Septic arthritis associated with systemic sepsis

Bone and joint infection complicated with sepsis in neonates and infants under three months of age

OBJECTIVE

Studies focusing on bone and joint infections (BJIs) in young infants are rare. Some cases of BJI are accompanied by sepsis. This study aimed to identify the clinical and bacteriological features of sepsis in neonates and young infants with BJIs.

METHODS

Neonates and infants younger than 3 months diagnosed with BJI in the present institution from 2014 to 2021 were retrospectively reviewed. Patient characteristics, clinical data, and outcomes were documented and compared between those with and without sepsis.

RESULTS

Twenty-five patients with a mean age of 34.8 days were included. Nine BJI cases had concomitant sepsis (group A), and 16 had BJI without sepsis (group B). Within group A, staphylococcus aureus was the major pathogenic germ (5 cases, of which 4 were of the methicillin-resistant staphylococcus aureus (MRSA) type). There was no statistical difference in male-to-female ratio, age, history of hospitalization, anemia, birth asphyxia, peripheral leukocyte counts, C-reactive protein on admission, and sequelae between groups. Univariate analyses indicated a significant difference in the incidence of septic arthritis (SA) combined with osteomyelitis (OM) (88.9% vs 37.5%), congenital deformities (44.4% vs 0%), and mean duration of symptoms (2.83 days vs 9.21 days) in comparisons between groups A and B.

CONCLUSION

Staphylococcus aureus is the main pathogenic bacteria in BJI cases complicated with sepsis in neonates and young infants. Among infants younger than 3 months diagnosed with BJI, those with concurrent SA and OM, MRSA infection, or congenital deformities are more likely to develop sepsis.

Multicenter evaluation of the BIOFIRE Joint Infection Panel for the detection of bacteria, yeast, and AMR genes in synovial fluid samples

The bioMérieux BIOFIRE Joint Infection (JI) Panel is a multiplex in vitro diagnostic test for the simultaneous and rapid (~1 h) detection of 39 potential pathogens and antimicrobial resistance (AMR) genes directly from synovial fluid (SF) samples. Thirty-one species or groups of microorganisms are included in the kit, as well as several AMR genes. This study, performed to evaluate the BIOFIRE JI Panel for regulatory clearance, provides data from a multicenter evaluation of 1,544 prospectively collected residual SF samples with performance compared to standard-of-care (SOC) culture for organisms or polymerase chain reaction (PCR) and sequencing for AMR genes. The BIOFIRE JI Panel demonstrated a sensitivity of 90.9% or greater for all but six organisms and a positive percent agreement (PPA) of 100% for all AMR genes. The BIOFIRE JI Panel demonstrated a specificity of 98.5% or greater for detection of all organisms and a negative percent agreement (NPA) of 95.7% or greater for all AMR genes. The BIOFIRE JI Panel provides an improvement over SOC culture, with a substantially shorter time to result for both organisms and AMR genes with excellent sensitivity/PPA and specificity/NPA, and is anticipated to provide timely and actionable diagnostic information for joint infections in a variety of clinical scenarios.

Failure rates in surgical treatment in adults with bacterial arthritis of a native joint: a systematic review of 8,586 native joints

INTRODUCTION

Most adult cases of bacterial-septic-arthritis of a native joint are effectively managed with a single surgical debridement, but some cases may require more than one debridement to control the infection. Consequently, this study assessed the failure rate of a single surgical debridement in adults with bacterial arthritis of a native joint. Additionally, risk factors for failure were assessed.

MATERIALS AND METHODS

The review protocol was registered on PROSPERO (CRD42021243460) before data collection and conducted in line with the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' (PRISMA) guidelines. Multiple libraries were systematically searched to identify articles including patients reporting on the incidence of failure (i.e. persistence of infection requiring reoperation) of the treatment of bacterial arthritis. The quality of individual evidence were assessed using the Quality in Prognosis Studies (QUIPS) tool. Failure rates were extracted from included studies and pooled. Risk factors for failure were extracted and grouped. Moreover, we evaluated which risk factors were significantly associated with failure.

