Prospective comparative study of patients with culture proven and high suspicion of adult onset septic arthritis

The Septic Elbow Joint: Treatment Approaches for Improved Patient Outcomes

Septic arthritis of the elbow is a serious problem requiring prompt, accurate diagnosis and urgent surgical intervention. Achieving successful patient outcomes depends heavily on early diagnosis and efficient streamlined surgical treatment. Essential tactics for treating the septic elbow joint include immediate joint irrigation and debridement in addition to administration of appropriate antibiotics. This comprehensive review delves into the cause of the septic elbow joint, identifies associated risk factors, and provides a comprehensive approach encompassing the diagnosis and treatment of the septic elbow. The aim of this review is to optimize patient care and outcomes.

Septic arthritis of the facet joint is also a severe vertebral infection: A multicenter retrospective study of 65 patients

OBJECTIVE

Septic arthritis of the Facet Joints (SAFJ) is a rare condition. Little data has been published on the subject. We aimed to describe the clinical, biological and imagery presentations, as well as the course of this rare infection.

METHODS

We included patients hospitalized between January 1st, 2016 and December 31th, 2019, in the Departments of Infectious Diseases or Rheumatology in 5 French centres in the CRIOGO network. We defined septic arthritis according to Newman's criteria and facet joint arthritis using imagery.

RESULTS

Sixty-five patients were included, predominantly males (64.6%), with a mean age of 68.1 years. The mean time to diagnosis was 25.0 days. The principal symptoms at diagnosis were acute back pain (95.2%) and fever (76.9%). Neurological symptoms were present for 60.7% of the patients, including 16.4% motor deficit or cauda equina syndrome. SAFJ was located on the lumbosacral spine (73.4%) and was rarely multifocal (4.7%). Bacteriological identification was performed by blood cultures in 84.4% of the cases, and the pathogen was mainly Staphylococcus aureus (49.2%). Infective endocarditis was present for 26.9% of patients assessed by echocardiography. On MRI, soft tissue abscess or inflammation, epiduritis and epidural abscess were present in 87.1%, 66.7% and 33.9% of cases, and the pathogen was significantly more frequently Staphylococcus aureus. Mortality reached 9.2%, 18.5% and 23% at one, two, and three years respectively.

CONCLUSION

SAFJ is a rare but severe disease. Microbiological diagnosis is primarily made on blood cultures, and S. Aureus was the main pathogen. Our results highlight the fact that SAFJ is associated with high morbidity and mortality, and with infective endocarditis.

Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis

Background

This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis.

Methods

We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery.

Results

Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/μL [standard deviation, 52 576.3/μL] vs 92 162.7/μL [59 330.6/μL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/μL [95% confidence interval, -65 355/μL to -20 213.90/μL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/μL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02).

Conclusions

The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.

Moraxella catarrhalis Septic Arthritis Unveils Undiagnosed Systemic Lupus Erythematous in a Pediatric Patient

Septic arthritis is uncommon in pediatric patients, who are less likely to have major risk factors such as underlying joint disease or prosthetic joints. It only rarely affects the elbow and is usually caused by Gram-positive cocci, with Staphylococcus aureus being the most common bacterial organism. We present the case of a 15-year-old previously healthy female who experienced new-onset monoarticular nontraumatic elbow pain and was found to have a synovial effusion growing from Moraxella catarrhalis. The atypical clinical presentation, coupled with the growth of an unusual organism, raised concern for an underlying immunocompromising or inflammatory joint disorder. Further laboratory workup ultimately revealed a diagnosis of systemic lupus erythematosus (SLE), which more commonly presents with arthralgias that are polyarticular, symmetric, and migratory. This case report should encourage clinicians to maintain a high degree of suspicion for underlying joint disease when septic arthritis presents atypically.

Administering Antibiotics for Less Than Four Weeks Increases the Risk of Relapse in Culture-Positive Septic Arthritis of Native Joints

(1) Objectives: This study investigated the optimal duration of antibiotic therapy and determined the risk factors associated with relapse in patients with culture-proven septic arthritis of native joints. (2) Methods: A retrospective review was conducted on patients aged ≥18 years diagnosed with native joint septic arthritis, with bacteria isolated from joints and/or blood. The exclusion criteria were prosthetic joint infections and cases with no identified microorganisms. The outcomes were assessed in the remission and relapse groups. (3) Results: Among 479 patients with native joint septic arthritis, 137 met the inclusion criteria, with a median follow-up duration of 2.7 years. The relapse rate was 9.5%, which mainly occurred within 30 days after antibiotic treatment completion. Compared with the remission group, the relapse group showed a significantly higher proportion of cases that received antibiotic therapy for ≤ 4 weeks (4.8% vs. 46.2%, p < 0.001), synovial fluid white blood cell (WBC) counts ≥150 × 103/mm3 (25.3% vs. 60.0%, p = 0.030), acute kidney injury (19.2% vs. 50%, p = 0.024), and extended-spectrum beta-lactamases-producing Enterobacteriaceae (0.8 vs. 15.4%, p = 0.024). Independent risk factors for relapse were determined as antibiotic therapy duration of ≤ 4 weeks (odds ratio (OR), 25.47; 95% confidence interval (CI), 1.57-412.33; p = 0.023) and synovial fluid WBC counts ≥150 × 103/mm3 (OR, 17.46; 95% CI, 1.74-175.62; p = 0.015). (4) Conclusions: Patients with native joint septic arthritis require vigilant monitoring for relapse, particularly when treated with antibiotic regimens administered for less than four weeks or when synovial aspirates exhibit elevated WBC counts at diagnosis.

Three Episodes of Presumed Culture-Negative Septic Arthritis Following Intramuscular Antipsychotic Injections: A Case Report

CASE

We present a male patient of low socioeconomic status and Māori ethnicity who experienced 3 episodes of presumed culture-negative septic arthritis of the native hip between ages 43 and 52 years. Each episode occurred within 3 weeks of intramuscular antipsychotic injection into the ipsilateral gluteal muscles. The right hip was involved in 2 presentations and the left hip in 1 presentation. No coexisting infection or underlying immune suppression was identified, and at follow-up 2 years after the last episode, he has no sequelae of septic arthritis.

CONCLUSION

This report describes 3 episodes of presumed culture-negative septic arthritis after intramuscular antipsychotic injection.

Clinical prediction rule for bacterial arthritis: Chi-squared automatic interaction detector decision tree analysis model

Objectives:

Differences in demographic factors, symptoms, and laboratory data between bacterial and non-bacterial arthritis have not been defined. We aimed to identify predictors of bacterial arthritis, excluding synovial testing.

Methods:

This retrospective cross-sectional survey was performed at a university hospital. All patients included received arthrocentesis from January 1, 2010, to December 31, 2020. Clinical information was gathered from medical charts from the time of synovial fluid sample collection. Factors potentially predictive of bacterial arthritis were analyzed using the Student’s t-test or chi-squared test, and the chi-squared automatic interaction detector decision tree analysis. The resulting subgroups were divided into three groups according to the risk of bacterial arthritis: low-risk, intermediate-risk, or high-risk groups.

