Septic Arthritis

Definition:
Septic arthritis is the purulent invasion of a joint by an infectious agent which
produces arthritis. The infection can be caused by bacteria, viruses, fungi, or
parasites. Joint infection caused by fungi or parasites is much less common than
that caused by bacteria or viruses. Typically, septic arthritis affects a single large
joint, such as the knee or hip, but it is possible for several joints to be infected.

Causes of Septic Arthritis:

The infection can originate anywhere in the body. The infection may also begin
as the result of an open wound, surgery, or unsterile injection. Whatever the initial
source of infection, septic arthritis occurs when the infective organism travels through
the bloodstream to the joint.

Points of Interest About Septic Arthritis:

• The most common type of bacteria involved in septic arthritis is Stahylococcus
aureus, usually referred to as Staph.
• The bacteria that causes gonorrhea used to be a common cause of septic arthritis,
but safe sex has made it less common.
• When viruses attack joints, it is called viral arthritis, and the condition usually
resolves on its own.
• Joint infection caused by a fungus, known as fungal arthritis, is considered very
rare.

A.K.A.
Septic arthritis is also referred to as infectious arthritis and pyogenic arthritis.
Septic arthritis is considered a medical emergency because of the serious damage that
can occur to bone and cartilage. Septic arthritis can cause septic shock, which can be
fatal.
The term "suppurative arthritis" is a near synonym for septic arthritis. ("Suppurative"
refers to the production of pus, without necessarily implying sepsis.)

3. Incidence rate
Frequency
United States
Approximately 20,000 cases of septic arthritis occur each year in the United States (7.8
cases per 100,000 person-years).4 The incidence of arthritis due to disseminated
gonococcal infection is 2.8 cases per 100,000 person-years. Septic arthritis is becoming
increasingly common among people who are immunosuppressed and elderly persons;
these groups are more likely to have various comorbid disease states. The incidence of
PJI among all prosthesis recipients ranges from 2-10%.
International
The incidence of septic arthritis in Europe is identical to that in the United States.
Mortality/Morbidity
The primary morbidity of septic arthritis is significant dysfunction of the joint, even if
treated properly. The mortality rate depends primarily on the causative organism. N
gonorrhoeae septic arthritis carries an extremely low mortality rate, while that of S
aureus can approach 50%.14

Race
Septic arthritis has no recognized racial predisposition.
Sex
Fifty-six percent of patients with septic arthritis are male.
Age
Forty-five percent of people with septic arthritis are older than 65 years.
Septic arthritis can affect anyone at any age -- including infants and children. In adults,
weightbearing joints (hips, knees, ankles) are most affected. In children, shoulders,
hips, and knees are commonly affected. As the population ages, doctors are seeing
more patients with septic arthritis.
4. risk/predisposing factors
Septic arthritis develops when bacteria spreads through the bloodstream to a joint. It
may also occur when the joint is directly infected with bacteria during injury or surgery.
Acute septic arthritis tends to be caused by organisms such as staphylococcus,
streptococcus pneumoniae and group B streptococcus.
Chronic septic arthritis (which occurs less frequently) is caused by organisms such as
Mycobacterium tuberculosis and Candida albicans. The knee and the hip are the most
commonly infected joints.
The following increase your risk for septic arthritis:
• Artificial joint implants
• Bacterial infection
• Chronic illness or disease
• Intravenous (IV) drug abuse
• Medications that suppress the immune system
• Recent joint trauma
• Recent joint arthroscopy or other surgery
• Rheumatoid arthritis
• Sickle cell disease
Septic arthritis may be seen at any age. In children, it occurs most often in those less
than 3 years old. The hip is a frequent site of infection in infants.
Septic arthritis is uncommon from age 3 to adolescence. Children with septic arthritis
are more likely than adults to be infected with group B streptococcus and Haemophilus
influenza

5. Manifestations
The onset of the symptoms is usually rapid with joint swelling, intense joint pain, and
low-grade fever.
Symptoms in newborns or infants:
• Unable to move the limb with the infected joint (pseudoparalysis)
 • Cries when infected joint is moved (example: diaper change causes crying if hip
infected)
• Irritability
• Fever
Symptoms in children and adults:
• Intense joint pain
• Joint swelling
• Joint redness
• Unable to move the limb with the infected joint
• Low-grade fever
Chills may occur, but are uncommon

