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Arthritis, Septic, Emergency Medicine

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Arthritis, Septic, Emergency Medicine

Basics

Description

  • Bacteria can be introduced into a joint by:Hematogenous spread (most common)Invasive proceduresContiguous infection (e.g., osteomyelitis, cellulitis)Direct inoculation such as plant thorns or nails
  • Acute inflammatory process results in migration of WBCs into joint.
  • Synovial hyperplasia, cartilage damage, and formation of a purulent effusion
  • Irreversible loss of function in up to 50%
  • Mortality rate reported as high as 11%
  • Hematogenous spread (most common)
  • Invasive procedures
  • Contiguous infection (e.g., osteomyelitis, cellulitis)
  • Direct inoculation such as plant thorns or nails
  • Hip infections are most common:Often in patients with otitis media, upper respiratory tract infections or history of femoral venipunctureComplications of septic arthritis (SA) of hip in children: Avascular necrosis, epiphyseal separation, pathologic dislocation, and arthritis
  • 50% occur in children <3 yr old.
  • Infants present with irritability, fever, and loss of appetite.
  • Older children present with fever, and a limp or refusal to bear weight or use joint.
  • Often in patients with otitis media, upper respiratory tract infections or history of femoral venipuncture
  • Complications of septic arthritis (SA) of hip in children: Avascular necrosis, epiphyseal separation, pathologic dislocation, and arthritis

Etiology

  • Risk factors:Old age, infancyRheumatoid arthritis and degenerative joint diseaseIntravenous drug user (IVDU), endocarditisFemales (gonococcal [GC] infection)Immunosuppression (AIDS, diabetes, chemotherapy, steroid therapy)Repeated joint injections, pre-existing joint diseases, trauma, or prosthesisSkin infection, cutaneous ulcers
  • No bacterial pathogen is identified in 10-20%.
  • Most common organisms:Staphylococcus aureus in adults, hip infections (80%), and patients with rheumatoid arthritis or diabetesMultidrug-resistant S. aureus (MRSA) has been noted in some studies to be the most common organism in community-onset adult SA.Neisseria gonorrhoeae most common in young, healthy, sexually active patients (incidence has decreased over the past decades due to a decrease in the incidence of mucosal GC infections)
  • Other pathogens: Group A β-hemolytic and group B, C, and G streptococci:Gram-negative rods (e.g., Pseudomonas aeruginosa, Escherichia. coli) in 10% of casesNeisseria meningitides (12% of patients with meningococcal meningitis)
  • Common in old age, infancy, immunosuppression, and IVDU (Pseudomonas)
  • Anaerobes: Diabetes, prosthetic joints
  • Mycobacterial and fungal causes: Atypical (e.g. in advanced HIV); more indolent course
  • Old age, infancy
  • Rheumatoid arthritis and degenerative joint disease
  • Intravenous drug user (IVDU), endocarditis
  • Females (gonococcal [GC] infection)
  • Immunosuppression (AIDS, diabetes, chemotherapy, steroid therapy)
  • Repeated joint injections, pre-existing joint diseases, trauma, or prosthesis
  • Skin infection, cutaneous ulcers
  • Staphylococcus aureus in adults, hip infections (80%), and patients with rheumatoid arthritis or diabetes
  • Multidrug-resistant S. aureus (MRSA) has been noted in some studies to be the most common organism in community-onset adult SA.
  • Neisseria gonorrhoeae most common in young, healthy, sexually active patients (incidence has decreased over the past decades due to a decrease in the incidence of mucosal GC infections)
  • Gram-negative rods (e.g., Pseudomonas aeruginosa, Escherichia. coli) in 10% of cases
  • Neisseria meningitides (12% of patients with meningococcal meningitis)

Diagnosis

Signs and Symptoms

  • Presents abruptly as a single painful, swollen, warm, tender joint
  • Common findings include:FeverA separate source of infection (e.g., skin)Extremely painful joint motion in all planesA joint effusion (less evident in sacroiliac, hip, and shoulder)
  • Any joint can be involved:Typically a single joint is involved.Most commonly knee, then hip, shoulder, and ankle
  • Commonly seen in IVDUs: Sacroiliac costochondral and sternoclavicular joints:Vertebral involvement such as lumbar facets possible
  • Human and animal bites, plant thorns, local steroid therapy, and trauma may lead to infection in atypical locations.
  • Polyarticular involvement in 10-20%:Mostly with rheumatoid arthritis; delay in diagnosis from low suspicion and more subtle presentations (fever in only 50%)Patients with sepsis
  • GC SA features:Develops in 1-3% of untreated gonorrhea and in 42-85% of disseminated GC infection:
  • Typically monoarticular but commonly polyarticular
  • Migratory polyarthralgia, tenosynovitis (present in 20% of patients with arthritis), and dermatitis:Involves small joints (e.g., fingers, wrist, elbow, ankle)
  • Signs of urethral or vaginal GC infection may be present.
  • Painless maculopapular lesions on trunk, arms, legs, and around affected joint
  • Fever
  • A separate source of infection (e.g., skin)
  • Extremely painful joint motion in all planes
  • A joint effusion (less evident in sacroiliac, hip, and shoulder)
  • Typically a single joint is involved.
  • Most commonly knee, then hip, shoulder, and ankle
  • Vertebral involvement such as lumbar facets possible
  • Mostly with rheumatoid arthritis; delay in diagnosis from low suspicion and more subtle presentations (fever in only 50%)
  • Patients with sepsis
  • Develops in 1-3% of untreated gonorrhea and in 42-85% of disseminated GC infection:
  • Involves small joints (e.g., fingers, wrist, elbow, ankle)

