Septic arthritis: Difference between revisions

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== Background ==
''This page is for <u>adult</u> patients; for pediatric patients see [[septic arthritis (peds)]].''
==Background==
*Most important diagnostic consideration in acute joint pain (can destroy joint in days)
*Most important diagnostic consideration in acute joint pain (can destroy joint in days)
*Knee most commonly involved in adults; hip most common in peds
*Knee most commonly involved in adults; hip most common in pediatric
*Most often seen in pts &gt;65yr  
*Most often seen in patients >65yr  
*Gonococcal arthritis is the most common cause in adolescents and young adults
*Most common causative organisms
**<35 y/o ''[[N. gonorrhoeae]]''
**>35 y/o ''[[S. aureus]]''


== Clinical Features ==
==Clinical Features==
*Fever  
*Fever  
*Warm, red, painful, swollen joint  
*Warm, red, painful, swollen joint  
*Decreased range of motion to active and passive movement
*Decreased range of motion to active and passive movement
*Gonococcal arthritis
*[[Gonococcal]] arthritis
**Urethritis/vaginitis may be absent  
**[[Urethritis]]/[[vaginitis]] may be absent  
**may have prodromal phase:
**May have prodromal phase:
***Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
***Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
***Macularpapular rash or pustules esp on hands/feet may proceed overt arthritis
***Macularpapular rash or pustules especially on hands/feet may proceed overt arthritis
*Endocarditis should be considered in the presence of 2 or more affected joints
*Endocarditis should be considered in the presence of 2 or more affected joints


== Diagnosis ==
==Differential Diagnosis==
*[[Transient (Toxic) Synovitis]]
*Abscess
*[[Cellulitis]]
*Primary rheumatologic disorder (i.e. vasculitis)
*Iatrogenic
*[[Reactive Arthritis (Poststreptococcal)]]
*Consider if patient has Sickle Cell (fever '''and''' limited joint ROM)
**Osteomyelitis typically has neither
 
{{Differential Diagnosis Monoarthritis}}
 
==Evaluation<ref>Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18(8):781-96.</ref>==
[[File:SepticJointFluid.jpg|thumb|Synovial fluid from a septic knee]]
===Work-Up===
*Arthrocentesis with synovial fluid analysis
**cell count with differential
**glucose
**protein
**bacterial culture and sensitivity (not 100% sn)
**polarized light microscopy for crystals
*CBC
*ESR - Sn 94% (with 15mm/h cut-off)<ref>Hariharan, H, et al. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients. J of Emerg Med. 2010; 40(4):428–431. http://dx.doi.org/10.1016/j.jemermed.2010.05.029</ref>
*CRP - Sn 92% (with 20mg/L cut-off)
*Blood Culture
*Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
*Imaging (may be helpful for excluding other diagnoses - e.g. trauma, osteo, etc)
*Immunocompromised
**Consider mycobacterial or fungal arthritis
**Leukemia history: predisposed to Aeromonas infections
*Periprosthetic infection
**Non-emergent: acute microbiological diagnosis is more important than rapid antibiotics
**Diagnose with two synovial fluid cultures (avoid collection from a draining sinus)
**CRP >100mg/L during first 6 weeks post-op warrants aspiration and may be used to differentiate from superficial skin infection
 
{{Arthrocentesis diagnostic chart}}
{{Arthrocentesis diagnostic chart}}


== DDx ==
==Management==
#Toxic synovitis
===[[Antibiotics]]===
#Abscess
{{Septic Arthritis Antibiotics}}
#Cellulitis
#Primary rheumatologic disorder (i.e. vasculitis)
#Iatrogenic
#Reactive arthritis (post-infectious)


== Work-Up ==
===Consultation===
#Arthrocentesis with synovial fluid analysis
*Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection
##Synovial fluid culture only (not 100% sensitive)
**Benefit of serial aspirations vs arthroscopy vs irrigation and debridement is unclear
#CBC
#ESR
##Sn 94% (with 15mm/h cut-off)<ref>Hariharan, H, et al. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients. J of Emerg Med. 2010; 40(4):428–431. http://dx.doi.org/10.1016/j.jemermed.2010.05.029</ref>
#CRP
##Sn 92% (with 20mg/L cut-off)
#Blood Culture
#Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
#Imaging
##Helpful for excluding other diagnoses (e.g. trauma, osteo)
#Immunocompromised
##Consider mycobacterial or fungal arthritis


== Treatment ==
==Disposition==
#Joint drainage
*Admit all
#Abx
##Gram stain can be used to guide treatment
###[[Gram+]]: [[vancomycin]] IV
###[[Gram-]] OR [[gonococcus]] suspected: [[Ceftriaxone]] IV 2gm daily
#Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection


