septic arthritis inflammation of a joint caused by a bacterial infection
TRANSCRIPT
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Septic arthritis
Inflammation
of a joint caused by
a bacterial infection
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Septic arthritis is also called infectious arthritis
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Septic arthritis is diagnosed by identifying
infected joint fluid
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Epidemiology
Incidence:
General population 2-5/100,000/yr
Children 5.5 - 12/100,000/yr
RA 28 - 38/100,000/yr
Prosthetic joint 40 - 68/100,000/yr
Monoarticular (<20% more than one joint)
Large joints>small joints
Knee (>50%), ankle, wrist, hip, …
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The most common joints to become infected are the knee
In infants under the age of three, septic arthritis usually affects the hip
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Epidemiology:
Tow peaks in the age related incidence children < 5 years adult > 64 years> 75% of childhood SA previously healthy> 75% of adult onset SA predisposing factor
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Etiology
Gonococcal
Non gonococcal
Gram-positive cocci (75-80%)
• Staphylococcus aureus (most common)
• Staphylococcus epidermidis
Immuncompromise, joint surgery
• β-Hemolytic Streptococci
• Streptococcus pneumoniae (polyarticular, bacteremia)
Hemophilia,Sickle cell disease
Older age, comorbidity
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Microbiology :
Every bacterium has been reported to cause SA.
Staph. aureus 40-60%Streptococcus 9.5-28%S. pneumoniae 5.5-9.7%gram negative bacilli 9-19%Anaerobes 1.2-6%
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Etiology Gram-negative bacilli (15-20%)
• E-coli• Pseudomonas IV drug abuse, immuncompromise Older age, Comorbidity, UTI
• Salmonella• Proteus SLE
Anaerobes (5-7%) Trauma, joint surgery
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Clinical presentation:
Acute onset of pain and swelling in a single joint.
The pain is typically severe and occurs at rest.Large joints (knee, hip, ankle, shoulder)Fever 60-80% (mild)Chills (unusual)Warmth, tenderness, effusion and limited
active and passive range of motion
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Polyarticular septic arthritis:
10-15%Two or more jointsS. aureus is the most common pathogenMore common in s. pneumoniae (36%)Streptococci, H-influenza, salmonella,
gonorrhoeae, anaerobesMany have comorbidity (RA, IVDA)Mortality
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Risk factors :Prosthetic jointUnderlying joint diseases ( RA , OA )Age > 80 yearsRecent joint surgery Previous SADiabetes mellitus, hemodialysis, advanced hepatic
disease, malignancy, hemophilia, sickle cell disease, hypogammaglobulinemia, IV drug abuse, AIDS
Low social economic status Skin infection
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Pathogenesis
Bacterial colonization
host immune response
Joint damage
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Pathogenesis
Hematogenous seeding• Most common• Abundant vascular supply of synovium and lack of a limiting basement
membrane
Direct inoculation• Trauma • Joint surgery• Arthroscopy (<0.5%)• Joint aspiration and injection (0.0002%)• Osteomyelitis, cellulitis, or septic bursitis
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Source of infection :
Hematogenous seeding (bacteremia): skin, lung, urinary tract, oral cavity, IV catheter Direct inoculation : joint aspiration and injection (0.0002 %) arthroscopic surgery (0.5 %)Spread from adjacent soft tissue infection or
osteomyelitis (hip and shoulder)
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Pathogenesis
Microbial factors:
virulence
Attach to host tissue within joint Evade host defenses
Host factors:
Immune response Opsonization Phagocytosis cytokines
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Clinical manifestations
Monoarticular, knee
• Febrile
• Acute onset of pain and swelling
• Warmth and tenderness, joint effusion, redness and limited
active and passive ROM
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How is it diagnosed?
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Diagnosis
History
PH/E
Arthrocentesis
Imaging
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Diagnosis
Arthrocentesis Normal synovial fluid:
• Small amount
• Clear
• Highly viscous
• Few WBCs (<200)
• Protein concentration is one third of plasma
• Glucose concentration is similar to plasma
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Diagnosis
Septic joint:
• Purulent
• Decreased viscosity
1. WBC > 50,000/mm³, PMN predominance
• Glucose less than half the serum glucose
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The normal joint fluid is sterile and, if removed and cultured in the laboratory, no microbes will be detected.
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Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved.
