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<!-- Definition and symptoms -->
'''Septic arthritis''', also known as '''joint infection''' or '''infectious arthritis''', is the invasion of a [[joint]] by an [[infectious agent]] resulting in [[arthritis|joint inflammation]].
<!-- Cause and diagnosis -->
Causes include [[bacteria]], [[viruses]], [[fungi]], and [[parasites]]. <ref name=
<!-- Treatment -->
Initial treatment typically include [[antibiotics]] such as [[vancomycin]], [[ceftriaxone]], or [[ceftazidime]].<ref name=AFP2011/><ref name=":1" /> Surgery may also be done to clean out the joint.<ref name=AFP2011/> Without early treatment long term joint problems may occur.<ref name=AFP2011/> Septic arthritis occurs in about 5 out
== Classification ==
Septic arthritis is usually caused by [[bacteria]], but may be caused by [[Virus|viral]], [[Mycobacteria|mycobacterial]], and [[Fungus|fungal]] pathogens as well.<ref name="AFP2011" />
=== Nongonoccocal Arthritis ===
These [[bacteria]] account for over 80% of septic arthritis cases and are usually [[Staphylococcus|staphyloccoci]] or [[Streptococcus|streptococci]]. <ref name="AFP2011" /> It is commonly spread through the blood from an infection site elsewhere, but can be introduced directly into the joint or from surrounding tissue.<ref name=":0" />
=== Gonococcal Arthritis ===
[[Neisseria gonorrhoeae]] is a common cause of septic arthritis in sexually active patients under 40 years old. <ref name="AFP2011" /><ref name=":0" /> The bacteria is spread through the blood to the joint following sexual transmission. Other symptoms of [[disseminated gonococcal infection]] can include [[tenosynovitis]] and dermatitis. <ref name=":3" /><ref name="AFP2011" />
=== Other ===
[[Fungus|Fungal]] and [[Mycobacterium|mycobacterial]] infections are rare causes of septic arthritis and usually have a slow onset of joint symptoms.<ref name="AFP2011" />
[[Borrelia burgdorferi|Borrelia burgodorferi]] infection, a bacteria that causes [[lyme disease]], can affect multiple joints. <ref name="AFP2011" />
Viruses such as [[rubella]], [[parvovirus B19]], [[chikungunya]], and [[HIV]] infection can also cause arthritis.<ref name=":0" />
==Signs and symptoms==
Septic arthritis
The most common joint affected is the knee. <ref name=":2" /> Hip, shoulder, wrist, or elbow joints are less commonly affected. <ref name=":1" /> Spine, [[Sternoclavicular joint|sternoclavicular]], and [[Sacroiliac joint|sacroiliac]] joints can also be involved; however, the most common cause of arthritis in these joints is [[Drug injection|intravenous drug use]]. <ref name=":0" />
Usually only one joint is effected. More than one joint can be involved if bacteria are seeded through the bloodstream.<ref name=":0" />
==Cause==
Septic arthritis is most commonly caused by bacteria reaching the [[synovial membrane]] of a joint. Bacteria can enter the joint by:
* The [[Circulatory system|bloodstream]] from an infection elsewhere (most common)
* Direct penetration into the joint
* A surrounding infection in the [[bone]] or [[Tissue (biology)|tissue]] (uncommon). <ref name="AFP2011" /><ref name=":4" /><ref name=":1" />
Micro-organisms in the blood may come from infections elsewhere in the body such as [[Abscess|abscesses]], [[Infection|wound infections]], [[osteomyelitis]], [[Urinary tract infection|urinary tract infections]], [[meningitis]] , or [[endocarditis]]. <ref name=":1" /> Sometimes the infection comes from an unknown location. Joints with preexisting arthritis, such as [[rheumatoid arthritis]], are especially prone to bacterial arthritis seeded through the blood stream. (6) In addition, some treatments for [[rheumatoid arthritis]] can also increase a patient's risk by causing an [[Immunodeficiency|immunocompromised]] state. (approach) [[Drug injection|Intravenous drug use]] can cause endocarditis that seeds bacteria into the bloodstream and subsequently causes septic arthritis.
