SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Suspicion of septic arthritis should be pursued with arthrocentesis, and synovial fluid should be sent C 21-23 for white blood cell count, crystal analysis, Gram stain, and culture. In addition to antibiotic therapy, evacuation of purulent material is necessary in patients with septic C 48 arthritis; arthrocentesis and surgical methods are appropriate. Intraarticular white blood cell cutoff values for infection as low as 1,100 per mm3 (1.10 × 109 per L) C 66 with a neutrophil differential of greater than 64 percent can help diagnose prosthetic joint infection. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml.anti–tumor-necrosis-factor-α, which fur-ther increases the risk of infection twofold.15 Table 1. Risk Factors for Septic Arthritis Constitutional symptoms such as fever,chills, or rigors may be present in patients Contiguous spread Hematogenous spread (continued)with septic arthritis, although their sensitiv- Skin infection, cutaneous ulcers8,9 Immunosuppressive medication9,11ities are 57, 27, and 19 percent, respectively.6 Direct inoculation Intravenous drug abuse11A detailed review of systems should be per- Previous intraarticular injection8,10 Osteoarthritis9formed to exclude other forms of inflamma- Prosthetic joint: early and Other cause of sepsis9tory arthritis (Table 2 6,16). delayed8 (Table 6) Prosthetic joint: late8 (Table 6) Recent joint surgery8,10 Rheumatoid arthritis8,9PHYSICAL EXAMINATION Hematogenous spread Sexual activity (specifically forThe physical examination should determine Diabetes mellitus8,10 gonococcal arthritis)12if the site of inflammation is intraarticu- Human immunodeficiency virus Other factorslar or periarticular, such as a bursa or skin. infection11 Age older than 80 years8Generally, intraarticular pathology results in Information from references 8 through 12.severe limitation of active and passive rangeof motion, and the joint is often held in theposition of maximal intraarticular space.For example, a septic knee will be extended Table 2. Differential Diagnosis of Acute Arthritisfully. Conversely, pain from periarticularpathology occurs only during active range of Diagnosis Etiologymotion, and swelling will be more localized. Although septic arthritis is usually mono- Crystal-induced Calcium oxalate, gout, cholesterol, pseudogout, arthritis hydroxyapatite crystalsarticular, up to 20 percent of cases are oli- Infectious arthritis Bacteria, fungi, mycobacteria, spirochetes, virusesgoarticular.1 In native joints, the knee is the Inflammatory Behçet syndrome,* rheumatoid arthritis,* sarcoid,most commonly affected, followed by the arthritis systemic lupus erythematosus,* Still disease,*hip, shoulder, ankle, elbow, and wrist.3,4,17,18 seronegative spondyloarthropathy (e.g., ankylosingInfections of axial joints, such as the ster- spondylitis, psoriatic arthritis, reactive arthritis,noclavicular or sacroiliac joint, may occur; inflammatory bowel disease–related arthritis),however, they are more common in patients systemic vasculitis*with a history of intravenous drug abuse.11,19 Osteoarthritis Erosive/inflammatory variants* Other Amyloidosis, avascular necrosis, clotting disorders/LABORATORY EVALUATION anticoagulant therapy, familial Mediterranean fever,* foreign body, fracture, hemarthrosis,Serum markers, such as white blood cell hyperlipoproteinemia,* meniscal tear(WBC) count, erythrocyte sedimentation Systemic infection Bacterial endocarditis, human immunodeficiencyrate,10,17 and C-reactive protein levels,9 are virus infectionoften used to determine the presence of Tumor Metastasis, pigmented villonodular synovitisinfection or inflammatory response. Patientswith confirmed septic arthritis have been *—Not usually monoarticular.found to have normal erythrocyte sedimen- Information from references 6 and 16.tation rates and C-reactive protein levels.9654 American Family Physician www.aafp.org/afp Volume 84, Number 6 ◆ September 15, 2011
