Non-gonococcal infectious arthritis: a retrospective study

The impact of gender on the clinical presentation, management, and surgical outcomes of patients with native-joint septic arthritis

RATIONALE, AIMS AND OBJECTIVES

Approximately 20 000 cases of septic arthritis (SA) occur in the U.S. yearly. We examined whether gender-related differences exist in the presentation, management, and outcomes of patients with native joint septic arthritis (NJSA).

METHODS

This was a retrospective study of medical files of patients aged 18 years and older admitted between 1998 and 2015 to a single tertiary care hospital and diagnosed with NJSA. All study subjects had positive synovial fluid or blood cultures and each was managed surgically. Patients' charts were reviewed for demographics, comorbidities, clinical presentations, microbiology profiles, management, and outcomes. Cases of osteomyelitis, septic bursitis, prosthetic joint, and culture-negative SA were excluded.

RESULTS

Of 324 NJSA patients, those who were female (n = 130; 40.1%) were significantly older at presentation than males (mean age: 63.6 vs 58.3; P = .006). Prior joint pathology was more common amongst females, including osteoarthritis (20.8% vs 12.9%; P = .04) and rheumatoid arthritis (10% vs 3.6%; P = .03). Female patients had a higher frequency of hip involvement (17.7% vs 10.8%; P = .05). No differences were observed in clinical presentations, culture results, medical management, or outcomes between genders.

CONCLUSIONS

Compared to men, women with NJSA presented at an older age and had more prior joint pathology and a higher frequency of hip involvement. These differences, however, had no significant impact on the clinical presentation, medical management, or outcomes of NJSA.

Septic arthritis due to Neisseria gonorrhoea in Western Australia

OBJECTIVE

To investigate the frequency, risk factors and long-term outcome of gonococcal arthritis in Western Australia (WA).

METHODS

A population-based data linkage study of patients with a hospital-based diagnosis of gonococcal arthritis (GA) in WA between 1990-2014. Demographics, standardised incidence rates (IR) per million and comorbidity accrued before (lookback 186 months ,IQR 86-267) and after the index hospital contact for GA (follow-up 100 months, IQR 60-209). are presented as frequency (%), median (interquartile range) or rates /1,000 months.

RESULTS

In total 98 patients were diagnosed with GA. The annual incidence of GA increased from 1.35 to 2.10 per million between 1990 and 2014, but the rate of GA complicating all gonococcal infections was stable around 0.25%. Female patients with GA (54%, n=53/98) were younger (24 vs 38 years), and more frequently identified as Indigenous (88% vs 49%) than male patients (46%, n=45/98) (p=0.002). Female patients had higher rates of prior infections (15.5 vs 8.1 per 1,000 months, p=0.002) and diabetes mellitus (15.9% vs 2.5%, p=0.03) and a longer hospital stay (10 vs 8 days, p=0.02). GA recurrence rate during follow-up was low (2%), but a broad range of comorbidities developed contributing to a 14% crude death rate.

CONCLUSIONS

GA stably complicates 0.25% of gonococcal infections in WA with young Indigenous females and middle-aged non-Indigenous males most affected. Prior infectious disease and diabetes mellitus are potential risk factors for GA in females. GA recurs rarely, but its development reflects a high risk of morbidity and mortality over the following ten years. This article is protected by copyright. All rights reserved.

Retrospective Analysis of Septic Arthritis Caused by Intra-Articular Viscosupplementation and Steroid Injections in a Single Outpatient Center

Background

Septic arthritis is defined by the presence of pathogen(s) in a joint by direct inoculation or hematogenous spread. Most common organisms include Staphylococcus aureus and Escherichia coli. Clinical presentation is fever, warmth and night pain, with most common joints involved being the knee and hip. Iatrogenic septic arthritis is an uncommon complication of intra-articular injection for osteoarthritis yet its complications can be devastating. We aim to highlight ten cases of iatrogenic septic arthritis in retrospective study reviewing symptoms, signs, laboratory data, causing organisms and reasons leading to those infections.

Methods

Retrospective analysis of charts of ten patients who were admitted to Jersey Shore University Medical Center with diagnosis of iatrogenic septic arthritis.

Results

Average age of patients is 69.9 years. Most common comorbidities seen in our patient were hypertension and diabetes mellitus. The most common intra-articular agents that were injected were cortisone and Synvisc. The mean incubation period was 11.9 days. Most common presenting symptoms were joint pain and swelling. The most common organism isolated in cultures was Streptococcus mitis. A total of 100% of patients underwent surgical intervention for septic arthritis. One case was complicated by sepsis.

