Septic Arthritis Lyme Disease Lecture

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Septic Arthritis Lyme Disease Lecture

  1. 1. JOINT AND BONE INFECTIONS
  2. 2. Introduction <ul><li>Micro-organisms causing joint & bone disease </li></ul><ul><ul><li>Bacteria </li></ul></ul><ul><ul><li>Viruses </li></ul></ul><ul><ul><li>Fungi </li></ul></ul><ul><ul><li>Parasites </li></ul></ul>
  3. 3. Introduction <ul><li>Mechanisms which cause disease </li></ul><ul><ul><li>Active infection </li></ul></ul><ul><ul><li>Induced reaction </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><li>These mechanisms are not mutually </li></ul><ul><li>exclusive </li></ul>
  4. 4. Bacterial Infections <ul><li>Factors such as </li></ul><ul><ul><li>Source of infection </li></ul></ul><ul><ul><li>Age of the patient </li></ul></ul><ul><ul><li>Underlying disease </li></ul></ul><ul><li>Determine the organism causing infection </li></ul>
  5. 5. Bacterial Infections <ul><li>Gram-positive cocci </li></ul><ul><li>Staphylococci: Most common in adult septic arthritis and osteomyelitis </li></ul><ul><li>Staphylococcus aureus, epidermidis, saprophyticus </li></ul><ul><li>Staphylococcal toxic shock syndrome </li></ul>
  6. 6. Bacterial Infections <ul><ul><li>Streptococci </li></ul></ul><ul><ul><ul><li>Group A b-haemolytic: Streptococcus pyogenes, Strep. Pneumoniae </li></ul></ul></ul><ul><ul><ul><li>Rheumatic fever, experimentally induced arthritis </li></ul></ul></ul>
  7. 7. Bacterial Infections <ul><li>Gram-negative cocci </li></ul><ul><li>Gonococcal arthritis </li></ul><ul><ul><li>Uncommon </li></ul></ul><ul><ul><li>Diffuse or migratory arthralgia </li></ul></ul><ul><ul><li>Low-grade fever </li></ul></ul><ul><ul><li>Mono-arthritis or oligoarthritis </li></ul></ul>
  8. 8. Bacterial Infections <ul><li>Gram-negative bacilli </li></ul><ul><li>Anaerobes </li></ul><ul><ul><li>Bacteroidaceae e.g. Bacteroides fragilis. </li></ul></ul><ul><li>Aerobes and faculative anaerobes </li></ul><ul><ul><li>Enterobacteriaceae e.g. Escherichia coli, particularly in neonates. </li></ul></ul>
  9. 9. Bacterial Infections <ul><ul><ul><li>Salmonella and Yersinia spp. </li></ul></ul></ul><ul><ul><ul><li>Shigella spp. Infection is uncommon. </li></ul></ul></ul><ul><ul><ul><li>Klebsiella pneumoniae and Proteus mirabilis. </li></ul></ul></ul>
  10. 10. Bacterial Infections <ul><li>Acid-fast bacilli </li></ul><ul><li>Tuberculosis: Mycobacterium </li></ul><ul><li>Tuberculosis and M. leprae </li></ul><ul><li>Joint/Bone </li></ul><ul><ul><li>10% of cases of extrapulmonary tuberculosis </li></ul></ul><ul><ul><li>2% of all new cases of tuberculosis </li></ul></ul>
  11. 11. Bacterial Infections <ul><li>Mycobacterium tuberculosis and M. leprae </li></ul><ul><li>5 clinical syndromes </li></ul><ul><ul><li>Spondylitis (Pott’s disease) </li></ul></ul><ul><ul><li>Peripheral arthritis </li></ul></ul><ul><ul><li>Osteomyelitis/dactylitis </li></ul></ul><ul><ul><li>Tenosynovitis/bursitis </li></ul></ul><ul><ul><li>Reactive arthritis (Poncet’s disease) </li></ul></ul>
