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Septic Arthritis

Septic Arthritis

Septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis is an infection of the joint due to direct inoculation, contiguous extension Extension Examination of the Upper Limbs, or hematogenous Hematogenous Hepatocellular Carcinoma (HCC) and Liver Metastases spread of infectious Infectious Febrile Infant organisms into the joint space. This process causes an acute, inflammatory, monoarticular arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis. A variety of organisms have been implicated, most commonly Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus aureus. Previously damaged joints (e.g., rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis) are at the highest risk of infection. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with a swollen, warm, and tender joint, most commonly involving the knee. Positive cultures Cultures Klebsiella from arthrocentesis are diagnostic, with antibiotic therapy tailored to the specific organism. Repeated joint aspiration, or surgical drainage, is required in some cases. If the joint space is infected with a prosthetic in place, debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome and prosthesis removal may also be required.

Last updated: 15 Mar, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Epidemiology and Etiology

Epidemiology

  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: 2–6 cases per 100,000 people in the United States
  • More common in children than adults: peaks between the ages of 2 and 3 years
  • 2:1 male predominance

Etiology

The majority of septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease are monomicrobial. Common organisms include:

  • Staphylococci:
    • Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus aureus (most common)
    • S. epidermidis S. epidermidis A species of staphylococcus that is a spherical, non-motile, gram-positive, chemoorganotrophic, facultative anaerobe. Mainly found on the skin and mucous membrane of warm-blooded animals, it can be primary pathogen or secondary invader. Staphylococcus
  • Streptococci:
    • Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus pyogenes
    • S. pneumoniae
    • S. agalactiae
  • Gram-negative bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: 
    • Pseudomonas Pseudomonas Pseudomonas is a non-lactose-fermenting, gram-negative bacillus that produces pyocyanin, which gives it a characteristic blue-green color. Pseudomonas is found ubiquitously in the environment, as well as in moist reservoirs, such as hospital sinks and respiratory equipment. Pseudomonas aeruginosa
    • Escheria coli
    • Kingella kingae
    • Neisseria Neisseria Neisseria is a genus of bacteria commonly present on mucosal surfaces. Several species exist, but only 2 are pathogenic to humans: N. gonorrhoeae and N. meningitidis. Neisseria species are non-motile, gram-negative diplococci most commonly isolated on modified Thayer-Martin (MTM) agar. Neisseria gonorrhoeae
    • Haemophilus influenzae Haemophilus Influenzae A species of Haemophilus found on the mucous membranes of humans and a variety of animals. The species is further divided into biotypes I through viii. Haemophilus
    • Salmonella Salmonella Salmonellae are gram-negative bacilli of the family Enterobacteriaceae. Salmonellae are flagellated, non-lactose-fermenting, and hydrogen sulfide-producing microbes. Salmonella enterica, the most common disease-causing species in humans, is further classified based on serotype as typhoidal (S. typhi and paratyphi) and nontyphoidal (S. enteritidis and typhimurium). Salmonella species

