulceration
• It usually presents as monoarthritis involving a large joint like the knee
• Because symptoms such as fever may be absent and tests such as FBC and CRP are non specific, joint aspiration is necessary to establish the diagnosis- for cell count, microscopy and culture. BC are also useful
• Staph and strep are the most common pathogens and are usually treated with flucloxicillin, but older patients, ICU patients, IVDUs may have gram-ves and given3rd gen cephalosporin
• Joint drainage- by needle aspiration or surgical means should also be considered
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References
• www.uptodate.com : Septic arthritis in adults
• Mary E. Margaretten, MD; Jeffrey Kohlwes, MD, MPH; Dan Moore, PhD; Stephen Bent, MD “Does This Adult Patient Have Septic Arthritis?” JAMA. 2007; 297(13):1478-1488
• C J Mathews, G Kingsley, M Field, A Jones, V C Weston, M Phillips, D Walker, G Coakley “Management of septic arthritis: a systematic review” Ann Rheum Dis 2007;66:440-445