Results:

A total of 460 patients (male/female = 229/231; mean ± standard deviation age, 70.26 ± 17.66 years) were included, of whom 68 patients (14.8%) had bacterial arthritis. The chi-squared automatic interaction detector decision tree analysis revealed that patients with C-reactive protein > 21.09 mg/dL (incidence of septic arthritis: 48.7%) and C-reactive protein ⩽ 21.09 mg/dL plus 27.70 < platelet count ⩽ 30.70 × 10⁴/μL (incidence: 36.1%) were high-risk groups.

Conclusions:

Our results emphasize that patients categorized as high risk of bacterial arthritis, and appropriate treatment could be initiated as soon as possible.

A case of septic arthritis of the elbow joint in rheumatoid arthritis diagnosed by arthroscopic synovectomy

We report a case of methicillin-resistant Staphylococcus aureus (MRSA) septic arthritis of the elbow detected by arthroscopic synovectomy in an 81-year-old woman with rheumatoid arthritis (RA) who was initially diagnosed with a rheumatoid arthritis flare-up. The patient was administered abatacept, an antirheumatic biological agent, as the synovial fluid culture was negative. Destruction of the joint progressed despite medication, and the patient underwent arthroscopic synovectomy. MRSA was detected in the culture of the synovium that was collected intraoperatively, and septic arthritis was diagnosed. The infection subsided with anti-MRSA antibiotics, but the patient continued to experience moderate pain and limited motion. In RA patients, it might be difficult to differentiate minor findings from infection. Arthroscopic synovectomy is one of the selectable procedures that should be actively considered when infection is suspected.

Comparison of MR Findings between Patients with Septic Arthritis and Acute Gouty Arthritis of the Knee

Purpose

To compare the MR findings of septic and acute gouty arthritis of the knee joint.

Materials and Methods

This retrospective study included patients who underwent knee MRI for septic or gouty arthritis at our hospital between October 2012 and October 2018. The MR findings were analyzed for the presence of bone marrow edema, soft tissue edema, abscess, pattern of synovial thickening (frondlike, lamellated, diffuse linear), maximum thickness of the synovium, and joint effusion volume. The gouty (n = 5) and septic arthritis (n = 10) groups were compared using the Wilcoxon rank-sum test and Fisher's exact test.

Results

No statistically significant differences were observed for each item. One patient in the gouty arthritis group and seven in the septic arthritis group had bone marrow edema. Soft tissue abscess formation was only observed in the septic group. The incidence of each synovial thickening pattern was as follows: 100% (diffuse linear) in the gouty arthritis group and 20% (frondlike), 50% (lamellated), and 30% (diffuse linear) in the septic arthritis group.

Conclusion

Differentiation of gouty arthritis and septic arthritis based on imaging findings is difficult. However, lamellated synovial thickening patterns, bone marrow edema, and soft tissue abscess formation are more commonly observed in patients with septic arthritis than in those with gouty arthritis.

Mortality of septic knee arthritis in Korea: risk factors analysis of a large national database

This study aimed to analyze the risk factors for mortality of septic knee arthritis in Korea through a large nationwide data research. The National Health Insurance Service-Health Screening database was used to analyze 89,120 hospitalizations for septic knee arthritis between 2005 and 2018. In-hospital, thirty-day, and ninety-day mortality, and their association with patient’s demographic factors, various comorbidities (i.e., cerebrovascular disease, congestive heart failure, and myocardial infarction) and Charlson Comorbidity Index (CCI) were assessed. Secondary outcomes of complications (osteomyelitis, knee arthroplasty, recurrence) were analyzed. The number of hospitalization with septic knee arthritis increased from 1847 cases in 2005 to 8749 cases in 2018. There was no significant difference in mortality after diagnosis of septic knee arthritis between years. The risk of mortality in patients who hospitalized with septic knee arthritis increased in comorbidities like Congestive heart failure, dementia, myocardial infarction, chronic kidney disease. Hazard ratio (HR) decreased in patients who have comorbidities such as rheumatoid arthritis, liver disease, rheumatologic disease. HR for mortality in septic knee arthritis increased in patients with CCI more than 1. The risk factors for mortality in all periods were male sex, old age, high CCI, comorbidities such as congestive heart failure, dementia, myocardial infarction, chronic kidney disease. Efforts to reduce mortality should be concentrate more on patients with these risk factors.

Management and outcome of native joint septic arthritis: a nationwide survey in French rheumatology departments, 2016-2017

OBJECTIVES

To describe current management and outcome of native joint septic arthritis (NJSA) in French rheumatology departments.

METHODS

For this retrospective, nationwide multicentric study, 127 French rheumatology departments were contacted to report up to 12 cases of NJSA that occurred between 1 January 2016 and 31 December 2017. Characteristics, diagnosis procedures, therapeutic management and outcome were recorded.

RESULTS

Overall, 362 patients were included (mean age 64.0±18.6 years, median Charlson comorbidity index 3.5 (0-14)). Knee was the most frequent site (n=160 (38.9%)), and Staphylococcus sp (n=185 (51.4%)), the most frequent pathogen. All patients received antibiotics for a mean duration of 46.8 (±22.0) days, including intravenous route for a mean of 17.2 (±15.4) days. Management was heterogeneous. Surgical procedure was performed in 171 (48.3%), joint immobilisation in 128 (43.8%). During follow-up, 91 (28.3%) patients have had serious complications and 28 (9.2%) of them died. Factors associated with 1-year mortality were age (OR 1.08, 95% CI 1.04 to 1.13; p<0.001), Charlson's index (OR 1.30, 95% CI 1.06 to 1.58; p=0.012), presence of bacteraemia (OR 4.02, 95% CI 1.35 to 11.99; p=0.008), antibiotic use in the previous 3 months (OR 3.32, 95% CI 1.11 to 9.87; p=0.029) and Staphylococcus aureus NJSA compared with Streptococcus sp. NJSA (OR 7.24, 95% CI 1.26 to 41.68, p=0.027). The complete recovery with no adverse joint outcome at 1 year was observed in n=125/278 patients (55.0%).

CONCLUSION

Prognosis of NJSA remained severe with a high rate of morbimortality. Its management was very heterogeneous. This study highlights the importance of the new French recommendations, published after the completion of the study, in order to facilitate NJSA management.