Risk factors

  • Infants and children:
    • Prematurity Prematurity Neonatal Respiratory Distress Syndrome
    • Hemophilia Hemophilia The hemophilias are a group of inherited, or sometimes acquired, disorders of secondary hemostasis due to deficiency of specific clotting factors. Hemophilia A is a deficiency of factor VIII, hemophilia B a deficiency of factor IX, and hemophilia C a deficiency of factor XI. Patients present with bleeding events that may be spontaneous or associated with minor or major trauma. Hemophilia (due to hemarthroses)
    • Immunosuppression:
      • Chemotherapy Chemotherapy Osteosarcoma
      • HIV HIV Anti-HIV Drugs
      • Sickle cell anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types
      • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • Adults:
    • Age > 80 years
    • Chronic disease/immunosuppression:
      • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
      • HIV HIV Anti-HIV Drugs
    • Joint disease:
      • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis
      • Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis
      • Gout Gout Gout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout
    • Joint procedures:
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease or ulcers
    • IV drug use
Table: Most common organisms in septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis, based on some notable underlying risk factors
Risk factors Infectious Infectious Febrile Infant agents
No specific risk factor S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus
Prosthetic joint replacement
  • S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus (particularly MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus)
  • S. epidermidis S. epidermidis A species of staphylococcus that is a spherical, non-motile, gram-positive, chemoorganotrophic, facultative anaerobe. Mainly found on the skin and mucous membrane of warm-blooded animals, it can be primary pathogen or secondary invader. Staphylococcus (creates biofilms Biofilms Encrustations formed from microbes (bacteria, algae, fungi, plankton, or protozoa) embedded in an extracellular polymeric substance matrix that is secreted by the microbes. They occur on body surfaces such as teeth (dental deposits); inanimate objects, and bodies of water. Biofilms are prevented from forming by treating surfaces with dentifrices; disinfectants; anti-infective agents; and anti-fouling agents. Proteus on prosthetics)
Chronic disease, autoimmune disorder, skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions infection, trauma, elderly S. pyogenes (group A beta-hemolytic strep)
Young, sexually active N. gonorrhoeae N. gonorrhoeae A species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea. Neisseria
Trauma S. epidermidis S. epidermidis A species of staphylococcus that is a spherical, non-motile, gram-positive, chemoorganotrophic, facultative anaerobe. Mainly found on the skin and mucous membrane of warm-blooded animals, it can be primary pathogen or secondary invader. Staphylococcus
Sickle cell anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types
  • Salmonella Salmonella Salmonellae are gram-negative bacilli of the family Enterobacteriaceae. Salmonellae are flagellated, non-lactose-fermenting, and hydrogen sulfide-producing microbes. Salmonella enterica, the most common disease-causing species in humans, is further classified based on serotype as typhoidal (S. typhi and paratyphi) and nontyphoidal (S. enteritidis and typhimurium). Salmonella
  • S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus

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Pathophysiology

  • Invasion of the joint occurs through:
  • Previously damaged joints are particularly susceptible to infection by way of:
    • Neovascularization
    • Dysfunctional cellular defenses
    • Absent basement membrane Basement membrane A darkly stained mat-like extracellular matrix (ecm) that separates cell layers, such as epithelium from endothelium or a layer of connective tissue. The ecm layer that supports an overlying epithelium or endothelium is called basal lamina. Basement membrane (bm) can be formed by the fusion of either two adjacent basal laminae or a basal lamina with an adjacent reticular lamina of connective tissue. Bm, composed mainly of type IV collagen; glycoprotein laminin; and proteoglycan, provides barriers as well as channels between interacting cell layers. Thin Basement Membrane Nephropathy (TBMN) on the synovial membrane Synovial Membrane The inner membrane of a joint capsule surrounding a freely movable joint. It is loosely attached to the external fibrous capsule and secretes synovial fluid. Hip Joint: Anatomy
  • Progression of the disease:
    • Bacterial invasion → inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation → release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology of cytokines Cytokines Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. Adaptive Immune Response and proteases Proteases Proteins and Peptides
    • This response, plus bacterial toxins → destruction of: 
      • Articular cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology
      • Synovium
      • Subchondral bone Subchondral Bone Osteochondritis Dissecans
    • Pannus formation occurs.
    • If a large effusion develops → impairment of the blood supply → aseptic necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage

Clinical Presentation and Diagnosis

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Usually acute in onset
  • Joint signs and symptoms:
    • Swelling Swelling Inflammation and effusion
    • Warmth
    • Moderate-to-severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion
    • Restricted movement
    • Usually monoarticular, but 20% of cases may be oligo- or polyarticular
  • Constitutional symptoms Constitutional Symptoms Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis:
    • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
    • Fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia
    • Tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children
  • Commonly affected joints:
  • Knee swelling and mild erythema in a patient with septic arthritis

    Knee swelling Swelling Inflammation and mild erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion in a patient with septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis

    Image: “Troublesome Tuberculosis Tuberculosis Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. Tuberculosis: A Case Report on Multi-focal Tuberculous Osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis in An Immunocompetent Patient” by Lynn MM MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma, Kukanesen JR, Khan AW. License: CC BY 2.0
  • Erythema in case of septic arthritis