Septic ArthritisWhen elevated, these markers may be used to moni- pathogen, underlying medical conditions, or exposurestor therapeutic response. Because pathogenesis may (Table 4 7,18,20,31-34). Clinical presentations can be broadlybe hematogenous, blood cultures are positive in 25 to grouped into three categories: nongonococcal, gonococ-50 percent of patients with septic arthritis.1,9,20 cal, and other (e.g., Lyme disease, mycobacterial, fungal).SYNOVIAL FLUID ANALYSIS NONGONOCOCCAL ARTHRITISBecause the clinical presentation of septic arthritis may Septic arthritis is caused by nongonococcal patho-overlap with other causes of acute arthritis (Table 2 6,16), gens in more than 80 percent of patients.2 Nongono-arthrocentesis is needed to identify the causative coccal arthritis often affects older persons, is acute ininfectious agent. Synovial fluid should be evaluated nature, and is monoarticular in more than 80 percentat the bedside and then sent for WBC count with dif- of patients.12 Synovial fluid cultures are positive in moreferential, crystal analysis, Gram stain, and culture21-23 than 90 percent of patients with nongonococcal arthri-(Table 319-21,24-26). In synovial fluid, a WBC count of more tis, as opposed to blood cultures, which are positive inthan 50,000 per mm3 (50 × 109 per L) and a polymor- only 50 percent of patients.12,30phonuclear cell count greater than 90 percent have been Gram-positive staphylococci and streptococci are thedirectly correlated with infectious arthritis, although causative agents in the majority of bacterial arthritisthis overlaps with crystalline disease.1,6 Lower synovial cases in which an organism is identified,3 and are associ-fluid WBC counts may occur in persons with dissemi- ated with drug abuse, cellulitis, abscesses, endocarditis,nated gonococcal disease, peripheral leukopenia, or joint and chronic osteomyelitis.18 Staphylococcus aureus is thereplacement.6,19,22 Septic arthritis can coexist with crystal organism most commonly found in patients with septicarthropathy; therefore, the presence of crystals does not arthritis in the United States and other developed coun-preclude a diagnosis of septic arthritis.27 tries,30,35 and Streptococcus species is the next most com- Measuring synovial fluid glucose or protein is not use- mon.30,36 The presence of methicillin-resistant S. aureusful because results are neither sensitive nor specific for (MRSA) is an emerging clinical problem. Although dataseptic arthritis.6 Polymerase chain reaction (PCR) testing are mostly limited to case reports, the incidence of MRSAmay help isolate less common organisms, such as Borrelia ranges between 5 and 25 percent of bacterial arthritisspecies,24,25 and should be ordered if there is a high level cases, and tends to affect older persons, involve the shoul-of clinical suspicion. The sensitivities of synovial fluid, der, and the health care–associated MRSA strain.37,38Gram stain, and culture vary by pathogenic organism. Gram-negative bacilli represent approximately 14 to 19 percent of septic arthritis cases12,18 and are associ-IMAGING ated with invasive urinary tract infections, intravenousThere are no data on imaging studies that are pathogno- drug use, older age, compromised immune system,monic for acute septic arthritis. Plain films establish a and skin infections.18 The two most common gram-baseline and may detect fractures, chondrocalcinosis, or negative organisms detected in adults are Pseudomonasinflammatory arthritis. Ultrasonography is more sensi- aeruginosa and Escherichia coli.10,12,17,18 Historically, Hae-tive for detecting effusions, particularly in difficult-to- mophilus influenzae infection has occurred more oftenexamine joints, such as the hip.28 Magnetic resonance in children,2,39 although this may be tempered by wide-imaging findings that suggest an acute intraarticular spread H. influenzae type b vaccination.40infection include the combination of bone erosions with GONOCOCCAL ARTHRITISmarrow edema.29 Imaging may allow guided arthrocen-tesis, particularly in difficult-to-examine joints (e.g., Patients with disseminated Neisseria gonorrhoeae infec-hip, sacroiliac, costochondral). tion are usually young, healthy, and sexually active.30 