septic arthritis

1. LE ARTRITI SETTICHE: ASPETTI CLINICI
IL PARERE DEL REUMATOLOGO
Villa Italia - Padova 24 ottobre 2014
Franco Schiavon
U.O.C. di Reumatologia
Azienda Ospedale-Università Padova

2. Epidemiology and risk factors

3. Septic arthritis: incidence
4-10/100.000 patient-year

4. Local soft-tissue infection
Diagnostic or therapeutic procedures
Penetrating trauma
Adjacent osteomyelitis
Hematogenous route

5. RISK FACTORS
• Age
• Rheumatic diseases
• Diabetes
• Alcholism
• Renal failure
• Immunosoppression
(therapy and diseases)
• Infections
• Rheumatic diseases
• Joint prostheses
• Orthopedic surgery
• Cutaneous ulcers
• Previuos intra-articular
corticosteroid injection
• Penetratig trauma
Gupta MN, Ann Rheum Dis 2003
SYSTEMIC ARTICULAR

6. RISK FACTORS
• Age
• Rheumatic diseases
• Diabetes
• Alcholism
• Renal failure
• Immunosoppression
(therapy and diseases)
• Infections
• Rheumatic diseases
• Joint prostheses
• Orthopedic surgery
• Cutaneous ulcers
• Previuos intra-articular
corticosteroid injection
• Penetratig trauma
Gupta MN, Ann Rheum Dis 2003
SYSTEMIC ARTICULAR

7. Gavet F, Tournadre A, Soubier M et al JAGS 2005; 53: 1210-13

8. Watson VC et al ARD 1999

9. Septic arthritis in patients aged 80 and older: a comparison with
younger adults
Gavet F, Tournade A, Soubrier M, Ristori JM, Dobost JJ. JAGS 2005; 53: 1210-3
Age Mortality
< 60 0.7%
60-80 4.8%
>80 9.5%

10. RISK FACTORS
• Age
• Rheumatic diseases
• Diabetes
• Alcholism
• Renal failure
• Immunosoppression
(therapy and diseases)
• Infections
• Rheumatic diseases
• Joint prostheses
• Orthopedic surgery
• Cutaneous ulcers
• Previuos intra-articular
corticosteroid injection
• Penetratig trauma
Gupta MN, Ann Rheum Dis 2003
SYSTEMIC ARTICULAR

11. Septic arthritis : incidence
4-10/100.000 patients-year (general populations)
30-70/100.000 rheumatoid arthritis

12. RB Kherani et al CMAJ 2007
M Favero, F Schiavon et al Autoimm. Rev 2009
Risk factors for septic arthritis in patients
with rheumatoid arthritis
Increases age (> 80 years)
History of chronic disease
Superficial skin ulceration or other minor primary infection
Oral carriage of St Aureus
Prosthetic joint
Diabetes
Biologic agent therapy

13. Pathogenic factors of Staphylococcus Aureus
Gordon RJ, Lowy FD Clin Infect. Dis. 2008

14. Incidence of Septic arthritis and treatment
Galloway JB ARD 2011

15. Galloway JB ARD 2011
Changing risk of septic arthritis over time

17. Hugle T et al Clin Exp Rheumatol 2008

18. Peltola H et al Clin Infect Dis .2008

19. Accuracy of the use of procalcitonin in
the diagnosis of septic arhiritis
Shen CJ et al Eur. J Clin Microbiol Infect Dis 2013

20. Most cases of septic arthritis occur by haematogenous spreading of
microorganisms to the synovial membrane of one or more joint
1. Blood cultures are an essential component of the diagnostic evaluation
2. Clinician should be obtain at least two sets of blood cultures before
initiating antibiotic therapy

21. The only definitive diagnostic test is the
demonstration of bacteria in synovial fluid,
or recovery of bacteria from a synovial
fluid culture
S. Nade Best Pract Clin Rheumatol 2003

22. Mathews C et al Lancet 2010
FLOW CHART FOR DIAGNOSIS OF SEPTIC ARTHRITIS

23. Treatment algorithmus for management of septic arthritis
Mathews C et al JAMA 2010

24. Synovial fluid changes in joint disease
GB/mm3 Colour Clarity Viscosity
Non inflammat. < 2000 Pale yellow Transparent Very high
Mod. inflammat. 2000-5000 Yellow Transparent High
Inflammatory 5000-50.000 Yellow or Translucent Low
opalescent
Septic > 50.000 Yellow-green Opaque Low or very
Brown low
Ropes MW Bauer W 1953