Risk Factors, Clinical Characteristics, Management, and Outcomes of Musculoskeletal Fungal Infection at Thailand’s Largest National Tertiary Referral Center

To investigate the risk factors, clinical characteristics, management, and outcomes of musculoskeletal fungal infection in Thai patients, patients aged ≥18 years definitively diagnosed with musculoskeletal fungal infection by culture and/or histopathology at Siriraj Hospital (Bangkok, Thailand) during 2002–2020 were retrospectively enrolled. Twenty-eight patients (median age: 58.5 years [range: 22–81], 57.1% male) with fungal osteomyelitis (n = 22), septic arthritis (n = 1), or fungal osteomyelitis with septic arthritis (n = 5) were included. Immunocompromised status was common (82%). Most patients had de novo infection from hematogenous spreading that usually presented at a single, non-contiguous site. The median symptom duration prior to diagnosis was 2 months. The tibia and knee were the most common site of osteomyelitis (30%) and septic arthritis (72%), respectively. The most common pathogens were Talaromyces marneffei and Cryptococcus neoformans. Organism identification from tissues at the affected sites was required in all cases. Most patients (82%) required combination surgery and systemic antifungal therapy. Among those with complete follow-up (23/28), 61% and 39% had complete and partial responses, respectively. Musculoskeletal fungal infection is an uncommon disease with insidious onset and non-specific manifestations that requires pathogen identification via tissue cultures and histopathologic studies. Combination surgery and systemic antifungal therapy yielded generally favorable outcomes.

Non-gonococcal septic arthritis of native joints in Western Australia. A longitudinal population-based study of frequency, risk factors and outcome

OBJECTIVE

To describe the incidence and long-term outcome of non-gonococcal septic arthritis (SA) in Western Australia (WA).

METHODS

Newman criteria were applied to define culture-positive SA and suspected SA cases in the state-wide West Australian Rheumatic Diseases Epidemiological Registry with longitudinally linked health data for patients >16 years with a first diagnostic code of pyogenic arthritis (711.xx [ICD-9-CM] and M00.xx [ICD-10-AM]) between 1990-2010. Annual incidence rates/100 000 (AIR) and standardized (against WA population) mortality rates/1000 person-years (SMR) and outcomes during 10.1 years follow-up are reported.

RESULTS

Among 2633 SA patients (68.6% male, age 47.4 years), 1146 (43.5%) had culture-positive SA. The overall AIR for culture-positive (1.6-6.3) and total SA cases (4.3-12.9) increased between 1990 and 2010 as did age at onset (39.5-54 years) and proportion of females (23-35.6%). Knees (33.6.%) were most frequently affected and 37.1% of cultures showed microorganisms other than Gram-positive cocci. Thirty-day rates for readmission and mortality were 25.4% and 3.2.%. During follow-up rates for serious infections (56.4%), osteoarthrosis (5.2%) and osteomyelitis (2.7%) were higher in culture-positive SA. SMR was increased for all SA patients but especially in those 17-40 years of age with culture-positive SA (24.2; 95% CI 2.3-261).

CONCLUSIONS

The incidence of SA in WA has risen steeply over 20 years. SA now occurs at higher age, affects females more often with over a third of cases caused by Gram-negative microorganisms. Not only culture-positive, but also suspected SA led to increased bone/joint complications, in-hospital and late mortality.

Streptococcus Pneumoniae septic arthritis in adults in Bristol and Bath, United Kingdom, 2006-2018: a 13-year retrospective observational cohort study

Few studies on adult pneumococcal septic arthritis are sufficiently large enough to assess both epidemiological trends following routine pneumococcal immunization and clinical disease. With major shifts in serotypes causing invasive pneumococcal disease (IPD), we wanted to determine the clinical phenotype of adult septic arthritis caused by Streptococcus pneumoniae. We conducted a retrospective cohort study of pneumococcal infections in Bristol and Bath, UK, 2006–2018. We defined pneumococcal septic arthritis as adults with clinically-confirmed septic arthritis, with pneumococcus isolated from sterile-site culture or urinary antigen test positivity. Clinical records were reviewed for each patient in the cohort. Septic arthritis accounted for 1.7% of all IPD cases. 45 cases of adult pneumococcal septic arthritis occurred, with disease typically affecting older adults and those with underlying comorbidity. 67% patients had another focus of infection during their illness. 66% patients required increased care on discharge and 43% had reduced range of movement. In-hospital case fatality rate was 6.7%. One-year patient mortality was 31%. Currently most cases of adult pneumococcal septic arthritis are due to non-PCV13 serotypes which are associated with more severe disease. Non-PCV-13 serotypes had higher prevalence of concomitant pneumococcal infection at another site (73.7% versus 36.6%), increased intensive care or high-dependency unit requirement (32.4% versus 0%), and increased inpatient and 1-year case fatality rate (8.8% versus 0%, and 32.4% versus 27.4% respectively) compared to PCV-13 serotypes. Pneumococcal septic arthritis remains a small proportion of IPD. However, there is significant associated morbidity and mortality, and pneumococcal septic arthritis requires monitoring in coming years.

Infection of the hip joint by Serratia marcescens

A 72-year-old male patient presented to the hospital because of sudden inability to bear weight and without a history of trauma. A fracture of the head of the femur was identified on CT scan of the pelvis. In his history, the patient had a hospital admission 3 months earlier, during which he had a urinary catheter, and a urine specimen was analysed. The same pathogen was found in the patient urine and in the head of the femur specimen. This is a report of blood-borne spread of Serratia marcescens infection from the urothelium to the hip joint, responsible for spontaneous fracture of the femoral head without history of trauma.

Bacterial Septic Arthritis of the Adult Native Knee Joint: A Review

» Acute bacterial septic arthritis of the knee is an orthopaedic emergency and, if left untreated, can result in substantial joint degradation. » Important risk factors for development of septic arthritis include age of >60 years, recent bacteremia, diabetes, cancer, cirrhosis, renal disease, drug or alcohol abuse, a history of corticosteroid injection, a recent injury or surgical procedure, a prosthetic joint, and a history of rheumatoid arthritis. » The diagnosis is primarily based on history and clinical presentation of a red, warm, swollen, and painful joint with limited range of motion. Laboratory values and inflammatory markers from serum and joint fluid may serve as adjuncts when there is clinical suspicion of septic arthritis. » The initial and general antibiotic regimen should cover methicillin-resistant Staphylococcus aureus and gram-negative and gram-positive organisms. The antibiotic regimen should be specified following the culture results of the infected joint. » Operative management involves either arthrotomy or arthroscopy of the knee with thorough irrigation and debridement of all infected tissue. The Gächter classification is useful in establishing a prognosis or in determining the need for an extensive debridement.

Clinical Outcomes and Global Health After Joint Debridement in Adult-Onset Septic Arthritis: A Prospective Observational Study

PURPOSE

Despite several reports on risk factors for septic arthritis (SA) in adults, the outcomes on quality of life and joint function are sparsely reported. This study aimed to investigate the quality of life and joint function in adult patients treated for SA.

METHODS

This prospective observational study enrolled clinically diagnosed adult SA patients and estimated Euroqol 5-dimension 5 levels (EQ-5D-5L) questionnaire, Euroqol Visual Analog Scale (EQ-VAS) and a validated tool for joint function at 1, 3, 6 and 12 months after debridement.

