Joint infection (Septic Arthritis)

Teguh Sarry Hartono Clinical Microbiology Resident May 2011

Introduction
Infection of a bone or joint implies that one or more species of bacteria have colonized the structure involved and are proliferating, causing a pathologic condition because of their presence.

Septic arthritis

Bramlage, 1998; Kirchheimer, 2010; Abelson, 2010

Origin of orthopedic infections :

Endogenous infections
Hematogenous (ussualy) Lymphatogenous (occasionally)

Exogenous infections
external inoculation direct trauma Injection surgical intervention

Bramlage, 1998

Anatomy
Joints or articulations are classified structurally depending on the material binding the bones together as :

Fibrous Cartilaginous Synovial

Synovial joints The ends of the bones are covered by articular cartilage. A baglike synovial capsule encases the joint. Its inner lining, the synovial membrane, makes oily synovial fluid to lubricate the joint.
Bender, 2005

Synovial fluid

The joint cavity is normally sterile, with synovial fluid and cellular matter, including a few white blood cells. Synovial fluid is a viscous fluid found in the cavities of synovial joints, with its yolk-like consistency. The principal role of synovial fluid is to reduce friction between the articular catilage of synovial joints during movement.
Abelson 2010, Wikipedia

Wikipedia

Prevalence
estimated at 2 to 10 cases per 100,000 in the general population 30 to 70 cases per 100,000 in patients with rheumatoid arthritis1 Involved joint2: Knee-48% Hip-24% (more frequently involved in children) Shoulder-15%S Elbow-11% Sternoclavicular-8% Ankle-7% Wrist-7%

1. Abelson, 2011 2. phdres.caregate.net/curriculum/ppt.../Bone&JointInf-5-10-04.ppt

PREDISPOSING & RISK FACTORS

o age older than 60 years o certain bacteremia o Degenerative joint disease o rheumatoid arthritis (>10x than gen. pop.) o Corticosteroid therapy o Intravenous drug use o presence of indwelling catheters o underlying immunocompromised states o Total joint arthroplasties susceptible subsequent prosthetic joint infections. o gonorrhea infections : 0.5 to 3% is able to gain access to the bloodstream from the primary mucosal site of infection and produce 42 - 85% DGI (disseminated gonococcal infection)
Abelson, 2010; Shirtliff, 2002

Potential risk factors for septic arthritis

Eder, 2005

PATHOGENESIS
the production of host-derived extracellular matrix proteins that aid in joint healing (e.g., fibronectin) may promote bacterial attachment and progression to infection

Bacteria gain entry into the joint by direct introduction or extension from a contiguous site of infection.

seeded within the closed joint space, the low fluid shear conditions enable bacterial adherence and infection.

Synovial membrane hyperplasia develops in 5 to 7 days, and the release of cytokines leads to hydrolysis of proteoglycans and collagen, cartilage destruction, and eventually bone loss

virulence and tropism of the microorganisms + the resistance or susceptibility of the synovium to microbial invasion = major determinants of joint infection

Abelson, 2010; Shirtliff, 2002

MICROBIOLOGY
Most are monomicrobial infections Polymicrobial infections In patients with direct inoculation of the joint space The most common bacterial isolates :
Gram-positive cocci S. aureus found in 40% to 50% of the cases N. gonorrhoeae, streptococci, and gram-negative cocci, each 10% - 20% of cases N. gonorrhoeae in sexually active young adults, usually with associated dermatitis and tenosynovitis Gram-negative bacilli are often present in neonates, the elderly, and patients with immune deficiency disorders Mycobacterial infections should be suspected in patients from endemic areas Fungal are seen in immunocompromised patients Haemophilus influenzae was a common cause of bacterial arthritis in young children with decreasing incidence almost 70% - 80% since the use of H. influenzae b vaccine
Abelson, 2010

Organisms causing spetic arthritis

Eder, 2005

Bacterial isolated from specimens from revision hip and knee arthroplasties

Sharma, 2008

CLINICAL MANIFESTATION
Fever Malaise local findings of pain, warmth, swelling, and decreased range of motion in the involved joint
significant number of patients have mild fever and may not demonstrate localized heat and erythema around the affected joint

Shirtliff, 2002

 Gonococcal arthritis may present as part

of a disseminated infection or as arthritis
presenting symptoms include migratory arthralgias, moderate fever, chills, dermatitis, and tenosynovitis. large majority have asymptomatic genital, anal, or pharyngeal gonococcal infections classic skin lesion manifests as small erythematous papules which progress to vesicular or pustular lesions and are often limited to the extremities and the trunk. typically 5 to 10 lesions if present on the affected joint tenosynovitis is characterized by pain, swelling, and periarticular erythema