Bacteria can enter the joint directly from prior surgery, [[Joint injection|intraarticular injection]], [[Major trauma|trauma]], or [[Joint replacement|joint prosthesis]]. <ref name=":0" /><ref name=":4" /><ref name=":3" />
=== Risk Factors ===
* Age over 80 years <ref name="AFP2011" /><ref name=":1" />
* [[Diabetes mellitus]] <ref name="AFP2011" /><ref name=":1" />
* [[Osteoarthritis]] <ref name="AFP2011" />
* [[Rheumatoid arthritis]] <ref name=":1" />
* [[Immunosuppressive drug|Immunosuppressive medication]] <ref name="AFP2011" />
* [[Drug injection|Intravenous drug abuse]] <ref name="AFP2011" />
* Recent joint surgery <ref name=":1" />
* [[Joint replacement|Hip or knee prosthesis]] and skin infection <ref name="AFP2011" /><ref name=":1" />
* [[HIV]] infection <ref name="AFP2011" /><ref name=":1" />
* Other causes of [[sepsis]] <ref name="AFP2011" />
Having more than one risk factor greatly increases risk of septic arthritis. <ref name=":1" />
=== Organisms ===
Most cases of septic arthritis involve only one organism; however, polymicrobial infections can occur, especially after large open injuries to the joint. <ref name=":3" />
* [[Staphylococcus|Staphyloccoci]]
** [[Staphylococcus aureus]] - the most common cause in most age groups. Can be caused by skin infection, previously damaged joint, prosthetic joint, or intravenous drug use. <ref name=":1" /><ref name=":3" />
** [[Staphylococcus epidermidis|coagulase-negative staphylococci]] - usually due to prosthetic joint <ref name=":0" />
* [[Streptococcus|Streptococci]] - the second most common cause <ref name=":3" /><ref name="AFP2011" />
** [[Streptococcus pyogenes]] - a common cause in children under 5 <ref name=":0" />
** [[Streptococcus pneumoniae]]
** [[Group B streptococci]] - a common cause in infants <ref name=":1" />
* [[Haemophilus influenzae]] <ref>{{cite journal|date=August 1997|title=Decline of bone and joint infections attributable to haemophilus influenzae type b|url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0009-921X&volume=341&spage=128|journal=Clin. Orthop. Relat. Res.|volume=|issue=341|pages=128–33|doi=|pmid=9269165|vauthors=Bowerman SG, Green NE, Mencio GA}}<br>
{{cite journal|date=May 1998|title=Reduced incidence of septic arthritis in children by Haemophilus influenzae type-b vaccination. Implications for treatment|url=http://www.jbjs.org.uk/cgi/pmidlookup?view=long&pmid=9619939|journal=J. Bone Joint Surg. Br.|volume=80|issue=3|pages=471–3|doi=10.1302/0301-620X.80B3.8296|pmid=9619939|vauthors=Peltola H, Kallio MJ, Unkila-Kallio L}}
</ref>
* [[Gonorrhea|Neisseria gonorrhoeae]] - the most common cause of septic arthritis in young, sexually active adults. <ref name="Malik2010">{{cite journal|date=November 2010|title=Emergent evaluation of injuries to the shoulder, clavicle, and humerus|journal=Emerg Med Clin North Am|volume=28|issue=4|pages=739–63|doi=10.1016/j.emc.2010.06.006|pmid=20971390|vauthors=Malik S, Chiampas G, Leonard H}}</ref> Multiple macules or vesicles seen over the trunk are a pathognomonic feature. <ref name="Kaandorp">{{cite journal|date=August 1997|title=Incidence and sources of native and prosthetic joint infection: a community based prospective survey|url=|journal=Ann. Rheum. Dis.|volume=56|issue=8|pages=470–5|doi=10.1136/ard.56.8.470|pmc=1752430|pmid=9306869|vauthors=Kaandorp CJ, Dinant HJ, van de Laar MA, Moens HJ, Prins AP, Dijkmans BA}}<br>
{{cite journal|date=April 1999|title=Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991|url=|journal=Ann. Rheum. Dis.|volume=58|issue=4|pages=214–9|doi=10.1136/ard.58.4.214|pmc=1752863|pmid=10364899|vauthors=Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M}}</ref>