RESULTS

Twenty seven patients (20 males/7 females) with 21 knees, four shoulders, and two elbows were evaluated. The mean age of the cases was 51(± 13.00) years. Three cases sustained mortality. EQ-5D-5L (P < 0.01) and EQ-VAS (P < 0.01) scores improved significantly between all time frames. Mean Knee society (P < 0.01), Shoulder QuickDASH, and Mayo elbow scores improved at all time frames. There was no difference in primary outcomes between early (< 14 days) and late (14 days or more) presentation. There was no difference in primary outcome measures between confirmed and suspected SA. Fifteen patients could ambulate without support, while 6 needed some support for walking at 1 year.

CONCLUSION

Improved outcomes can be expected in quality of life and joint function in adults' septic arthritis at the end of 1 year after surgical treatment; however, the effects of delay in presentation need to be investigated further. Isolation of the microorganism from an infected joint has no bearing on the outcome measures.

Clinical and laboratory profile in confirmed vs. suspected septic arthritis patients and its relevance in decision making: A comparative cross-sectional study

PURPOSE

There were 10%-30% of patients with adult-onset septic arthritis (SA) exhibiting sterile synovial fluid (SF), and the uncertainty in the determining diagnosis of these patients posed a challenge in management. The purpose of this study was to investigate the differences between confirmed (Newman A) and suspected (Newman B & C) SA in adults.

METHODS

This was a descriptive study with a cross-sectional study design conducted at a tertiary referral centre from July 2016 to February 2019. Patients aged over 18 years presented to the emergency department with clinical features suggestive of SA and were scheduled to undergo arthrotomy and joint lavage by the treating surgeon were included in the study. Patients with prosthetic joint infections and open joint injuries were excluded. Patients' demographic data, clinical features and laboratory parameters were collected. The clinical and laboratory profile (blood and SF) of the adult patients presenting with features suggestive of SA based on Newman criteria was statistically analyzed by SPSS version 20 software and Microsoft Excel. The categorical variables were expressed as proportions while the continuous variables were expressed as mean (SD) or median (IQR) depending upon the normality of distribution. The difference between the two groups for categorical variables was assessed using the Chi-square test and the difference for continuous variables was assessed using the unpaired t-test and the Mann-Whitney test depending upon normality. A p value < 0.05 was considered significant.

RESULTS

Thirty-six patients were divided into confirmed (n = 19) or suspected (n = 17) SA for assessment based on SF culture. The median (IQR) age of the patients was 50 years (37-60 years). There was no significant difference in demographic, clinical and laboratory parameters between the concerned groups. Eight patients presented with fever. Among the confirmed SA cases, 8 were negative for C-reactive protein and 6 had synovial white blood cell count <50,000. Staphylococcus species were isolated in 8 cases. The most common risk factors for SA were chronic kidney disease (25.0%), diabetes mellitus (25.0%), pharmacologic immunosuppression (16.7%), recent joint surgery (11.1%) and distant site infection (11.1%).

CONCLUSION

SA is an orthopaedic emergency that needs prompt and aggressive treatment to prevent catastrophic complications. Confirmed and suspected cases of SA exhibit similar demography, clinical features and laboratory parameters at presentation which may mislead the treating surgeon. Management should be based on sound clinical judgment in the event of failure to culture microorganisms.

Efficacy of microbiological culturing in the diagnostics of joint and periprosthetic infections

OBJECTIVES

To evaluate the efficacy of conventional microbiological examinations in the diagnostics of septic joint and periprosthetic inflammations.

DESIGN AND SETTING

Evidence Level IV, retrospective clinical study of case series. Patients treated with small and large joint septic inflammations or with periprosthetic joint infections (PJI) were entered into the study. Demographics, microbiological cultures and inflammatory mediators were evaluated.

PARTICIPANTS

Between 2012 and 2016, total of 1116 hip and 241 knee surgeries were performed at our Department in relation to prostheses; including primary and revision arthroplasties and further surgeries due to PJI. During this period, 72 patients were operated with large joints infections or PJI and another 65 patients were treated due to small joint infections.

MAIN OUTCOME MEASURES

The main outcome of interest was to evaluate the sensitivity of conventional microbiological cultures in the primary diagnostics of joint and periprosthetic infections.

RESULTS

The most frequent bacteria strains were the Staphylococci: in 43 cases (22.16%) Staphylococcus aureus, in 22 cases (11.34%) coagulase-negative Staphylococcus, in 3 cases (1.54%) Staphylococcus epidermidis and in 4 cases (2.06%) methicillin-resistant S. aureus (MRSA) were detected. In 30 cases (21.88%), the primary microbiological investigation could not reveal the presence of bacteria.

CONCLUSION

Based on our data, the efficacy of conventional microbiological testing in the diagnostics of different type of joint infections is questionable. Therefore, further studies are warranted to evaluate the efficacy of novel diagnostic testing tools in prospective randomized controlled trials.

Evaluation for septic arthritis of the native adult knee is aided by multivariable assessment

INTRODUCTION

Evaluation of suspected septic arthritis of the native adult knee is a common diagnostic dilemma. Pre-aspirate criteria predictive of septic arthritis do not exist for the adult knee and investigations of aspiration results (cell count, differential, gram stain and crystal analysis) have been limited to univariate analyses. Given numerous clinical variables inform the risk of septic arthritis, multivariable analysis that incorporates all clinically available information is critical to allowing accurate decision-making.

METHODS

We retrospectively identified 455 cases of potential septic arthritis of a native adult knee at a tertiary health system from 2012 to 2017, of which 281 underwent aspiration. We recorded demographics, comorbidities, history, exam, laboratory, and radiographic data. Among aspirated cases, we performed univariate analyses of all variables for association with septic arthritis followed by multivariable logistic regression analysis.

RESULTS

Septic arthritis was confirmed in 61 of 281 patients who underwent aspiration. Independent associations of risk for septic arthritis included synovial fluid WBC ≥ 30,000 (Odds Ratio 90.8, 95% Confidence Interval 26.6-310.1, p < 0.001), bacteria reported on synovial fluid gram stain (OR 21.5, 95% CI 3.9-119.2, p < 0.001), duration of pain >2 days (OR 6.9, 95% CI. 2.3-20.9, p < 0.001), history of septic arthritis at any joint (OR 5.0, 95% CI 1.1-23.4, p = 0.039), clinical effusion (OR 4.8, 95% CI 1.2-20.0, p = 0.030). Independent associations protective against septic arthritis included presence of synovial fluid crystals (OR 0.1, 95% CI 0.1-0.4, p < 0.001). The multivariable model was highly accurate in discriminating between septic and aseptic cases (AUC = 0.942). A web-based tool was created to aid clinical decision-making.

CONCLUSION

When evaluating for septic arthritis of a native adult knee, several independent associations were identified for variables related and unrelated to joint aspiration. The associated multivariable model discriminated very well between patients with and without septic arthritis, outperforming previous univariate assessments. A web-based tool was created that estimates the probability of septic arthritis based on this model. This may aid decision-making in complex clinical scenarios.

