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Septic Arthritis

Arthritis Pyogenic

Bacterial arthritis is predominantly caused by Staphylococcus aureus, streptococci, and Neisseria gonorrhoeae. Joint pain and swelling (involving either one or more joints), as well as fever, are three cardinal symptoms seen in these patients. The diagnosis can be made after a proper physical examination, while the determination of the underlying pathogen is achieved through microbiological studies, primarily in the form of blood and synovial fluid cultures.


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Presentation

Bacterial arthritis or infection of the joints and the articular tissues is encountered across all age groups. Overall, Staphylococcus aureus is the most common cause (although Neisseria gonorrhoeae is the number one cause of septic arthritis in younger adults), but streptococcal species (including S. pneumoniae, S. viridans, S. pyogenes), tuberculosis, and a range of both gram-positive and gram-negative bacteria can be responsible for the infection [1]. Several conditions have been described in the literature as potential risk factors for bacterial arthritis, including diabetes mellitus, previous skin infection, rheumatoid arthritis (RA), human immunodeficiency virus (HIV) type 1 infection, as well as increasing age, joint surgery, intravenous drug abuse, and the presence of hip or knee prostheses [2] [3]. The clinical presentation is centered around three main complaints - joint pain, swelling, and fever (about 40% of patients have a fever of >39C) [3] [4]. Either one (monoarticular) or more than one (polyarticular) joint can be affected. Gonococcal arthritis is typically polyarticular [5]. The pain is often severe and is exacerbated with minimal movement, thus a decreased range of motion is also an important finding [4] [6]. Additional less common features of bacterial arthritis include erythema of the skin over the infected joint, rigors, excessive sweating, and constitutional symptoms [1] [3] [4] [6].

