A few words about septic joints sm

To the "aseptic necrosis" know-it'-alls. Now who's "scary?"



Rheumatology
Infectious Disease

Intra-Articular Disorders

Septic Joint
Septic Arthritis Causes

Causes
See Septic Joint Causes

Risk Factors for septic arthritis in adults
Prosthetic hip joint
Prosthetic knee joint
Skin Infection
Joint surgery
Rheumatoid Arthritis
Elderly patients over age 80 years old
Diabetes Mellitus
Intravenous drug use (unusual joints affected)
Large vein catheterization (unusual joints affected)
Kaandorp (1995) Arthritis Rheum 38:1819-25

Differential Diagnosis
See Monoarticular Arthritis
See Joint Pain Causes (Monoarticular)

Signs and symptoms
Rapid onset monoarticular joint inflammation
Joint Pain
Joint swelling
Joint warmth and erythema
Significantly decreased joint range of motion
Limb paralysis from inflammatory neuritis
Joints affected in bacterial infection
Septic Knee (50% of cases)
Septic Hip (especially in young children)
Septic Ankle
Septic Shoulder
Joints affected with intravenous Drug Abuse
Sacroiliac joint
Sternoclavicular joint
Symphysis pubis
Vertebral disc spaces

Labs: General
Erythrocyte Sedimentation Rate (ESR)
ESR > 25 mm/hour suggests infection in children
C-Reactive Protein
Closely mirrors infectious, inflammatory process
Sensitivity: 95% in children

Labs: Synovial Fluid Exam via arthrocentesis
Synovial Fluid culture is imperative
See Synovial Fluid White Blood Cell Count
Bacterial arthritis
Opaque to turbid Synovial Fluid
Synovial Fluid WBC: >50,000 (>90% PMNs)
Gram Stain positive in 50% of cases
Culture positive in 30-50% (75% polyarticular)
Gonococcal Arthritis
Clear to opaque Synovial Fluid
Synovial Fluid WBC: 30,000 to 100,000 (>80% PMNs)
Gram Stain positive in <25% of cases
Culture positive in <50% of cases
Tuberculous Arthritis
Opaque Synovial Fluid
Synovial Fluid WBC: 10,000 to 20,000 (>50% PMNs)
Gram Stain positive in <20% of cases
Culture positive in 80% of cases

Radiology: Joint Xray
Early changes
Distention of joint capsule
Joint Dislocation
Late changes
Joint space destruction
Epiphyseal cartilage resorption
Metaphysis Erosion

Management: Surgical
Frequent joint aspiration (once to twice daily)
Consider saline lavage
Open Surgical drainage indications
Difficult joint aspiration access (e.g. hip)
Persistent fever and symptoms >24 hours
Leukocytosis persists beyond 48 to 72 hours
Repeat blood or joint cultures positive >48 hours
Infected joint prosthesis
Prosthesis may be salvaged if infection <1-2 weeks
Most infected prostheses must be removed

Management: Antibiotics
Infant under age 3 months (2 drug regimens)
Drug 1: Nafcillin or Oxacillin
Use Vancomycin instead if MRSA common
Drug 2: Cefotaxime, Ceftriaxone, or Gentamicin
Children under age 15 years (2 drug regimens)
Drug 1: Nafcillin, Oxacillin, or Vancomycin
Drug 2: Cefotaxime, or Ceftriaxone
Young Adults (Under age 40 years)
Negative Gram Stain
Ceftriaxone 1 gram IV every 24 hours or
Cefotaxime or Ceftizoxime 1 gram IV every 8 hours
Gram Stain with Gram Positive Cocci in clusters
Nafcillin 2 grams IV every 4 hours or
Oxacillin 2 grams IV every 4 hours
Older Adults (Over age 40 years)
Negative Gram Stain
Drug 1: Nafcillin or Oxacillin
Drug 2: Cefotaxime, Ceftriaxone
Gram Stain with Gram Positive Cocci in clusters
Drug 1: Nafcillin or Oxacillin
Drug 2: Ciprofloxacin
Iatrogenic Infection (Joint Injection or prosthesis)
Empiric therapy before culture results
Option 1 (2 drug regimen)
Drug 1: Vancomycin
Drug 2: Ciprofloxacin, Aztreonam, or Gentamycin
Option 2 (2 drug regimen)
Drug 1
Ciprofloxacin 750 PO bid or
Ofloxacin 200 mg PO tid
Drug 2: Rifampin 900 mg PO qd
Ciprofloxacin and Rifampin sensitive by culture
Option 1 (2 drug regimen)
Drug 1: Ciprofloxacin or Ofloxacin
Drug 2: Rifampin 900 mg PO qd
Option 2 (2 drug regimen)
Drug 1: Oxacillin 2 grams IV every 4 hours
Drug 2: Rifampin 900 mg PO qd
Ciprofloxacin or Rifampin resistance by culture
Vancomycin and
Rifampin (if sensitive)

Management: Antibiotic Course
Nongonococcal bacterial infection
Parenteral antibiotics for 2 to 4 weeks
Oral antibiotics for 2 to 4 weeks
See Gonococcal Arthritis
See Tuberculous Arthritis

Prognosis
Early joint drainage and antibiotics
Good prognosis
Delayed management >24 hours
Risk of joint arthrosis, fibrosis and osteonecrosis

References
Klippel (1997) Primer Rheumatic Diseases, p. 196-200
Gilbert (2000) Sanford Guide to Antimicrobials, p. 22-3
Stimmler (1996) Postgrad Med 99(4):127-39
Kallio (1997) Pediatr Infect Dis 16:411-2
Merenstein (1994) Handbook Pediatrics, Lange

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