Essential Workup

  • Perform joint aspiration in any suspected case.
  • Send fluid for protein and glucose, cell count, Gram stain, and culture.
  • Typical SA findings:A turbid, purulent, or serosanguineous fluidA leukocytosis (50,000-150,000/mm3) with a polymorphonuclear predominance (>75%)Often a decreased glucose and elevated protein level
  • Appearance of crystals does not rule out SA.
  • Use special stain or culture media when indicated (e.g., GC, anaerobes, fungus, mycobacterium)
  • Intra-articular lidocaine reduces the sensitivity of subsequent cultures; immediate emptying of aspirated sample into a blood culture flask increases the yield.
  • In non-GC SA, Gram stain and culture are positive in 50% and 90% of cases, respectively:Drops to nearly 10% and 50% in GC SA, respectively
  • Real-time PCR can detect bacterial pathogen DNA in many culture-negative aspirates.
  • Fluoroscopic, sonographic, or CT guidance can be used in technically difficult aspirations.
  • CT scan and MRI may aid in the diagnosis for joints such as the sacroiliac joint.
  • Arthrocentesis is contraindicated whenever there is an underlying joint prosthesis or an overlying skin infection:If cellulitis present, use an alternate approach through normal skin.
  • A turbid, purulent, or serosanguineous fluid
  • A leukocytosis (50,000-150,000/mm3) with a polymorphonuclear predominance (>75%)
  • Often a decreased glucose and elevated protein level
  • Drops to nearly 10% and 50% in GC SA, respectively
  • If cellulitis present, use an alternate approach through normal skin.

Diagnosis Tests & Interpretation

  • Nonspecific serum leukocytosis (more common in children), left shift, and C-reactive protein (CRP) and ESR elevation are usually present.
  • Procalcitonin can be a helpful aid to rule in rather than rule out SA
  • UA and culture can reveal a urologic source for the pathogen.
  • Blood cultures may be useful: Positive in 50-70% of non-GC SA.
  • Culture any potential focus of infection (pharynx, urine, cervix, or anus), particularly when suspecting GC.
  • Plain radiographs to identify:EffusionBaseline status of the jointContiguous osteomyelitisConcurrent rheumatologic diseasesFractures or foreign bodyJoint loosening (a late nonspecific sign)
  • US, CT, and MRI are more sensitive:US may be used to guide aspiration of some joints (e.g., hip) and to detect joint effusions.
  • Scintigraphic techniques are sensitive and specific in diagnosis of SA. However, they are often not available through ED.
  • Other tests:Bacterial DNA amplification techniques in rapid detection and identification of organisms
  • Effusion
  • Baseline status of the joint
  • Contiguous osteomyelitis
  • Concurrent rheumatologic diseases
  • Fractures or foreign body
  • Joint loosening (a late nonspecific sign)
  • US may be used to guide aspiration of some joints (e.g., hip) and to detect joint effusions.
  • Bacterial DNA amplification techniques in rapid detection and identification of organisms

Differential Diagnosis

  • Viral arthritis
  • Rheumatoid arthritis
  • Gout or pseudogout
  • HIV-associated arthritis
  • Reactive arthritis
  • Lyme disease
  • Osteomyelitis
  • Endocarditis
  • Septic bursitis
  • Trauma
  • In children:Juvenile idiopathic arthritisSlipped capital femoral epiphysisLegg-Calv ©-Perthes diseaseMetaphyseal osteomyelitisTransient synovitis
  • Juvenile idiopathic arthritis
  • Slipped capital femoral epiphysis
  • Legg-Calv ©-Perthes disease
  • Metaphyseal osteomyelitis
  • Transient synovitis
  • Because of vaccine, Haemophilus influenzae is no longer the most common agent.
  • S. aureus is most common.
  • Group B streptococcus, enterobacteria, and gram-negative rods in the newborn

Treatment

Pre-Hospital

Initial Stabilization/Therapy

  • Patient may be septic and require resuscitation.
  • If patient is toxic, do not delay antibiotics for aspiration results.