Synovial fluid presepsin as a novel biomarker for the rapid differential diagnosis of native joint septic arthritis from crystal arthritis

OBJECTIVE

To investigate whether presepsin can be used as a novel biomarker to differentiate between native joint septic arthritis (NJSA) and crystal arthritis (CA).

METHODS

This study included 75 patients diagnosed with either NJSA (n = 21) or CA (n = 54). Presepsin in synovial fluid and blood, C-reactive protein, and procalcitonin were measured and compared between the NJSA and CA groups. Receiver operating characteristic (ROC) curve analyses were performed to differentiate between the two groups.

RESULTS

Synovial fluid and blood presepsin were significantly higher in the NJSA group than in the CA group (p < 0.0001 and p < 0.01, respectively). The area under the ROC curve for synovial fluid presepsin in the NJSA group compared with the CA group was 0.93 (sensitivity 85.7%, specificity 85.2%, positive predictive value 69.2%, negative predictive value 93.9%, positive likelihood ratio 5.79, negative likelihood ratio 0.17). Among the tests, synovial fluid presepsin was the most accurate.

CONCLUSIONS

Measurement of synovial fluid presepsin is reliable for the early diagnosis of NJSA, and synovial fluid presepsin could be used as a novel biomarker for differentiating between NJSA and CA.

Infectious arthritis and the temporomandibular joint. A review

OBJECTIVE

Microorganisms can cause acute infectious arthritis, chronic infectious arthritis, or reactive inflammatory arthritis. The aim of this study is to perform a narrative review of the pathophysiology, etiology, and diagnostic features of infectious arthritis and TMJ infectious arthritis.

METHODS

A search of the literature was performed using Medline, Scielo, Embase, and Google Scholar databases. The terms employed for the search were "Temporomandibular Joint Disorders" and "Infectious Arthritis"; or "Septic Arthritis"; or "Bacterial, Fungal, or Viral Arthritis." Over three hundred articles were screened for eligibility.

RESULTS

The selected articles were utilized to perform a narrative review of the general aspects of infectious arthritis and infectious arthritis affecting the TMJ.

CONCLUSION

Infectious arthritis is a rare, yet very morbid, form of arthritis. Understanding general aspects of joint infections and specific features of TMJ infectious arthritis is imperative for an adequate diagnosis.

[Septic arthritis of the native joint and after ligamentoplasty : Diagnosis and treatment]

BACKGROUND

Septic arthritis is an acute emergency. It occurs more frequently in patients with pre-existing degenerative or chronic inflammatory joint diseases than in the general population. The causative microorganisms can be introduced in various ways.

DIAGNOSTICS

A rapid diagnosis is of great importance for the success of the therapy. In the clinical examination, the typical signs of inflammation are noticeable. The gold standard is the aspiration of synovial fluid and the subsequent laboratory and microbiological investigation.

THERAPY

A prerequisite for successful therapy is the early initiation of an antimicrobial pathogen-specific treatment and the surgical alleviation of the joint.

Septic Arthritis: An Evidence-Based Review of Diagnosis and Image-Guided Aspiration

OBJECTIVE. The purpose of this evidence-based review is to equip radiologists to discuss and interpret findings obtained with various imaging modalities, guide patient selection for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both native and prosthetic joints. CONCLUSION. Septic arthritis is an emergency that can lead to rapidly progressive, irreversible joint damage. Despite the urgency associated with this diagnosis, there remains a lack of consensus regarding many aspects of the management of native and periprosthetic joint infections.

Patients with surgically treated culture-negative native joint septic arthritis have less severe disease and better outcomes

Background: Patients with culture-negative septic arthritis patients are often treated surgically but might be successfully managed medically. We compared clinical characteristics and outcomes in patients with culture negative and culture positive native joint monoarticular septic arthritis.Methods: This retrospective study included all patients age ≥18 years admitted to a single, tertiary-care hospital between 1998 and 2015 with native joint monoarticular SA and treated with antibiotics and surgery.Results: Of 306 patients, 85 had negative and 221 had positive cultures. Mean C-reactive protein (p < .01) and mean percentage of peripheral polymorphonuclear cells (p = .01) were higher in culture-positive patients who had higher intensive care unit admission rates (16.7% vs. 4.7%, respectively, [p < .01]), longer length of hospital stay (11.4 vs. 7.1 days, respectively, [p < .01]) and higher mortality rates within 30 days (0% vs. 5.5%, respectively,[p = .02]). Of culture-negative patients, 28.6% received an alternative diagnosis within one year. Logistic regression models showed that culture positive patients had an adjusted odds ratio for length of stay of 4.5 (2.69, 7.51), intensive care unit admission of 5.76 (1.31, 25.22), discharge to rehabilitation of 4.7 (2.28, 9.71) and an alternative diagnosis within one year of 0.05 (0.02, 0.15) compared to culture negative patients.Conclusion: Patients with culture-negative native joint septic arthritis had less severe disease, better outcomes and higher rates of alternative diagnosis within one year than patients with positive cultures.

Secondary purulent infections of the elbow joint: a retrospective, single-center study

Background

Septic arthritis of the elbow joint is a rare condition. Limited data is available on infections of the elbow joint following trauma or prior surgery on this joint. The aim of this study was to describe the etiology, comorbidities, bacterial spectrum and therapy of secondary purulent elbow infections.

Methods

Patients treated in our hospital were selected through retrospective chart review between 2006 and 2015. We included all patients with an empyema of the elbow after a trauma or surgical intervention on this joint. 30 patients between 26 and 82 years (mean: 52.47) were included.

Results

Seven patients (23.3%) were female, 23 (76.7%) male. 22 patients (73.3%) had a history of trauma, eight (26.7%) had prior elective surgeries on their elbow. Between one and 25 surgeries (mean: 5.77) were necessary for treatment. In nine patients, debridement and synovectomy were sufficient, eight patients (26.7%) received resection of the elbow joint. One patient was treated with a chronic fistula. In 18 patients (60%), cultures of aspiration/intraoperative swabs were positive for Staphylococcus aureus, four of these were methicillin-resistant. Four patients (13.3%) had positive cultures for Staphylococcus epidermidis, in five patients (16.7%) no bacteria could be cultured.

Conclusions

Secondary infections of the elbow joint are a rare disease with potentially severe courses, requiring aggressive surgical treatment and possibly severely impacting elbow function. Staphylococcus aureus was the most common bacteria in secondary infections and should be addressed by empiric antibiotic treatment when no suspicion for other participating organisms is present.

Epidemiology, Management, and Outcomes of Large and Small Native Joint Septic Arthritis in Adults

Background

Native joint septic arthritis (NJSA) is poorly studied. We describe the epidemiology, treatment, and outcomes of large joint NJSA (LNJSA) and small joint NJSA (SNJSA) in adults at Middlemore Hospital, Auckland, New Zealand.

Methods

This was a coding-based retrospective study of patients ≥16 years old admitted between 2009 and 2014. Prosthetic joint infections were excluded.

