Septic Arthritis and Bursitis

By admin On Oct 29, 2023

Ovid: 5-Minute Sports Medicine Consult, The

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

P.529

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.