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Septic Arthritis and Bursitis

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Ovid: 5-Minute Sports Medicine Consult, The


Septic Arthritis and Bursitis
Kevin B. Gebke
Paul Reehal
Basics
Description
  • Infection of articular joints or bursae with a bacterial, mycobacterial, spirochetal, fungal, or viral source
  • May be an indication of systemic infection
  • Synonym(s): Infectious arthritis; Infectious bursitis
Epidemiology
  • Usually a monarticular or oligoarticular pattern for acute bacterial infection, chronic mycobacterial infection, or fungal infection
  • Acute polyarticular involvement usually signifies disseminated neisserial infection or acute hepatitis B.
  • Neisserial involvement is responsible for ∼50% of infectious arthritis.
Risk Factors
  • Sexually active person at risk for STDs
  • Joint penetration or recent surgery
  • Trauma
  • Immunocompromised patient
  • History of arthritis in affected joint (greatest incidence in patients with rheumatoid arthritis)
  • IV drug abuse
  • Significant comorbid diseases (diabetes, malignancy, hepatic failure, sickle-cell disease, immunocompromised states)
Diagnosis
History
  • Rapid or insidious onset (patient may describe crescendo-like throbbing pain)
  • Single joint involvement in more than 90% of patients
  • Most commonly involves knee > hip > shoulder, wrist, or elbow joints
  • Presence of infection leading to bacterial seeding of joint (skin infection, pneumonia, pyelonephritis, or gonorrhea are commonly the source)
Physical Exam
  • Various degrees of pain in region of joint or bursa
  • Swelling
  • Decreased range of joint motion
  • Erythema overlying joint or bursa
  • Localized or systemic fever
  • Possible associated skin lesions (petechial or pustular rash, Kaposi sarcoma)
  • Concomitant urethral discharge
  • Erythema and tenderness to palpation of affected joint or bursa
  • Joint effusion
  • Decreased range of motion (usually secondary to pain or effusion/swelling)
  • Local warmth or generalized fever
  • Cutaneous lesions (Lyme disease, meningococcal infection, gonorrhea)
Diagnostic Tests & Interpretation
Lab
  • Laboratory evaluation of joint or bursal aspirate is essential for diagnosis.
  • Laboratory specimens should be collected prior to antibiotic administration.
  • CBC, blood cultures, erythrocyte sedimentation rate, C-reactive protein
  • Prompt collection of joint or bursal aspirate if clinical suspicion of infectious process
  • Contaminated overlying tissue (ie, cellulitis) should be avoided during arthrocentesis or bursal aspiration.
  • Synovial or bursal fluid aspirate should be sent for Gram stain and examination for crystals, chemistry (lactate dehydrogenase, protein, and glucose), and culture.
  • In acute septic arthritis, synovial WBC counts typically average 100,000 WBC/mL with >90% neutrophils.
Imaging
  • Plain radiographs may show soft tissue swelling, joint space widening, or displacement, radiolucent areas indicating presence of gas, erosions, or joint space loss.
  • US is useful for identifying hip effusions.
  • CT scan and MRI are useful for evaluation of sacroiliac joint and vertebral joints.
  • Bone scan is indicated for identification of region affected by inflammatory process.
Differential Diagnosis
  • Cellulitis
  • Osteomyelitis
  • Gout
  • Pseudogout (calcium pyrophosphate deposition disease)
  • Rheumatoid arthritis
  • Juvenile rheumatoid arthritis
  • Rheumatic fever
  • Lyme disease
  • Spondyloarthropathy (Reiter syndrome, psoriatic arthritis, ankylosing spondylitis, irritable bowel disease)
  • Sarcoidosis
  • Synovitis
  • Synovial papilloma
  • AIDS