  12. 12. Bacterial Infections <ul><li>Brucellosis </li></ul><ul><ul><li>Contracted from infected animals </li></ul></ul><ul><li>Spirochaetes </li></ul><ul><li>B. burgdorferi </li></ul><ul><li>Lyme disease </li></ul>
  13. 13. Bacterial Infections <ul><li>Chlamydia </li></ul><ul><ul><li>C. trachomatis, psittaci, pneumoniae </li></ul></ul><ul><ul><ul><li>reactive arthritis </li></ul></ul></ul><ul><li>Mycoplasmas </li></ul><ul><ul><li>M. hominis and ureaplasma urealyticum </li></ul></ul><ul><ul><ul><li>genital tract. </li></ul></ul></ul>
  14. 14. Borrelia Burgdorferi Species <ul><li>North American and Europe </li></ul><ul><ul><li>B. burgdorferi sensu stricto </li></ul></ul><ul><li>Europe </li></ul><ul><ul><li>B. afzelii and B. garinii </li></ul></ul>
  15. 15. Clinical Features of Lyme Borreliosis <ul><li>Stage I: Early localised </li></ul><ul><li>Stage II: Early disseminated </li></ul><ul><li>Stage III: Late Lyme borreliosis </li></ul>
  16. 16. Lyme Borreliosis <ul><li>Treatment </li></ul><ul><li>Erythema migrans and facial palsy </li></ul><ul><ul><li>Amoxycillin or Doxycycline 21 days </li></ul></ul><ul><li>Acute arthritis </li></ul><ul><ul><li>Increase treatment time to 30 days </li></ul></ul>
  17. 17. Lyme Borreliosis <ul><li>Treatment </li></ul><ul><li>Neuroborreliosis </li></ul><ul><ul><li>IV antibiotics eg. ceftriaxone 2mg daily 21 days </li></ul></ul>
  18. 18. Lyme Borreliosis <ul><li>Prophylaxis </li></ul><ul><li>Avoidance </li></ul><ul><ul><li>keep skin covered </li></ul></ul><ul><ul><li>insect repellent </li></ul></ul><ul><ul><li>examine clothes and skin </li></ul></ul><ul><li>To remove ticks </li></ul><ul><ul><li>oil </li></ul></ul><ul><ul><li>lift with twisting motion – DO NOT squeeze! </li></ul></ul>
  19. 19. Lyme Disease <ul><li>Vaccination </li></ul><ul><ul><li>OspA preparation offer oral </li></ul></ul><ul><ul><li>protection </li></ul></ul><ul><li>Safe and immunogenic LD patients </li></ul>References J. Infect Dis. 1995, 171: 1368-1370 K. Infect Dis. 1995, 1324-1329
  20. 20. Septic Arthritis <ul><li>Lyme Disease Vaccine </li></ul><ul><li>10,936 individuals received three doses of either OspA with aluminum hydroxide adjuvant (Lymerix) or placebo upon entry into the study, at 1 month, and 12 months later </li></ul><ul><li>Reports of adverse musculoskeletal and neurologic events following vaccine </li></ul>
  21. 21. Septic Arthritis <ul><li>Lyme Disease Vaccine </li></ul><ul><li>Use of the vaccine decreased dramatically </li></ul><ul><li>2002, Manufacture stopped </li></ul><ul><li>There is no currently licensed vaccine against Lyme disease </li></ul><ul><li>Reference </li></ul><ul><li>Steere et al. N Engl J Med 1998; 339:209. </li></ul><ul><li>GSK Lymerix. The Pink Sheet, F-D-C Reports, Inc. Chevy Chase, Maryland 2002; 64(9):23. </li></ul>
  22. 22. Viral Infections <ul><ul><li>Few viruses have been unequivocally identified as the direct cause of human joint inflammation </li></ul></ul><ul><li>Aetiopathogenesis </li></ul><ul><ul><li>Direct toxic effect, immune complex formation, virus or viral antigen persistence, molecular mimicry, superantigen function, modification of the immune response </li></ul></ul>