Shirtliff, 2002

DIAGNOSTIC
Arthroscopic classification
Arthroscopic classification of joint infections according to Gchter

Anagnostakos, 2009

Laboratory Findings
Diagnosis by synovial fluid testing Synovial culture and Gram stain Leukocyte counts in excess of 50,000/mm3 Glucose level of 40 mg/dl or less than half that seen in the serum High concentration of lactate 90% polymorphonuclear leukocytes Lack of bifringent crystals (Note: simultaneous crystalline and bacterial arthritis has been reported)

Shirtliff, 2002

Other laboratory indicators May have an elevated erythrocyte sedimentation rate, C-reactive protein levels, and/or peripheral leukocyte levels Sputum, urine, and blood cultures may be warranted o Blood cultures are positive in 50% of cases

Shirtliff, 2002

Aspiration Techniques for Septic Arthritis

The key diagnostic test when septic arthritis is suggested is arthrocentesis with analysis and culture of synovial fluid The important message for the physician is to be aggressive in looking for infectious arthritis The speed of diagnosis is the most important determinant of the outcome.

Sweiss, 2009

Indications for aspiration

Diagnostic indications oUnexplained arthritis with synovial effusion oSuggestion of an infected joint oSuspicion of crystal-induced arthritis oEvaluation of therapeutic response in septic arthritis
Therapeutic indications oDrainage of septic joint oRelief of elevated intra-articular pressure oInjection of medications oEvacuation of a painful hemarthrosis
Sweiss, 2009

 Potential complications of aspiration

Iatrogenic infection: The risk of inducing joint infection is low when sterile technique is used. Tendon injury, rupture, nerve and blood vessel injury, which can result from improper needle insertion

Contraindications to aspiration
Severe coagulopathy Severe thrombocytopenia Overlying cellulitis

Sweiss, 2009

Equipment needed for aspiration

Alcohol sponges Iodinated solution and surgical soap Gauze HemostatEthyl chloride Sterile gloves and drapes 18-gauge needle Sterile 20-mL syringes Blood collection tubes Anaerobic transport media Trypticase soy broth for most bacteria 1% Lidocaine

Sweiss, 2009

Skin preparation for aspiration

Kelley's Textbook of Rheumatology advocates the use of aseptic method similar to that used for a lumber puncture. In one small study, no evidence justified the use of full sterile aseptic skin preparation.[3] Some authors recommend proper cleansing of the skin by swabbing with alcohol to remove natural oils and debris, followed by an iodine-based antiseptic and then by swabbing with alcohol. Spraying the area with ethyl chloride should decrease the superficial pain. The use of a spray coolant has been shown to be safe and is not associated with increased risk of infection.
Sweiss, 2009

 Synovial fluid should be evaluated in gross terms for the color, clarity, viscosity, and mucin clot formation.

Microscopic evaluation includes leukocyte count differential, wet smear inspection by polarized light, and phase contrast microscopy. Cultures should be performed for bacteria, fungi, viruses, or tubercle bacilli if indicated.

Sweiss, 2009

Aspiration technique
Hip The anterior, lateral, or medial approach may be used to aspirate the hip joint. As the hip joint is deep, aspiration under fluoroscopic guidance helps to assist with intracapsular needle placement

Sweiss, 2009

Aspiration technique
Knee
Arthrocentesis with a large-bore needle (18- to 20-gauge) should be performed within 12 hours of suspicion The procedure should adhere to strict aseptic technique, and suitable local anesthetics, sedatives, and analgesics should be administered. The most common means to access the knee joint is from the lateral side at the level of the superior pole of the patella. The needle is advanced through the lateral retinaculum into the joint. Another common approach is through the medial joint line
Sweiss, 2009

Aspiration technique
Ankle
Same as knee The most common and safest means to aspirate the ankle joint is an anterolateral approach Insertion point of the needle should be 2.5 cm proximal and 1.3 cm anterior to the tip of the lateral malleolus, just lateral to the peroneus tertius tendon.

anterolateral approach

anterior approach

Sweiss, 2009

Aspiration technique
Shoulder
Aspiration of the glenohumeral joint can be accomplished from an anterior or posterior approach. Use an 18-gauge needle for all aspirations to allow for egress of viscous fluid. A spinal needle may be needed in obese or muscular patients. Aseptic technique should be followed for all aspirations, and local anesthesia may be used to infiltrate the skin only

Anterior approach.