Fever
  • [ 713.6 ] Staphylococcus 711.0 Streptococcus 711.0 syphilis (see also Syphilis) 094.0 [ 711.4 ] syringomyelia 336.0 [ 713.5 ] thalassemia (see also Thalassemia) 282.40 [ 713.2 ] tuberculosis (see also Tuberculosis, arthritis) 015.9 [ 711.4 ] typhoid fever[icd9data.com]
  • We conclude, that the absence of fever, rigors, blood leucocytosis and positive blood cultures does not rule out the possibility of bacterial arthritis.[ncbi.nlm.nih.gov]
  • In patients with cirrhosis and fever, a high index of suspicion is required for joint infection as a potential cause of fever or deterioration in the cirrhotic's patient general condition.[ncbi.nlm.nih.gov]
  • The clinical presentation is centered around three main complaints - joint pain, swelling, and fever (about 40% of patients have a fever of 39C). Either one (monoarticular) or more than one (polyarticular) joint can be affected.[symptoma.com]
  • […] the infected joint (pseudoparalysis) Severe joint pain Joint swelling Joint redness Fever Chills may occur, but are uncommon.[nlm.nih.gov]
Chills
  • Constitutional symptoms such as fever, chills, and rigors are poorly sensitive for septic arthritis.[ncbi.nlm.nih.gov]
  • […] diaper changes) Fever Not able to move the limb with the infected joint (pseudoparalysis) Fussiness Symptoms in children and adults: Not able to move the limb with the infected joint (pseudoparalysis) Severe joint pain Joint swelling Joint redness Fever Chills[nlm.nih.gov]
  • With septic arthritis, patients may experience symptoms and signs that include fever, chills, as well as joint pain, swelling, redness, stiffness, and warmth.[medicinenet.com]
Reiter's Syndrome
  • “Reactive” (sterile) arthritis, formerly known as Reiter’s syndrome, may occur following chlamydial genital infection or bacterial gastroenteritis caused by campylobacter, salmonella, and other agents.[clinicaladvisor.com]
  • syndrome Rheumatoid Arthritis Crystal Disease - gout, pseudogout Treatment 1.Depends on organism and host 2.Antibiotics a.Usually begin with oxacillin (nafcillin) or vancomycin b.Add gentamicin initially until culture results back c.Consider broader[enotes.tripod.com]
  • Reactive arthritis (including Reiter's syndrome, psoriatic arthritis, ankylosing spondylitis and arthritis associated with inflammatory bowel disease) often presents with inflammation in a few large joints, distributed asymmetrically.[patient.info]
  • Reactive arthritis (Reiter's syndrome). American Family Physician. Vol. 60(2): 499-503.[consumer.healthday.com]
  • Reiter’s Syndrome and other reactive arthritis: A Current Review. Semen Arthritis Rehm, 1994; 24:190-210. [PubMed] 12. Hughes JG, Vetter EA, Patel R, Schleck CD, Harmsen S, Turgeant LT, Cockerill FR 3rd.[antimicrobe.org]
Rigor
  • We conclude, that the absence of fever, rigors, blood leucocytosis and positive blood cultures does not rule out the possibility of bacterial arthritis.[ncbi.nlm.nih.gov]
  • Constitutional symptoms such as fever, chills, and rigors are poorly sensitive for septic arthritis.[ncbi.nlm.nih.gov]
  • Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis.[doi.org]
  • Additional less common features of bacterial arthritis include erythema of the skin over the infected joint, rigors, excessive sweating, and constitutional symptoms.[symptoma.com]
High Fever
  • —Staphylococcal arthritis: Usually monarticular (seldom polyarticular), staphy-lococcal arthritis affects the knee, hip, shoulder, elbow, wrist, or ankle, and 90% of patients exhibit high fevers.[rheumaknowledgy.com]
  • Neonates and infants may not appear that unwell and may not always have a high fever. Careful examination and clinical suspicion are important.[pmmonline.org]
Tachycardia
  • […] on septicaemia large joint(esp hip)  Often in the superficialRather than joint pain joint(knee, wrist or ankle ) o Pseudoparesis Baby is irritable &  Joints painful, swollenrefuse to feed o Child is ill,rapid pulse & inflamed. and swingingfever Tachycardia[slideshare.net]
  • […] vary from case to case, but the following are the most commonly seen signs and symptoms: Severe pain that worsens with movement Swelling of the joint Warmth and redness around the joint Fever Chills Fatigue Weakness Decreased appetite Rapid heart rate (tachycardia[belmarrahealth.com]
