Septic arthritis in the elderly

Native joint septic arthritis with Veillonella species

Septic arthritis usually presents as subacute monoarticular inflammation. Majority of the cases in healthy adults are caused by methicillin-resistant Staphylococcus aureus, streptococci and certain gram-negative organisms, mostly in the setting of extremes of ages, trauma or immunosuppression. This is a case of a healthy adult with a sudden onset of inflammation of the knee joint, being diagnosed with septic arthritis of the left knee with Veillonella sp. growing from the joint aspirate on two successive cultures. The patient was treated with 6 weeks of oral metronidazole and 4 weeks of intravenous ceftriaxone in addition to arthroscopic drainage and irrigation. Rare causes of septic arthritis should be considered even in healthy adults with native joints. Closer follow-up might be needed to ensure successful treatment.

Septic Arthritis and Prosthetic Joint Infections in Older Adults

Older adults are at increased risk for septic arthritis and prosthetic joint infections (PJI), owing at least in part to comorbid conditions and frailty. An increasing number of older adults undergo total joint arthroplasty to improve their quality of life. Infections in older adults differ from younger populations by the causative organisms, a great proportion of which are Staphylococcal infections. Targeting important modifiable and nonmodifiable risk factors may prevent or reduce the burden of joint infections in older adults. This review summarizes the epidemiology, pathogenesis, clinical manifestations, diagnosis, management, and prevention of septic arthritis and PJI in older adults.

Septic arthritis significantly increased the long-term mortality in geriatric patients

Background

The elderly are predisposed to septic arthritis (SA) because of the aging nature and increasing comorbidities. SA may in turn increase the long-term mortality in the geriatric patients; however, it remains unclear. We conducted this prospective nationwide population-based cohort study to clarify this issue.

Methods

Using Taiwan National Health Insurance Research Database (NHIRD), we identified 1667 geriatric participants (≥ 65 years) with SA and 16,670 geriatric participants without SA matched at a ratio of 1:10 by age, sex, and index date between 1999 and 2010. A comparison of the long-term mortality between the two cohorts through follow-up until 2011 was performed.

Results

Geriatric participants with SA had a significantly increased mortality than those without SA [Adjusted hazard ratio (AHR): 1.49, 95% confidence interval (CI): 1.34–1.66], particularly the old elderly (≥ 85 years, AHR: 2.12, 95% CI: 1.58–2.84) and males (AHR: 1.54, 95% CI: 1.33–1.79). These results were stated after adjustment for osteoarthritis, diabetes, gout, renal disease, liver disease, cancer, rheumatoid arthritis, systemic lupus erythematosus, alcoholism, and human immunodeficiency virus infection. The increased mortality risk was highest in the first month (AHR: 3.93, 95% CI: 2.94–5.25) and remained increased even after following up for 2–4 years (AHR: 1.30, 95% CI: 1.03–1.65). After Cox proportional hazard regression analysis, SA (AHR: 1.37, 95% CI: 1.20–1.56), older age (≥ 85 years, AHR: 1.79, 95% CI: 1.59–2.02, 75–84 years, AHR: 1.65, 95% CI: 1.53–1.78), male sex, diabetes, renal disease, liver disease, cancer, and gout were independent mortality predictors. There was no significant difference in the mortality for SA between upper limb affected and lower limb affected.

Conclusions

This study delineated that SA significantly increased the long-term mortality in geriatric participants. For the increasing aging population worldwide, strategies for the prevention and treatment of SA and concomitant control of comorbidities are very important.

Pseudomonas Infection of the Temporomandibular Joint (TMJ) Health and Public Health Issues

The authors describe a case of a rare infectious disease of intra-articular tissues of the temporomandibular joint caused mainly by Pseudomonas aeruginosa. In scientific literature, under the heading invasive (malignant) external otitis, we can find cases of an infectious disease of the external acoustic meatus caused by a microbial agent of Pseudomonas aeruginosa which can subsequently penetrate into structures. However, a primary affliction of the abovementioned structures has not been described. Localisation and severity of the infection requires long-term and massive treatment with antibiotics.

