Current Approach to the Evaluation and Management of Septic Arthritis

Native Joint Septic Arthritis

Native joint septic arthritis (NJSA) is a severe and rapidly progressing joint infection, predominantly bacterial but also potentially fungal or viral, characterized by synovial membrane inflammation and joint damage, necessitating urgent and multidisciplinary management to prevent permanent joint damage and systemic sepsis. Common in large joints like knees, hips, shoulders, and elbows, NJSA's incidence is elevated in individuals with conditions like rheumatoid arthritis, diabetes, immunosuppression, joint replacement history, or intravenous drug use. This review provides a comprehensive overview of NJSA, encompassing its diagnosis, treatment, antibiotic therapy duration, and surgical interventions, as well as the comparison between arthroscopic and open debridement approaches. Additionally, it explores the unique challenges of managing NJSA in patients who have undergone graft anterior cruciate ligament (ACL) reconstruction. The epidemiology, risk factors, pathogenesis, microbiology, clinical manifestations, diagnosis, differential diagnosis, antibiotic treatment, surgical intervention, prevention, and prophylaxis of NJSA are discussed, highlighting the need for prompt diagnosis, aggressive treatment, and ongoing research to enhance patient outcomes.

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.

Septic arthritis in the pediatric hip joint: a systematic review of diagnosis, management, and outcomes

Septic arthritis of the pediatric hip joint (SAH) is a rare but serious orthopedic emergency requiring immediate diagnosis and management. Delayed recognition can lead to severe complications, emphasizing the need for timely intervention. This systematic review aims to provide a comprehensive analysis of SAH in the pediatric population, focusing on its diagnosis, management, and outcomes. The review included 11 studies involving 391 patients with SAH, aged between three months and 12 years. Staphylococcus aureus was identified as the most common causative pathogen, with increasing cases of methicillin-resistant strains. Diagnosis is challenging due to nonspecific clinical presentations, necessitating validated criteria and a multidisciplinary approach. Ultrasound emerged as a valuable tool for early detection, and MRI was used in challenging cases. Treatment options include hip aspiration, arthrotomy, and arthroscopy, often combined with appropriate antibiotic therapy. Success rates were comparable among different surgical procedures. Early intervention is vital for optimal outcomes. However, the review highlights the need for standardized protocols and further prospective studies to address limitations and improve understanding and management of SAH in the pediatric hip joint.

Septic Arthritis of the Knee in Children

Septic arthritis of the knee is the most common form of septic arthritis in children and can lead to irreversible damage to the joint. Staphylococcus aureus is the primary pathogen associated with septic arthritis, although other causative pathogens may be isolate in children with specific risk factors. The diagnosis of knee septic arthritis is based on comprehensive evaluation, including the patient's medical history, physical examination, blood tests, and arthrocentesis. Empirical treatment typically involves anti-staphylococcal penicillin or a first-generation cephalosporin, although modifications may be made based on local resistance patterns and clinical culture data. Surgical debridement, either through open surgery or arthroscopy, involving extensive debridement of the joint, is effective in eliminating the infection. In most cases, additional surgical intervention is not necessary.

Mid- to Long-Term Survival of Geriatric Patients with Primary Septic Arthritis of the Shoulder: A Retrospective Study over a Period of 20 Years

Septic arthritis of the shoulder is an urgent medical emergency that often occurs in elderly patients and is associated with high morbidity and mortality. Retrospectively, 56 patients aged ≥60 years, treated for primary septic monoarthritis of the shoulder at a maximum care hospital between 1 July 2001, and 30 July 2022, were included in this study. The primary aim of the study was analyzing survival rates and different bacteria in these patients. For statistical analysis, Kaplan-Meier curves were used for survival probability and the log-rank test was used to compare a survival probability of 5 years. The mean patient age was 78.7 years and a mean follow-up time of 3011.8 days. The mean survival of the entire study population was 920.3 days or 2.5 years. Significantly impaired 5-year survival was found only with increasing age and higher American Society of Anesthesiologists (ASA) physical status (PS) classification scores. Eight different types of bacteria were detected in the synovial fluid cultures. A total of 42 of 48 overall pathogens was Gram-positive and 6 were Gram-negative bacteria. Staphylococcus aureus was identified as the most frequent variant. We conclude that the mean survival is significantly shortened within the first 5 years with increasing age and ASA PS classification.

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.