  • : Sleep Disturbance in the Hospitalized Patient -- Chapter 97: Nausea and Vomiting -- Chapter 98: Numbness: A Localization-Based Approach -- Chapter 99: Pain -- Chapter 100: Suspected Intoxication and Overdose -- Chapter 101: Syncope -- Chapter 102: Tachycardia[worldcat.org]
  • Clinical manifestations may include vague complaints like irritability, anxiety, failure to thrive, tachycardia and anemia.[omicsonline.org]
Arthritis
  • Twenty patients with culture-proven bacterial arthritis had higher levels of synovial TNF-alpha than patients with osteoarthritis or with inflammatory arthritis, including gouty arthritis, rheumatoid arthritis, reactive arthritis, and lupus arthritis.[ncbi.nlm.nih.gov]
  • Septic arthritis is inflammation of a joint due to a bacterial or fungal infection. Septic arthritis that is due to the bacteria that cause gonorrhea has different symptoms and is also called gonococcal arthritis.[nlm.nih.gov]
  • Conclusions Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis.[doi.org]
  • Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis.[ncbi.nlm.nih.gov]
  • A normal WBC count does not rule out septic arthritis. The erythrocyte sedimentation rate (ESR) is elevated in septic arthritis; it returns to normal levels with resolution of the infection.[emedicine.com]
Joint Effusion
  • In a prospective diagnostic study, 102 consecutive patients with atraumatic joint effusion were included. Synovial fluid glucose concentrations were determined using both glucometer and automated analyzer respectively.[ncbi.nlm.nih.gov]
  • […] on both sides of a joint if left untreated, reactive juxta-articular sclerosis and, in severe cases, ankylosis will develop Ultrasound useful in superficial joints and in children shows joint effusion echogenic debris may be present color Doppler may[radiopaedia.org]
  • Ultrasonography is useful in confirming a joint effusion in a deeply placed joint such as the hip. It can also be used to guide joint aspiration. Magnetic resonance imaging (MRI) has no role in the initial workup.[emedicine.com]
  • Radiograph: An x-ray that can be useful in initial stages of the disease to show joint effusion. Ultrasound: Useful in children, can be used to show joint effusion.[belmarrahealth.com]
  • In the affected joint, there is moderate to severe pain accompanied by joint effusion, muscle spasm and decreased range of motion. There is also high-grade fever.[boneandspine.com]
Joint Swelling
  • There is a fever and joint swelling that is usually in just one joint. There is also intense joint pain, which gets worse with movement.[nlm.nih.gov]
  • Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients.[doi.org]
Arthralgia
  • Early disseminated - weeks after infection with neurological features (facial nerve palsy, meningitis and rarely meningoencephalitis), heart conduction defects and arthralgia.[pmmonline.org]
  • Tenosynovitis and migratory arthralgias are common, and characteristic pustular (often painful) lesions are found on the skin. Fever may be absent, and a minority will have genitourinary, pharyngeal, or rectal symptoms on presentation.[rheumaknowledgy.com]
  • Gonococcal disease usually presents with fever, arthralgia, multiple skin lesions (dermatitis-arthritis syndrome) and tenosynovitis of the hand joints, knees, wrists, ankles and elbows.[patient.info]
  • Tenosynovitis, dermatitis, and polyarthritis syndrome or dermatitis-arthritis syndrome; the initial manifestations include fever, malaise, and arthralgias following an infection of the cervix, urethra, or pharynx.[atsu.edu]
  • The presenting symptoms in DGI may include migratory arthralgias, moderate fever, chills, dermatitis, and tenosynovitis. The large majority of these patients have asymptomatic genital, anal, or pharyngeal gonococcal infections ( 122 ).[doi.org]
Joint Deformity
  • During the acute phase of bacterial arthritis, patient rest and optimal joint position are absolutely required to prevent the occurrence of joint deformation and deleterious contractures.[doi.org]
Urethral Discharge
  • If gonococcal arthritis is suspected, [8] cultures and Gram stain material should be obtained from the cervix in postpubertal girls, from the vagina of prepubertal girls, and from any urethral discharge in a male.[emedicine.com]