Conclusions

Iatrogenic septic arthritis is not common; however its complications can be catastrophic to patients. Improper sterile techniques and untrained physicians are the main risks factors for this complication. Physicians should take proper sterile measures to avoid complications of intra-articular injections.

Subtalar joint septic arthritis in a patient with hypogammaglobulinemia

The clinical presentation of a monoarticular, red, hot, and swollen joint has many possible diagnoses, including septic arthritis, which is 1 of the most devastating. The morbidity associated with this pathologic process involves permanent joint damage and the potential for progression to systemic illness and, even, mortality. The common risk factors for joint sepsis include a history of rheumatoid arthritis, previous joint surgery, joint prosthesis, intravenous drug abuse, alcoholism, diabetes, previous intra-articular steroid use, and cutaneous ulceration. The diagnosis is primarily determined from the culture results after arthrocentesis and correlation with direct visualization, imaging, and various serologies, including synovial analysis. In the present report, a case of an insidious presentation of subtalar joint septic arthritis and its association with a unique patient presentation concomitant with primary immunodeficiency and culture-proven Myocplasma hominis infection is discussed. Septic arthritis has a predilection for the lower extremities and typically is isolated to the hip or knee, with less common involvement of the ankle or metatarsophalangeal joints. Owing to the uncommon nature of primary immunodeficiency disorders and the paucity of studies discussing their association with septic arthridites, we aimed to raise awareness of subtalar joint septic arthritis and to provide a brief overview of the pathogenesis as it presented in a 33-year-old male with X-linked hypogammaglobulinemia/agammaglobulinema.

Streptococcus gordonii septic arthritis: two cases and review of literature

Background

Despite advances in antimicrobial and surgical therapy, septic arthritis remains a rheumatologic emergency that can lead to rapid joint destruction and irreversible loss of function. In adults, Staphylococcus aureus is the most common microorganism isolated from native joints. Streptococcus gordonii is a prominent member of the viridans group of oral bacteria and is among the bacteria most frequently identified as being primary agent of subacute bacterial endocarditis. To the best of our knowledge, Streptococcus gordonii has not yet been described as agent of septic arthritis.

Case Presentation

We describe here two cases of septic arthritis due to Streptococcus gordonii. It gives us an opportunity to review epidemiology, diagnosis criteria and management of septic arthritis.

Conclusion

Although implication of S. gordonii as aetiologic agent of subacute endocarditis is well known, this organism is a rare cause of septic arthritis. In this case, the exclusion of associated endocarditis is warranted.

Time delay between diagnosis and arthroscopic lavage in septic arthritis. Does it matter?

PURPOSE

Septic arthritis is a life-threatening emergency with high mortality of up to 11 %. We investigated if delay of arthroscopic lavage of infected major joints would have a bearing on the mortality and morbidity such as admission to an intensive care unit (ICU).

METHODS

We retrospectively reviewed patients presenting with septic arthritis to two regional hospitals over a period of seven years from 1 January 2005 to 31 December 2011. We divided our sample of 82 patients into four groups based on the time delay between clinical diagnosis and arthroscopic lavage ranging from less than six hours to more than 24 hours.

RESULTS

We determined that 35.4 % of patients had prosthetic joints. Knee joints were predominantly involved (74.4 %). Staphylococcus aureus was the most commonly isolated pathogen (41.5 %). There were ten (12.2 %) deaths and the same number of admissions to an ICU. Our study revealed there was no statistical significance between the time delay and mortality (P = 0.25) or ICU admission (P = 0.74) or the number of washouts (P = 0.08) in all four groups.

CONCLUSIONS

Up to 48 hours delayed arthroscopic lavage for septic arthritis does not increase the risk of mortality. Further prospective large sample studies are recommended to investigate this and the risk of long-term morbidity.

Polyarticular Septic Arthritis with Bilateral Psoas Abscesses following Acupuncture

We report a case of polyarticular septic arthritis with bilateral psoas abscesses. A 50-year-old woman was admitted with fever, multiple joint swelling and pain. She had a clinical history of acupuncture therapy for treatment of her chronic lower back pain two days before the appearance of her symptoms. Methicillin-sensitive Staphylococcus aureus was isolated from blood culture, knee joint fluids and psoas abscess. After a long course of antibiotics for 70 days together with drainage of the abscess, the condition completely resolved. The acupuncture is the probable cause of the infection, and this case report reveals the importance of asking about a clinical history of acupuncture treatment and of making repeated bacterial examinations in undiagnosed polyarthritis patients.