  23. 23. Viral Infections <ul><li>Rubella </li></ul><ul><ul><li>50% of infected women, 6% of men. Uncommon in children. Rubella vaccine is not associated with clinically important acute or chronic joint disease </li></ul></ul><ul><li>Parvovirus B19 </li></ul><ul><ul><li>Acute, benign, self-limiting disease, rheumatoid-like polyarthritis. Rheumatic symptoms occur in 95% of infected children </li></ul></ul>
  24. 24. Viral Infections <ul><li>HIV </li></ul><ul><ul><li>Affects 8-10 million individuals. Arthralgia, Reiter’s syndrome, psoriatic arthritis, HIV-associated arthritis, avascular necrosis of bone, septic arthritis and autoimmune rheumatic disease-like syndromes </li></ul></ul>
  25. 25. Viral Infections <ul><li>Hepatitis Viruses </li></ul><ul><ul><ul><li>Acute hepatitis B virus, transient polyarthritis, in 30% of patients </li></ul></ul></ul><ul><ul><ul><li>Hepatitis C virus type II cryoglobulinaemia. Immunosuppressive agents should be avoided in these patients </li></ul></ul></ul>
  26. 26. Fungal Infections <ul><li>Immunosuppression </li></ul><ul><ul><li>Actinomyces, Aspergillus and Candida </li></ul></ul><ul><ul><li>Uncommon. One-quarter of all candidal prosthetic joint infections occur in patients with rheumatoid arthritis </li></ul></ul>
  27. 27. Parasitic Infection <ul><li>Protozoa </li></ul><ul><li>Roundworms (eg. Strongyloides) </li></ul><ul><li>Giardia </li></ul><ul><li>Flatworms (eg. taeniae) </li></ul><ul><ul><ul><li>Areas endemic for parasitic disease. </li></ul></ul></ul><ul><ul><ul><li>Symptoms: localization, reaction, immune-mediated response, following treatment. </li></ul></ul></ul>
  28. 28. Septic Arthritis <ul><li>Most common </li></ul><ul><ul><li>Children </li></ul></ul><ul><ul><li>Elderly </li></ul></ul><ul><ul><li>Immunosuppressed </li></ul></ul><ul><ul><li>Damaged joints </li></ul></ul>
  29. 29. Septic Arthritis <ul><li>Joints may be held in flexion </li></ul><ul><li>Adults may complain of pain </li></ul><ul><li>Begin treatment early </li></ul><ul><li>1% septic skeletal infections spinal </li></ul>
  30. 30. Septic Arthritis <ul><li>Pathogenesis </li></ul><ul><li>Dissemination </li></ul><ul><ul><li>Via the bloodstream. </li></ul></ul><ul><ul><li>Acute osteomyelitic focus </li></ul></ul><ul><ul><li>Spread from an adjacent infection </li></ul></ul><ul><ul><li>Penetrating trauma </li></ul></ul>
  31. 31. Septic Arthritis <ul><li>191 cases of septic arthritis </li></ul><ul><li>72 percent hematogenous </li></ul><ul><li>Injection drug use, in dwelling catheters, immunocompromised state e.g. HIV infection. </li></ul><ul><li>Neonates and the elderly are at highest risk. </li></ul>References Morgan et al Epidemiol Infect 1996; 117:423 .
  32. 32. Septic Arthritis <ul><li>Underlying Arthritis </li></ul><ul><li>Bacteremia more likely to localize in a joint with pre-existing arthritis, particularly if associated with synovitis. </li></ul><ul><li>In 154 patients with bacterial arthritis 40 percent had pre-existing joint disease, rheumatoid arthritis or osteoarthritis </li></ul>Reference Kaandorp et al Arthritis Rheum 1997; 40: 884.