== Disposition ==
==See Also==
*Admit all to ortho
*[[Arthrocentesis]]
*[[Monoarticular arthritis]]
*[[Septic arthritis of the hip (peds)]]
*[[Septic arthritis (peds)]]
*[[Knee diagnoses]]


==External Links==
==External Links==
*[http://www.mdcalc.com/kocher-criteria-septic-arthritis/ MDCalc - Kocher Criteria for Septic Arthritis]
*[http://www.mdcalc.com/kocher-criteria-septic-arthritis/ MDCalc - Kocher Criteria for Septic Arthritis]


== See Also ==
==References==
*[[Arthrocentesis]]
<references/>
*[[Monoarticular Arthritis]]
*[[Septic Arthritis (Hip)]]
*[[Septic Arthritis (Peds)]]
*[[Knee Diagnoses]]
 
== Source ==
*Tintinalli


[[Category:ID]] [[Category:Ortho]]
[[Category:ID]]
[[Category:Orthopedics]]

Latest revision as of 03:31, 11 December 2019

This page is for adult patients; for pediatric patients see septic arthritis (peds).

Background

  • Most important diagnostic consideration in acute joint pain (can destroy joint in days)
  • Knee most commonly involved in adults; hip most common in pediatric
  • Most often seen in patients >65yr
  • Most common causative organisms

Clinical Features

  • Fever
  • Warm, red, painful, swollen joint
  • Decreased range of motion to active and passive movement
  • Gonococcal arthritis
    • Urethritis/vaginitis may be absent
    • May have prodromal phase:
      • Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
      • Macularpapular rash or pustules especially on hands/feet may proceed overt arthritis
  • Endocarditis should be considered in the presence of 2 or more affected joints

Differential Diagnosis

Monoarticular arthritis

Algorithm for Monoarticular arthralgia

Evaluation[1]

Synovial fluid from a septic knee

Work-Up

  • Arthrocentesis with synovial fluid analysis
    • cell count with differential
    • glucose
    • protein
    • bacterial culture and sensitivity (not 100% sn)
    • polarized light microscopy for crystals
  • CBC
  • ESR - Sn 94% (with 15mm/h cut-off)[2]
  • CRP - Sn 92% (with 20mg/L cut-off)
  • Blood Culture
  • Gonorrhea culture (urethral/cervical/pharyngeal/rectal)
  • Imaging (may be helpful for excluding other diagnoses - e.g. trauma, osteo, etc)
  • Immunocompromised
    • Consider mycobacterial or fungal arthritis
    • Leukemia history: predisposed to Aeromonas infections
  • Periprosthetic infection
    • Non-emergent: acute microbiological diagnosis is more important than rapid antibiotics
    • Diagnose with two synovial fluid cultures (avoid collection from a draining sinus)
    • CRP >100mg/L during first 6 weeks post-op warrants aspiration and may be used to differentiate from superficial skin infection

Arthrocentesis of synoval fluid

Synovium Normal Noninflammatory Inflammatory Septic
Clarity Transparent Transparent Cloudy Cloudy
Color Clear Yellow Yellow Yellow
WBC <200 <200-2000 200-50,000

>1,100 (prosthetic joint)

>25,000; LR=2.9

>50,000; LR=7.7

>100,000; LR=28

PMN <25% <25% >50%

>64% (prosthetic joint)

>90%

Culture Neg Neg Neg >50% positive
Lactate <5.6 mmol/L <5.6 mmol/L <5.6 mmol/L >5.6 mmol/L
LDH <250 <250 <250 >250
Crystals None None Multiple or none None
  • Viscosity of synovial fluid may actually be decreased in inflammatory or infectious etiologies, as hyaluronic acid concentrations decrease
  • The presence of crystals does not rule out septic arthritis; however, the diagnosis is highly unlikely with synovial WBC < 50,000[3]

Management

Antibiotics

For adults treatment should be divided into Gonococcal and Non-Gonococcal

Gonococcal

Non-Gonococcal

Pediatrics

Sickle Cell

Coverage for Salmonella and Staphylococcus spp

  • Vancomycin 20mg/kg IV twice daily PLUS
    • Ciprofloxacin 400mg IV three times daily OR
    • Imipenem/cilastatin 1g IV three times daily

Consultation

  • Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection
    • Benefit of serial aspirations vs arthroscopy vs irrigation and debridement is unclear

Disposition

  • Admit all

See Also

External Links

References

  1. ↑ Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18(8):781-96.
  2. ↑ Hariharan, H, et al. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients. J of Emerg Med. 2010; 40(4):428–431. http://dx.doi.org/10.1016/j.jemermed.2010.05.029
  3. ↑ Shah K, Spear J, Nathanson LA, Mccauley J, Edlow JA. Does the presence of crystal arthritis rule out septic arthritis?. J Emerg Med. 2007;32(1):23-6.
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