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Treatment
  • Septic bursitis:
    • Most common organisms include Staphylococcus aureus, β-hemolytic Streptococcus, and Staphylococcus epidermidis. Rarely mycobacterial infection is identified.
    • Potential exists for overwhelming sepsis or extension of infection into the adjacent joint.
    • Primary therapy includes penicillinase-resistant penicillins (nafcillin or dicloxacillin) or 1st-generation cephalosporins.
    • Therapy should be continued for a minimum of 2–3 wks.
    • Hospitalization for parenteral therapy is required when signs of systemic or bony extension of infection are observed.
  • Septic arthritis:
    • Usually requires hospitalization for parenteral antibiotics
    • Owing to potential for rapid joint destruction, treat with broad-spectrum antibiotics while culture results are pending.
    • Choice of broad-spectrum antibiotic coverage is based on Gram stain result.
    • If Gram stain shows gram-positive cocci, treat with a 1st-generation cephalosporin such as cefazolin.
    • If Gram stain shows gram-negative bacilli, treat with a 3rd-generation cephalosporin such as ceftriaxone, and add an aminoglycoside such as gentamicin if Pseudomonas is suspected.
    • Infection eradication is complicated by the presence of joint prostheses, and removal of the prosthesis may be necessary.
    • No indication for intraarticular antibiotics
    • Antibiotics are to be continued for 1–2 wks after resolution of symptoms.
    • Patients treated for gonorrhea also should receive doxycycline 100 mg PO b.i.d. × 7 days to cover possible concurrent Chlamydia infection.
    • Longer treatment is required for joints affected by arthritis.
    • Surgical intervention via arthroscopic lavage or arthrotomy is indicated only if needle drainage is ineffective (fluid loculation or inaccessible joint).
Ongoing Care
  • Complete resolution and restoration of joint function is the goal.
  • Possible adverse outcomes include death, impaired joint function (eg, decreased motion, fusion, dislocation), septic necrosis, sinus formation, ankylosis, osteomyelitis, synovitis, and limb-length changes.
Follow-Up Recommendations
  • Recurrent arthrocentesis is recommended as joint fluid reaccumulates to rule out persistent/recurrent infection.
  • Regular office visits are recommended after hospital discharge for revaluation and early recognition of persistent or new problems.
  • Prosthesis replacement is possible in the future after clearance of infection.
Additional Reading
Dambro MR, Rothschild BM. Griffith's 5-minute clinical consult. Philadelphia: Lippincott Williams & Wilkins, 1999.
García-De La Torre I. Advances in the management of septic arthritis. Infect Dis Clin North Am. 2006;20:773–788.
Gilbert DN, Moellering RC Jr, Sande MA. The Sanford guide to antimicrobial therapy. Hyde Park, NY: Antimicrobial Therapy, Inc., 2000.
Goldman L, Ausiello D (eds). Cecil Medicine, 23rd Ed. Philadelphia: Saunders Elsevier, 2008.
Pioro MH, Mandell BF. Septic arthritis. Rheum Dis Clin North Am. 1997;23:239–258.
Stell IM, Gransden WR. Simple tests for septic bursitis. BMJ. 1998;316:187–189.
Thaler SJ, Maguire JH. Harrison's principles of internal medicine. 14th ed. New York: McGraw-Hill, 1998.
Codes
ICD9
  • 711.00 Pyogenic arthritis, site unspecified
  • 711.01 Pyogenic arthritis involving shoulder region
  • 711.02 Pyogenic arthritis involving upper arm
Clinical Pearls
  • Septic arthritis is considered an emergency, and prompt drainage and administration of IV antibiotics can prevent joint damage.
  • If joint cannot be drained, do not simply treat with antibiotics; immediately consult orthopedic surgery or other service for drainage and/or further management.
  • Complete restoration of joint function is expected if early diagnosis and treatment occur before articular damage is seen.
  • Prophylaxis may be indicated in certain conditions.
  • Protection from sexually transmitted diseases should be discussed with all high-risk patients.
  • Sign of hip infection, more common in children, is hip held in flexed and externally rotated position.


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