Predictors of treatment failure and mortality in native septic arthritis

The aims of this study are to analyse the characteristics of septic arthritis stratified by age and to identify the predictors of treatment failure and mortality in septic arthritis. A retrospective single-centre study was conducted in patients with native septic arthritis between 1994 and 2012. The primary outcome was treatment failure. Secondary outcomes included mortality, complications, endocarditis, bacteraemia, hospital readmission and the duration of the hospital stay. Logistic regression analyses with a propensity score were performed to identify the predictors of response and mortality. Additional analyses were performed according to age and the initial treatment (surgery or conservative). A total of 186 patients were studied. The median (interquartile range) age was 64 (46, 74) years, and the percentage of male patients was 68.9%. A logistic regression analysis showed that Staphylococcus aureus infection [OR 2.39 (1.20-4.77), p = 0.013], endocarditis [OR 4.74 (1.16-19.24), p = 0.029] and the involvement of joints difficult to access with needle drainage [OR 2.33 (1.06-5.11), p = 0.034] predict treatment failure and that age [OR 1.27 (1.07 = 1.50), p = 0.005], the leucocyte count at baseline [OR 1.01 (1.00-1.02), p = 0.023], bacteraemia [OR 27.66 (1.39-551.20), p = 0.030], diabetes mellitus [OR 15.33 (1.36-172.67), p = 0.027] and chronic renal failure [OR 81.27 (3.32-1990.20), p = 0.007] predict mortality. No significant differences in treatment failure by age were found. In septic arthritis, the predictors of mortality and the predictors of treatment failure differ. The predictors of treatment failure concern local factors and systemic complications, whereas conditions related to the host's immune competence, such as age and comorbidities that hamper the host's response, predict mortality.

Morganella morganii-associated arthritis in a diabetic patient

This case report involves a 60-year-old diabetic man who developed septic arthritis as a result of the pathogen Morganella morganii. The patient had complaints of elevated body temperature, malaise, rigors and pain in the left knee, despite no history of trauma. On examination of the knee, erythema, warmth, tenderness and swelling was observed. Arthrocentesis performed on his left knee indicated the presence of straw-coloured, cloudy fluid without crystals. Bacterial identification based on biochemical and automated methods indicated the growth of M morganii. M morganii was also isolated sedimentafrom the exudate of a diabetic ulcer in the left foot, with antibiotic susceptibilities identical to those from the knee effusion. This case indicates that M morganii may be considered as a possible cause of septic arthritis in diabetic patients, especially those with diabetic foot infections.

Septic arthritis in Iceland 1990-2002: increasing incidence due to iatrogenic infections

Objectives:

To assess the impact of increased number of diagnostic and therapeutic joint procedures on the incidence and type of septic arthritis (SA).

Methods:

All cases of SA in Iceland from 1990–2002 were identified by thorough review of the available medical information. The results of synovial fluid cultures from every microbiology department in Iceland were checked and positive culture results reviewed, as well as patient charts with a discharge diagnosis of septic arthritis (International Statistical Classification of Diseases and Related Health Problems (ICD) code M009).

Results:

A total of 253 cases of SA (69 children and 184 adults) were diagnosed in Iceland in 1990–2002, giving an average incidence of 7.1 cases/100 000 inhabitants. The incidence of SA increased from 4.2 cases/100 000 in 1990 to 11.0 cases/100 000 in 2002. This rise in SA was primarily observed in adults where the incidence rose by 0.61 cases/100 000 per year (p<0.001). SA was iatrogenic in 41.8% of adults and the number of iatrogenic infections increased from 2.8 cases/year in 1990–1994 to 9.0 cases/year in 1998–2002 (p<0.01). The annual number of arthroscopies increased from 430 in 1990–1994 to 2303 in 1998–2002 (p<0.001) and there was a correlation between the total usage of intra-articular drugs in Iceland and the incidence of SA (p<0.01). The frequency of post-arthroscopy SA was 0.14% and post-arthrocentesis SA 0.037%.

Conclusions:

The incidence of SA has increased in recent years due to an increased number of arthroscopies and joint injections. Although the frequency of SA per procedure has not changed, these results emphasise the importance of sterile technique and firm indications for joint procedures.

Septic arthritis in patients aged 80 and older: a comparison with younger adults

OBJECTIVES

To compare the frequency and characteristics of septic arthritis in patients younger than 80 and aged 80 and older.

DESIGN

Retrospective.

SETTING

Single hospital center.

PARTICIPANTS

Patients admitted between 1979 and 2002 for septic arthritis.

MEASUREMENTS

Age, sex, time to diagnosis, predisposing factors, joint, temperature, white blood cell count, microorganism, and short-term outcome.

RESULTS

Of 335 patients, 206 (61.4%) were aged 60 and older, and 42 (12.5%) were 80 and older. The latter had an average age of 84 (range 80-97) and were mainly women (72%). Eighteen of the 42 had at least one risk factor. The mean time to diagnosis was 21 days (range 1 day to 3 months). Twenty patients (47%) had knee involvement, six (14%) shoulder involvement, ten (23.8%) a prosthetic infection, and five (12%) polyarticular infection. Ten (23%) were afebrile. In half of the cases, there was no increase in white blood cell count. The microorganisms isolated were Staphylococcus aureus (n=16, 38%), coagulase negative staphylococci (n=8, 19%), streptococci (n=12, 28%), and gram-negative bacilli (n=6, 14%). The mortality rate increased with age: 0.7% of patients younger than 60, 4.8% of those aged 60 to 79, and 9.5% of those aged 80 and older.

