Septic Arthritis Dr.noori/Rheumatologist

1. Septic Arthritis Dr.noori/Rheumatologist

2. Infectious Arthritis Septic Gonococcal Viral Fungal Tuberculous Lyme

3. Definition • Acute joint infection due to bacterial agents • Medical emergency

4. Epidemiology • Incidence: • 40-68/100000/ yr in Prosthetic joint • 28-38/ 100000/ yr in RA • 5- 12/ 100000/ yr in Children • 2-5/ 100000/ yr in GP

5. SEPTIC ARTHRITIS • Infection of synovium and synovial fluid • Seen in every ages • Hip joint in children • Knee in adults } frequent

6. In Adult: 75% with risk factor

7. Risk factors: • Systemic: • Old age (>65 Y) • RA • DM • Immunosuppressive • Hemodyalisis • Malignancy • Local: • RA • OA • Prosthetic joint

8. Etiology (microbiology) • Microbial agent: • Staphylococcus aureus: most common (75-80%) • Other organism in special patients: • Sexually active woman: Neisseria gonorrheae • Elderly, IV drug abuser, immunocompromised, UTI: Gram negative (p. aeruginosa and E.coli) • SLE: Salmonella • HIV:Pneumococci, Salmonella, H. influenzae • Alcoholism, Humeral immunity abnormality, Hemoglobinopathies:Pneumococcal infections • Primary immunoglobolin deficiency: Mycoplasma

9. ETIOLOGY • S. aureus →in every ages • H. influenzae →6 mo-5 years • N. gonorrhoeae → >10 years, adults (in Western populations) • Gram negative bacilli →Immune deficiency, urinary or intestinal invasive procedures, elderly people, renal failure, chronic joint disorders and diabetes

10. PATHOGENESIS • Hemotogenous spread • Spread through adjacent tissues • Direct inoculation(aspiration/arthrotomy) *Rheumatic diseases are underlying disorders for septic arthritis -Structural abnormalities in the joint -Steroid use (abnormal phagocytosis…) *DM, immune def, hematological diseases, trauma, systemic infections…

12. Site of involvement: • Mono (80-90%) • Knee: 50% • Hip: 13-20% • Shoulder:10-15 %- • Ankle: 5% • Wrist: 5% • Elbow: 5% • SC: 5%- IV drug abuser • SI: 2%- IV drug abuser • Small joints of the hand andFoot : 2% • Poly (more than 1 joint): RA

13. CLINICAL FEATURES • Usually, there is a history of recent trauma/infection • Frequently hip and knee joints • Sacroiliac joint is affected in brucellosis • Interphalangeal joints: human and animal bites • Fever, fatigue, anorexia, nausea… • Local findings of inflammation

14. Clinical manifestations • Fever (toxic):60-80% • Acute • Sever pain • Sever swelling of one joint • Sever tenderness • Warmth • Sever effusion • Sever limited ROM

15. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS • Synovial fluid sampling: >50.000 leukocytes/ml (crystal arthropathies and RA) • Leukocytes <50.000/ml (Malignancy, steroid use) • Gram staining and culture • Gram-positive bacteria 60%, Gram-negative bacteria 40%

17. Diagnosis Acute Monoarthritis Sepsis workup Biochemist Synovial Fluid Aspiration (rule)

21. کنتراندیکاسیونهای آرتروسنتز • سلولیت بروی مفصل مورد نظر • عفونت پوست مفصل • پلاکهای پسوریازیس بروی مفصل • باکتریمی(نسبی) • مصرف داروهای ضد انعقاد

22. Acute Monoarthritis Sepsis workup Biochemist Synovial Fluid Aspiration Light microscope Smear- Culture

23. Acute Monoarthritis Sepsis workup Biochemist Synovial Fluid Aspiration Light microscope Smear- Culture Turbid - Purulent Leukocyte> 50,000/ml (> 90% PMN) Damaged WBC Crystal (-)

25. مایع مفصل سپتیک در 3 مورد WBCخیلی بالا نیست : • 1)بیماران ایمنوساپرس • 2)مصرف آنتی بیوتیک • 3)اوایل عفونی شدن مفصل

26. Acute Monoarthritis Sepsis workup Biochemist Synovial Fluid Aspiration Light microscope Smear- Culture Positive Gram stain: 75% in s. aureus 30-50% in gram (-) Positive Fluid culture: 90% PCR: partially treated or culture negative

27. Acute Monoarthritis Sepsis workup Biochemist Synovial Fluid Aspiration Positive B/C: 50-70% Light microscope Smear- Culture Leukocytosis ESR & CRP Positive Gram stain: 75% in s. aureus 30-50% in gram (-) Positive Fluid culture: 90% PCR: partially treated or culture negative

28. Radiography • Early:(1-7d) • (baseline/exclude contiguous osteomyelitis) • Soft tissue swelling Joint space widening • Late (2-3 w): • Erosion • Joint space narrowing • Periosteal new bone formation

32. DIFFERENTIAL DIAGNOSIS • Rheumatic fever • Acute juvenile arthritis • RA, gout, reactive arthritis • Viral arthritis • Fungal arthritis • Tuberculous arthritis • Osteomyelitis • Cellulitis • Bleeding into the joint (hemarthrosis)

33. TREATMENT Antibiotic Joint Drainage

34. TREATMENT Antibiotic Joint Drainage Empiric (IV): Smear Age or Risk factors Extra articular site

35. Empirical antibiotic • Gram stain result: • Gram positive cocci: • Oxacillin or Naficillin (2g /q 4h) • Vancomycin (1g /q 12h) if methycillin-resistant S. aureus • Gram Negative: • Ampicillin or Cephalosporin • No organism: • In healthy, sexually active: Cefotaxime or ceftriaxone • In elderly debilitated patients: antistaphylococcal + Aminoglycoside + antipseudomonal penicillin or a third generation cephalosporin

36. TREATMENT Antibiotic Joint Drainage Empiric (IV): Smear Age or Risk factors Extra articular site Definitive therapy; based on culture

37. Definitive therapy • S. aureous:4 weeks • Oxacillin • Naficillin • Vancomycin • Pneumococal and streptococcal inf :2 weeks • Penicillin G, 2mU /q 4h • H. influenzae and s. pneumoniae resistant to penicillin: 2 weeks • Cefotaxime or Ceftriaxone • Enteric gram negative: 3-4 w • Second or Third Gen cephalosporin • Fluoroquinolone (levofloxacin 500mg IV or Po every 24h) • P. aeruginosa: 4 weeks • Combination of AG + mezlocillin or ceftazidime (IV) 2 weeks • Ciprofloxacin 750mg twice daily (oral) 2 weeks

38. TREATMENT Antibiotic Joint Drainage Empiric (IV): Smear Age or Risk factors Extra articular site Closed needle Aspiration Arthrotomy: Hip, Shoulder Definitive therapy; based on culture

39. TREATMENT Antibiotic Joint Drainage Empiric (IV): Smear Age or Risk factors Extra articular site Closed needle Aspiration Arthrotomy: Hip, Shoulder Arthroscopic Drainage: Symptom S. fluid volume S. fluid WBC S. fluid smear & culture Definitive therapy; based on culture

40. TREATMENT Antibiotic Joint Drainage No weight bearing Frequent passive motion Until removal of inflammation signs