Group B streptococcus is the most common pathogen for septic arthritis with unique clinical characteristics: data from 12 years retrospective cohort study

Group B streptococcus — a pathogen not restricted to neonates

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Invasive group B streptococcal (GBS) infections can occur in any age group, not only neonates.

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Most of the patients are elderly or have severe concomitant diseases.

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Screening-based intrapartum antibiotic prophylaxis (based on maternal risk factors) significantly decreases very early-onset infections.

Objectives

This was a retropective study of invasive group B streptococcal (GBS) infections isolated from blood, cerebrospinal fluid (CSF), synovial fluid, peritoneal fluid, pleural fluid, pericardial fluid and corpus vitreum in a defined region in southwest Sweden over a 14-year period.

Design

Information on all invasive GBS infections was obtained from all four bacteriological laboratories in the region, with data obtained from individual patient records.

Results

GBS was isolated from normally sterile body fluids in 1244 samples (579 from females and 665 from males) from 1101 patients. Of these patients, 196 were neonates. The incidence in neonates (0–27 days) was 7.3 per 100 000 live births per year, but there was a significant decrease from 2012 when risk-factor-based intrapartum antibibiotic prophylaxis was implemented. The great majority of neonatal infections were very early-onset infections. The incidence rates in children (28 days to 17 years), adults (18–64 years) and elderly patients (≥ 65 years) were 1.3, 3.6, and 12.9 per 100 000 per year, respectively. The majority of children and adults had severe underlying diseases, but severe infections were also seen in individuals with no risk factors.

Conclusions

GBS is an important pathogen in all age groups. Intrapartum antibiotic prophylaxis significantly decreases very early-onset infections.

Lumbar osteomyelitis and knee septic arthritis caused by Streptococcus agalactiae bacteraemia

A man in his late 70s presented to the emergency department endorsing a week of malaise. He was recently hospitalised for 2 days for new back pain and was discharged with non-opioid pain medications but continued to seek care as he felt unwell. On presentation, he was afebrile with a leukocytosis. Physical examination revealed a painful left knee with no evidence of trauma. Arthrocentesis revealed purulent fluid with elevated white blood cell consistent with septic arthritis. He was started on broad-spectrum antibiotics and underwent irrigation and synovectomy of the left knee. Aspirate and blood cultures grew Streptococcus agalactiae Transthoracic echocardiogram showed no vegetations; however, an MRI of lumbar spine showed L2-L3 and L4-L5 osteomyelitis. He was treated with intravenous ceftriaxone for 3 weeks and then oral levofloxacin for 3 weeks, for a total 6 week course of antibiotics.

Diffuse-Type Tenosynovial Giant Cell Tumor of the Knee with Concurrent Polymicrobial Infection (Klebsiella oxytoca and Group B Streptococcus)

Tenosynovial giant cell tumors (TGCT) are a rare class of benign proliferative tumors that are classified according to their presentation: localized-type (L-TGCT) or diffuse-type (D-TGCT). TGCT is synonymous with pigmented villonodular synovitis (PVNS). We describe the unique case of a 56-year-old obese male with type 2 diabetes who had polymicrobial septic arthritis of his left knee joint with concurrent D-TGCT in the same knee. While on a vacation, he noticed spontaneous left knee pain and swelling with an acute onset of fever. He was diagnosed with septic arthritis that was attributed to hematogenous spread from a leg laceration. The septic arthritis was treated with arthroscopic lavage and debridement, including simultaneous excision of the D-TGCT lesions, followed by intravenous ceftriaxone. Cultures of the synovial tissue that were obtained during arthroscopy grew Klebsiella oxytoca and beta-hemolytic (group B) Streptococcus agalactiae. We were not able to find another reported case of any joint with (1) a polymicrobial bacterial infection that included Klebsiella oxytoca and (2) concurrent bacterial septic arthritis and TGCT.

Clinical manifestations and prognostic factors for Streptococcus agalactiae bacteremia among nonpregnant adults in Thailand

BACKGROUND

Streptococcus agalactiae infection in nonpregnant adults is an emerging disease with increasing burden. This study described epidemiologic, clinical characteristics, and treatment options among patients with S. agalactiae bacteremia, and determined the factors associated with mortality.