* [[Neisseria meningitidis]] <ref name=":1" /><ref name=":3" />
* [[Escherichia coli]] - in the elderly, IV drug users and the seriously ill <ref name=":1" />
* [[Pseudomonas aeruginosa]] - IV drug users or penetrating trauma through the shoe <ref name=":0" /><ref name=":3" />
* [[M. tuberculosis]], [[Salmonella]] spp. and [[Brucella]] spp. - cause septic spinal arthritis <ref name="Axford">{{cite book|title=Medicine|vauthors=O'Callaghan C, Axford JS|publisher=Blackwell Science|year=2004|isbn=0-632-05162-0|edition=2nd|location=Oxford|pages=}}</ref>
* [[Eikenella corrodens]] - human bites <ref name=":0" />
* [[Pasteurella multocida]], [[bartonella henselae]] - animal bites or scratches <ref name=":0" />
* Fungal species - [[Immunodeficiency|immunocompromised]] state <ref name=":1" />
* [[Borrelia burgdorferi|Borrelia burgodorferi]] - ticks, causes [[lyme disease]] <ref name=":1" />
==Diagnosis==
Septic arthritis should be considered whenever
The diagnosis of septic arthritis is based on
Other studies such as blood cultures, [[white blood cell count]] with differential, [[Erythrocyte sedimentation rate|ESR]], and [[C-reactive protein|CRP]] should also be included. However, these tests are nonspecific and could be elevated due to infection elsewhere in the body. [[Serology|Serologic]] studies should be done if [[lyme disease]] is suspected. <ref name=":0" /><ref name=":3" />
In children, the [[Kocher criteria]] is used for diagnosis of septic arthritis.<ref>{{Cite journal|last=Kocher|first=Mininder S.|last2=Mandiga|first2=Rahul|last3=Murphy|first3=Jane M.|last4=Goldmann|first4=Donald|last5=Harper|first5=Marvin|last6=Sundel|first6=Robert|last7=Ecklund|first7=Kirsten|last8=Kasser|first8=James R.|date=June 2003|title=A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip|url=https://www.ncbi.nlm.nih.gov/pubmed/12783993|journal=The Journal of Bone and Joint Surgery. American Volume|volume=85-A|issue=6|pages=994–999|issn=0021-9355|pmid=12783993}}</ref>
=== Joint aspiration ===
In the [[Joint aspiration|joint fluid]], the typical white blood cell count in septic arthritis is over 50,000-100,000 cells per 10<sup>−6</sup>/l (50,000-100,000 cell/[[Cubic millimetre|mm<sup>3</sup>]]). <ref name=":5">{{Cite journal|last=Courtney|first=Philip|last2=Doherty|first2=Michael|title=Joint aspiration and injection and synovial fluid analysis|url=http://linkinghub.elsevier.com/retrieve/pii/S1521694213000120|journal=Best Practice & Research Clinical Rheumatology|volume=27|issue=2|pages=137–169|doi=10.1016/j.berh.2013.02.005}}</ref> However, septic [[synovial fluid]] can have white blood cell counts as low as a few thousand in the early stages. Therefore, differentiation of septic arthritis from other causes is not always possible based on cell counts alone.<ref name=":5" /><ref name=":1" />
The [[Gram stain]] can rule in the diagnosis of septic arthritis, however, cannot exclude it. <ref name=":1" />
[[Synovial fluid|Synovial]] fluid [[Microbiological culture|cultures]] are positive in over 90% of nongonoccocal arthritis; however, it is possible for the culture to be negative if the patient received antibiotics prior to the joint aspiration. <ref name=":1" /><ref name=":0" /> Cultures are usually negative in gonoccocal arthritis or if [[Fastidious organism|fastidious organisms]] are involved. <ref name=":0" /><ref name=":1" />
If the culture is negative or if a gonococcal cause is suspected, [[NAAT]] testing of the synovial fluid should be done. <ref name=":0" />
Positive crystal studies do not rule out septic arthritis. Crystal induced arthritis such as [[gout]] can occur at the same time as septic arthritis. <ref name="AFP2011" />