Disseminated gonococcal infection may have variousOrganisms clinical musculoskeletal presentations, with or withoutAlmost any microorganism may be pathogenic in sep- associated dermatitis. Patients typically display a migra-tic arthritis. Bacterial causes of septic arthritis include tory pattern of arthralgias, tenosynovial inflammation,staphylococci (40 percent), streptococci (28 percent), or nonerosive arthritis.6,23,30 Blood cultures are seldomgram-negative bacilli (19 percent), mycobacteria (8 per- positive, and synovial fluid cultures are variable, with acent), gram-negative cocci (3 percent), gram-positive positive result in only 25 to 70 percent of patients withbacilli (1 percent), and anaerobes (1 percent).30 There are gonococcal arthritis.19,23 When a disseminated gonococ-various characteristic presentations depending on the cal infection is suspected, cultures should be taken fromSeptember 15, 2011 ◆ Volume 84, Number 6 www.aafp.org/afp American Family Physician 655
Table 3. Synovial Fluid Analysis PMN cellArthritis diagnosis Color Transparency Viscosity WBC count (per mm3) count (%) Gram stainNormal Clear Transparent High/thick 200 25 NegativeNoninflammatory Straw Translucent High/thick 200 to 2,000 25 NegativeInflammatory: Yellow Cloudy Low/thin 2,000 to 100,000 50 Negative crystalline diseaseInflammatory: Yellow Cloudy Low/thin 2,000 to 100,000 50 Negative noncrystalline diseaseInfectious: Lyme disease Yellow Cloudy Low 3,000 to 100,000 50 Negative (mean: 25,000)Infectious: gonococcal Yellow Cloudy-opaque Low 34,000 to 68,000 75 Variable ( 50 percent)Infectious: Yellow- Opaque Very low 50,000 ( 100,000 is 75 Positive (60 to nongonococcal green more specific) 80 percent)NOTE: These are general guidelines in the interpretation of synovial fluid. Many parameters vary widely and must be interpreted in the clinical context.Three bedside observations (color, transparency, and viscosity) are quick and easy to assess. With normal transparent fluid, words can be read clearlythrough the fluid. The words become less crisp and gradually obscured with increasing turbidity. Viscosity is assessed by observing the fluid droppingfrom the syringe. Normal viscosity has a long, stringy tail.PCR = polymerase chain reaction; PMN = polymorphonuclear; WBC = white blood cell.*—Crystalline disease can coexist with septic arthritis. A positive result does not exclude infection.Information from references 19 through 21, and 24 through 26.Table 4. Clinical Presentations of Septic ArthritisClinical history or exposure Joint involvement PathogenCleaning fish tank7,31 Small joints (fingers, wrists) Mycobacterium marinumDog or cat bite7,32 Small joints (fingers, toes) Capnocytophaga species, Pasteurella multocidaIngestion of unpasteurized dairy products7,32 Monoarticular: sacroiliac joint Brucella speciesIntravenous drug use 7,18,32 Axial joints, such as Pseudomonas aeruginosa, sternoclavicular or sacroiliac Staphylococcus aureusNail through shoe20 Foot P. aeruginosaSexual activity 32 Tenosynovial component in Neisseria gonorrhoeae hands, wrists, or anklesSoil exposure/gardening Monoarticular: knee, hand, Nocardia species, Pantoea or wrist agglomerans, Sporothrix schenckiiSoil or dust exposure containing decomposed wood Monoarticular: knee, ankle, Blastomyces dermatitidis (north-central and southern United States) or elbowSouthwestern United States, Central and South Knee Coccidioides immitis America (primary respiratory illness) 33Systemic lupus erythematosus (particularly if — N. gonorrhoeae, Proteus species, functional hyposplenism) 34 Salmonella speciesTerminal complement deficiency 7 Tenosynovial component in N. gonorrhoeae hands, wrists, or anklesNOTE: Clinical presentations of septic arthritis vary widely from the typical acute, monoarticular large joint arthritis. Distinctive presentations may occurwith certain organisms or historical background.Information from references 7, 18, 20, and 31 through 34.