  33. 33. Septic Arthritis <ul><li>Pathogenesis </li></ul><ul><li>Bacteria enter the joint </li></ul><ul><li>Deposit in the synovial membrane </li></ul><ul><li>Produce an acute inflammatory cell response </li></ul><ul><li>Synovial tissue has no limiting basement plate </li></ul>
  34. 34. Septic Arthritis <ul><li>Pathogenesis </li></ul><ul><li>Organisms may quickly gain access to the synovial fluid </li></ul><ul><li>Creating the characteristic acute purulent joint inflammation </li></ul>
  35. 35. Septic Arthritis <ul><li>Pathogenesis </li></ul><ul><li>5 days </li></ul><ul><ul><li>Marked hyperplasia of the lining cells in the synovial membrane </li></ul></ul><ul><ul><li>Inflammatory cells release cytokines and proteases </li></ul></ul><ul><ul><ul><li>Cartilage degradation </li></ul></ul></ul><ul><ul><ul><li>Inhibit cartilage synthesis. </li></ul></ul></ul><ul><ul><li>Pressure necrosis results in further cartilage and bone loss </li></ul></ul>
  36. 36. Osteomyelitis <ul><li>Acute Osteomyelitis </li></ul><ul><li>Metaphysis </li></ul><ul><ul><li>Rich blood supply </li></ul></ul><ul><ul><li>Slow circulation time </li></ul></ul><ul><li>Bone </li></ul><ul><ul><li>Locally tender </li></ul></ul><ul><ul><li>Swelling and warmth </li></ul></ul><ul><li>If treatment within 2-3 days prognosis good </li></ul>
  37. 37. Osteomyelitis <ul><li>Chronic and Subacute Osteomyelitis </li></ul><ul><li>Trauma or surgery </li></ul><ul><ul><li>‘ Brodie’s abscess’. </li></ul></ul>
  38. 38. Diagnosing Joint and Bone Infection <ul><li>Blood Tests </li></ul><ul><li>Acute phase response raised </li></ul><ul><li>Immune tests </li></ul><ul><ul><li>e.g. IgM and IgG antibodies to B19 parvovirus. </li></ul></ul>
  39. 39. Diagnosing Joint and Bone Infection <ul><li>Imaging </li></ul><ul><li>Radiographic </li></ul><ul><li>Infection has been present for > 2 weeks </li></ul><ul><ul><li>CT and MRI </li></ul></ul><ul><ul><li>In-labelled leucocytes </li></ul></ul><ul><ul><li>Scintigraphy ( 99m Tc phosphate) </li></ul></ul>
  40. 40. Diagnosing Joint and Bone Infection <ul><li>Microbiology </li></ul><ul><li>Synovial fluid culture </li></ul><ul><li>Blood and urine cultures </li></ul><ul><li>Suspected infectious foci </li></ul><ul><li>Tissue biopsy </li></ul><ul><li>Mantoux test </li></ul>
  41. 41. Management of Joint and Bone Infections <ul><li>The Principles are: </li></ul><ul><li>Prompt diagnosis </li></ul><ul><li>Early therapy with appropriate antibiotics </li></ul>
  42. 42. Management of Joint and Bone Infections <ul><ul><li>Antibiotic Regimen </li></ul></ul><ul><ul><li>Specific bacterial resistance </li></ul></ul><ul><ul><li>Physician’s preference </li></ul></ul><ul><ul><li>Switch culture results known </li></ul></ul>
  43. 43. Management of Joint and Bone Infections <ul><li>Antibiotics </li></ul><ul><li>Staph. Aureus/Gram-positive cocci </li></ul><ul><ul><li>Adults: flucloxacillin and fusidic </li></ul></ul><ul><ul><li>acid or clindamycin </li></ul></ul>
  44. 44. Septic Arthritis <ul><li>Antibiotic Therapy </li></ul><ul><li>Choice based upon the Gram stain and/or the clinical presentation. </li></ul><ul><li>Gram positive cocci </li></ul><ul><ul><li>Cefazolin (1 to 2 g IV q8h) community acquired infections </li></ul></ul><ul><ul><li>Vancomycin (30 mg/kg daily IV in two divided doses) hospital/nursing home acquired infection </li></ul></ul><ul><li>   </li></ul>
  45. 45. Management of Joint and Bone Infections <ul><li>H. Influenzae </li></ul><ul><ul><li>Children under 3 years of age </li></ul></ul><ul><ul><li>Ampicillin or a cephalosporin-cefotaxamine or ceftrioxone). </li></ul></ul>
