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Septic arthritis
- 1. Stick a needle in it Diagnosis and management of septic arthritis in the ED Dr Sarah Dawson, May 2014
- 2. Why septic arthritis? • Most dangerous and destructive monoarthritis • Can destroy cartilage within days • Mortality 7-15 % despite antibiotic use
- 3. 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
- 4. Differential • Infection- bacterial, mycobacterial, fungal • Gout • Pseudogout • Reactive arthritis • Osteoarthritis • Haemarthrosis • Lyme disease • SLE • RA
- 5. Incidence • 2-9 / 100 000 person years • 8-27% patients presenting to ED with acute arthritis
- 6. Defitition • Joint sepsis • 2ry to pathogenic innoculation of joint • By direct or haematogenous routes
- 8. Organisms • Can be bacterial, fungal, mycobacterial or viral • Bacterial divided into gonococcal and nongonococcal • Gonococcal more common but less morbidity and mortality • Staphylococcus • Streptococcus
- 9. 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
- 10. 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
- 11. Signs • Fever >37.5 57% • Hot, swollen tender joint (or joints) • Reduced ROM
- 12. 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
- 14. Anatomy of the knee
- 15. Arthrocentesis
- 16. 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
- 17. 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
- 18. 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
- 19. 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
- 20. 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
- 21. 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
Editor's Notes
- Synovial tissue has no basement membrane, so bacteria in synovial membrane spread quickly to the synovial fluid
- Neisseria Gonorhoea- gram –ve diplococci Staph- gram + clusters- most common Strep- gram +ve chains inc strep pneumoniae Also meningococcus, gram –ves Gram –ve- tauma, IVDU, neonates, elderly, underlying immunosuppresion
- ? Sending synovial fluid in BC bottles may increase yield Incidence of septic arthritis increases with increasing synovial fluid wcc May also have low glucose and raised lactate but not of diagnostic utility
- Arthrocentesis INDICATIONS Arthrocentesis is used to establish the cause of an acute monoarthritis or polyarthritis. Nongonococcal bacterial arthritis is a “do-not-miss” diagnosis, since a delay in identification and treatment may lead to clinically significant joint destruction and even death. Other infectious causes include disseminated gonococcal infections, tuberculosis, fungal infections, and Lyme disease. Crystal arthropathies (gout and pseudogout), rheumatic disorders, osteoarthritis, trauma, and hemarthrosis may also lead to acute joint effusions. Arthrocentesis is also used as a therapeutic procedure, to drain large effusions or hemarthroses, and to instill corticosteroids or local anesthetic. CONTRAINDICATIONS Cellulitis overlying the site of needle entry. Suspected bacteremia is a relative contraindication to arthrocentesis; if septic arthritis is suspected, however, the procedure should be performed. The safety of arthrocentesis has not been established for patients with coagulopathy or patients who are receiving anticoagulant medications, and the use of reversal agents or products (e.g., fresh-frozen plasma or platelet concentrates) should be considered on a case-by-case basis. COMPLICATIONS Arthrocentesis is a relatively benign procedure, and if properly performed, complications are rare. Potential complications include iatrogenic infection, localized trauma, pain, and reaccumulation of the effusion PREPARATION The knee may be tapped from either the medial or the lateral side. The patient’s knee should be extended or flexed at an angle of 15 to 20 degrees. The needle will enter the skin 1 cm medial (or lateral) to the superior third of the patella and is directed toward the intracondylar notch. JOINT ASPIRATION Explain the procedure to the patient, obtain written informed consent, and then gather the equipment you will need. Position the patient supine on a stretcher, with his or her knee extended or slightly flexed. Identify the landmarks and demarcate the entry site with a skin-marking pen, or use another appropriate method. Prepare the skin with a cleansing agent such as povidone–iodine or chlorhexidine. You may place a sterile drape around the site. Begin to anesthetize the region by placing a wheal of lidocaine in the epidermis, using a small (25-gauge) needle, and then anesthetize the deeper tissues in the anticipated trajectory of the arthrocentesis needle. Intermittently pull back