Septic ArthritisCulture PCR test Crystals Borrelia burgdorferi infection initially causes viral-likeNegative Negative Negative migratory arthralgias of Lyme disease. Late disease isNegative Negative Negative characterized by an intermittent oligoarthritis that usu-Negative Negative Positive ally involves the knee or other large joints.44 The diagnosis of Lyme arthritis can be made with a two-step serologic testing process involving enzyme-linked immunosor-Negative Negative Negative bent assay, followed by confirmation with a Western blot or immunoblot test.45 B. burgdorferi cannot be culturedNegative Positive (85 percent) Negative from synovial fluid46 ; however, PCR testing is positive in 85 percent of patients with Lyme arthritis, making it aPositive (25 to 70 percent) Positive ( 75 percent) Negative confirmatory test.47 It should be noted that PCR testing cannot distinguish live from dead organisms.46Positive ( 90 percent) — Negative* Management Empiric intravenous antibiotic treatment of septic arthritis should be based on the organism found in the Gram stain of the synovial fluid, or on the suspicion of a pathogen from the patient’s clinical presentation (Table 4 7,18,20,31-34). Treatment options include vancomy- cin for gram-positive cocci, ceftriaxone (Rocephin) for gram-negative cocci, and ceftazidime (Fortaz) for gram- negative rods (Table 5 32). If the Gram stain is negativepotentially infected mucosal sites (e.g., urethra, rectum, but there is suspicion of bacterial arthritis, vancomy-pharynx, cervix).30,41 PCR testing has a sensitivity of cin plus either ceftazidime or an aminoglycoside is76 percent and a specificity of 96 percent for N. gonor- appropriate.32 Adjustments to the administration routerhoeae, and may be useful in patients with culture- and the duration of treatment should be based on thenegative disease if the clinical scenario is unclear or sim- clinical response and microbiology results. The Sanfordilar to a reactive arthritis.26 Guide (http://www.sanfordguide.com; subscription required) is a resource for the management of infectiousOTHER INFECTIONS syndromes. It includes dosing options for patients withFungal arthritis usually has an insidious onset and indo- renal insufficiency and drug allergies, and lists commonlent course.42,43 Pathogen-specific clinical scenarios are drug interactions.presented in Table 4.7,18,20,31-34 Synovial fluidcultures or biopsy can confirm the diagnosis. Mycobacterial infectious arthritis is also Table 5. Empiric Antibiotic Therapy for Suspectedindolent, which can cause a considerable Bacterial Arthritisdelay in diagnosis, although joint damagedoes not occur as rapidly as it does in bac- Gram stain result Antibioticterial infections.31 Articular Mycobacteriumtuberculosis infection typically affects the Gram-positive cocci Vancomycinhip or knee; is usually caused by reactiva- Gram-negative cocci Ceftriaxone (Rocephin)tion from past dissemination; and may occur Gram-negative rods Ceftazidime (Fortaz), cefepime (Maxipime),without other manifestations of active tuber- piperacillin/tazobactam (Zosyn), or carbapenemsculosis. 31,42 Synovial fluid culture is positive If patient is allergic to penicillin or cephalosporins: aztreonam (Azactam) or fluoroquinolonesin 80 percent of patients with M. tuberculosis Negative Gram stain Vancomycin plus either ceftazidime or aninfection. Acid-fast smears are not help- 34 aminoglycosideful and are often negative.31 Histology is notspecific because it may mimic other granu- NOTE: A general guide for antibiotic selection should be used to help determine dos-lomatous diseases, although synovial biopsy ages for individual patients.will be positive for M. tuberculosis in about Information from reference 32.95 percent of cases.34September 15, 2011 ◆ Volume 84, Number 6 www.aafp.org/afp American Family Physician 657
