Transcript 12 Martin - SepticArthritisx

SEPTIC ARTHRITIS
ALLISON I. MARTIN, BSN, RN
DIAGNOSIS
• Septic arthritis is an infection in the joint cavity most
often caused by bacteria, but also can be caused by fungi
or mycobacteria
• Nongonococcal bacteria can lead to irreversible joint
damage
• Gonococcal bacteria is far less destructive to joints
• Acute monoarticular arthritis
• Infectious and inflammatory
MECHANISM OF INFECTION
• Hematogenous spread
• Bacteremia
• IV drug abuse
• Immunocompromised state
(Diabetes, HIV)
• Direct inoculation
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Recent joint surgery
Prosthetic joint
Steroid injections
Trauma
• Spread from local infection
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Skin infection or ulcer
Osteomyelitis
Septic bursitis
Abscess
http://www.physio-pedia.com/Septic_(Infectious)_Arthritis
PATHOGENESIS
• The synovial fluid within the joint cavity is normally sterile
• Synovial tissue has no limiting basement plate so bacteria quickly
gain access
• Most common causative agents:
• Staphylococcus aureus
• Streptococcus species
• Gram-negative bacilli in immunocompromised and IV drug abusers
• Bacteria cause an acute inflammatory cell response in the synovial
membrane with purulent effusion into the joint capsule
• Following onset, there is a marked hyperplasia of the lining cells
in the synovial membrane within 7 days
• Inflammatory cells release cytokines and proteases that cause
cartilage degradation and inhibit cartilage synthesis leading to
rapid destruction of the joint
RISK FACTORS
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Advanced age (50% of patients are > 60 years)
Diabetes mellitus
Rheumatoid arthritis
Presence of prosthetic joint
Recent joint surgery
Skin infection
Intravenous drug use, alcoholism
Prior intraarticular corticosteroid injection
CLINICAL MANIFESTATIONS
• History
• Presentation
• Monoarticular acute joint swelling, pain, erythema, warmth, joint
immobility; ROM is significantly restricted and very painful
• Infection in the knee is most common (> 50% of cases), but the hip,
shoulder, ankle, elbow, and wrist can also be affected
• HPI – OLDCARTS
• Onset, location, associated symptoms, risk factors, concurrent illness
• Ask about injury or trauma, recent infections of skin or urinary tract
• Abrupt onset with fever and chills points to infectious cause
• History of skin lesions, vaginal or urethral discharge, exposure
to gonorrhea, tick bites or exposure to ticks
CLINICAL MANIFESTATIONS
• ROS:
• General: fever and chills (common but are absent in up to 20% of
cases), fatigue
• HEENT: drainage, mucosal ulcers, petechiae in eyes or mouth
• Cardiovascular: chest pain, syncope
• Respiratory: cough, shortness of breath, dyspnea
• GU: urinary symptoms, hematuria, discharge
• GI: bowel changes, N/V
• Skin: skin wound, lesion, ulcers, bites, petechiae
• Musculoskeletal: swelling, erythema, warmth, joint stiffness and
immobility (mono-, oligo- or polyarticular)
CLINICAL MANIFESTATIONS
• PMH: Diabetes mellitus, rheumatoid arthritis, gout or
pseudogout, prosthetic joint, osteoarthritis, prior
intraarticular corticosteroid injections,
immunosuppression, HIV infection, previous trauma
• PSH: Recent joint surgery (within 24 months), dental
procedures
• Social history: IV drug abuse, alcoholism, sexual history
and STDs (gonococcal arthritis)
• Medications: Immunosuppressive therapy, steroids,
chemotherapy
PHYSICAL EXAMINATION
• Vitals: Note temperature
• Most patients with septic arthritis are febrile with high fever
• Patients with gout and rheumatoid arthritis may have low-grade fever
• HEENT: Examine eyes for conjunctivitis and iritis, fundi for signs of
endocarditis, mouth for mucosal ulcers
• Cardiovascular: Auscultate for murmur
• Respiratory: Auscultate lungs
• Integumentary: Lesions, wounds, ulcers, track marks, tophi
• Genitalia: Check for signs of gonococcal urethritis and cervicitis
• Musculoskeletal: Examine all joints; assess involved joint for
increased warmth, swelling, redness, effusion, and immobility; test
active and passive ROM
• Differentiate inflammation of the joint space versus periarticular process
(tendons, bursa, or skin) which may have preserved ROM despite pain
• Check spine ROM, restriction and tenderness can indicate spondylitis
DIAGNOSTIC TESTS
• Synovial fluid aspiration is the definitive diagnostic test
• Gram stain: gram positive bacteria in about 80% of cases
• Culture: positive in 90% of cases with nongonococcal arthritis
• Leukocyte count with differential: exceeds 50,000/mcL and often >
100,000/mcL
• Crystal analysis
Blood cultures should be obtained (positive in 50% of patients)
CBC: elevated WBCs, common, but not specific
C-reactive protein: 92% sensitive, not specific
Erythrocyte sedimentation rate: 98% sensitive, not specific
Radiographs obtained for baseline image, detect fracture, or
underlying inflammatory arthritis
• MRI to detect effusions and inflammation in joints that are
difficult to examine, including the hip and sacroiliac joints