6. type
None

7. pathophysiology

Organisms may invade the joint by direct inoculation, by contiguous spread from
infected periarticular tissue, or via the bloodstream (the most common route)
When joint infection occurs as a result of bacteremia, the initial growth of
microorganisms is either in the synovial membrane or in the adjacent bone. In either
case, an inflammation of the synovial membrane is quickly established and results in a
marked increase in leukocytes in the synovial fluid, even though the fluid itself is sterile.
When the microorganisms have spread into the joint fluid, culture of the fluid reveals the
etiology of the infection. The pathologic findings are varied and depend on the duration
of the infection, the organism and the resistance of the host. Early in the infection, only
inflammatory changes in the synovium are seen. Late in the course of untreated septic
arthritis, destruction of joint structures is marked. Articular cartilage is particularly
vulnerable because it is an avascular tissue.
In acute, pyogenic arthritis, the cartilage characteristically dissolves first at points of
articular contact to expose the underlying bone. As destructive changes occur several
abnormalities appear in the synovial fluid:
Increased pressure
Low pH
Low concentration of glucose
Activation of proteolytic enzymes
Increased turbidity
Presence of mucin precipitate

8. dx studies
How is septic arthritis diagnosed?
Prompt diagnosis of septic arthritis is necessary to prevent permanent damage to the
joint.
In addition to a complete medical history and physical examination, diagnostic
procedures for septic arthritis may include:
 • removal of joint fluid - to examine for white blood cells and bacteria.
• blood tests - to detect bacteria.
• phlegm, spinal fluid, and urine tests - to detect bacteria and find the source of
infection.
• x-ray - a diagnostic test which uses invisible electromagnetic energy beams to
produce images of internal tissues, bones, and organs onto film.
• bone scan - a nuclear imaging method to evaluate any degenerative and/or
arthritic changes in the joints; to detect bone diseases and tumors; to determine
the cause of bone pain or inflammation.
• magnetic resonance imaging (MRI) - a diagnostic procedure that uses a
combination of large magnets, radiofrequencies, and a computer to produce
detailed images of organs and structures within the body.
• radionuclide scans - nuclear scans of various organs to determine blood flow to
the organs

9. management
Medical Care
Medical management of infective arthritis focuses on adequate and timely drainage of
the infected synovial fluid, administration of appropriate antimicrobial therapy, and
immobilization of the joint to control pain. Acute PJI (<3 wk in duration) can be cured
medically if it is of the early type or secondary to hematogenous spread without any
evidence of periarticular soft-tissue involvement or joint instability.5
• In native joint infections, antibiotics usually need to be administered parenterally
for at least 2 weeks. However, each case must be evaluated independently.
Infection with either methicillin-resistant S aureus (MRSA) or methicillin-
susceptible S aureus (MSSA) requires at least 4 full weeks of intravenous
antibiotic therapy. Orally administered antimicrobial agents are almost never
indicated in the treatment of S aureus infections. Gram-negative native joint
infections with a pathogen that is sensitive to quinolones can be treated with oral
ciprofloxacin for the final 1-2 weeks of treatment. As a rule, a 2-week course of
intravenous antibiotics is sufficient to treat gonococcal arthritis.
• Initial antibiotic choices must be empirical, based on the sensitivity pattern of the
pathogens of the community. Consider the rise of resistance among potential
bacteria when choosing an initial antibiotic regimen. If local incidence of MRSA is
high (in particular, marked increase in the resistance of the pneumococcus),
prescribe alternate antibiotics initially. Because many isolates of group B
streptococci have become tolerant of penicillin, use a combination of penicillin
and gentamicin or a later-generation cephalosporin. MRSA is becoming
established outside of the hospital. Enterobacteriaceae and P aeruginosa are
becoming more resistant to multiple antibiotics. Knowing the resistance patterns
in the community, as well as in the hospital, is most important.
• Preferably, the antibiotic should be bactericidal with some effect against the slow-
growing organisms that are protected within a biofilm (eg, CONS). Rifampin
fulfills these requirements. It should never be used alone because of the rapid
development of bacterial resistance to the drug.
 • The choice of the type of drainage, whether percutaneous or surgical, has not
been resolved completely.19,20 In general, use a needle aspirate initially, repeating
joint taps frequently enough to prevent significant reaccumulation of fluid.
Aspirating the joint 2-3 times a day may be necessary during the first few days. If
frequent drainage is necessary, surgical drainage becomes more attractive.
• If, after 5 days of therapy, the joint shows some degree of improvement, consider
an empirical trial of an anti-inflammatory agent.
• If the joint fails to respond after 5 days of appropriate antibiotic therapy (eg,
presence of clinically significant fever, continued synovial purulence, persistently
positive findings on culture), reassess the therapeutic approach.
• Reculture the fluid and reexamine for crystals.
• Perform appropriate serologies for diagnosis of Lyme disease. If these are
positive, treat per current guidelines.
• If fungal or mycobacterial infection is possible, consider obtaining a synovial
biopsy.
• Consider the possibility of reactive arthritis. Nonsteroidal inflammatory agents are
the primary therapeutic agents for reactive arthritis.
• Perform imaging studies, either radiographs or an MRI, to rule out periarticular
osteomyelitis.
• The use of fluoroquinolones for an extended period should be considered when
the removal of an infected prosthesis is not possible. Cure rates as high as 62%
have been documented in relatively small series. Generally, such prolonged
therapy is seen as suppressive and not curative.