Septic Arthritis Table 6. Phases of Prosthetic Joint Infections Timing after Infection joint replacement Clinical presentation Mode of infection Common pathogens Early Less than three Erythema, warmth, fever, chills, During implantation Staphylococcus aureus, months joint pain, effusion, excessive gram-negative bacilli perioperative drainage Delayed Three to 24 months Persistent pain and/or aseptic During implantation Coagulase-negative staphylococci, loosening Propionibacterium acnes Late More than Sudden-onset joint pain; fever Hematogenous Same as native joints 24 months and leukocytosis less likely Information from references 19, and 63 through 65. The duration of therapy in patients with nongono- baseline joint function.9 In contrast, adults with pneu-coccal septic arthritis is typically three to four weeks. mococcal septic arthritis who survive infection (theTherapy for disseminated gonococcal infection involves mortality rate is approximately 20 percent) will return toa third-generation cephalosporin, such as ceftriaxone, 95 percent of their baseline joint function after complet-for 24 to 48 hours after improvement begins, followed ing antimicrobial therapy.3 Morbidity (e.g., amputation,by oral therapy.41 The clinical response should be rapid, arthrodesis, prosthetic surgery, severe functional dete-with symptoms improving within 24 to 48 hours. Treat- rioration) occurs in one-third of patients with bacterialment then may be switched to oral cefixime (Suprax), arthritis, usually affecting older patients, those with pre-or ciprofloxacin (Cipro) if quinolone resistance is not a existing joint disease, and those with synthetic intraar-concern, for at least one week.41 Treatment of chlamydia ticular material.52also should be considered in the absence of appropri-ate testing.41 Treatment of fungal arthritis is species- Special Considerationsdependent, but usually includes an oral azole or paren- Prosthetic joint infections occur in 0.86 to 1.1 percentteral amphotericin B.42,43 Lyme arthritis responds well to of knee arthroplasties53,54 and in 0.3 to 1.7 percent of hipparenteral ceftriaxone or oral doxycycline.47 arthroplasties.53,55 These infections may result in failure In addition to antibiotic therapy, evacuation of puru- of the joint replacement. In prosthetic joint infections,lent material is necessary. Guidelines from 2006 do bacterial adherence to prosthetic surfaces forms bio-not distinguish between arthrocentesis and surgical films, which can lead to increased resistance to the host’smethods.48 Repeated daily joint aspirations are success- immune system and to antimicrobials.56-58ful during the first five days of treatment.49 With each Prosthetic joint infections are usually caused byaspirate, synovial fluid WBC count, polymorphonuclear gram-positive cocci, including coagulase-negativecell count, Gram stain, and culture should be evaluated staphylococci and S. aureus.53,54 Other organisms, suchto ensure clinical response. Open or arthroscopic tech- as gram-negative bacilli53,59 and mycobacteria,60 haveniques can be used to surgically drain the infected joint. also been implicated. Polymicrobial infections afterArthroscopic drainage is associated with rapid recovery hip and knee arthroplasties have been reported in up toand low morbidity.50 Direct visualization of the joint tis- 20 percent of patients.61 Risk factors for the developmentsue facilitates the lysis of adhesions, drainage of purulent of prosthetic joint infections include previous fracture,pockets, and debridement of necrotic material. seropositive rheumatoid arthritis, high body mass index, revision arthroplasty, and surgical site infections.59,61,62Prognosis Table 6 19,63-65 lists the three categories of prosthetic jointBefore antibiotics were available, two-thirds of patients infections with typical pathogenesis, timing, clinicaldied from septic arthritis.51 Current mortality rates of presentation, and mode of infection.bacterial arthritis range from 10 to 20 percent, depend- A key distinction in the diagnostic workup of patientsing on the presence of comorbid conditions, such as with a prosthetic joint infection is that the intraarticularolder age, coexisting renal or cardiac disease, and con- WBC cutoff values for infection may be as low as 1,100current immunosuppression.3,9,52 Factors associated with per mm3 (1.10 × 109 per L), with a neutrophil differen-death include age 65 years or older, and infection in the tial of greater than 64 percent.66 This low WBC count,shoulder, elbow, or at multiple sites.52 combined with occasionally more indolent clinical pre- After completing antimicrobial therapy, patients with sentations, can make diagnosis problematic. DiagnosticS. aureus septic arthritis regain 46 to 50 percent of their imaging modalities include fluorodeoxyglucose positron658 American Family Physician www.aafp.org/afp Volume 84, Number 6 ◆ September 15, 2011