Management of septic arthritis: a systematic review

OBJECTIVE

To evaluate the existing evidence on the diagnosis and management of septic arthritis in native joints.

DESIGN

Systematic review.

DATA SOURCES

Cochrane Library, Medline, Embase, National Electronic Library for Health, reference lists, national experts.

REVIEW METHODS

Systematic review of the literature with evaluation of the methodological quality of the selected papers using defined criteria set out by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians.

RESULTS

3291 citations were initially identified. Of these, 189 full text articles were identified for potential selection. Following review of these full text articles, 80 articles were found to fulfil the inclusion criteria and were included in the final list.

CONCLUSIONS

were drawn on the diagnosis, investigation and management of septic arthritis.

DISCUSSION

Little good quality evidence exists to guide the diagnosis and management of septic arthritis. Overall, no investigation is more reliable in the diagnosis of septic arthritis than the opinion of an experienced doctor. Aspiration and culture of synovial fluid is crucial to the diagnosis, but measurement of cell count is unhelpful. Antibiotics are clearly required for a prolonged period, but there are no data to indicate by which route or for how long. Key unanswered questions remain surrounding the medical and surgical management of the infected joint.

Septic arthritis in patients with systemic lupus erythematosus: salmonella and nonsalmonella infections compared

OBJECTIVES

To assess the clinical characteristics and outcome of systemic lupus erythematosus (SLE) with septic arthritis.

METHODS

In this 20-year retrospective study, we reviewed the charts of SLE patients with septic arthritis confirmed by synovial fluid analysis and culture. To identify risk factors for septic arthritis, data of SLE patients with septic arthritis were compared with data of 100 hospitalized SLE patients without septic arthritis.

RESULTS

There were 10,732 inpatient records of 3,127 SLE patients; 29 SLE patients had septic arthritis. Their ages ranged from 14 to 68 years (mean, 35.1 +/- 14.1 years). The mean SLE duration before septic arthritis onset was 30.6 months. All patients received corticosteroids; 93% had active disease (SLEDAI > or = 4). Compared with controls, avascular necrosis (AVN) of the femoral head was the most common predisposing articular disease (Odds ratio, 3.799;CI, 1.59 to 9.05). Of the 29 patients, 17 (59%) had salmonella infections and 12 (41%) had other infections. Salmonella-infected patients were younger (28.7 +/- 10.4 years) than those with nonsalmonella infections (44.1 +/- 14.0 years; P = 0.002). The hip was the most commonly affected joint, especially in the salmonella group, followed by the knees and ankles. Salmonella-infected patients were more prone to oligo-articular septic arthritis. The overall mortality rate was 10%.

CONCLUSIONS

Salmonella enteritidis B is the most common pathogen causing septic arthritis in younger SLE patients. Septic arthritis tended to be oligo-articular and involve the hip joint. AVN of the femoral head was the most common predisposing articular disease. Once septic arthritis is suspected, culture specimens should be collected and appropriate antibiotics given immediately.

Acute hot joint

The acute hot joint has a broad differential diagnosis. It presents to a wide spectrum of practitioners in primary and secondary care, many of whom may be unfamiliar with the management of musculoskeletal disease. This review discusses the most serious cause of the hot joint, sepsis, and discusses the other less worrying, but more frequent, diagnoses.

Infections of the Skeletal System

Infections of the skeletal system are caused by a variety of organisms and generally occur through two routes, direct inoculation or hematogenous spread. Treatment requires long-term antimicrobial therapy with or without surgery to remove devitalized bone, inflammatory debris, foreign material, and necrotic tissue. This article reviews the causative agents,common diagnostics, and nuances of antimicrobial therapy commonly used to treat infection. It also reviews the major classifications of skeletal infections (hematogenous bone infections, bone infection from exogenous sources, and septic arthritis), with details covering pathophysiology,clinical presentation, treatment, and prognosis.

Streptococcal septic arthritis in adults. A study of 55 cases with a literature review

OBJECTIVES

To evaluate the rate of occurrence and characteristics of streptococcal septic arthritis.

METHODS

Retrospective single-center study of patients with bacteriologically documented septic arthritis admitted to a rheumatology department over a 20-year period.