  46. 46. Management of Joint and Bone Infections <ul><ul><li>Gram-negative organisms </li></ul></ul><ul><ul><ul><li>Elderly/predisposing e.g. RA </li></ul></ul></ul><ul><ul><ul><li>Cephalosporine - cefotaxime or ceftrioxone </li></ul></ul></ul>
  47. 47. Septic Arthritis <ul><li>  Gram negative bacilli </li></ul><ul><ul><li>Third generation cephalosporin e.g. Certazidime (1 to 2 g IV q8h) </li></ul></ul><ul><ul><li>Aminoglycoside e.g. Gentamicin when Pseudomonas aeruginosa is considered to be a likely pathogen (e.g. in patients who inject illicit drugs). </li></ul></ul>
  48. 48. Septic Arthritis <ul><li>Gram negative bacilli </li></ul><ul><ul><li>Ceftriaxone (2 g IV q24h), </li></ul></ul><ul><ul><li>Cefotaxime (2 g IV q8h) Ceftazidime should be given </li></ul></ul><ul><li>Modifications made when the culture and susceptibility results are available </li></ul>
  49. 49. Management of Joint and Bone Infections <ul><li>Antibiotics </li></ul><ul><li>6 weeks </li></ul><ul><ul><li>Septic arthritis </li></ul></ul><ul><li>2-3 months </li></ul><ul><ul><li>Osteomyelitis </li></ul></ul>
  50. 50. Septic Arthritis <ul><li>Duration of antimicrobial </li></ul><ul><ul><li>Parenteral antibiotics for at least 14 days followed by oral therapy (if possible) for an additional 14 days </li></ul></ul>
  51. 51. Septic Arthritis <ul><li>Joint Drainage </li></ul><ul><li>Peripheral joints closed needle aspiration </li></ul><ul><li>Daily aspiration may be necessary </li></ul><ul><li>Arthroscopy or open drainage maybe necessary </li></ul>
  52. 52. Septic Arthritis <ul><li>Prognosis </li></ul><ul><li>Not improved significantly in the past few decades </li></ul><ul><li>Outcome is directly related to host factors </li></ul><ul><li>Prior joint damage </li></ul><ul><li>Virulence of the infecting organism </li></ul>
  53. 53. Septic Arthritis <ul><li>Prognosis </li></ul><ul><li>Speed with which adequate treatment begun </li></ul><ul><li>Inflammation and destruction of joints may continue in sterile joints despite effective antimicrobial therapy </li></ul><ul><li>121 adults and 31 children with bacterial arthritis had poor joint outcome </li></ul>
  54. 54. Septic Arthritis <ul><li>Prognosis </li></ul><ul><li>Amputation, arthrodesis, prosthetic surgery or severe functional deterioration occurred in one-third of the patients </li></ul>Reference Kaandorp et al Arthritis Rheum 1997; 40: 884.
  55. 55. Septic Arthritis <ul><li>Mortality </li></ul><ul><li>Dependent upon the presence of co-morbid conditions </li></ul><ul><li>Advanced age, coexistent renal or cardiac disease, and immunosuppression </li></ul><ul><li>Mortality rates range from 10 to 15 percent </li></ul>
  56. 56. Septic Arthritis <ul><li>Mortality </li></ul><ul><li>Polyarticular septic arthritis </li></ul><ul><li>Due to S. aureus or with rheumatoid arthritis </li></ul><ul><li>Extremely poor prognosis with mortality rates as high as 50 percent </li></ul>Reference Dubost et al Polyarticular septic arthritis. Medicine (Baltimore) 1993; 72:296.
  57. 57. Chronic Fatigue Syndrome <ul><li>Epidemic or sporadic. </li></ul><ul><li>Males = females </li></ul><ul><li>Peaks: 25-30 years and 40-45 years.. </li></ul>
  58. 58. Chronic Fatigue Syndrome <ul><li>Debilitating fatigue </li></ul><ul><li>Muscle aches, pains </li></ul><ul><li>Lymph node tenderness </li></ul><ul><li>Pyrexia </li></ul><ul><li>Exhaustion </li></ul><ul><li>Invariable psychiatric symptoms </li></ul>
  59. 59. The Sir Joseph Hotung Centre for Musculoskeletal Diseases St George’s Hospital & Medical School London SW17 OQT UK

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