Septic Arthritisemission tomography and combined leukocyte-marrow 3. Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthri- tis: review of 190 cases. Clin Infect Dis. 2003;36(3):319-327.imaging.67,68 Antimicrobial treatment must be effective 4. Cooper C, Cawley MI. Bacterial arthritis in an English health district:against surface-adhering, biofilm-producing bacteria.58,63 a 10 year review. Ann Rheum Dis. 1986;45(6):458-463.Debridement, exchange, or permanent removal of the 5. McCarthy DJ. Joint sepsis: a chance for cure. JAMA. 1982;247(6):835.prosthesis may be necessary, depending on the clinical 6. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patientscenario.65 In some persons, long-term suppressive anti- have septic arthritis? JAMA. 2007;297(13):1478-1488.microbial therapy may be warranted.63 Research is being 7. Smith JW, Piercy EA. Infectious arthritis. Clin Infect Dis. 1995;20(2): 225-230.performed on the development of antibiofilm technology 8. Kaandorp CJ, Van Schaardenburg D, Krijnen P, Habbema JD, van deto reduce the incidence of prosthetic joint infections.56,57 Laar MA. Risk factors for septic arthritis in patients with joint disease. A The use of prophylactic antibiotics for invasive dental, prospective study. Arthritis Rheum. 1995;38(12):1819-1825.genitourinary, gastrointestinal, and other invasive pro- 9. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health Districtcedures within the first two years after prosthetic joint 1982-1991. Ann Rheum Dis. 1999;58(4):214-219.implantation is controversial. The American Academy 1 0. Le Dantec L, Maury F, Flipo RM, et al. Peripheral pyogenic arthritis.of Orthopaedic Surgeons recommends that physicians A study of one hundred seventy-nine cases. Rev Rhum Engl Ed. 1996;strongly consider antibiotic prophylaxis in patients with 63(2):103-110.one or more risk factors (i.e., comorbidities, immu- 1. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 1 cases. Medicine (Baltimore). 2004;83(3):139-148.nosuppression, and previous infection).69 However, a 2. Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. 2002; 1more recent prospective case-control study does not 15(4):527-544.support this recommendation, showing no change in the 1 3. Kaandorp CJ, Dinant HJ, van de Laar MA, Moens HJ, Prins AP, Dijkmansincidence of prosthetic joint infections with antibiotic BA. Incidence and sources of native and prosthetic joint infection: a com-prophylaxis.70 The decision to use prophylactic antibiot- munity based prospective survey. Ann Rheum Dis. 1997;56(8):470-475. 1 4. Vassilopoulos D, Chalasani P, Jurado RL, Workowski K, Agudelo CA.ics should be made on a case-by-case basis with input Musculoskeletal infections in patients with human immunodeficiencyfrom the orthopedic surgeon and with consideration of virus infection. Medicine (Baltimore). 1997;76(4):284-294.underlying comorbidities. 1 5. Galloway JB, Hyrich KL, Mercer LK, et al. Risk of septic arthritis in patients with rheumatoid arthritis treated with anti-TNF therapy: results from the BSR Biologics Register (BSRBR). Paper presented at: AmericanThe Authors College of Rheumatology/Association of Rheumatology Health Profes- sionals Annual Meeting; October 2009; Philadelphia, Pa.DIANE LEWIS HOROWITZ, MD, is an attending physician in the Divisionof Rheumatology at North Shore–Long Island Jewish Health System, 1 6. Schumacher HR, Chen LX. Musculoskeletal signs and symptoms: mono- articular joint disease. In: Klippel JH, ed. Primer on the Rheumatic Dis-Manhasset, NY. eases. 13th ed. New York, NY: Springer; 2008:42-46.ELENA KATZAP, DO, is a fellow in the Department of Rheumatology, North 7. Morgan DS, Fisher D, Merianos A, Currie BJ. An 18 year clinical review 1Shore–Long Island Jewish Health System. of septic arthritis from tropical Australia. Epidemiol Infect. 