RESULTS

Of 303 cases of septic arthritis, 55 (18%) were due to streptococci and 166 (55%) to Staphylococcus aureus (55%). As compared to patients with S. aureus arthritis, patients with streptococcal arthritis was more likely to be in female (56% vs. 36%, P < 0.006) and older than 60 years of age (71% vs. 58%), less likely to have comorbidities (36% vs. 56%), rheumatoid arthritis (5% vs. 19%, P < 0.01), or diabetes (2% vs. 15%, P < 0.01), and more likely to have cancer (13% vs. 7%). Involved joints and proportions of patients with arthritis in multiple joints were similar in two groups. Mortality was lower in the group with streptococcal infection (3.6% vs. 7.8%). The streptococci were distributed as follows: group A (n = 7), group B (n = 12), group C (n = 4), group D (n = 7), group F (n = 1), group G (n = 2), nongroupable (n = 14), nontypable (n = 1), and Streptococcus pneumoniae (n = 7). Groups A and B and nongroupable strains mainly affected women; group A selectively involved younger patients and group B very elderly patients. Comorbidity, most notably cancer, was common in patients with S. pneumoniae or group D streptococci. The portal of entry was often a skin lesion for groups A and B and a medical procedure for group D. Multiple joint involvement was common with groups A and B and prosthetic joint infection with groups B and C. Group A and S. pneumoniae were associated with severe systemic symptoms and extra articular foci of infection, whereas a smoldering course was more common with groups D and G and with nongroupable strains. Residual joint abnormalities were noted in half the patients, with no differences across groups.

CONCLUSIONS

The features of streptococcal septic arthritis vary according to the group of the causative organism and differ from those of S. aureus arthritis.

Cost-effectiveness of antibiotic prophylaxis for bacterial arthritis

The outcome of bacterial arthritis is generally poor: the mortality is 10 - 15% and there is loss of joint function in 25 - 50% of the survivors. The incidence of bacterial arthritis is low: 2 - 6 cases per 100,000 people per year. Risk factors are age, joint disease (especially rheumatoid arthritis [RA]), diabetes mellitus and the presence of a prosthetic joint. The predominant situations that can lead to bacterial arthritis are skin infections of the feet and rarely invasive medical or dental procedures. Due to the severity of the disease, antibiotic prophylaxis of haematogenous bacterial arthritis in patients with prosthetic joints is advocated. However, due to the rarity of the disease it is unclear whether the advantages of prophylaxis outweigh the disadvantages of the large-scale use of antibiotics, such as side effects, costs and bacterial resistance. In a decision-analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be cost-effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients. On the other hand, prophylaxis around medical or dental procedures was not cost-effective, except possibly in a small group of patients with increased risk.

Antibiotic prophylaxis for haematogenous bacterial arthritis in patients with joint disease: a cost effectiveness analysis

OBJECTIVE

To assess the cost effectiveness of antibiotic prophylaxis for haematogenous bacterial arthritis in patients with joint disease.

METHODS

In a decision analysis, data from a prospective study on bacterial arthritis in 4907 patients with joint disease were combined with literature data to assess risks and benefits of antibiotic prophylaxis. Effectiveness and cost effectiveness calculations were performed on antibiotic prophylaxis for various patient groups. Grouping was based on (a) type of event leading to transient bacteraemia-that is, infections (dermal, respiratory/urinary tract) and invasive medical procedures-and (b) the patient's susceptibility to bacterial arthritis which was increased in the presence of rheumatoid arthritis, large joint prostheses, comorbidity, and old age.

RESULTS

Of the patients with joint disease, 59% had no characteristics that increased susceptibility to bacterial arthritis, and 31% had one. For dermal infections, the effectiveness of antibiotic prophylaxis was maximally 35 quality adjusted life days (QALDs) and the cost effectiveness maximally $52 000 per quality adjusted life year (QALY). For other infections, the effectiveness of prophylaxis was lower and the cost effectiveness higher. Prophylaxis for invasive medical procedures seemed to be acceptable only in patients with high susceptibility: 1 QALD at a cost of $1300/QALY; however, the results were influenced substantially when the level of efficacy of the prophylaxis or cost of prophylactic antibiotics was changed.

CONCLUSION

Prophylaxis seems to be indicated only for dermal infections, and for infections of the urinary and respiratory tract in patients with increased susceptibility to bacterial arthritis. Prophylaxis for invasive medical procedures, such as dental treatment, may only be indicated for patients with joint disease who are highly susceptible.