Results

Five hundred forty-three NJSA episodes were included (302 LNJSA, 250 SNJSA). Only 40% had positive synovial fluid culture. Compared to SNJSA, LNJSA has higher incidence (13 vs 8/100 000 person-years [PY]), occurs in older, more comorbid patients, and is associated with greater rates of treatment failure (23% vs 12%) and mortality, despite longer antibiotic treatment. Total incidence is higher than previously reported (21/100 000 PY), with marked interethnic variation. Incidence rises with age (LNJSA only) and socioeconomic deprivation (LNJSA and SNJSA). Tobacco smokers and males are overrepresented. The most commonly involved joints were knee (21%) and hand interphalangeal (20%). Staphylococcus aureus was the most common pathogen (53%). Mean antibiotic duration was 25 days for SNJSA and 40 days for LNJSA, and the mean number of surgical procedures was 1.5 and 1.6, respectively. Treatment failure was independently associated with LNJSA, age, intra-articular nonarthroplasty prosthesis, and number of surgical procedures.

Conclusions

This is the largest contemporary series of adult NJSA. SNJSA has better outcomes than LNJSA and may be able to be safely treated with shorter antimicrobial courses. Incidence is high, with significant ethnic and socioeconomic variation. Microbiological NJSA case ascertainment underestimates case numbers as it frequently excludes SNJSA.

Bacteriological profile of community-acquired musculoskeletal infections: a study from Queensland

BACKGROUND

The purpose of this study was to determine bacteriology of community-acquired musculoskeletal infections requiring hospitalization and to compare this with published national and international data. This will help treating physicians select the appropriate antibiotic.

METHODS

All patients who underwent surgical procedures for community-acquired musculoskeletal infections over a period of 22 months were included in the study. Hospital acquired infections, post-operative infections and infections involving prosthetic joints were excluded. Patient characteristics, treatment details, cultured organisms and their antibiotic sensitivity were recorded.

RESULTS

Forty-five patients with 46 cases met the inclusion criteria. Ten patients were from paediatric age group. Soft tissue infections were the most common diagnosis and accounted for 20 cases. The remainder were septic arthritis (n = 17) and osteomyelitis (n = 9). Thirteen patients (28.3%) had negative cultures from the operative samples. Staphylococcus aureus was the most common isolated organism overall accounting for 23 cases (69.7%). Methicillin-resistant S. aureus (MRSA) sensitive to vancomycin was cultured in four adult cases (12.1%), of which three were hand infections (50%). For the entire cohort, 67.7% and 61.3% isolates that were tested were sensitive to cefazolin and flucloxacillin, respectively.

CONCLUSION

The bacteriological profile in this study is consistent with European and Australian data. While the overall MRSA infection rate was low, it was much higher among hand infections and is comparable to reports from the USA. Flucloxacillin and cefazolin should be considered as the first line of antibiotic therapy for all cases. Vancomycin should be considered when MRSA is suspected.

A retrospective study of joint infections in patients with systemic lupus erythematosus

The aim of this study was to analyze the clinical characteristics of systemic lupus erythematosus (SLE) patients with joint infections. We retrospectively reviewed the medical records of 11,734 SLE patients admitted to Peking Union Medical College Hospital (PUMCH) from January 1990 to December 2016. Twenty patients who developed joint infections were identified. Subjects without joint infections (designated as control patients) were selected from the pool of SLE patients using a 1:4 systematic sampling method. The median disease duration from SLE onset to joint infection was 23 months (range 4 to 156 months). The symptoms of patients with joint infections manifested as joint pain (all cases), swelling (14 cases), and fever (15 cases). All patients had oligo-arthritis, and the knee was the joint most commonly affected joint. There were 7 patients in the Salmonella group and 5 in the Staphylococcus aureus group. One patient was infected with Streptococcus, and 7 patients were infected with Mycobacterium. SLE patients with and without joint infections demonstrated significant differences (P < 0.05) regarding the following symptoms: pre-existing arthritis (65.0 vs 33.8%), gastrointestinal involvement (5.0 vs 26.3%), cardiac damage (5.0 vs 31.3%), elevated C-reactive protein (CRP) (80.0 vs 22.5%), and elevated SLE Disease Activity Index (SLEDAI) score (≥5) (30.0 vs 77.5%). When an SLE patient presents with pre-existing arthritis and suddenly develops asymmetric oligo- or large-joint swelling and pain with elevated CRP levels and low disease activity, joint infections should be considered. Early treatment could protect the joint and improve functional outcomes.

Rheumatoid arthritis: Recent advances on its etiology, role of cytokines and pharmacotherapy

An autoimmune disease is defined as a clinical syndrome resulted from an instigation of both T cell and B cell or individually, in the absence of any present infection or any sort of distinguishable cause. Clonal deletion of auto reactive cells remains the central canon of immunology for decades, keeping the role of T cell and B cell aside, which are actually the guards to recognize the entry of foreign body. According to NIH, 23.5 million Americans are all together affected by these diseases. They are rare, but with the exception of RA. Rheumatoid arthritis is chronic and systemic autoimmune response to the multiple joints with unknown ethology, progressive disability, systemic complications, early death and high socioeconomic costs. Its ancient disease with an old history found in North American tribes since 1500 BCE, but its etiology is yet to be explored. Current conventional and biological therapies used for RA are not fulfilling the need of the patients but give only partial responses. There is a lack of consistent and liable biomarkers of prognosis therapeutic response, and toxicity. Rheumatoid arthritis is characterized by hyperplasic synovium, production of cytokines, chemokines, autoantibodies like rheumatoid factor (RF) and anticitrullinated protein antibody (ACPA), osteoclastogensis, angiogenesis and systemic consequences like cardiovascular, pulmonary, psychological, and skeletal disorders. Cytokines, a diverse group of polypeptides, play critical role in the pathogenesis of RA. Their involvement in autoimmune diseases is a rapidly growing area of biological and clinical research. Among the proinflammatory cytokines, IL-1α/β and TNF-α trigger the intracellular molecular signalling pathway responsible for the pathogenesis of RA that leads to the activation of mesenchymal cell, recruitment of innate and adaptive immune system cells, activation of synoviocytes which in term activates various mediators including tumour necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), interleukin-6 (IL-6) and interleukin-8 (IL-8), resulting in inflamed synovium, increase angiogenesis and decrease lymphangiogensis. Their current pharmacotherapy should focus on their three phases of progression i.e. prearthritis phase, transition phase and clinical phase. In this way we will be able to find a way to keep the balance between the pro and anti-inflammatory cytokines that is believe to be the dogma of pathogenesis of RA. For this we need to explore new agents, whether from synthetic or natural source to find the answers for unresolved etiology of autoimmune diseases and to provide a quality of life to the patients suffering from these diseases specifically RA.