Sweiss, 2009

Aspiration technique
Elbow and Wrist
Arthrocentesis or injection of the elbow is performed with the posterolateral approach

Aspiration of the wrist joint can be accomplished from several sites on the dorsum of the wrist

posterolateral approach, elbow in the flexed position at 90

Sweiss, 2009

Handling of synovial fluid specimens

generally accepted that samples of freshly aspirated joint fluid should be sent to the laboratory for immediate analysis should be routine practice to inoculate blood culture bottles in the laboratory to increase the yield of fastidious organisms, in addition to direct culture on agar plates Subsequent studies have confirmed that both inoculation into culture bottles and the use of lysis centrifugation tubes in the laboratory are superior to conventional agar plate methods for the detection of clinically significant micro-organisms.
Mathews CJ, 2007

MANAGEMENT

Antibiotic treatment Joint drainage and surgical options

Antibiotic treatment
Initial antibiotic therapy should be started empirically without awaiting the final results of culture.
Choice of antibiotic is based on the patient's age, presumed source of infection, patient's own infection profile, presence of immunosuppression including history of diabetes, and the suspected pathogenic organism.

Parenteral antibiotics should always be used, at least in the initial part of the treatment regimen Direct instillation of the antibiotic into the joint is not necessary and has not been shown to be more effective than parenteral antibiotics.

Abelson, 2010

Mathews CJ, 2007

 Duration of antibiotic treatment is more controversial and depends on the organism isolated at final culture and its response to the given antibiotic. In uncomplicated cases 2 weeks of therapy for H. influenzae, streptococci, or gram-negative cocci 4 weeks of therapy for staphylococci and gramnegative bacilli may be adequate Directed therapy for gonococcus with cephtriaxone should be given for 2 weeks. With the advent of home intravenous antibiotic therapy, these patients can be treated with parenteral antibiotics on an outpatient basis.
Abelson, 2010

A decrease in the white blood cell count in serial synovial fluid samples between 5 and 7 days of therapy reflects a control of infection

Abelson, 2010

Joint drainage and surgical options

Most uncomplicated cases can be drained with needle aspiration. Some infected joints, including the hip, shoulder, and sacroiliac joints, might not be easily aspirated. In these cases, an open arthrotomy may be considered as an initial approach.

Abelson, 2010

 Any joint with limited accessibility, including the sternoclavicular or the sternomanubrial joints, should also be managed surgically. Any joint that does not respond quickly to antibiotic therapy must also be treated surgically.
The goal of surgery is to remove all purulent material and nonviable tissue and to determine the need for synovectomy.

Culture and synovial biopsies can be obtained after dbridement to ensure sterility of the joint
Abelson, 2010

Suggested Readings
Bramlage IR. Infection of Bones and Joints. AAEP Proceedings. Vol. 44,1998.

Kirchheimer S. Septic Arthritis. Available at http://healthlibrary.epnet.com/GetContent.aspx?token=0a1af4895b4c-4f2d-978e-3930be13b1f6&chunkiid=165436 Update January 12th, 2010. Accessed May 12th, 2011. Abelson A. Septic Arthritis. Cleaveland Clinic website 2010-2011 Available at http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagem ent/rheumatology/septic-arthritis/ Accessed May 12th, 2011
Bender L. The Facts On File Illustrated Guide to the Human Body: Skeletal and Muscular Systems. The Diagram Group. 2005

 Wikipedia. Synovial fluid. www.wikipedia.com. Accessed May 29th 2011

Bone and Joint Infections. Available at phdres.caregate.net/curriculum/ppt.../Bone&JointInf-5-10-04.ppt Accessed May 18th 2011. Shirtliff ME, Mader T. Acute Septic Arthritis. Clin. Microbiol. Rev. Vol. 15, No. 4. 2002 Eder L, Zisman D. Clinical features and aetiology of septic arthritis in northern Israel. Rheumatology Vol. 44, 2005 Sharma D, Douglas J. Microbiology of infected arthroplasty: implications for empiric peri-operative antibiotics. Journal of Orthopaedic Surgery Vol.16, No.3. 2008

 Anagnostakos K. Classification of hip joint infections. Int. J. Med. Sci. Vol. 6 N0.5. 2009

Sweiss N. Aspiration Techniques and Indications for Surgery, Septic Arthritis. Available at http://emedicine.medscape.com/article/1268807. Updated April 1st, 2009. Accessed May 29th, 2011 Mathews CJ. Kingsley G. Management of septic arthritis: a systematic review. Ann Rheum Dis Vol. 66, 2007 Dryden M. Bone and joint infection. Available at http://www.scribd.com/doc/46323738/Bone-and-Joint-InfectionMD2009. Accessed May 29th, 2011