• Ultrasound more sensitive for effusions of the hip
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CATEGORIES OF SYNOVIAL FLUID BASED
UPON CLINICAL AND LAB FINDINGS
Measure
Normal
Noninflammatory
Inflammatory
Septic
Volume, mL
(knee)
< 3.5
Often > 3.5
Often > 3.5
Often > 3.5
Clarity
Transparent
Translucent
Translucentopaque
Opaque
Color
Clear
Yellow
Yellow to
opalescent
Yellow to
green, frank
pus
Viscosity
High
High
Low
Variable
WBC, per
mm3
< 200
0 to 2000
2000 to 100,000
15,000 to >
100,000
PMNs (%)
< 25
< 25
>= 50
>= 75
Culture
Negative
Negative
Negative
Positive
Adapted from https://www.uptodate.com/contents/septic-arthritis-in-adults
DIFFERENTIAL DIAGNOSIS
• Inflammatory
• Crystal-induced arthritis:
• Gout: uric acid crystals
• Pseudogout: calcium
pyrophosphate crystals
• Rheumatoid arthritis
• Reactive arthritis
• Infectious
• Lyme disease
• Disseminated Gonorrhea
• Non-inflammatory
• Hemarthrosis
• Red flags
• Septic arthritis
• Emergency
• Immediate hospital
admission required
• Significant joint
destruction and other
complications, including
amputation, sepsis, and
death
• Osteomyelitis
• Avascular necrosis
TREATMENT
• Treatment includes immediate hospitalization for antibiotics and joint
drainage
• Early consult with orthopedics, rheumatology, and infectious disease
• Synovial fluid aspiration analysis, start empirical antibiotics according
to gram stain, then tailor antibiotics to culture results
• Antibiotic therapy
• Gram positive cocci:
• Vancomycin (also 1st line for MRSA)
• Daptomycin, linezolid, and clindamycin are alternatives
• Gram negative bacilli: third-generation cephalosporin
• Ceftriaxone, cefotaxime, ceftazidime
• Pseudomonas aeruginosa (IV drug abusers)
• Ceftazidime and gentamicin
• Cephalosporin-allergic patients
• Ciprofloxacin and aminoglycoside
TREATMENT
• Duration of therapy
• Parenteral antibiotics for at least 14 days followed by oral therapy for an
additional 14 days
• Parenteral antibiotics for 4-7 days followed by 14-21 days of oral therapy
• Three to four weeks of IV therapy may be needed for arthritis caused by
P. aeruginosa, Enterobacter spp., S. aureus, or in the setting of
bacteremia
• Joint drainage
• Needle aspiration (arthrocentesis)
• Arthroscopic drainage
• Arthrotomy (open surgical drainage)
• Immobilization, elevation, ice packs
• Postpone anti-inflammatory medications for 12-24 hours; can use
analgesics without anti-inflammatories if pain is severe
• Early active range of motion as tolerated will speed recovery
TREATMENT
• Needle aspiration
• Knee, perform until culture
negative
• If not adequate for joint
decompression after 3-5 days,
then surgical drainage is
required
• Arthroscopy
• Provides easy irrigation and
better visualization
• Knee, shoulder, wrist
• Surgical drainage
• Hips, shoulders, and
prosthetic joint infections
• Any joint not improving after
serial needle aspiration or if
needle drainage is inadequate
http://jama.jamanetwork.com/article.aspx?articleid=206414
OUTCOMES
• Prognosis dependent on prior health of the patient, the causative
organism, and promptness of treatment
• S. aureus is associated with poor functional outcome in 46-50% of cases
• Overall mortality rates range from 10 -15%
• Mortality rate increases to 30% for patients with polyarticular sepsis
• Morality is 50% if infection due to S. aureus or occurs in the presence of RA
• Morbidity occurs in one-third of patients with bacterial arthritis
• Amputation, arthrodesis, prosthetic surgery, severe functional
deterioration
• Failure to initiate appropriate antibiotic therapy within 24 to 48
hours of onset can cause subchondral bone loss and permanent
irreversible joint damage and dysfunction
• Prompt identification and referral for treatment are imperative
SUMMARY
https://www.uptodate.com/contents/septic-arthritis-in-adults
REFERENCES
Evaluation of acute monoarticular arthritis (2014). In A. H. Goroll & A. G. Mulley (Ed.), Primary care medicine: Office
evaluation and management of the adult patient (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
Goldenberg, D. L., & Sexton, D. J. (2016). Septic arthritis in adults. In Calderwood, S. B.
(Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/septic-arthritis-in-adults
Hellman, D. B., & Imboden, J. B. (2015). Nongocococcal acute bacterial (septic) arthritis. In
M. A. Papadakis, S. J. McPhee, & M. W. Rabow (Eds.). Current medical diagnosis & treatment (54th ed., pp. 849-851). New
York: McGraw-Hill
Horowitz, D. L., Katzap, E., Horowitz, S., & Barilla-LaBarca, M. (2011). Approach to
septic arthritis. American Family Physician. 84(6), 653-660. Retrieved from
http://www.aafp.org/afp/2011/0915/p653.html
Omar, M., Ettinger, M., Reichling, M., Petri, M., Lichtinghagen, R., Guenther, D.,…Krettek, C. (2014). Preliminary results of a new test
for rapid diagnosis of septic arthritis with use of leukocyte esterase and glucose reagent strips. The Journal of Bone and Joint
Surgery. American Volume, 96(24), 2032-2037. doi:10.2106/JBJS.N.00173
QUESTIONS?
http://www.aafp.org/afp/2011/0915/p653.html