25. Margaretten ME JAMA 2009

26. Li SF Acad Emerg Med 2004
Li SF, Henderson J, Dickman E, Darzynkiewicz R
Laboratory tests in adults with monoarticular arthritis: can they rule out a septic joint?
Acad. Emerg. Med 2004; 11: 276-80
…..More than one third of adults patients with septic arthritis had joint WBC less than
50.000 cells/mm3 . ……The sensitivity of an elevated joint WBC was 64%

27. Margaretten ME JAMA 2009

28. sWBC sPMN
sWBC = 1100/mm3 64% PMN
< LR- 99.6%
both tests
> LR+ 100%

29. Differential diagnosis of synovial fluid with
WBC>50.000/mm3
•Gout
•Pseudogout
•Psoriatic arthritis
•Reactive arthritis
•Lyme disease
•Rheumatoid arthritis

30. Questions without answer
How long to continue i.v. and p.o antibioticum therapy
What strategy to increase microorganisms identification
What is the role of PCR
 Is better percutaneous joint fluid aspiration or arthrotomy /arthroscopy needle lavage
Innovative therapy (corticosteroids, biphosphonates)
When to start physiotherapy

32. Peltola H et al Clin Infect Dis .2008

33. Complete
recovery (%)
22 (69) 10 (53) 0.24
Deterioration in
functional status
9 (29) 8 (44) 0.27
Complete recovery
in knee joint sepsis
17 (71) 5 (38) 0.05
Lenght of
hospital stay
16.5 (14-19) 15 (11-17) 0.34
Physiotherapy
session
7±2 10±3 0.002
Outcome Medical n= 32 Surgical n=19 P value
Treatment groups
Ravindran V et al Rheumatology 2009

34. Glucosio (< 1.5 mmol/ml) sensibilità 51% specificità 85%
LDH (> 250 U/l) sensibilità 100% specificità 51%
Margaretten M JAMA 2007
Efficacia di altri test di laboratorio
eseguibili nel Liquido Sinoviale

36. Peltola H et al Clin Infect Dis .2008

37. Li SF, Henderson J, Dickman E, Darzynkiewicz R
Laboratory tests in adults with monoarticular arthritis:
can they rule out a septic joint?
Acad. Emerg. Med 2004; 11: 276-80
…..More than one third of adults patients with septic arthritis had joint WBC less than
50.000 cells/mm3 . ……The sensitivity of an elevated joint WBC was 64%
Press J , Peled N, Buskila D, Yagupsky P
Leukocyte count in the synovial fluid of chldren with culture-
proven brucellar arthritis.
Clin. Rheumatol 2002; 21: 191-93
…..the median leukocyte count in the synovial fluid was 9500 WBC/mm3
(range 300-61500 WBC/mm3) and in eight out of nine patients it was less
tha 50.000 WBC/mm3

38. R.R. Laffer , P. Graber et al Clin. Microbiol. Infect. 2006; 12: 433-439
Type infection and pathogens in knee arthroplasty

39. RISK FACTORS
• Age
• Rheumatic diseases
• Diabetes
• Alcholism
• Renal failure
• Immunosoppression
(therapy and
diseases)
• Infections
• Rheumatic diseases
• Joint prostheses
• Orthopedic surgery
• Cutaneous ulcers
• Previuos intra-articular
corticosteroid injection
• Penetratig trauma
Gupta MN, Ann Rheum Dis 2003
SYSTEMIC ARTICULAR

40. Fangham M et al Sem Arthritis Rheum 2012
Allison DC et al Clin Ortop Relat Res 2010
Methicillin-resistant St aureus: risk factors and percentage

41. RISK FACTORS
• Age
• Rheumatic diseases
• Diabetes
• Alcholism
• Renal failure
• Immunosoppression
(therapy and
diseases)
• Infections
• Rheumatic diseases
• Joint prostheses
• Orthopedic surgery
• Cutaneous ulcers
• Previuos intra-articular
corticosteroid injection
• Penetratig trauma
Gupta MN, Ann Rheum Dis 2003
SYSTEMIC ARTICULAR

42. Synovial fluid in septic arthritis
Gross inspection Color yellow-green or brown
Opaque
Viscosity very low

43. Body temperature on admission
Kuong EE et al Hong Kong Med J 2012

44. South Med Ass. 2010

45. Synovial fluid in septic arthritis I
Gross inspection Color yellow-green or brown
Opaque
Viscosity very low
WBC count > 50.000 GB/mm3->90% PMN cell count (%)

46. Watson VC et al ARD 1999

47. Butt U et al Clin Rheumatol. 2011