Role of IL-12 in Staphylococcus aureus-triggered arthritis and sepsis

The present study demonstrates that endogenous production of IL-12 is crucial for survival in Staphylococcus aureus-induced arthritis in mice. Staphylococcal load is enhanced in several organs, because of lack of IL-12. This might be due to decreased production of IFN-gamma in IL-12-deficient mice. Although IL-12-deficient mice were exposed to higher staphylococcal load, they demonstrated no increased severity of arthritis as compared with control animals.

Magnetic resonance imaging of septic arthritis

Septic arthritis is a disabling and life-threatening disease that requires early diagnosis for optimal outcome. Although traditionally a clinical and laboratory diagnosis, some patients may be misdiagnosed and referred for magnetic resonance (MR) imaging. Therefore, radiologists need to be aware of the MR imaging findings of septic arthritis, its complications, and diagnostic pitfalls.

Septic arthritis due to Streptococcus pneumoniae in Nottingham, United Kingdom, 1985-1998

Pneumonia and meningitis are the 2 most frequent manifestations of Streptococcus neumoniae infection. Pneumococcal septic arthritis is considered to be relatively uncommon. Between 1985 and 1998, 32 (8. 2%) of 389 cases of septic arthritis seen in the 2 hospitals in Nottingham, United Kingdom, were due to S. pneumoniae. Six of 7 children with pneumococcal septic arthritis were aged <2 years. Of the 25 adults, 20 (80%) were aged >60 years, 11 (44%) had concomitant pneumococcal infection elsewhere, and 23 (92%) had articular or nonarticular diseases and/or other risk factors. In the elderly, a lack of febrile response was striking. S. pneumoniae was isolated from blood and joint cultures in >70% of cases, and gram-positive diplococci were seen in the joint fluids of 90% of patients. The mean duration of antimicrobial therapy for adults was twice as long as that for children. Eight (32%) of the adults died.

TNF/Lymphotoxin-α Double-Mutant Mice Resist Septic Arthritis but Display Increased Mortality in Response to Staphylococcus aureus

To evaluate the importance of the proinflammatory cytokines TNF and lymphotoxin-α (LTα) in an experimental model of Staphylococcus aureus sepsis and arthritis, we used TNF/LTα-double-deficient mice raised on the C57BL/6 background. Mice were i.v. inoculated with a toxic shock syndrome toxin-1 (TSST-1)-producing S. aureus strain, LS-1. Intravenous inoculation of a high dose of bacteria (1 × 107/mouse) resulted in 67% mortality in TNF/LTα-deficient mice, whereas none of the controls died (p = 0.009). Those results correlated to a significantly decreased phagocytosis in vitro and inefficient bacterial clearance in vivo in mice lacking capacity to produce TNF/LTα. Thus, at day 6 after inoculation, S. aureus could not be found in the bloodstream of controls, but bacteremia developed in all TNF/LTα-deficient mice examined (p = 0.02). Interestingly, upon infection with a lower dose of staphylococci (3 × 106/mouse) the mortality was overall low, but the frequency of arthritis was clearly higher in the wild-type group as compared with the TNF/LTα-deficient mice (40% vs 13%). Histopathologic examination revealed a lower frequency of synovitis (38% vs 90%, p &lt; 0.05) and erosivity (25% vs 60%, NS) in TNF/LTα-deficient mice as compared with wild-type counterparts. Our results show the importance of TNF/LTα in defense against systemic S. aureus infections and point out the detrimental role of these cytokines as mediators of inflammatory response in S. aureus arthritis.

Occurrence of HLA-B27 tissue antigen in patients with purulent arthritis caused by Staphylococcus aureus or beta-haemolytic streptococci

The HLA-B27 tissue antigen is associated with reactive arthritis caused by different bacterial infections but its occurrence in purulent arthritis has not been studied earlier. We analysed the frequency of HLA-B27 in patients with culture proven purulent arthritis caused by Staphylococcus aureus or beta-haemolytic streptococci. The study included 41 patients treated during the years 1979-96 (15 female and 26 male) with a mean age of 52 years (range 16-80 years). HLA-B27 was found in 24% (9/37) of the tested patients compared with 14% in the healthy Finnish population, but the difference was not statistically significant (P < 0.50). No statistical difference in disease activity according to febrile days or duration of the disease could be found between HLA-B27 positive and negative patients. We conclude that HLA-B27 is not a risk factor for purulent arthritis, and when present it has no significant modifying effect on the clinical picture of purulent arthritis.