on the plunger during the injection of the anesthetic to exclude intravascular placement. Using an 18-gauge needle and large syringe, direct the needle behind the patella and toward the intracondylar notch. Resist the temptation to “walk” the needle along the inferior surface of the patella, since this practice may damage the delicate articular cartilage. Constantly pull back on the plunger while you advance the needle; you will know when the needle enters the synovial cavity, because fluid will enter the syringe. You should remove as much fluid as possible. “Milking” the effusion, by gently compressing the suprapatellar region with the opposite hand, may aid in this endeavor. In cases of large effusions, you may need a second syringe to complete the aspiration. Once the aspiration is completed, remove the needle, cleanse the skin, and apply a bandage. You may apply a woven elastic bandage or knee immobilizer to reduce post procedural swelling and discomfort. TROUBLESHOOTING Failure to aspirate synovial fluid results in a “dry tap.” Misdiagnosis of knee effusion, obesity, obstruction of the needle lumen by particulate matter or a plica, or hypertrophy of the synovium (owing to chronic inflammation) may all result in a dry tap. If the medial approach was used initially, a lateral approach should be attempted, since this may overcome difficulties presented by a medial plica or thick medial fat pad. SYNOVIAL-FLUID ANALYSIS Collected fluid should immediately be placed into appropriate containers and analyzed expediently. Check with the laboratory regarding specific submission procedures (e.g., the correct tubes and the volume of fluid required for each test). If only minute volumes of synovial fluid are obtained, discussions with laboratory personnel are indicated to prioritize testing. As little as one drop of fluid may be sufficient for crystal analysis, and 1 ml may suffice for a cell count and a differential count. Gram’s Staining and Culture Gram’s staining and culture of synovial fluid provide the most definitive evidence of septic arthritis. The sensitivity of these techniques is much higher for nongonococcal infections (50 to 75 percent for Gram’s staining and 75 to 95 percent for culture) than for disseminated gonococcal disease (less than 10 percent and 10 to 50 percent, respectively.) If gonococcus is suspected, cultures of the blood and of urethral, rectal, or oropharyngeal swabs should be considered. To minimize the risk of contamination, the synovial fluid is often submitted for testing in the syringe used for the arthrocentesis. Cell Count and Differential Count The cell count and differential count are used to differentiate between non inflammatory effusions (e.g., osteoarthritis and trauma) and inflammatory conditions (e.g., septic and crystal-induced arthritis). A cutoff of 2000 white cells per milliliter and 75 percent polymorphonuclear cells is generally used. It should be emphasized that the cell count and differential count cannot reliably differentiate among various inflammatory entities. For example, up to 33 percent of patients with septic arthritis may have white-cell counts below 50,000 per milliliter, and patients with acute gouty arthritis may have counts exceeding 100,000 per milliliter. Synovial fluid is usually submitted for cell and differential counts in specimen tubes treated with EDTA. Crystal Analysis Evaluation of synovial fluid under a polarizing-light microscope may reveal the presence of monosodium urate crystals (seen in gout) or calcium pyrophosphate dihydrate crystals (seen in pseudogout). The sensitivity of crystal analysis is relatively high (80 to 95 percent for gout and 65 to 80 percent for pseudogout). It should be noted that the presence of crystals does not exclude the possibility of septic arthritis, since the two conditions may coexist. Synovial fluid is usually submitted for crystal analysis in a lithium heparin–treated specimen tube. Other Tests Although often ordered, biochemical assays such as for glucose, protein, and lactate dehydrogenase have little discriminatory value and should not be included in routine synovial-fluid analysis. Other tests, such as specific stains and cultures for atypical infectious agents and cytologic evaluation for suspected malignant effusions, may be indicated in certain situations.
- Adequacy of aspiration assessed by clinical criteria- improving temp, wcc, joint swelling and pain
- S aureus 46-50% have poor joint outcome vs strep pneumoniae- 90% have good joint outcome Polyarticular septic arthritis due to S aureus, or in the presence of RA has particularly high mortality upto 50%