Septic Arthritis of Native Joints

Septic arthritis is a rheumatologic emergency that may lead to disability or death. Prompt evacuation of the joint, either by arthrocentesis at the bedside, open or arthroscopic drainage in the operating room, or imaging-guided drainage in the radiology suite, is mandatory. Methicillin-resistant Staphylococcus aureus (MRSA) has become a major cause of septic arthritis in the United States. MRSA joint infection seems to be associated with worse outcomes. Antibiotic courses of 3 to 4 weeks in duration are usually adequate for uncomplicated bacterial arthritis. Treatment duration should be extended to 6 weeks if there is imaging evidence of accompanying osteomyelitis.

Pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) syndrome: differential diagnosis of septic arthritis by regular detection of exceedingly high synovial cell counts

Pyogenic arthritis, pyoderma gangrenosum and acne syndrome was diagnosed in a 42-year-old patient, after an unusual persistency of high synovial cell counts had been noticed. Clinical peculiarities and problems with diagnosing septic versus non-septic arthritis are discussed.

Retrospective evaluation of the efficacy of isolating bacteria from synovial fluid in dogs with suspected septic arthritis

OBJECTIVE

To evaluate the efficacy of synovial fluid culture in obtaining the causative organism from dogs with suspected septic arthritis.

METHODS

In this retrospective evaluation, synovial fluid cytology and microbiology submissions from dogs with suspected septic arthritis from March 2007 to August 2011 were reviewed. Synovial fluid cytology consistent with joint sepsis was identified. Cultures of synovial fluid from dogs with clinical histories and abnormalities consistent with septic arthritis were used to evaluate the efficacy of bacterial isolation.

RESULTS

In total, 36 dogs met the inclusion criteria. Initial aerobic cultures of joint fluid yielded bacterial growth in 44% of these dogs. All anaerobic cultures were negative. In 19% of the dogs with positive cultures, antibiotics had been administered prior to arthrocentesis compared with 10% of dogs with negative cultures. There was no association between culture efficacy and the administration of antimicrobial treatment prior to synovial fluid culture or recent surgery involving the affected joint (P=0.637 and P=0.106, respectively).

CONCLUSION

Culture of synovial fluid from dogs with suspected septic arthritis has a low yield, necessitating a more effective means of identifying bacteria from suspected septic joints in dogs.

Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management

Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.

Infections and arthritis

Bacteria, viruses, fungi, and parasites can all cause arthritis of either acute or chronic nature, which can be divided into infective/septic, reactive, or inflammatory. Considerable advances have occurred in diagnostic techniques in the recent decades resulting in better treatment outcomes in patients with infective arthritis. Detection of emerging arthritogenic viruses has changed the epidemiology of infection-related arthritis. The role of viruses in the pathogenesis of chronic inflammatory arthritides such as rheumatoid arthritis is increasingly being recognized. We discuss the various causative agents of infective arthritis and emphasize on the approach to each type of arthritis, highlighting the diagnostic tests, along with their statistical accuracy. Various investigations including newer methods such as nucleic acid amplification using polymerase chain reaction are discussed along with the pitfalls in interpreting the tests.

Risk factors for failure of a single surgical debridement in adults with acute septic arthritis

BACKGROUND

Acute septic arthritis in a native joint may require more than one surgical debridement to eradicate the infection. Our objectives were to determine the prevalence of failure of a single surgical debridement for acute septic arthritis, to identify risk factors for failure of a single debridement, and to develop a prognostic probability algorithm to predict failure of a single surgical debridement for acute septic arthritis in adults.

METHODS

We collected initial laboratory and medical comorbidity data of 128 adults (132 native joints) with acute septic arthritis who underwent at least one surgical debridement at our institution between 2000 and 2011. Univariate and logistic regression analyses were used to identify potential risk factors for failure of a single surgical debridement. Stepwise variable selection was used to develop a prediction model and identify probabilities of failure of a single surgical debridement.

RESULTS

Of the 128 patients (132 affected joints) who underwent surgical debridement for acute septic arthritis, forty-nine (38%) of the patients (fifty joints) experienced failure of a single debridement and required at least two debridements (range, two to four debridements). Staphylococcus aureus was the most common bacterial isolate (in sixty, or 45%, of the 132 joints). Logistic regression analysis identified five independent clinical predictors for failure of a single surgical debridement: a history of inflammatory arthropathy (odds ratio [OR], 7.3; 95% confidence interval [CI], 2.4 to 22.6; p < 0.001), the involvement of a large joint (knee, shoulder, or hip) (OR, 7.0; 95% CI, 1.2 to 37.5; p = 0.02), a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L (OR, 4.7; 95% CI, 1.8 to 17.7; p = 0.002), S. aureus as the bacterial isolate (OR, 4.6; 95% CI, 1.8 to 11.9; p = 0.002), and a history of diabetes (OR, 2.6; 95% CI, 1.1 to 6.2; p = 0.04).

CONCLUSIONS

Most (62%) of the septic joints were managed effectively with a single surgical debridement. Adults with a history of inflammatory arthropathy, involvement of a large joint, a synovial-fluid nucleated cell count of >85.0 x 10(9) cells/L, an infection with S. aureus, or a history of diabetes had a higher risk of failure of a single surgical debridement for acute septic arthritis and requiring additional surgical debridement(s).

Predictive value of the usual clinical signs and laboratory tests in the diagnosis of septic arthritis

OBJECTIVE

To determine the sensitivity and specificity of clinical and laboratory signs for the diagnosis of septic arthritis (SA). Patients and methods This prospective study included all adult patients with suspected SA seen in the emergency department or rheumatology department at the University Hospital, Clermont-Ferrand, France, over a period of 18 months.

RESULTS

In total, 105 patients with suspected SA were included, 38 (36%) presenting with SA (29 [28%] with bacteriologically documented SA). In the univariate analysis, chills (p=0.015), gradual onset (p=0.04), local redness (p=0.01), as well as an entry site for infection (p=0.01) were most often identified in SA. A history of crystal-induced arthritis (p=0.004) was more frequent in non-SA cases. An erythrocyte sedimentation rate (ESR)>50 mm (p=0.005), a C-reactive protein (CRP) level >100 mg/L (p=0.019), and radiological signs suggestive of SA (p=0.001) were more frequent in the SA cases. Synovial fluid appearance: purulent (p50,000/μL (p < 0.001), differentiated between SA and non-SA. In multivariate analysis, only chills (odds ration [OR]=4.7, 95% confidence interval [CI] 1.3-17.1), a history of crystal-induced arthritis (OR=0.09, 95% CI 0.01-0.9), purulent appearance of the joint fluid (OR=8.4, 95% CI 2.4-28.5), synovial WBC count >50,000/mm3 (OR=6.8, 95% CI 1.3-36), and radiological findings (OR=7.1, 95% CI 13-37.9) remained significant.

CONCLUSION

No clinical sign or laboratory test (excluding bacteriological test), taken alone, is conclusive for the differentiation between SA and non-SA, but the association of several signs, notably chills, history of crystal-induced arthritis, radiological findings, and the appearance and cellularity of joint fluid may be suggestive.