Staphylococcus aureus-Induced Septic Arthritis and Septic Death Is Decreased in IL-4-Deficient Mice: Role of IL-4 as Promoter for Bacterial Growth

Lack of IL-4 has been shown to be protective in some experimental models of infectious diseases in mice such as cutaneous leishmaniasis. At the same time IL-4, together with other Th2 cytokines, including IL-10 and IL-13, is known as an anti-inflammatory cytokine with the potential to down-regulate proinflammatory cytokine production. To investigate the role of IL-4 in experimental Staphylococcus aureus-induced and T lymphocyte-mediated arthritis, IL-4-deficient C57BL/6 mice (IL-4−/−) and their congenic controls (IL-4+/+) were inoculated with a toxic shock syndrome toxin-1-producing S. aureus strain. In IL-4+/+ mice, arthritis peaked 14 days after bacterial inoculation, whereas, at that time, IL-4−/− mice displayed significantly less frequent (p &lt; 0.05) joint inflammation. Paralleling lower frequency of arthritis, IL-4-deficient mice showed a decreased bacterial burden in joints (p = 0.014) and kidneys (p = 0.029), as well as lower infection-triggered weight decrease and mortality. In vitro, IL-4 inhibited intracellular killing of S. aureus in infected macrophages, without affecting phagocytosis. This finding may explain the enhanced staphylococcal clearance observed in IL-4−/− mice in vivo. Our results suggest that IL-4 and IL-4-dependent Th2 responses promote septic arthritis and sepsis-related mortality by inhibition of bacterial clearance during S. aureus infection.

Incidence and sources of native and prosthetic joint infection: a community based prospective survey

OBJECTIVES

To determine the incidence and sources of bacterial arthritis in the Amsterdam health district and the maximum percentage of cases that theoretically would be preventable.

METHODS

Patients with bacterial arthritis diagnosed between 1 October 1990 and 1 October 1993 were prospectively reported to the study centre by all 12 hospitals serving the district. Data were gathered on previous health status, source of infection, and microorganisms involved.

RESULTS

188 episodes of bacterial arthritis were found in 186 patients. Most of the 38 children were previously healthy. Fifty per cent of the adults were 65 years or older. Of the adults 84% had an underlying disease, in 59% a joint disorder. Joint surgery constituted the largest part of direct infections (33%) and skin defects were the most important source of haematogenous infections (67%). Infection of joints containing prosthetic or osteosynthetic material by a known haematogenous source occurred 15 times (8%). Staphylococcus aureus was the causative organism in 44% of all positive cultures.

CONCLUSION

The incidence of bacterial arthritis was 5.7 per 100,000 inhabitants per year. Preventive measures directed to patients with prosthetic joints or osteosynthetic material, and a known haematogenous source would have prevented at most 8% of all cases.

The outcome of bacterial arthritis: a prospective community-based study

OBJECTIVE

To assess the outcome and adverse prognostic factors of bacterial arthritis (BA).

METHODS

In a prospective community survey of BA, data were collected at the time of diagnosis and at a mean of 2 years later. A poor patient outcome was defined as death due to BA or severe overall functional deterioration. A poor joint outcome was defined as amputation, arthrodesis, prosthetic surgery, or severe functional deterioration. Possible prognostic factors were analyzed by univariate analysis.

RESULTS

BA was diagnosed in 154 patients, 121 adults and 33 children. One-half of the adults had a preexisting joint disease and 29% of the infected joints contained synthetic material. The patient outcome was poor in 21% of all patients, and the joint outcome was poor in 33% of the surviving patients. Adverse prognostic factors were an older age, preexisting joint disease, and an infected joint containing synthetic material. These factors were interrelated. There was no association between a poor outcome and young age, comorbidity, immunosuppressive medication, functional class, multiple infected joints, type of microorganism, or treatment delay.

CONCLUSION

BA had a poor outcome in almost one-half of the patients. Patients who were older, had a preexisting joint disease, and/or had an infected joint containing synthetic material had the poorest prognosis.