First evaluation of a commercial multiplex PCR panel for rapid detection of pathogens associated with acute joint infections

Background: prompt recognition and identification of the causative microorganism in acute septic arthritis of native and prosthetic joints is vital to increase the chances of successful treatment. The aim of this study was to independently assess the diagnostic accuracy of the multiplex BIOFIRE^® Joint Infection (JI) Panel (investigational use only) in synovial fluid for rapid diagnosis. Methods: synovial fluid samples were collected at the University Medical Center Groningen from patients who had a clinical suspicion of a native septic arthritis, early acute (post-operative, within 3 months after arthroplasty) periprosthetic joint infection (PJI) or late acute (hematogenous, ≥ 3 months after arthroplasty) PJI. JI Panel results were compared to infection according to Musculoskeletal Infection Society criteria and culture-based methods as reference standard. Results: a total of 45 samples were analysed. The BIOFIRE JI Panel showed a high specificity (100 %, 95 % confidence interval (CI): 78-100) in all patient categories. Sensitivity was 83 % (95 % CI: 44-97) for patients with a clinical suspicion of native septic arthritis ( n = 12 ), 73 % (95 % CI: 48-89) for patients with a clinical suspicion of a late acute PJI ( n = 14 ), and 30 % (95 % CI: 11-60) for patients with a clinical suspicion of an early acute PJI ( n = 19 ). Conclusion: the results of this study indicate a clear clinical benefit of the BIOFIRE JI Panel in patients with a suspected native septic arthritis and late acute (hematogenous) PJI, but a low clinical benefit in patients with an early acute (post-operative) PJI due to the absence of certain relevant microorganisms, such as Staphylococcus epidermidis, from the panel.

Therapeutic Effects of Boric Acid in a Septic Arthritis Model Induced by Escherichia coli in Rats

The study aimed to evaluate the therapeutic effect of boric acid (BA) in experimentally induced septic arthritis. A total of 30 rats, 6 rats in each group (5 groups), were used in the study. No treatment was applied to the rats in the control group. Only BA was administered intraperitoneally (IP) to the rats in the bor group. Escherichia coli was administered at a single dose of 25 μL, 1 × 10¹⁰ cfu/rat from the right foot pad of the rats, via intra-articular route, to the mice in the arthritis, arthritis-bor, and arthritis-antb groups. Then, BA at a dose of 50 mg/kg and cefazolin at a dose of 25 mg/kg were administered to the rats in the arthritis-bor and arthritis-antb groups, respectively, for 7 days via the IP route. At the end of the study, all animals were euthanized following the ethical rules. Blood and tissue samples were taken from the rats for biochemical and histopathological analyses. The levels of GSH, MDA, Endoglin, Endocan, and TNF-β markers were measured in the blood samples taken. A significant decrease was observed in MDA and Endoglin levels in the boric acid-administered group compared with the arthritis group, while a significant increase was observed at the GSH level. Histopathologically, it was determined that the reactive surrounding tissue response in the bor group was significantly reduced. As a result, a significant decrease in inflammation was found biochemically and histopathologically in the groups treated with BA.

Multiple organ failure and death caused by Staphylococcus aureus hip infection: A case report

Suppurative arthritis has an acute onset and mostly affects old people and children. Recently, the incidence of adult suppurative hip arthritis, as well as its serious consequences, has increased. The deep hip joint and surrounding hypertrophic muscle tissue limit physical examination. Furthermore, they may cause variable and atypical symptoms of suppurative hip arthritis, possibly inducing delayed diagnosis and treatment. This atypical presentation is uncommon, causing delayed diagnosis and treatment, thus worsening the outcomes. We herein report the case of a 58-year-old man with Staphylococcus aureus (S. aureus) septicemia and multiple organ failure due to left pyogenic arthritis of the hip. The patient's early symptoms were extremely atypical given that he only presented hip pain. Moreover, there was no obvious history of trauma or inflammatory manifestations, such as fever or local swelling, and laboratory examination results and imaging findings were atypical. However, the disease progressed rapidly, developing into systemic sepsis within a short period of time followed by multiple organ failure and death. Early diagnosis and effective treatment of S. aureus hip arthritis are essential to avoid poor outcomes.

Fever and Knee Effusion in the Pediatric Patient

ABSTRACT

The pediatric patient with fever and knee effusion is always a cause for clinical concern. A thorough history and physical examination is required to guide appropriate diagnostic evaluation and management. Although pediatric knee effusions are common in the setting of trauma, the presence of fever should prompt consideration of infectious, rheumatologic, vasculitic, and malignant etiologies. This review covers the key components of the history, physical examination, diagnostic strategies, common etiologies, and initial management of the pediatric patient with fever and knee effusion.

Validation of Septic Knee Monoarthritis Prediction Rule in a Lyme Disease Endemic Area

OBJECTIVE

In Lyme disease endemic areas, Lyme and septic arthritis often present similarly. A published septic knee arthritis clinical prediction rule includes 2 high-risk predictors: absolute neutrophil count of 10,000 cells/mm3 or greater and erythrocyte sedimentation rate of 40 mm/h or greater. The objective of the study was to externally validate this prediction rule in a multicenter prospective cohort.

