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Intra-articular corticosteroids in septic arthritis: beneficial or barmy?
  1. SUZANNE E LANE,
  2. PETER MERRY
  1. Department of Rheumatology, Norfolk and Norwich Hospital, Brunswick Road, Norwich NR1 3SR

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    We read with interest the paper by Wysenbeeket al about the treatment of staphylococcal septic arthritis in rabbits by intra-articular corticosteroids in addition to antibiotics1 and would like to share our recent clinical experience that we feel pertinent to this scientific research.

    Traditional teaching dictates that intra-articular corticosteroids are contraindicated in the management of septic arthritis, the appropriate treatment being antibiotics and lavage or surgical drainage. The following two cases of septic arthritis illustrate the apparent benefits of the unconventional use of intra-articular corticosteroids. Both patients presented with a septic arthritis of an osteoarthritic knee. The first patient, a 87 year old women, had developed a staphylococcus aureus infection (sensitive to flucloxacillin) while the second, a 62 year old man, had a proteus infection (sensitive to cephalosporins). Surgical management was inappropriate because of frailty and warfarin treatment respectively. Despite treatment of both patients with appropriate intravenous antibiotics for two weeks and joint lavage, pain and synovitis persisted. At this stage, in both cases, knee aspirates and blood cultures on two separate occasions were negative. After a single intra-articular injection of 80 mg depomedrone and lignocaine (lidocaine) their symptoms resolved dramatically. Both were able to return to a full and independent life with no sequelae.

    Our decision to use corticosteroids was based on the observation that bacterial antigens can promote cytokine proliferation2 within the joint and activate chondrocyte proteases.3 We postulate that despite adequate treatment of infection, cytokine mediated inflammation persists and that intra-articular corticosteroid may limit damage and improve outcome. The use of intra-articular corticosteroids in addition to antibiotics in experimental staphylococcal septic arthritis in rabbits found no adverse effects of the corticosteroids and an improvement in joint histological-histochemical parameters.1

    We therefore propose that intra-articular corticosteroids may be useful in septic arthritis where: (a) synovitis persists despite adequate intravenous antibiotic treatment and ravage; and (b) repeat synovial fluid and blood cultures are found to be sterile.

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