An 18 year clinical review of septic arthritis from tropical Australia

A retrospective study of 191 cases of septic arthritis was undertaken at Royal Darwin Hospital in the tropical north of Australia. Incidence was 9.2 per 100,000 overall and 29.1 per 100,000 in Aboriginal Australians (RR 6.6; 95% CI 5.0-8.9). Males were affected more than females (RR 1.6; 95% CI 1.2-2.1). There was no previous joint disease or medical illness in 54%. The commonest joints involved were the knee (54%) and hip (13%). Significant age associations were infected hips in those under 15 years and infected knees in those over 45 years. Seventy two percent of infections were haematogenous. Causative organisms included Staphylococcus aureus (37%), Streptococcus pyogenes (16%) and Neisseria gonorrhoeae (12%). Unusual infections included three melioidosis cases. Polyarthritis occurred in 17%, with N. gonorrhoeae (11/23) more likely to present as polyarthritis than other organisms (22/168) (OR 6.0; 95% CI 2.1-16.7). Univariate and multivariate analysis showed the hip to be at greater risk for S. aureus than other joints. Open arthrotomy was a more successful treatment procedure than arthroscopic washout or needle aspiration.

Septic arthritis of the knee: a 10-year review and long-term follow-up using a new scoring system

The case records of 64 patients with 65 episodes of infectious gonarthritis during 1979-88 were reviewed regarding epidemiological, clinical and laboratory data of possible relevance to the course and outcome of the disease. Long-term healing results were evaluated by means of a new scoring system 2-11 years after the acute disease in 46 patients. The infection was acquired by inoculation in 37% and by the hematogenous route in 55%. The major risk factors were trauma to the joint and arthrosis. Staphylococcus aureus was the causative agent in 58% and Streptococci in 15%. Treatment consisted of suction irrigation (86%) or intermittent aspiration (5%) combined with systemic antibiotic treatment. At follow-up, the pain and ache scores of the arthritic joint had decreased by 21% and 16% respectively, compared with the scores of the contralateral control joints. Anatomy and motility were reduced by 9% and 8% respectively. Age < 45 was associated with a greater score loss than in older patients. Treatment delayed by > 5 days was associated with increased loss of motility. We estimate that 79% of the patients had excellent or good long-term results following treatment of infectious arthritis of the knee. Evaluation of healing after infectious gonarthritis by use of a scoring system is quite feasible and allows comparison of different treatment regimes with improved accuracy.

Bacterial arthritis in a district hospital

Between 1977 and 1988 in the Enschede hospital 72 patients were seen with bacterial arthritis of one or more joints. Staphylococcus aureus was most frequently the causative agent (52%) and the knee was the most frequently infected joint (42%); the mortality rate was 11%. Complete restoration of pre-existent function was seen in 52% of the affected joints. In patients with severe deterioration of joint function after the bacterial infection, the period between the first symptoms and start of treatment (mean 30 days) was significantly longer than in patients with no or moderately deteriorated joint function (mean 10 days). The primary focus was mostly a skin infection, predominantly localized on the lower extremities. Half of all cases of bacterial arthritis occurred in patients with rheumatoid arthritis (RA). We therefore conclude that patients with RA and skin infections, especially if localized on legs or feet, should be treated without delay and that one should not hesitate to prescribe antibiotics. Erythrocyte sedimentation rate (ESR) was less than 20 mm after one hour in 13% and blood leucocyte count less than 10 x 10(9)/liter in 55% of all patients, showing that a normal ESR and/or blood leucocyte count do not exclude bacterial arthritis. In 4 out of 9 patients with infected prosthetic joints the infection resulted in loosening of the joint, before antibiotic treatment was started. In the other 5 patients bacterial arthritis recurred, in one patient resulting in loosening of the joint, only shortly after stopping long-term successful antibiotic treatment (6-24 months). Thus, we feel that lifelong treatment with antibiotics is a reasonable alternative in cases, where the risk of surgery is very high.

Infectious arthritis caused by Propionibacterium acnes: a report of two cases

Propionibacterium acnes, a micro-organism with low pathogenicity, rarely causes arthritis in a joint without a prosthesis. This report deals with two cases of P acnes infectious arthritis probably caused by direct penetration of the micro-organism into the joint space during arthrocentesis, despite the use of strict disinfection procedures. P acnes isolated from synovial fluid cannot be dismissed as a bothersome contaminant without due consideration of the clinical status of the individual patient.

Bacterial infection following intra-articular injection. A brief review

The literature on 443 cases of postinjection bacterial arthritis is reviewed. The utter rarity of the condition may have been overemphasized in the past. Haematogenous infection of the puncture track may be more important than the transfer of skin bacteria into the joint.