RESULTS

Thirty studies (8,586 native joints) were included in the final analysis. The overall pooled failure rate was 26% (95% CI 20 to 32%). The failure rate of arthroscopy and arthrotomy was 26% (95% CI 19 to 34%) and 24% (95% CI 17 to 33%), respectively. Seventy-nine potential risk factors were extracted and grouped. Moderate evidence was found for one risk factor (synovial white blood cell count), and limited evidence was found for five risk factors (i.e. sepsis, large joint infection, the volume of irrigation, blood urea nitrogen-test, and blood urea nitrogen/creatinine ratio).

CONCLUSION

A single surgical debridement fails to control bacterial arthritis of a native joint in approximately a quarter of all adult cases. Limited to moderate evidence exists that risk factors associated with failure are: synovial white blood cell count, sepsis, large joint infection, and the volume of irrigation. These factors should urge physicians to be especially receptive to signs of an adverse clinical course.

An update on recent progress of the epidemiology, etiology, diagnosis, and treatment of acute septic arthritis: a review

Acute septic arthritis is on the rise among all patients. Acute septic arthritis must be extensively assessed, identified, and treated to prevent fatal consequences. Antimicrobial therapy administered intravenously has long been considered the gold standard for treating acute osteoarticular infections. According to clinical research, parenteral antibiotics for a few days, followed by oral antibiotics, are safe and effective for treating infections without complications. This article focuses on bringing physicians up-to-date on the most recent findings and discussions about the epidemiology, etiology, diagnosis, and treatment of acute septic arthritis. In recent years, the emergence of antibiotic-resistant, particularly aggressive bacterial species has highlighted the need for more research to enhance treatment approaches and develop innovative diagnosis methods and drugs that might combat better in all patients. This article aims to furnish radiologists, orthopaedic surgeons, and other medical practitioners with contemporary insights on the subject matter and foster collaborative efforts to improve patient outcomes. This review represents the initial comprehensive update encompassing patients across all age groups.

Raised initial total white cell count and lower post-operative decline of C reactive protein increases the risk of secondary surgery in septic arthritis of the native knee

PURPOSE

Septic arthritis is an orthopaedic emergency with high morbidity and mortality. The aim of this study is to determine the risk factors associated with secondary surgery for septic arthritis of the native knee joint.

METHODS

This is a retrospective study reviewing all patients who underwent surgery for septic arthritis of the knee from 2012 to 2019 in a single institution. A total of 117 patients were recruited. Patients were divided into 2 groups: Group I (79/117, 67.5%) underwent one surgery and Group II (38/117, 32.5%) underwent more than one surgery.

RESULTS

Patients with a raised initial total white (TW) cell count of > 20 × 10⁹/L had a significantly higher risk of secondary surgery. (Adjusted hazard ratio 2.42, p < 0.05) A decline of CRP level of less than 20% within 24 h from initial operation was also a risk for secondary surgery. (Adjusted hazard ratio 0.34, p < 0.01) Patients in group II also had significantly higher post-operative median TW cell count and neutrophil count. There was no significant difference in the offending microbe, surgical approach, and duration of operation from initial presentation between the groups.

CONCLUSIONS

Patients with septic arthritis of the native knee joint who present with raised initial total white cell count of > 20 × 10⁹/L and decline of CRP level of less than 20% within 24 h from initial operation are at higher risk of secondary operation. In these patients, more aggressive treatment strategies and appropriate counselling on the risks of repeated surgery are recommended.

LEVEL OF EVIDENCE

Level IV.

Percutaneous Kyphoplasty in Patients with Severe Osteoporotic Vertebral Compression Fracture with and without Intravertebral Cleft: A Retrospective Comparative Study

Purpose

To comparatively analyze the clinical and radiographic outcomes of percutaneous kyphoplasty (PKP) in patients with severe osteoporotic vertebral compression fracture (sOVCF) with or without intravertebral cleft (IVC).

