Rheumatology Book

Intra-Articular Disorders

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Septic JointAka: Septic Arthritis, Infectious Arthritis, Pyogenic Arthritis, Suppurative Arthritis

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  1. Causes
    1. See Septic Joint Causes
  2. Risk Factors for septic arthritis in adults
    1. Prosthetic hip joint
    2. Prosthetic knee joint
    3. Skin Infection
    4. Joint surgery
    5. Rheumatoid Arthritis
    6. Elderly patients over age 80 years old
    7. Diabetes Mellitus
    8. Intravenous drug use (unusual joints affected)
    9. Large vein catheterization (unusual joints affected)
    10. Kaandorp (1995) Arthritis Rheum 38:1819
  3. Differential Diagnosis
    1. See Monoarticular Arthritis
    2. See Joint Pain Causes (Monoarticular)
  4. Signs and symptoms
    1. Rapid onset monoarticular joint inflammation
      1. Joint Pain
      2. Joint swelling
      3. Joint warmth and erythema
      4. Significantly decreased joint range of motion
      5. Limb paralysis from inflammatory neuritis
    2. Joints affected in bacterial infection
      1. Septic Knee (50% of cases)
      2. Septic Hip (especially in young children)
      3. Septic Ankle
      4. Septic Shoulder
    3. Joints affected with intravenous Drug Abuse
      1. Sacroiliac joint
      2. Sternoclavicular joint
      3. Symphysis pubis
      4. Vertebral disc spaces
  5. Labs: General
    1. Erythrocyte Sedimentation Rate (ESR)
      1. ESR > 25 mm/hour suggests infection in children
    2. C-Reactive Protein
      1. Closely mirrors infectious, inflammatory process
      2. Sensitivity: 95% in children
  6. Labs: Synovial Fluid Exam via arthrocentesis
    1. Synovial Fluid culture is imperative
    2. See Synovial Fluid White Blood Cell Count
    3. Bacterial arthritis
      1. Opaque to turbid Synovial Fluid
      2. Synovial Fluid WBC: >50,000 (>90% PMNs)
      3. Gram Stain positive in 50% of cases
      4. Culture positive in 30-50% (75% polyarticular)
    4. Gonococcal Arthritis
      1. Clear to opaque Synovial Fluid
      2. Synovial Fluid WBC: 30,000 to 100,000 (>80% PMNs)
      3. Gram Stain positive in <25% of cases
      4. Culture positive in <50% of cases
    5. Tuberculous Arthritis
      1. Opaque Synovial Fluid
      2. Synovial Fluid WBC: 10,000 to 20,000 (>50% PMNs)
      3. Gram Stain positive in <20% of cases
      4. Culture positive in 80% of cases
  7. Radiology: Joint Xray
    1. Early changes
      1. Distention of joint capsule
      2. Joint Dislocation
    2. Late changes
      1. Joint space destruction
      2. Epiphyseal cartilage resorption
      3. Metaphysis Erosion
  8. Management: Surgical
    1. Frequent joint aspiration (once to twice daily)
      1. Consider saline lavage
    2. Open Surgical drainage indications
      1. Difficult joint aspiration access (e.g. hip)
      2. Persistent fever and symptoms >24 hours
      3. Leukocytosis persists beyond 48 to 72 hours
      4. Repeat blood or joint cultures positive >48 hours
      5. Infected joint prosthesis
        1. Prosthesis may be salvaged if infection <1-2 weeks
        2. Most infected prostheses must be removed
  9. Management: Antibiotics
    1. Infant under age 3 months (2 drug regimens)
      1. Drug 1: Nafcillin or Oxacillin
        1. Use Vancomycin instead if MRSA common
      2. Drug 2: Cefotaxime, Ceftriaxone, or Gentamicin
    2. Children under age 15 years (2 drug regimens)
      1. Drug 1: Nafcillin, Oxacillin, or Vancomycin
      2. Drug 2: Cefotaxime, or Ceftriaxone
    3. Young Adults (Under age 40 years)
      1. Negative Gram Stain
        1. Ceftriaxone 1 gram IV every 24 hours or
        2. Cefotaxime or Ceftizoxime 1 gram IV every 8 hours
      2. Gram Stain with Gram Positive Cocci in clusters
        1. Nafcillin 2 grams IV every 4 hours or
        2. Oxacillin 2 grams IV every 4 hours
    4. Older Adults (Over age 40 years)
      1. Negative Gram Stain
        1. Drug 1: Nafcillin or Oxacillin
        2. Drug 2: Cefotaxime, Ceftriaxone
      2. Gram Stain with Gram Positive Cocci in clusters
        1. Drug 1: Nafcillin or Oxacillin
        2. Drug 2: Ciprofloxacin
    5. Iatrogenic Infection (Joint Injection or prosthesis)
      1. Empiric therapy before culture results
        1. Option 1 (2 drug regimen)
          1. Drug 1: Vancomycin
          2. Drug 2: Ciprofloxacin, Aztreonam, or Gentamycin
        2. Option 2 (2 drug regimen)
          1. Drug 1
            1. Ciprofloxacin 750 PO bid or
            2. Ofloxacin 200 mg PO tid
          2. Drug 2: Rifampin 900 mg PO qd
      2. Ciprofloxacin and Rifampin sensitive by culture
        1. Option 1 (2 drug regimen)
          1. Drug 1: Ciprofloxacin or Ofloxacin
          2. Drug 2: Rifampin 900 mg PO qd
        2. Option 2 (2 drug regimen)
          1. Drug 1: Oxacillin 2 grams IV every 4 hours
          2. Drug 2: Rifampin 900 mg PO qd
      3. Ciprofloxacin or Rifampin resistance by culture
        1. Vancomycin and
        2. Rifampin (if sensitive)
  10. Management: Antibiotic Course
    1. Nongonococcal bacterial infection
      1. Parenteral antibiotics for 2 to 4 weeks
      2. Oral antibiotics for 2 to 4 weeks
    2. See Gonococcal Arthritis
    3. See Tuberculous Arthritis
  11. Prognosis
    1. Early joint drainage and antibiotics
      1. Good prognosis
    2. Delayed management >24 hours
      1. Risk of joint arthrosis, fibrosis and osteonecrosis
  12. References
    1. Klippel (1997) Primer Rheumatic Diseases, p. 196-200
    2. Gilbert (2000) Sanford Guide to Antimicrobials, p. 22-3
    3. Stimmler (1996) Postgrad Med 99(4):127
    4. Kallio (1997) Pediatr Infect Dis 16:411
    5. Merenstein (1994) Handbook Pediatrics, Lange, p.710-2

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