Ed Treatment/Procedures

  • Promptly aspirate joint fluid.
  • Obtain cultures.
  • Start empiric antibiotics based on Gram stain (if available) and age group or risk factors-consider staphylococcal, streptococcal, and gram-negative coverage; and MRSA in the appropriate setting. Recommended duration of treatment is 2-4 wk. Intra-articular antibiotics are contraindicated.
  • No risk factors for atypical organisms:Use Flucloxacillin or equivalent 2 g QDS IV. Local policy may be to add gentamicin IV.If penicillin allergic, clindamycin 450-600 mg QDS IV or 2nd or 3rd generation cephalosporin IV.
  • High risk of gram-negative sepsis (elderly, frail, recurrent UTI, and recent abdominal surgery):2nd or 3rd generation cephalosporin for example, cefuroxime 1.5 g TDS IV. Local policy may be to add flucloxacillin IV to 3rd generation cephalosporin.Gram stain may influence antibiotic choice.
  • MRSA risk (known MRSA, recent inpatient, nursing home resident, leg ulcers or catheters, or other risk factors determined locally):Vancomycin IV + 2nd or 3rd generation cephalosporin IV
  • Suspected gonococcus or meningococcus:Ceftriaxone IV or similarDependent on local policy or resistance
  • IVDUs: Discuss with microbiologist
  • ICU patients, known colonization of other organs (e.g., cystic fibrosis): Discuss with microbiologist
  • Early orthopedic consultation to evaluate eligibility for surgical drainage
  • Pain control: Narcotics and moderately flexed splinting
  • Immunologic therapies are experimental.
  • Prosthesis: Some may try to preserve the limb unless it is loose on plain films.
  • Patients should be at rest with joint maintained in optimal position to prevent damage.
  • Use Flucloxacillin or equivalent 2 g QDS IV. Local policy may be to add gentamicin IV.
  • If penicillin allergic, clindamycin 450-600 mg QDS IV or 2nd or 3rd generation cephalosporin IV.
  • 2nd or 3rd generation cephalosporin for example, cefuroxime 1.5 g TDS IV. Local policy may be to add flucloxacillin IV to 3rd generation cephalosporin.
  • Gram stain may influence antibiotic choice.
  • Vancomycin IV + 2nd or 3rd generation cephalosporin IV
  • Ceftriaxone IV or similar
  • Dependent on local policy or resistance

Medication

  • Cefazolin: 1-2 g IV q6h
  • Ceftazidime: 1-2 g IV q8h
  • Cefotaxime: 2 g IV q8h; peds: 50 mg/kg q12h
  • Ceftriaxone:2 g IV QD; peds: 50 mg/kg
  • Ciprofloxacin: 400 mg IV q12h
  • Flucloxacillin: 2 g QD IV
  • Gentamicin: 2-5 mg/kg IV load
  • Nafcillin: 2 g IV q4h; peds: 25 mg/kg q6h
  • Tobramycin: 1 mg/kg IV q8h; peds: 2.5 mg/kg q8h
  • Vancomycin: 1 g IV q12h; peds: 10 mg/kg q6h
  • Open surgical drainage is the method of choice in pediatric hip SA.
  • Cover H. influenzae type B if prior immunization cannot be established.

Follow-Up

Disposition

  • All patients with suspected SA should be admitted until SA is ruled out.
  • May undergo drainage of joint, as indicated, by serial aspirations, arthroscopy, or arthrotomy

Pearls and Pitfalls

  • CRP and ESR can be used to follow up response to treatment
  • It can be difficult to distinguish SA from toxic synovitis or crystal arthropathy; have a low threshold for arthrocentesis.

Additional Reading

  • Carpenter CR, Schuur JD, Everett WW, et al. Evidence-based diagnostics: Adult septic arthritis. Acad Emerg Med. 2011;18:781-796.
  • Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology. 2006;45:1039-1041.
  • Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet. 2010;375:846-855.
  • Rosey AL, Abachin E, Quesnes G, et al. Development of a broad-range 16S rDNA real-time PCR for the diagnosis of septic arthritis in children. J Microbiol Methods. 2007;68:88-93.
  • Shen CJ, Wu MS, Lin KH, et al. The use of procalcitonin in the diagnosis of bone and joint infection: A systemic review and meta-analysis. Eur J Clin Microbiol Infect Dis. 2013;32(6):807-814.
  • Weisfelt M, van de Beek D, Spanjaard L, et al. Arthritis in adults with community-acquired bacterial meningitis: A prospective cohort study. BMC Infect Dis. 2006;6:64.

Codes

ICD9

  • 711.00 Pyogenic arthritis, site unspecified
  • 711.05 Pyogenic arthritis, pelvic region and thigh
  • 711.45 Arthropathy associated with other bacterial diseases, pelvic region and thigh

ICD10

  • M00.9 Pyogenic arthritis, unspecified
  • M00.052 Staphylococcal arthritis, left hip
  • M00.059 Staphylococcal arthritis, unspecified hip
  • M00.051 Staphylococcal arthritis, right hip
  • M00.05 Staphylococcal arthritis, hip
  • M00.859 Arthritis due to other bacteria, unspecified hip

SNOMED

  • 396234004 Infective arthritis (disorder)
  • 372941008 Pyogenic arthritis of hip