Surgical Care
Surgical drainage is indicated when one or more of the following occur: the appropriate
choice of antibiotic and vigorous percutaneous drainage fails to clear the infection after
5-7 days, the infected joints are difficult to aspirate (eg, hip), or adjacent soft tissue is
infected.
• Routine arthroscopic lavage is rarely indicated. However, drainage through the
arthroscope is replacing open surgical drainage. With arthroscopic drainage, the
operator can visualize the interior of the joint and can drain pus, debride, and
lyse adhesions.
• Gonococcal-infected joints rarely require surgical drainage.
• In cases of PJI that require surgery for cure (see above), successful treatment
requires appropriate antibiotic therapy combined with removal of the hardware.
Despite appropriate antibiotic use, the success rate is only about 20% if the
prosthesis is left in place. A 2-stage approach is the most effective technique.
o First, remove the prosthesis and follow with 6 weeks of antibiotic therapy.
Then, place the new joint, impregnating the methylmethacrylate cement
with an anti-infective agent (ie, gentamicin, tobramycin). Antibiotic diffusion
into the surrounding tissues is the goal. The success rate for this approach
is approximately 95% for both hip and knee joints.
o An intermediate method is to exchange the new joint for the infected joint
in a 1-stage surgical procedure with concomitant antibiotic therapy. This
 method, with concurrent use of antibiotic cement, succeeds in 70-90% of
cases.
Consultations
In general, obtain a consultation with an orthopedic surgeon or rheumatologist. If the
initial treatment response is poor or the etiology of the synovitis remains unknown,
consult with an infectious disease specialist.
Activity
If the patient's condition responds adequately after 5 days of treatment, begin gentle
mobilization of the infected joint. Most patients require aggressive physical therapy to
allow maximum postinfection functioning of the joint.

Medication
The empirical choice of antibiotic therapy is based on results of the Gram stain and the
clinical picture and background of the patient. When the Gram stain fails to reveal any
microorganisms (40-50% of cases), the individual's age and sexual activity become the
major determinants to differentiate gonococcal from nongonococcal arthritis. When no
evidence suggests infection elsewhere, antibiotics must cover S aureus, streptococcal
species, and gonococci (in patients who are sexually active).
Evidence shows that earlier initiation of an appropriate antibiotic regimen produces
better functional results. Generally, treatment is administered intravenously for 3-4
weeks. The major exception to this is in the case of joints with gonococcal infection, for
which total therapy is approximately 2 weeks, with switch to oral therapy. No indication
exists for direct installation of antibiotics into the joint cavity. Such practice may increase
the degree of inflammation.

10. Nursing dx
a. Acute pain related to inflammation of joints
b. Impaired physical mobility related to musculoskeletal impairment
c. Risk for infection related to inadequate primary and secondary defenses
d. Risk for activity intolerance related to presence of musculoskeletal
problem
e. Anxiety related to threat to health roles

11. Nursing responsibilities:

a. Effective nursing management requires scrupulous attention to the client’s

position, exercise and rehabilitation. In the acute phase, the client is likely
to hold joint in slight to moderate flexion as a position of comfort. Because
this can lead to flexion, deformities, slings, immobilizers or splints may be
used temporarily to hold the joint in an optimal position.
b. As inflammation begins to resolve, passive ROM exercises are initiated to
preserve joint function. CPM has also been used.
c. Active motion and weight bearing may not be initiated until clinical
manifestations and inflammation have almost totally disappeared.
d. Pain management is also important for the client with septic arthritis to
provide comfort and to allow greater ease in exercise participation
 12. Illustrations

Septic arthritis with associated soft tissue abscess. Coronal T2-weighted fat-saturated
MRI of the shoulder demonstrates a joint effusion, bone marrow edema, and marked
adjacent soft tissue inflammation with a fluid collection in the infraspinatus muscle.

Septic arthropathy right hip with joint space loss and loss of the subchondral line in the
tectum of the acetabulum
Figure 1 Septic arthiritis of the right hip joint

13. References:

www.wikipedia.com, arthritis.about.com, mayoclnic.com,