    Significant erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion and swelling Swelling Inflammation over the right sternoclavicular joint Sternoclavicular Joint Examination of the Upper Limbs, which is concerning for septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis

    Image: “ Sternoclavicular joint Sternoclavicular Joint Examination of the Upper Limbs septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis with chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall: Anatomy abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease in a healthy adult: a case report” by Tanaka Y, Kato H, Shirai K, Nakajima Y, Yamada N, Okada H, Yoshida T, Toyoda I, Ogura S. License: CC BY 4.0

Arthrocentesis

The diagnosis of septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis is made with synovial fluid analysis Synovial Fluid Analysis Rheumatoid Arthritis.

  • Should be attempted before antibiotics are given
  • A positive Gram stain Gram stain Klebsiella and/or culture confirms the diagnosis.
  • A purulent aspirate gives a presumptive diagnosis:
  • Nucleic acid amplification testing may be performed if N. gonorrhoeae N. gonorrhoeae A species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea. Neisseria is suspected.
  • Include an analysis for crystals to rule out gout Gout Gout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout.

Laboratory evaluation

Laboratory studies that support the diagnosis:

Imaging

  • Plain X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays:
  • Ultrasound: 
  • MRI: 
    • Sensitive for early identification Identification Defense Mechanisms of joint effusion
    • Evaluates the extent of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types and soft-tissue abnormalities
    • Assesses for associated osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis
    • Particularly helpful in evaluating sacroiliac and sternoclavicular joint Sternoclavicular Joint Examination of the Upper Limbs infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
  • Radiograph septic arthritis in infant

    X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests showing soft-tissue swelling Swelling Inflammation of the right ankle in an 8-month-old patient with septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis

    Image: “Polyarticular Septic Arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis Caused by Haemophilus influenzae Haemophilus Influenzae A species of Haemophilus found on the mucous membranes of humans and a variety of animals. The species is further divided into biotypes I through viii. Haemophilus Serotype f in an 8-Month-Old Immunocompetent Infant: A Case Report and Review of the Literature” by Ali RA, Kaplan SL, Rosenfeld SB. License: CC BY 3.0
  • Mri septic arthritis in pediatric patient

    MRI showing a large effusion between the humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy and olecranon Olecranon A prominent projection of the ulna that articulates with the humerus and forms the outer protuberance of the elbow joint. Arm: Anatomy process in a pediatric patient with septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis

    Image: “Polyarticular Septic Arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis Caused by Haemophilus influenzae Haemophilus Influenzae A species of Haemophilus found on the mucous membranes of humans and a variety of animals. The species is further divided into biotypes I through viii. Haemophilus Serotype f in an 8-Month-Old Immunocompetent Infant: A Case Report and Review of the Literature” by Ali RA, Kaplan SL, Rosenfeld SB. License: CC BY 3.0
  • Plain radiograph septic arthritis

    X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests of the knee demonstrating mild periarticular osteopenia Osteopenia Osteoporosis and significant joint-space narrowing in a patient with septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis

    Image: “Disseminated Aspergillus Aspergillus A genus of mitosporic fungi containing about 100 species and eleven different teleomorphs in the family trichocomaceae. Echinocandins flavus following septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis in an immunocompetent patient: a case report” by Tiwari V, Khatri K, Khan SA, Nath D. License: CC BY 4.0
  • Ultrasound septic arthritis

    Ultrasound of the right shoulder glenohumeral articulation showing a distended posterior aspect of joint capsule Joint capsule The sac enclosing a joint. It is composed of an outer fibrous articular capsule and an inner synovial membrane. Hip Joint: Anatomy by fluid (A) in a patient with septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis

    Image: “ Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus agalactiae Septic Arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis of the Shoulder and the Sacroiliac Joints: A Case Report” by Imam YZ, Sarakbi HA HA Hemolytic anemia (HA) is the term given to a large group of anemias that are caused by the premature destruction/hemolysis of circulating red blood cells (RBCs). Hemolysis can occur within (intravascular hemolysis) or outside the blood vessels (extravascular hemolysis). Hemolytic Anemia, Abdelwahab N, Mattar I. License: CC BY 3.0

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Management

Antibiotic therapy

Antibiotic selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions is based on the initial Gram stain Gram stain Klebsiella and tailored based on culture data.