1996;117(3): 423-428.SCOTT HOROWITZ, MD, is an infectious disease hospitalist at the North 1 8. Deesomchok U, Tumrasvin T. Clinical study of culture-proven cases ofShore–Long Island Jewish Health System at Franklin Hospital, Valley non-gonococcal arthritis. J Med Assoc Thai. 1990;73(11):615-623.Stream, NY. 1 9. Goldenberg DL. Bacterial arthritis. In: Ruddy S, Harris ED, Sledge CB,MARIA-LOUISE BARILLA-LaBARCA, MD, is an attending physician and Kelley WN, eds. Kelley’s Textbook of Rheumatology. 6th ed. Philadel-fellowship program director of the Division of Rheumatology at North phia, Pa.: Saunders; 2001:1469-1483.Shore–Long Island Jewish Health System. 2 0. Bockenstedt LK. Infectious disorders: Lyme disease. In: Klippel JH, Stone JH, Crofford LJ, White PH, eds. Primer on the Rheumatic Diseases. 13thAddress correspondence to Maria-Louise Barilla-LaBarca, MD, North ed. New York, NY: Springer; 2008:282-289.Shore–LIJ Health System, 2800 Marcus Ave., Ste. 200, Lake Success, NY 2 1. Schumacher HR Jr. Synovial fluid analysis and synovial biopsy. In: Ruddy11042 (e-mail: firstname.lastname@example.org). Reprints are not available from the S, Harris ED, Sledge CB, Kelley WN, eds. Kelley’s Textbook of Rheuma-authors. tology. 6th ed. Philadelphia, Pa.: Saunders; 2001:605-619.Author disclosure: Dr. Scott Horowitz and his wife, Dr. Diane Horowitz, 2 2. Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluiddisclose that he is on the speakers’ bureaus of Merck/Schering-Plough tests. What should be ordered? JAMA. 1990;264(8):1009-1014.(Avelox) and Pfizer (Vfend and Zyvox). However, none of the drugs that 2 3. O’Brien JP, Goldenberg DL, Rice PA. Disseminated gonococcal infection:are the basis of his affiliations are mentioned in this article, and the topic a prospective analysis of 49 patients and a review of pathophysiologyis not directly related to his affiliations. The other authors have no rel- and immune mechanisms. Medicine (Baltimore). 1983;62(6):395-406.evant financial affiliations to disclose. 2 4. Mathews CJ, Kingsley G, Field M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66(4):440-445.REFERENCES 2 5. Jalava J, Skurnik M, Toivanen A, Toivanen P, Eerola E. Bacterial PCR in the diagnosis of joint infection. Ann Rheum Dis. 2001;60(3):287-289. 1. Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic 6. Liebling MR, Arkfeld DG, Michelini GA, et al. Identification of Neisse- 2 arthritis in adults. Lancet. 2010;375(9717):846-855. ria gonorrhoeae in synovial fluid using the polymerase chain reaction. 2. Goldenberg DL. Septic arthritis. Lancet. 1998;351(9097):197-202. 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Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee3 3. Chapman SW. Blastomyces dermatitidis. In: Mandell GL, Bennett JE, replacement: a retrospective review of 6489 total knee replacements. Dolin R, eds. Principles and Practice of Infectious Diseases. 4th ed. New Clin Orthop Relat Res. 2001;(392):15-23. York, NY: Churchill Livingstone; 1995:2353-2364. 5 5. Choong PF, Dowsey MM, Carr D, Daffy J, Stanley P. Risk factors associ-3 4. Harrington JT. Mycobacterial and fungal infections. In: Ruddy S, Harris ated with acute hip prosthetic joint infections and outcome of treatment ED, Sledge CB, Kelley WN, eds. Kelley’s Textbook of Rheumatology. 6th with a rifampin-based regimen. Acta Orthop. 2007;78(6):755-765. ed. Philadelphia, Pa.: Saunders; 2001:1493-1505. 5 6. Trampuz A, Osmon DR, Hanssen AD, Steckelberg JM, Patel R. Molecular3 5. Cunningham R, Cockayne A, Humphreys H. Clinical and molecular and antibiofilm approaches to prosthetic joint infection. 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Coakley G, Mathews C, Field M, et al.; British Society for Rheumatology case-control study [published correction appears in Clin Infect Dis. Standards, Guidelines and Audit Working Group. BSR BHPR, BOA, 2010;50(6):944]. Clin Infect Dis. 2010;50(1):8-16.660 American Family Physician www.aafp.org/afp Volume 84, Number 6 ◆ September 15, 2011