Workup

The physician's ability to recognize signs and symptoms of bacterial arthritis through a detailed patient history and a thorough physical examination is essential for making the diagnosis. Information regarding the onset and course of symptoms should be noted, whereas the assessment of preexisting comorbidities that could predispose individuals to this infection is mandatory. Joint pain and swelling, as principal complaints, need to be evaluated during a physical exam, and as soon as valid clinical suspicion is raised, a complete laboratory workup must be conducted. Serum inflammatory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), are often elevated in bacterial arthritis [4]. One of the key steps in solidifying the diagnosis is the analysis of synovial fluid [7]. Many studies have confirmed that the white blood cell count of > 50 × 109/L (with a predominance of polymorphonuclear cells, or PMNs) in synovial fluid is highly indicative of septic arthritis [2] [3] [4]. Furthermore, cultivation of synovial fluid is a definite method for identifying the causative agent of joint infection, and both anaerobic, but more importantly aerobic cultures should be drawn [7]. Gram staining is also described as an important microbiological method in the case of arthritis, but its variable sensitivity is an important limitation [1] [7].

Joint Space Narrowing
  • In later stages, diffuse joint space narrowing due to cartilage destruction may be evident.[patient.info]
  • Later findings include joint space narrowing due to destruction of the joint.Ultrasound is effective at detecting joint effusions.CT and MRI are not required for diagnosis; but if the diagnosis is unclear or the joints are hard to examine (ie.sacroiliac[en.wikipedia.org]
  • As the infection progresses, radiographic detection of diffuse joint space narrowing due to cartilage destruction is possible.[doi.org]
Elevated Sedimentation Rate
  • L ABORATORY DIAGNOSIS The laboratory abnormalities suggestive septic arthritis includes peripheral leucocytosis, elevated sedimentation rate and C-reactive protein.[antimicrobe.org]
Blood Culture Positive
  • cultures Positive in 50-70% of patients with nongonococcal bacterial arthritis Diagnostic if positive Limited usefulness but may be helpful when ruling out other diseases, particularly in children Lower rate of positivity in prosthetic joints Tissue[arupconsult.com]
  • Other important diagnostic tests include blood cultures (positive in 50–70% of acute bacterial arthritides) (27), but in only 30% or less of gonococcal arthritis cases) (38), wound cultures (although these often correlate poorly with synovial fluid culture[the-hospitalist.org]
Listeria Monocytogenes
  • We also look at some unusual microorganisms, eg, group C Streptococcus, Streptococcus viridans, Listeria monocytogenes, Pseudomonas cepacia, Pseudomonas maltophilia, and Neisseria sicca.[ncbi.nlm.nih.gov]

Treatment
  • Abstract The key to successful treatment of acute bacterial arthritis is early diagnosis and initiation of empirical antibacterial therapy. Treatment includes antimicrobial therapy, debridement of the infected joint and treatment of pain.[ncbi.nlm.nih.gov]
  • Especially in infants, treatment delay or inappropriate treatment may result in cartilage destruction, avascular necrosis and physeal injury [ 5, 6 ], with an increased risk of severe deformation and functional impairment.[doi.org]
  • A secondary objective was to quantify test and treatment thresholds using derived estimates of sensitivity and specificity, as well as best-evidence diagnostic and treatment risks and anticipated benefits from appropriate therapy.[ncbi.nlm.nih.gov]
  • Thus, we feel that lifelong treatment with antibiotics is a reasonable alternative in cases, where the risk of surgery is very high.[ncbi.nlm.nih.gov]
  • Abstract Acute bacterial arthritis continues to be a common occurrence, and despite improved treatment regimens, the prognosis has not improved significantly over the past 20 years.[ncbi.nlm.nih.gov]

Prognosis
  • In contrast, gonococcal arthritis is often successfully treated with antimicrobial therapy alone and demonstrates a very low rate of complications and an excellent prognosis for full return of normal joint function.[ncbi.nlm.nih.gov]
  • Abstract Acute bacterial arthritis continues to be a common occurrence, and despite improved treatment regimens, the prognosis has not improved significantly over the past 20 years.[ncbi.nlm.nih.gov]
  • Patients who were older, had a preexisting joint disease, and/or had an infected joint containing synthetic material had the poorest prognosis.[ncbi.nlm.nih.gov]
  • Recent reports using a staging system based on arthroscopic findings have proven that the prognosis worsens as the stage advances [ 10, 11 ].[doi.org]

Etiology
  • Septic arthritis in adults is a challenging diagnosis, but prompt differentiation of a bacterial etiology is crucial to minimize morbidity and mortality.[ncbi.nlm.nih.gov]
  • […] pain and inflammation (better than acetaminophen) Septic Bursitis 1.Most commonly occurs in olecranon or pre-patellar bursa a.Trauma is major risk factor b.Alcoholism c.Diabetes mellitus d.Typically occurs in middle-aged men involved in manual labor 2.Etiology[enotes.tripod.com]
  • Clinicians are able to deduce the etiology of acute nontraumatic joint pain/swelling within 3-days in most cases, but in an era of “ overdiagnosis ” and “overtreatment” ED providers lack the luxury of a 3-day admission for most monoarticular arthritis[epmonthly.com]
  • PubMed Google Scholar Nelson JD: The bacterial etiology and antibiotic management of septic arthritis in infants and children. Pediatrics. 1972, 50: 437-440. PubMed Google Scholar Gillespie R: Septic arthritis of childhood.[doi.org]