Methods

We enrolled a total of 75 patients with sOVCF receiving PKP between January 2016 and December 2018. The patients were divided into the following two groups based on their radiographic findings: with IVC (IVC group) and without IVC (NIVC group). The following radiographic outcomes were determined: anterior vertebral height (AVH), kyphotic angle (KA), lumbar lordosis (LL), sacral slope (SS), pelvic incidence (PI), and pelvic tilt (PT). The clinical functional assessment included Oswestry disability index (ODI) and visual analog scale (VAS) scores.

Results

No significant difference was found between the demographic data of the two groups (P > 0.05). AVH, KA, and LL in both groups were significantly corrected one month after surgery (P < 0.05). There was statistical difference between the two groups in AVH and KA one year and three years after surgery, and in LL and PT three years after surgery (P < 0.05). Compared with the results one month after surgery, AVH, KA, and LL of the IVC group deteriorated significantly one year and three years after surgery, whereas AVH, KA, and LL of the NIVC group deteriorated significantly three years after surgery (P < 0.05). The VAS and ODI scores in both groups decreased significantly one month, one year, and three years after surgery than preoperative results (P < 0.05), and a statistical difference was observed between the two groups three years after surgery (P < 0.05).

Conclusion

PKP can give satisfactory outcomes for the treatment of sOVCF with or without IVC. However, the NIVC group showed better clinical outcomes and could maintain spinal sagittal balance better than the IVC group during long-term follow-up.

Optimal Synovial Fluid Leukocyte Count Cutoff for Diagnosing Native Joint Septic Arthritis After Antibiotics: A Receiver Operating Characteristic Analysis of Accuracy

INTRODUCTION

Urgent treatment of septic arthritis is key in preventing devastating morbidity or mortality. Accurate diagnosis is critical, and the standard diagnostic cutoff of 50,000 synovial leukocytes may be altered by previous administration of antibiotics. Our objective was to identify and compare a cutoff synovial leukocyte count with a high sensitivity and specificity for diagnosis of septic arthritis in patients who received antibiotics and those who had not. A receiver operating characteristic (ROC) curve was used to provide a discriminate cutoff value for diagnosing septic arthritis.

METHODS

A retrospective chart review of 383 patients was done over a 13-year period including those who had arthrocentesis of any joint. Two groups were created, those who had not been given antibiotics within 2 weeks (control) and those who received intravenous or oral antibiotics within 2 weeks before arthrocentesis. Relevant data included synovial leukocyte count and differential cell count. Additional metrics included temperature, erythrocyte sedimentation rate, and C-reactive protein. A ROC curve determined the optimal synovial white blood cell cutoff for diagnosing septic arthritis in native joints for each group.

RESULTS

The ROC curve determined that patients who received antibiotics had an optimal cutoff of >16,000 cells (sensitivity = 82%, specificity = 76%), and a neutrophil percentage cutoff of >90% (sensitivity = 73%, specificity = 74%). The control group had an optimal synovial leukocyte cutoff of >33,000 cells (sensitivity = 96%, specificity = 95%). The optimal neutrophil percentage cutoff in the control group was >83% neutrophils (sensitivity = 89%, specificity = 79%).

CONCLUSION

When a patient is given antibiotics before arthrocentesis, a diagnostic value of >16,000 synovial leukocytes should be used to guide treatment of septic arthritis. A diagnostic value of >33,000 synovial leukocytes yields the highest accuracy for diagnosis of septic arthritis in patients who have not been given antibiotics before arthrocentesis.

LEVEL OF EVIDENCE

III.

Novel therapeutic interventions towards improved management of septic arthritis

Septic arthritis (SA) represents a medical emergency that needs immediate diagnosis and urgent treatment. Despite aggressive treatment and rapid diagnosis of the causative agent, the mortality and lifelong disability, associated with septic arthritis remain high as close to 11%. Moreover, with the rise in drug resistance, the rates of failure of conventional antibiotic therapy have also increased. Among the etiological agents frequently isolated from cases of septic arthritis, Staphylococcus aureus emerges as a dominating pathogen, and to worsen, the rise in methicillin-resistant S. aureus (MRSA) isolates in bone and joint infections is worrisome. MRSA associated cases of septic arthritis exhibit higher mortality, longer hospital stay, and higher treatment failure with poorer clinical outcomes as compared to cases caused by the sensitive strain i.e methicillin-sensitive S. aureus (MSSA).