CONCLUSION

Advanced age is a risk factor for septic arthritis and poor outcome.

Acute septic arthritis

Acute septic arthritis may develop as a result of hematogenous seeding, direct introduction, or extension from a contiguous focus of infection. The pathogenesis of acute septic arthritis is multifactorial and depends on the interaction of the host immune response and the adherence factors, toxins, and immunoavoidance strategies of the invading pathogen. Neisseria gonorrhoeae and Staphylococcus aureus are used in discussing the host-pathogen interaction in the pathogenesis of acute septic arthritis. While diagnosis rests on isolation of the bacterial species from synovial fluid samples, patient history, clinical presentation, laboratory findings, and imaging studies are also important. Acute nongonococcal septic arthritis is a medical emergency that can lead to significant morbidity and mortality. Therefore, prompt recognition, rapid and aggressive antimicrobial therapy, and surgical treatment are critical to ensuring a good prognosis. Even with prompt diagnosis and treatment, high mortality and morbidity rates still occur. In contrast, gonococcal arthritis is often successfully treated with antimicrobial therapy alone and demonstrates a very low rate of complications and an excellent prognosis for full return of normal joint function. In the case of prosthetic joint infections, the hardware must be eventually removed by a two-stage revision in order to cure the infection.

Spontaneous bacterial arthritis in a cirrhotic patient

Septic arthritis is usually of hematogenous origin and is increasingly being reported in elderly patients, who often have underlying medical conditions such as diabetes or alcoholism. We report a 62-year-old patient with alcoholic liver disease who presented with Escherichia coli bacteremia and septic arthritis in a previously fractured ankle. There are scarce reports of infectious arthritis in cirrhotic patients, but this is the first report of arthritis after a primary enteric bacteremia. We believe that the patient described here developed E. coli bacteremia as a result of bacterial overgrowth and translocation related to alcoholic liver disease and cirrhosis. The resulting bacteremia resulted in the development of infection in the left ankle, which had preexisting disease and was thus vulnerable. This case provides further evidence for the mode of infection being bacteremia in cirrhotic patients. In patients with cirrhosis and fever, a high index of suspicion is required for joint infection as a potential cause of fever or deterioration in the cirrhotic's patient general condition.

Septic arthritis in adults: clinical features, outcome, and intensive care requirements

A review of adults with septic arthritis was undertaken to evaluate outcome of treatment and intensive care requirements in a community-based teaching hospital. During an 80-month period (1986-1992), 38 cases of septic arthritis were identified. Underlying joint disease was present in 84% of patients. Mean age was 68 years, with a range of 26 to 100 years and a median of 70 years. Patients did not always initially display signs of infection; fever was present in only 42%, and leukocytosis was present in 67%. Total in-hospital mortality was 26%, but the mortality attributed to septic arthritis was 13%. Polyarticular septic arthritis occurred in 26% of patients and carried a 40% mortality. Twenty-four percent of patients required transfer to the intensive care unit (ICU); they had a 67% mortality. Three of four patients with polyarticular septic arthritis requiring intensive care died. Average length of hospital stay for survivors receiving a full course of antibiotics was 35 days; it diminished to 14 days for 5 uncomplicated cases who received home IV antibiotics. Eighty-nine percent of survivors had return of function of the affected joints. Thirty-two percent required surgical intervention, and 5% were complicated by osteomyelitis. Septic arthritis remains a costly disease affecting primarily the elderly with underlying joint disease. Polyarticular septic arthritis and the need for ICU care portend a high mortality. The functional outcome of those who recovered was generally good.

Septic arthritis complicating hip osteoarthritis

Four patients with osteoarthritis of the hip, who developed septic arthritis of the affected joint, are reported. The septic arthritis developed insidiously and was diagnosed with difficulty. One patient died, two required subsequent joint excision, and one arthrodesis despite antibiotics. The presence of a recognised predisposing factor to septic arthritis, such as rheumatoid arthritis or a surgically replaced joint, can provide a diagnostic pointer. These cases suggest that osteoarthritis, similarly, is a predisposing factor. It is concluded that joint sepsis should be considered if a patient with osteoarthritis develops new symptoms from a single joint with associated systemic features.

Chronic Morganella morganii arthritis in an elderly patient

This report describes the first case of septic arthritis caused by Morganella morganii. The elderly patient's course of pyoarthritis was atypical in its benign clinical presentation, having little inflammatory response over a prolonged period. Septic arthritis should be considered as a possible diagnosis in all elderly patients with joint effusions.