Epidemiology
  • Epidemiology The epidemiology is described above. Prognosis See above. Special considerations for nursing and allied health professionals. NA What's the evidence? Gupta, MN, Sturrock, RD, Field, M.[clinicaladvisor.com]
  • Epidemiology Information concerning the epidemiology of septic arthritis is limited due to several factors.[omicsonline.org]
  • Background Epidemiology Incidence – 2-10/100,000 in the U.S. 30-40/100,000 in patients with rheumatoid arthritis 40-70/100,000 in patients with prosthetic joints Transmission Most cases are hematogenously acquired Other mechanisms for infection Surgery[arupconsult.com]
  • Prompt diagnosis and treatment of infectious arthritis can help prevent significant morbidity and mortality. [ 1 ] Epidemiology Staphylococcus aureus is the most frequent pathogen responsible for septic arthritis in any age group, mainly meticillin-sensitive[patient.info]
  • Preventive measures directed to patients with prosthetic joints or osteosynthetic material, and a known haematogenous source would have prevented at most 8% of all cases. bacterial arthritis prosthetic joint infection epidemiology prevention Statistics[doi.org]
Sex distribution
Age distribution

Pathophysiology
  • Polymerase chain reaction may be an important diagnostic test in culture-negative cases and may be very helpful in understanding the pathophysiology of gonococcal arthritis.[ncbi.nlm.nih.gov]
  • The clinical features, pathophysiology, and treatment of this disorder are reviewed.[ncbi.nlm.nih.gov]
  • We review the pathophysiology of bacterial arthritis, clinical and microbiologic characteristics of its common forms, and current approaches to diagnosis and treatment of this condition.PathophysiologyBacterial arthritis is usually hematogenously acquired[nejm.org]
  • The pathophysiology of septic arthritis – or how the disease occurs – is when organisms such as viruses, bacteria, or fungi enter the joint space directly (as in the case of an injury or injection that breaks the skin) or through the bloodstream from[joybauer.com]
  • Pathophysiology The pathophysiology of bacterial (or fungal) arthritis differs according to the route of entry; that is: Hematogenous (either in the course of a primary bacteremic illness, including endocarditis, or from another focus such as urinary[clinicaladvisor.com]

Prevention
  • It is important to recognise the coexistence of these two pathologies, so as to avoid a delay in diagnosis and prevent significant morbidity and mortality.[ncbi.nlm.nih.gov]
  • The trend in antibiotic prophylaxis to prevent late infections in total joint replacement is to narrow the targeted hosts to those most at risk, to define the procedures associated with the greatest risk of bacteremia, and to simplify the antibiotic regimen[ncbi.nlm.nih.gov]
  • In a decision-analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be cost-effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients.[ncbi.nlm.nih.gov]
  • Synovectomy, even when performed after 5 days and up to 4 weeks later, could prevent joint destruction in the knee but not in the hip. The average follow-up time was 5 (2-9) years.[ncbi.nlm.nih.gov]
  • Corollary strategies under investigation include corticosteroids to prevent joint damage, monoclonal antibodies to arthritogenic peptides of bacteria or to surface markets of host lymphocytes, and modulators of synovial fluid cytokines.[ncbi.nlm.nih.gov]

References

Article

  1. Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis. 2003;36(3):319-327.
  2. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488.
  3. Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based Diagnostics: Adult Septic Arthritis. Acad Emerg Med. 2011;18(8):781-796.
  4. Smith JW, Chalupa P, Shabaz Hasan M. Infectious arthritis: clinical features, laboratory findings and treatment. Clin Microbiol Infect. 2006;12(4):309-314.
  5. Bardin T. Gonococcal arthritis. Best Pract Res Clin Rheumatol. 2003;17(2):201-208.
  6. Al-Ahaideb A. Septic arthritis in patients with rheumatoid arthritis. J Orthop Surg. 2008;3:33.
  7. Wilson ML, Winn W. Laboratory diagnosis of bone, joint, soft-tissue, and skin infections. Clin Infect Dis. 2008;46(3):453-457.

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Last updated: 2019-06-28 11:25