In addition to this, equal or even greater damage is imposed by the exacerbated immune response mounted by the patient’s body in a futile attempt to eradicate the bacteria. The antibiotic therapy may not be sufficient enough to control the progression of damage to the joint involved thus, adding to higher mortality and disability rates despite the prompt and timely start of treatment. This situation implies that efforts and focus towards studying/understanding new strategies for improved management of sepsis arthritis is prudent and worth exploring.

The review article aims to give a complete insight into the new therapeutic approaches studied by workers lately in this field. To the best of our knowledge studies highlighting the novel therapeutic strategies against septic arthritis are limited in the literature, although articles on pathogenic mechanism and choice of antibiotics for therapy, current treatment algorithms followed have been discussed by workers in the past. The present study presents and discusses the new alternative approaches, their mechanism of action, proof of concept, and work done so far towards their clinical success. This will surely help to enlighten the researchers with comprehensive knowledge of the new interventions that can be used as an adjunct therapy along with conventional treatment protocol for improved success rates.

Clinical features, risk factors, and outcomes of septic arthritis in patients on maintenance hemodialysis

The aim of this study was to investigate the clinical features, risk factors, and outcomes of septic arthritis in patients on maintenance hemodialysis (HD). We systematically reviewed medical records of 16 HD patients with septic arthritis admitted to our hospital from April 2008 to April 2018. A total of 16 HD in patients with bloodstream infection but without septic arthritis were randomly selected as controls. The incidence of septic arthritis in our patient group was 0.2% per year. Organisms isolated were Staphylococcus aureus in 11 (68.7%), Gram-negative bacilli in 3, streptococci in 1, and fungi in 1. Patients with septic arthritis were significantly older (72.7 ± 9.4 vs 63.5 ± 8.7 years, p = 0.035) and had more joint diseases (62.5% vs 12.5%, p = 0.003) and a longer duration of hospitalization (35.2 ± 5.7 vs 22.1 ± 3.5 days, p = 0.021) than the control group. In a logistic regression analysis, patients with older age and more joint diseases were more likely to have septic arthritis compared with controls (OR = 1.39, p = 0.024 and OR = 3.24, p = 0.003, respectively). These findings indicate that old age and joint diseases (osteoarthritis or inflammatory arthritis) were independent risk factors for septic arthritis in patients on HD when bloodstream infection occurred. Key Points • Patients with septic arthritis were significantly older and had more joint diseases than the control group. • Old age and joint diseases are independent risk factors for septic arthritis in patients on HD when bloodstream infection occurs.

Surgical Options and Approaches for Septic Arthritis of the Native Hip and Knee Joint

Septic arthritis (SA) of the adult knee and hip is a constantly evolving and urgent surgical issue. The epidemiology has shifted over the last few decades as have the most popular antibiotics and surgical treatments. SA of all types is increasing in the United States. There remains a high variability in the conservative and surgical management options available. This review will outline the most current understanding of the etiology and epidemiology of SA and will also discuss the distribution of causative organisms and appropriate treatments for each. A summary of evidence for different debridement and reconstructive techniques will also be presented in addition to novel areas of research to decrease the morbidity of this constantly growing problem.

Mycobacterium abscessus Prosthetic Joint Infections of the Knee

M. abscessus complex prosthetic joint infections (PJI) of the knee are rare. We present a patient with an M. abscessus subsp. massiliense, a nontuberculous mycobacterium (NTM), peri-prosthetic knee infection who presented with wound drainage followed by sepsis. The published peer-reviewed literature on knee PJIs due to this organism is reviewed to highlight its clinical presentation,symptomatology, microbiology, surgical interventions, antimicrobial regimens, and outcomes.