Septic arthritis due to methylcyllin-resistant Staphylococcus aureus in adults

INTRODUCTION

Septic arthritis due to methylcyllin resistant Staphylococcus aureus (MRSA) is a serious infection that has increased in incidence in the past 10years.

METHODS

We conducted a retrospective study (1984-2011) in which a description of the clinical and epidemiological characteristics of MRSA arthritis in adults was performed and then compared to native joint infections caused by MRSA vs. methylcyllin sensitive Staphylococcus aureus (MSSA).

RESULTS

Fourteen MRSA infections were included (7 native joint, 5 prosthetic and 2 bursae). No case was polyarticular. There was significant comorbidity, although none was associated to rheumatoid arthritis. Seven patients had bacteremia. Four required surgical treatment. Six died. When comparing the 7 patients with native joint MRSA infection with the 17 cases caused by MSSA, no significant differences in risk factors were seen, except more malignancies in the MRSA group. The infection was polyarticular in 7 cases (41%) of the MSSA group. Bacteremia was more frequent in the MRSA group (71.4 vs 58.8%). Empirical antibiotic was useful in 28.6% of MRSA cases versus 100% of MSSA cases. There was a greater tendency to associated mortality in MRSA arthritis (57.1% vs 17.6%, P=.07).

CONCLUSIONS

MRSA septic arthritis is a serious condition that occurs in the elderly and patients with high comorbidity. It is usually monoarticular, with positive blood cultures and higher mortality than MSSA arthritis. In patients at risk, vancomycin empiric antibiotic therapy is indicated.

A retrospective study of septic arthritis in a tertiary hospital in West Texas with high rates of methicillin-resistant Staphylococcus aureus infection

Septic arthritis is an important concern for rheumatologists in the evaluation of joint disease. Very few studies have addressed the microbiologic epidemiology and outcomes of septic arthritis in the USA since the year 2000. We performed a retrospective study of septic arthritis in a tertiary hospital in West Texas from the year 2000 to 2013. We recorded data on patient demographics, microbiologic etiology, treatment patterns, and outcomes. The most common causative organisms were Staphylococcus aureus and Streptococcus spp. Methicillin-resistant Staphylococcus aureus (MRSA) caused septic arthritis in 22.6 % of the cases. MRSA septic arthritis was associated with low rates of adequate empiric antimicrobial therapy. The mortality due to sepsis in our study was 5.5 %. Patients with septic arthritis had a mean length of stay of 13.5 ± 12.1 days and required 2.1 ± 1.4 joint operations. Many patients (29.2 %) had readmissions due to complications, and these patients had high rates of home health utilization and transfers to other facilities post hospital discharge. In our logistic regression analysis model, factors associated with poor outcomes in septic arthritis were MRSA, older age, and prosthetic joint infection. Septic arthritis is associated with significant mortality, morbidity, and health care costs, and more studies are needed to improve outcomes, especially considering the increasing rates of MRSA as the pathogen.

High Prevalence of Methicillin-Resistant Staphylococcus aureus among Patients with Septic Arthritis Caused by Staphylococcus aureus

BACKGROUND

This study investigated the clinical characteristics of patients with septic arthritis caused by Staphylococcus aureus and tried to identify the risk factors for methicillin-resistant S. aureus (MRSA) arthritis.

METHODS

Between January 2008 and December 2011, patients with septic arthritis caused by S. aureus were identified from the computerized databases of a regional hospital and a medical center in southern Taiwan. The medical records of these patients were retrospectively reviewed.

RESULTS

A total of 93 patients with S. aureus arthritis were identified, and MRSA arthritis was found in 38 (40.9%) cases. The mean age of the patients was 58 years, and 86 (92.5%) episodes were classified as community-acquired infections. Diabetes mellitus (n = 41, 44.1%) was the most common underlying disease, followed by chronic kidney disease and liver cirrhosis. Patients with MRSA arthritis were more frequently elderly and found in the setting of healthcare-associated infection than patients with methicillin-susceptible S. aureus (MSSA) infections. No other significant differences in clinical manifestations and outcomes were noted between these two groups of patients. Overall, the in-hospital mortality rate was 5.4%, and diabetes mellitus was the only risk factor for mortality.

CONCLUSIONS

MRSA is emerging in the setting of community-acquired septic arthritis. MRSA septic arthritis is more likely to develop in the elderly and in healthcare-associated infections than MSSA septic arthritis.

Propionibacterium acnes infections in shoulder surgery

Perioperative shoulder infections involving Propionibacterium acnes can be difficult to identify in a patient who presents with little more than pain and stiffness in the postoperative period. Although indolent in its growth and presentation, infection of the shoulder with P acnes can have devastating effects, including failure of the surgical intervention. This article reviews the importance of a comprehensive physical, radiologic, and laboratory evaluation, and discusses appropriate preventive and treatment strategies for P acnes infections of the shoulder.

Clinical guidelines for the antimicrobial treatment of bone and joint infections in Korea

There are many various diseases in the bone and joint infections, and we tried to make antimicrobial treatment guidelines for common infectious diseases based on available data for microbiology and clinical trials. This guidelines focused on the treatment of osteomyelitis and septic arthritis, which can be experienced by physicians at diverse clinical settings. This guidelines is not applicable to diabetic foot infections, postoperative infections or post-traumatic infections which need special considerations. The guidelines for those conditions will be separately developed later. Surgical treatment of bone and joint infections, pediatric bone and joint infection, tuberculous bone and joint infection, and prophylactic antibiotic use were not included in this guideline.

Indicators for detection of septic arthritis in the acutely swollen joint cohort of those without joint prostheses

Differentiating septic arthritis from culture-negative, acute atraumatic joint effusion is difficult. Studies have attempted to elucidate factors that herald infection, but, due to overlap, most conclude that the diagnosis ultimately relies on clinical judgment. Furthermore, studies are limited by broad inclusion criteria. The current retrospective case study sought to examine (1) which markers differentiate a culture-positive septic joint from culture-negative effusion in patients suspicious for infection despite no growth on Gram stain and without previous surgery in the affected joint and (2) whether threshold values of these markers exist that predict septic arthritis. The study was performed by reviewing records of those who underwent operative irrigation and debridement involving the shoulder, elbow, wrist, hip, knee, and ankle. Patients were included if they were older than 18 years and had an acutely swollen/painful joint and no organisms on initial Gram stain. Exclusion criteria were lack of serum markers or synovial fluid aspirate, antibiotics within 1 week, adjacent wound or skin infection, recent trauma to the joint, and previous joint infection or surgery to the joint. Several clinical, serological, and synovial parameters were collected and analyzed using paired t test with Bonferonni correction. Serum C-reactive protein was the only significantly different variable between groups. Serum C-reactive protein greater than 10.5 mg/dL was predictive of infection. In those suspicious for infection despite no growth on Gram stain and without previous surgery in the affected joint, C-reactive protein greater than 10.5 mg/dL is suspicious for joint sepsis and should warrant consideration for urgent irrigation and debridement.