METHODS

We enrolled a prospective cohort of children with knee monoarthritis undergoing evaluation for Lyme disease at 1 of 8 Pedi Lyme Net emergency departments located in endemic areas. We defined a case of septic arthritis with a positive synovial fluid culture or a synovial fluid white blood cell count of 50,000 or greater per high powered field with a positive blood culture and Lyme arthritis with a positive or equivocal C6 EIA, followed by a positive supplemental immunoblot. Other children were classified as having inflammatory arthritis. We report the performance of the septic arthritis clinical prediction rule in our study population.

RESULTS

Of the 543 eligible children, 13 had septic arthritis (2.4%), 234 Lyme arthritis (43.1%), and 296 inflammatory arthritis (54.5%). Of the 457 children (84.2%) with available laboratory predictors, all children with septic arthritis were classified as high risk (sensitivity, 100%; 95% confidence interval [CI], 77.2%-100%; specificity, 68.1%; 95% CI, 63.6-73.3; negative predictive value, 278/278 [100%]; 95% CI, 98.6%-100%). Of the 303 low-risk children, 52 (17.2%) underwent diagnostic arthrocentesis.

CONCLUSIONS

The septic knee arthritis clinical prediction rule accurately distinguished between septic and Lyme arthritis in an endemic area. Clinical application may reduce unnecessary invasive diagnostic procedures.

Short- and Mid-Term Survival of Geriatric Patients with Septic Arthritis of the Knee and the Impact of Risk Factors on Survival

Septic arthritis is common in older adults and can be related to joint surgery or hematogenous distribution. To date, the risk factors affecting survival are unknown. This study aimed to evaluate the effects of existing implants, positive synovial microbiological culture results, and the American Society of Anesthesiology Physical Status (ASA) classification on the short- and mid-term survival of older patients with primary septic gonarthritis. This retrospective study included 133 older adults >60 years who underwent surgery for primary septic gonarthritis. Data were collected from medical records and public obituaries. Kaplan–Meier survival curves were used to estimate the probability of survival, as well as log-rank tests to measure and compare survival rates over one- and five-year periods. The mean age was 74.9 years (SD ± 9.2), and the 5-year follow-up rate was 74.3% (the mean follow-up was 3000.5 days; SD ± 1771.6). Mean survival was significantly different in patients with implants and without implants (p = 0.015), and between ASA II, ASA III, and ASA IV (p < 0.001). There was no significant difference in the survival of patients with or without a positive synovial microbiological culture (p = 0.08). Older adults with septic monoarthritis and pre-existing medical implants showed impaired survival. The ASA classification prior to surgery for primary septic monoarthritis can be helpful in identifying patients with poorer mid-term outcomes.

Ultrasound-Guided Talonavicular Arthrocentesis

BACKGROUND

Joint arthrocentesis is a commonly performed procedure by the emergency physician (EP). Point of care ultrasound (POCUS) has demonstrated promise in identifying joint effusions and guiding arthrocentesis procedures. EP-performed talonavicular joint arthrocentesis has not been previously described in the literature. We present a case in which an isolated talonavicular joint effusion was identified and then subsequently aspirated using POCUS.

CASE REPORT

A 65-year-old man presented with atraumatic right ankle pain. On arrival, he was noted to have diffuse warmth and edema around the ankle and midfoot. POCUS was performed to evaluate for an ankle joint effusion, which was not present. The ultrasound was then moved distally, where a talonavicular joint effusion was noted. Inflammatory markers were found to be elevated. A magnetic resonance imaging scan revealed an isolated talonavicular joint effusion without additional acute findings. POCUS was then used to perform an arthrocentesis, which revealed monosodium urate crystals consistent with an initial episode of gouty arthritis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS provides the EP with an efficient tool to diagnose joint effusions and guide arthrocentesis procedures. The foot is composed of several small joints where ultrasound can be particularly helpful. Similar to the ankle joint, these joints can be afflicted with pyogenic infections and crystalline arthropathies. To our knowledge, we present the first report of EP-performed talonavicular arthrocentesis guided by POCUS. The approach to this joint and technique for arthrocentesis are presented.

Septic arthritis due to non-tuberculous mycobacterium without effusion

Septic arthritis is an important but difficult to make diagnosis that leads to significant morbidity and mortality. Joint effusion is generally accepted to be a highly sensitive finding in septic arthritis; however, final diagnosis requires synovial fluid studies. Without a significant joint effusion, it is difficult to obtain synovial fluid. In this case report, we describe the presentation and diagnosis of septic arthritis in the first MTP due to mycobacterium chelonae in a 69 year old man with a history of gout and immunosuppression due to a heart transplant. There was notably no significant effusion in the joint on clinical examination or bedside ultrasound. As the patient was immunosuppressed, arthrocentesis was performed under ultrasound guidance. A needle was clearly visualized in the joint; however, minimal synovial fluid was obtained. The fluid grew Mycobacterium chelonae in culture. Subsequent joint washout revealed purulent synovial fluid that grew out the same bacteria. This case emphasizes the importance of obtaining synovial fluid to evaluate for septic arthritis, even when joint effusion is absent. Ultrasound guidance can facilitate this.