SeminarSeptic arthritis
Section snippets
Bacterial arthritis
Bacterial arthritis is the most rapidly destructive joint disease. The yearly incidence of bacterial arthritis varies from 2 to 10 per 100000 in the general population to 30–70 per 100000 in patients with rheumatoid arthritis and in patients with joint prostheses.1, 2 Irreversible loss of joint function develops in 25–50% of patients.1, 3, 4, 5 Despite better antimicrobial agents and improved hospital care, the case fatality rate for bacterial arthritis has not changed substantially in the past
Pathophysiology
In native joints, bacterial arthritis is usually secondary to the haematogenous seeding of a joint during a transient or persistent bacteraemia. The bacteria enter the closed joint space and within hours trigger an acute inflammatory synovitis. The synovial membrane reacts with a proliferative lining-cell hyperplasia, and there is an influx of acute and chronic inflammatory cells. Release of cytokines and proteases leads to cartilage degradation. Within a few days, irreversible subchondral bone
Clinical manifestations
Non-gonococcal bacterial arthritis usually presents with the abrupt onset of a single hot, swollen, and very painful joint (panel 2).3 The knee is the site of infection in 50% of cases but any joint may be involved. Hip infections are more common in young children.2 The hip is often held in a flexed and externally rotated position and there is extreme pain on motion. It is often difficult to detect an effusion of the hip or the shoulder although the joint is frequently warm and very tender.
Diagnosis
The definitive diagnosis of bacterial arthritis requires identification of bacteria in the synovial fluid by Gram's stain or by culture. Clinical suspicion of joint sepsis should prompt immediate synovial fluid aspiration. If synovial fluid cannot be obtained with closed needle aspiration, the joint should be aspirated again, with imaging guidance for joints that are not very accessible, such as hips, shoulders, or sacroiliac joints. Such joints may require surgical arthrotomy to obtain
Other rheumatic disorders
Physicians should always consider the possibility of concurrent septic arthritis in patients with chronic joint disease who present with one or two new inflamed joints. Septic arthritis is most likely in patients with longstanding rheumatoid arthritis (panel 2), and in such patients treatment is often delayed because it is wrongly assumed that the joint symptoms are related to an exacerbation of the underlying rheumatoid arthritis.10 The patient will often be afebrile and the presentation
Treatment of bacterial arthritis
The treatment of acute bacterial arthritis requires antibiotics and joint drainage (figure 1). The initial choice of antibiotics should be based on the Gram's stain and the age and risk factors of the patient. If the Gram's stain is negative, empirical therapy should usually include antimicrobial activity against S aureus and streptococci.25 Ceftriaxone, 1 g parenterally every 24 h, or ceftizoxime or cefotaxime, 1 g parenterally every 8 h, are the initial antibiotics of choice for suspected DGI.
Pathophysiology
The rate of infection ranges from 0.5% to 2% for hip and knee replacements. Early-onset infections are usually the results of perioperative wound contamination and are most often caused by coagulase-negative staphylococci. Infections that begin later than three months after the joint implant are usually haematogenously acquired. S aureus, streptococci, gram-negative aerobes, and anaerobes are the most common bacteria in late-onset prosthetic joint infections. When certain bacteria attach to the
Conclusion
The outcome of bacterial arthritis has not changed much in the past few decades despite more effective antibiotics and improved methods of joint drainage. Permanent joint damage develops in 50% of cases and mortality is 10–16%.2, 6, 7 Outcome is directly related to host factors, such as prior joint damage, and to virulence of the infecting organism. The large number of total joint arthroplasties being done have resulted in joint prostheses becoming the most important risk factor in septic
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