METHODS

Medical records from all adult patients with S. agalactiae isolated from blood cultures from 2006 to 2016 were retrospectively reviewed. Patients, who had mixed bacteremia, were transferred to other hospitals, or missing records were excluded from the study.

RESULTS

During the study period, S. agalactiae was isolated from 282 individuals. Increasing trend was observed, with peak incidence from May to July. Study criteria were met among 238 patients. Most patients (64%) had underlying medical conditions, with diabetes as the most common disease, followed by malignancy, chronic kidney disease and alcoholism. The most common manifestations were primary bacteremia, followed by arthritis, cellulitis, meningitis, osteomyelitis and endocarditis. Three patients had transient bacteremia. Thirty-day mortality was 16.4%, with age of ≥65 years, alteration of consciousness, absence of fever, high Pitt bacteremia score (≥4) and shock, as associating factors on univariate analysis. In a subgroup of patients with prolonged intravenous antibiotic, penicillin G treatment was identified as a protective factor against mortality. Multivariate analysis found independent associating factors of 30-day mortality were high Pitt bacteremia score and absence of fever.

CONCLUSION

S. agalactiae bacteremia in nonpregnant adults showed an increasing trend. High mortality was observed, especially among those with severe clinical manifestations at presentation. Penicillin G is still the drug of choice for the definite intravenous treatment.

Bilateral shoulder septic arthritis due to suspected bacterial endocarditis: A case report

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Septic arthritis of the shoulder is rare but potentially devastating. Bilateral shoulder septic arthritis is even more rare of a diagnosis.

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Patients can often present with unimpressive physical examination findings, so it is of utmost importance to keep septic arthritis as a differential diagnosis.

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It is paramount that patients be promptly treated with surgical intervention and the appropriate antibiotic therapy for preservation of life and limb, regardless of the chronicity or severity of the septic joint.

Introduction

Septic arthritis is an orthopedic emergency that requires rapid diagnosis and treatment. It is typically caused by occult bacteremia which allows bacteria to seed the joint or local invasion of a soft tissue infection. Most cases of septic arthritis are caused by gram-positive bacteria, with the most common culprit being Staphylococcus Aureus. The reason septic arthritis is an orthopedic emergency is because of rapid destruction to cartilage. The mechanism of injury to cartilage is two-fold: bacterial enzymes are directly toxic to joint cartilage, and buildup of exudate can tamponade blood flow and cause anoxic injury. Typically, the knee is the most commonly involved joint. This is followed by the hip, ankle, elbow, wrist, and shoulder in descending order of occurrence. Polyarticular disease makes up a small percentage of these cases and if present, it is usually asymmetric and will involve at least one knee joint.

Presentation of case

Bilateral joint septic arthritis is relatively rare. We present an uncommon case of atraumatic bilateral septic shoulders in an elderly man with a history of heart disease and insidious bilateral shoulder pain after golfing 18 holes. This presentation is unique not only in its rarity but also in its impact on our understanding of septic arthritis in the setting of medical comorbidities and a relatively unimpressive presentation. With a recent golfing day just prior to presentation, differential diagnoses other than septic arthritis included deltoid/rotator cuff muscle strain, acute on chronic rotator cuff tendinosis, acute on chronic rotator cuff tearing, acute flare up of osteoarthritis, rheumatoid arthritis, or crystalline arthropathy. With elevated inflammatory markers and an equivocal physical examination, our patient underwent advanced imaging via MRI and subsequent bilateral glenohumeral joint diagnostic aspirations that were consistent with septic arthritis due to his complaining of contralateral shoulder pain shortly after his admission. Immediately after said diagnosis was made, the patient was taken back for emergent bilateral open irrigation and debridement, as septic arthritis is an orthopedic emergency, and went on to recover appropriately on culture-directed intravenous antibiotic therapy.

Discussion/conclusion

This case report is impactful with regard to clinical practice for multiple reasons. First and foremost it is a cautionary tale for all clinicians with regard to the level of suspicion one must have for polyarticular septic arthritis in the setting of the multiply painful patient. Second, it demonstrates the utility of advanced imaging in the equivocal patient. Lastly, it underscores the importance of prompt diagnosis and treatment, validating the existing algorithm for septic arthritis.