Organisms in septic arthritis• Gram -positive cocci
– S. aureus – S. pyogenes– S. pneumoniae – S. viridans group
• Gram-negative cocci– N. gonorrhoeae and meningitidis – H. influenzae
• Gram-negative bacilli– E. coli– Salmonella – Pseudomonas species
• Mycobacteria and Fungi
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Diagnosis
Definite diagnosis: Gram-stained smear and culture of synovial fluid
• Smear: Gram-positive cocci: 50% - 75% Gram-negative bacilli: <50%
• Culture: 70% - 90%
• Blood culture: 40% - 50%
• Extraarticular site of infection
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Diagnosis
Imaging: Plain radiographs
• Early stages: normal, soft tissue swelling
• Advanced infection: periosteal reaction, marginal or central erosions, destruction of subchondral bone, Bony ankylosis
• Baseline films should be obtained to look for evidence of other
disease and osteomyelitis
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Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved.
Staphylococcal arthritis: wrists (radiograph)
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Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved.
Septic arthritis: early and late changes, hip (radiographs)
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Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved.
Septic arthritis: sternoclavicular joint (technetium radioisotope scan)
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Differential diagnosis
Crystal induced arthritis
RA
Reactive arthritis
Trauma
………………..
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If septic arthritis is left untreated
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Treatment: septic arthritis is suspected
blood and synovial fluid sample
empiric parenteral antibiotics based on gram stain
joint drainage
adjust antibiotics based on culture and sensitivity results
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Treatment
Immediate treatment after clinical
evaluation and cultures
Appropriate antibiotics and adequate
drainage
Initial treatment is IV
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Treatment
Gram-positive cocci• MSSA Nafcillin/Oxacillin 2gr IV q4h • MRSA Vancomycin
1gr IV q12h
Gram-negative bacilli Ceftriaxone/Cefotaxime 2gr IV q24h/ 2gr IV q8h
• Pseudomonas Piperacillin/Ceftazidime + AG
3gr IV q6h/ 2gr IVq8h
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Treatment
No organism• Healthy, sexually active patient with community-acquired septic
arthritis
Ceftriaxone or Cefotaxime
• Elderly debilitated patient
Antistaphylococcal + Antipseudomonal
+ AG
Polymicrobial
Nafcillin/oxacillin + ceftriaxone/cefotaxime
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Prognosis
Patients receiving immunosuppressive therapy
Serious underlying comorbidities (liver, kidney, or heart diseases)
Juxta-articular osteomyelitis
Disability: 25-50%
Mortality: 5-20%
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Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved.
Septic olecranon bursa
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There are more than 150 bursae in the human body.
Superficial
Deep
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Gonococcal arthritis
Neisseria gonorrhea
Clinical presentation:
• Disseminated gonococcal infection (DGI)
• Gonococcal septic arthritis
Most common cause of acute monoarthritis in sexually
active healthy young adults
DGI is more common in women than men (3/1)
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Gonococcal arthritis
Clinical features
DGI
• Women/men: 3/1
• Intrauterine devices, menstruation, pregnancy, and pelvic operation
• Fever, shaking chills, skin lesions (vesiculopustular, hemmorhagic),
tenosynovitis (wrist, fingers, ankle, and toes), polyarthralgias, and arthritis
septic arthritis
• knee, wrist, ankle, or more than one joint
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Gonococcal arthritis Diagnosis
DGI:
• Skin lesion culture: negative • SF culture: often negative• Blood culture: 50% positive• Culture from genital, rectal, and pharyngeal sites
Septic arthritis:
• SF culture: 50% positive• Blood culture: often negative
DNA-PCR
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Gonococcal arthritis
Treatment
DGI:
• Ceftriaxone/cefotaxime 7-10 days
• Doxycycline
Septic arthritis:
• Ceftriaxone/cefotaxime 7-14 days
• drainage
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Prosthetic joints infection
Epidemiology
• Knee: 1-2%
• Hip: 0.5-1%
• Shoulder: <1%
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Prosthetic joints infection
Clinical manifestations Depend on the timing of infection:
Early (<3 m)
• Acquired during implantation
• Virulent pathogens such as S. aureus or gram-negative bacilli
• Joint pain, and effusion, wound drainage, fever,
implant site erythema, induration or edema, sinus tract
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Prosthetic joints infection
Delayed (3 - 24 m)
• Acquired during implantation
• Less virulent pathogens such as S. epidermidis, P. acnes
• Persistent joint pain, with or without implant loosening, fever< 50% and
leukocytosis<10
Late (>24 m)
• Hematogenous
• S. aureus
• Joint pain, tenderness and swelling, fever, leukocytosis
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Prosthetic joints infection
Treatment
Medical and surgical
• Organisms within biofilms are resistant to antibiotics:
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