  • Empiric regimen if Gram stain Gram stain Klebsiella is negative:
  • Gram-positive Gram-Positive Penicillins cocci Cocci Bacteriology:
    • Empiric vancomycin Vancomycin Antibacterial obtained from streptomyces orientalis. It is a glycopeptide related to ristocetin that inhibits bacterial cell wall assembly and is toxic to kidneys and the inner ear. Glycopeptides
    • If cultures Cultures Klebsiella grow MSSA: 
    • If cultures Cultures Klebsiella grow MRSA MRSA A strain of Staphylococcus aureus that is non-susceptible to the action of methicillin. The mechanism of resistance usually involves modification of normal or the presence of acquired penicillin binding proteins. Staphylococcus: 
      • Vancomycin Vancomycin Antibacterial obtained from streptomyces orientalis. It is a glycopeptide related to ristocetin that inhibits bacterial cell wall assembly and is toxic to kidneys and the inner ear. Glycopeptides
      • Daptomycin Daptomycin A cyclic lipopeptide antibiotic that inhibits gram-positive bacteria. Lipopeptides and Lipoglycopeptides
      • Linezolid Linezolid An oxazolidinone and acetamide derived anti-bacterial agent and protein synthesis inhibitor that is used in the treatment of gram-positive bacterial infections of the skin and respiratory tract. Oxazolidinones
      • Clindamycin Clindamycin An antibacterial agent that is a semisynthetic analog of lincomycin. Lincosamides
  • Gram-negative bacilli Bacilli Shigella:
    • Empiric options:
      • 3rd- or 4th-generation cephalosporins Cephalosporins Cephalosporins are a group of bactericidal beta-lactam antibiotics (similar to penicillins) that exert their effects by preventing bacteria from producing their cell walls, ultimately leading to cell death. Cephalosporins are categorized by generation and all drug names begin with “cef-” or “ceph-.” Cephalosporins
      • Aztreonam Aztreonam The carbapenems and aztreonam are both members of the bactericidal beta-lactam family of antibiotics (similar to penicillins). They work by preventing bacteria from producing their cell wall, ultimately leading to bacterial cell death. Carbapenems and Aztreonam
    • For P. aeruginosa P. aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas, add 1 of the following:
  • Gram-negative cocci Cocci Bacteriology:
    • Ceftriaxone Ceftriaxone A broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears. Cephalosporins (management of choice in N. gonorrhoeae N. gonorrhoeae A species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea. Neisseria infection)
    • Aminoglycosides Aminoglycosides Aminoglycosides are a class of antibiotics including gentamicin, tobramycin, amikacin, neomycin, plazomicin, and streptomycin. The class binds the 30S ribosomal subunit to inhibit bacterial protein synthesis. Unlike other medications with a similar mechanism of action, aminoglycosides are bactericidal. Aminoglycosides

Duration of therapy depends on additional factors:

  • With negative blood cultures Cultures Klebsiella:
    • 2 weeks of parenteral antibiotics
    • Additional 1–2 weeks of oral antibiotics
  • With positive blood cultures Cultures Klebsiella: 4 weeks of parenteral antibiotics
  • P. aeruginosa P. aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas infection: 4–6 weeks

Surgical interventions

Joint drainage:

  • Generally warranted in all patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • Often requires repeated drainage
  • Options:
    • Needle aspiration Needle aspiration Using fine needles (finer than 22-gauge) to remove tissue or fluid specimens from the living body for examination in the pathology laboratory and for disease diagnosis. Peritonsillar Abscess
    • Arthroscopic drainage
    • Arthrotomy (open surgery) is indicated when:

Surgical debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with prosthesis:

  • Debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome with preservation of prosthesis:
    • Infection occurs within 30 days of implantation Implantation Endometrial implantation of embryo, mammalian at the blastocyst stage. Fertilization and First Week.
    • Presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor within 3 weeks of symptom onset
    • No evidence of draining sinus tract
  • Debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome with removal of prosthesis:
    • Prosthesis is removed and a joint spacer placed.
    • 6-week course of antibiotics
    • Eventual replacement with a new joint prosthesis Joint prosthesis Prostheses used to partially or totally replace a human or animal joint. Soft Tissue Abscess

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Quick Review: Septic Arthritis

Differential Diagnosis

  • Reactive arthritis Reactive arthritis Reactive arthritis is a seronegative autoimmune spondyloarthropathy that occurs in response to a previous gastrointestinal (GI) or genitourinary (GU) infection. The disease manifests as asymmetric oligoarthritis (particularly of large joints in the lower extremities), enthesopathy, dactylitis, and/or sacroiliitis. Reactive Arthritis: a seronegative, autoimmune spondyloarthropathy Spondyloarthropathy Ankylosing Spondylitis that is often precipitated by a GI or genitourinary infection. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with an asymmetric oligoarthritis Oligoarthritis Ankylosing Spondylitis, enthesopathy Enthesopathy Reactive Arthritis, dactylitis Dactylitis Ankylosing Spondylitis, and/or sacroiliitis Sacroiliitis Inflammation of the sacroiliac joint. It is characterized by lower back pain, especially upon walking, fever, uveitis; psoriasis; and decreased range of motion. Many factors are associated with and cause sacroiliitis including infection; injury to spine, lower back, and pelvis; degenerative arthritis; and pregnancy. Ankylosing Spondylitis. The diagnosis is clinical, and a negative synovial Gram stain Gram stain Klebsiella and culture will help rule out septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis. Management includes NSAIDs NSAIDS Primary vs Secondary Headaches, disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects. Disease-Modifying Antirheumatic Drugs (DMARDs) ( DMARDs DMARDs Disease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects. Disease-Modifying Antirheumatic Drugs (DMARDs)), and treatment of an active infection.
  • Gout Gout Gout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis: an arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis due to precipitation of monosodium urate crystals Monosodium Urate Crystals Gout in the joints. The condition is characterized by acute, painful, recurring, monoarticular arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis. The most commonly involved joint is the 1st metatarsophalangeal joint Metatarsophalangeal Joint Foot: Anatomy. The diagnosis is made with identification Identification Defense Mechanisms of negatively birefringent, needle-shaped crystals in the synovial fluid, which differentiates gout Gout Gout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or “gout flare,” followed later by chronic deforming arthritis. Gout from septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis. Therapies include NSAIDs NSAIDS Primary vs Secondary Headaches, colchicine Colchicine A major alkaloid from colchicum autumnale l. And found also in other colchicum species. Its primary therapeutic use is in the treatment of gout. Gout Drugs, steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors, and uric acid Uric acid An oxidation product, via xanthine oxidase, of oxypurines such as xanthine and hypoxanthine. It is the final oxidation product of purine catabolism in humans and primates, whereas in most other mammals urate oxidase further oxidizes it to allantoin. Nephrolithiasis reduction with allopurinol Allopurinol A xanthine oxidase inhibitor that decreases uric acid production. It also acts as an antimetabolite on some simpler organisms. Gout Drugs.
  • Pseudogout: intra-articular calcium Calcium A basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes. Electrolytes pyrophosphate deposition. The etiology is not clear. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with acute flares of joint swelling Swelling Inflammation, warmth, and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways. Pseudogout usually affects larger joints, such as the knee. Diagnosis is with identification Identification Defense Mechanisms of positively birefringent and rhomboid crystals in the synovial fluid, which differentiates pseudogout from septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis. Management includes NSAIDs NSAIDS Primary vs Secondary Headaches, corticosteroids Corticosteroids Chorioretinitis, and colchicine Colchicine A major alkaloid from colchicum autumnale l. And found also in other colchicum species. Its primary therapeutic use is in the treatment of gout. Gout Drugs.
  • Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis ( OA OA Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis): arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis due to cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology destruction and changes in the subchondral bone Subchondral Bone Osteochondritis Dissecans. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship develop gradual joint pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, stiffness lasting < 30 minutes, and decreased range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs. Physical exam may reveal crepitus Crepitus Osteoarthritis with joint motion and osteophyte Osteophyte Bony outgrowth usually found around joints and often seen in conditions such as arthritis. Osteoarthritis formation. The diagnosis is clinical. Synovial fluid will be non-inflammatory, which differentiates OA OA Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis from septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis. Management includes analgesics, glucocorticoid intra-articular injections, and surgery for advanced disease.
  • Osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis: an infection of the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types most commonly caused by S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, redness Redness Inflammation, and swelling Swelling Inflammation of the affected site, and may have associated symptoms such as fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever and chills Chills The sudden sensation of being cold. It may be accompanied by shivering. Fever. Laboratory values will demonstrate elevated WBC, CRP, and ESR ESR Soft Tissue Abscess in most cases. The most sensitive and specific imaging modality to diagnose osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis is MRI. Management requires long-term antibiotics and potential surgical debridement Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Stevens-Johnson Syndrome.
  • Lyme disease Lyme disease Lyme disease is a tick-borne infection caused by the gram-negative spirochete Borrelia burgdorferi. Lyme disease is transmitted by the black-legged Ixodes tick (known as a deer tick), which is only found in specific geographic regions. Patient presentation can vary depending on the stage of the disease and may include a characteristic erythema migrans rash. Lyme Disease: a tick-borne infection caused by the gram-negative spirochete Spirochete Treponema is a gram-negative, microaerophilic spirochete. Owing to its very thin structure, it is not easily seen on Gram stain, but can be visualized using dark-field microscopy. This spirochete contains endoflagella, which allow for a characteristic corkscrew movement. Treponema Borrelia Borrelia Borrelia are gram-negative microaerophilic spirochetes. Owing to their small size, they are not easily seen on Gram stain but can be visualized using dark-field microscopy, Giemsa, or Wright stain. Spirochetes are motile and move in a characteristic spinning fashion due to axial filaments in the periplasmic space. Borrelia burgdorferi. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with late disease may develop a migratory polyarthritis Polyarthritis Rheumatoid Arthritis, particularly in large joints. An erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion migrans rash Rash Rocky Mountain Spotted Fever as well as neurologic, cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR), and ocular manifestations may also be present. Synovial fluid analysis Synovial Fluid Analysis Rheumatoid Arthritis and serologic testing can confirm a Lyme infection and will differentiate the disease from septic arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis. Antibiotic therapy is used for treatment.

References

  1. Foldenberg, D. L., Sexton, D. J. (2020). Septic arthritis in adults. In Baron, E. L. (Ed.), UpToDate. Retrieved March 4, 2021, from https://www.uptodate.com/contents/septic-arthritis-in-adults
  2. Helfgott, S.M. (2019). Monoarthritis in adults: Etiology and evaluation. In Ramirez Curtis, M. (Ed.), UpToDate. Retrieved March 8, 2021, from https://www.uptodate.com/contents/monoarthritis-in-adults-etiology-and-evaluation
  3. Momodu, I. (2021). Septic arthritis. In Savaliya, V. (Ed.), StatPearls. Retrieved March 4, 2021, from https://www.statpearls.com/articlelibrary/viewarticle/17857/
  4. Brusch, J. L. (2020). Septic arthritis treatment & management. In Bronze, M. S. (Ed.), Medscape. Retrieved March 5, 2021, from https://emedicine.medscape.com/article/236299-overview#a6
  5. Schmitt, S. (2020). Acute infectious arthritis. MSD Manual Professional Version. Retrieved March 8, 2021, from https://www.msdmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/infections-of-joints-and-bones/acute-infectious-arthritis

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