A lactate level in the synovial fluid of greater than 10 mmol/l makes the diagnosis very likely. <ref name="Car2011" />
===Blood tests===
Laboratory testing includes [[white blood cell count]], [[Erythrocyte sedimentation rate|ESR]], and [[C-reactive protein|CRP]]. These values are usually elevated in those with septic arthritis; however, these can be elevated by other infections or [[Inflammation|inflammatory conditions]] and are, therefore, [[Specificity and sensitivity|nonspecific]]. <ref name="AFP2011" /><ref name=":0" /> [[Procalcitonin]] may be more useful than CRP. <ref>{{cite journal|last1=Zhao|first1=J|last2=Zhang|first2=S|last3=Zhang|first3=L|last4=Dong|first4=X|last5=Li|first5=J|last6=Wang|first6=Y|last7=Yao|first7=Y|date=August 2017|title=Serum procalcitonin levels as a diagnostic marker for septic arthritis: A meta-analysis.|journal=The American journal of emergency medicine|volume=35|issue=8|pages=1166–1171|doi=10.1016/j.ajem.2017.06.014|pmid=28623003}}</ref>
[[Blood culture|Blood cultures]] can be positive in up to half of patients with septic arthritis. <ref name="AFP2011" /><ref name=":1" />
===Imaging===
Imaging such as [[x-ray]], [[CT scan|CT]], [[Magnetic resonance imaging|MRI]], or [[ultrasound]] are [[Sensitivity and specificity|nonspecific]]. They can help determine areas of inflammation but cannot confirm septic arthritis. <ref name=":4" />
When septic arthritis is suspected, [[X-ray|x-rays]] should generally be taken. <ref name=":1" /> This is used to assess for involvement of surrounding structures such as bone and also for comparison purposes when future x-rays are taken. <ref name=":1" /> While x-rays may not be helpful early in the diagnosis/treatment, they may show subtle increase in joint space and tissue swelling.<ref name=":0" /> Later findings include joint space narrowing due to destruction of the joint. <ref name=":4" />
[[Ultrasound]] can be done and is effective at detecting joint effusions. <ref name=":4" />
[[CT scan|CT]] and [[Magnetic resonance imaging|MRI]] are not required for diagnosis but can be used if diagnosis is unclear or in joints that are hard to examine (ie. [[Sacroiliac joint|sacroiliac]] or [[Hip|hip joints]]). They can can help assess for inflammation/infection in or about the joint (ie. [[Osteomyelitis|osteomyeltis]]). <ref name=":1" /><ref name=":4" />
=== Differential Diagnosis ===
* Crystal induced arthritis such as [[gout]] or [[Calcium pyrophosphate dihydrate crystal deposition disease|pseudogout]] <ref name=":1" /><ref name=":3" />
* [[Inflammatory arthritis]] <ref name=":1" /><ref name=":3" />
** [[Rheumatoid arthritis]]
** Seronegative spondyloarthropathy such as [[ankylosing spondylitis]] or [[reactive arthritis]]
* Traumatic arthritis due to [[hemarthrosis]], [[Bone fracture|fracture]], or [[foreign body]] <ref name=":1" />
* [[Osteoarthritis]] <ref name=":1" /><ref name=":3" />
== Treatment ==
Treatment is usually with [[intravenous]] [[Antibiotic|antibiotics]], [[analgesia]] and [[Debridement|washout]] and/or [[Arthrocentesis|aspiration]] of the joint. <ref name=":1" /><ref name=":0" /> Draining the pus from the joint is important and can be done either by needle ([[arthrocentesis]]) or opening the joint surgically ([[arthrotomy]]). <ref name="AFP2011" />
[[Empiric antibiotics]] for suspected bacteria should be started. This should be based on [[gram stain]] of the [[synovial fluid]] as well as other clinical findings. <ref name="AFP2011" /><ref name=":0" /> General guidelines are as follows:
* Gram positive [[Coccus|cocci]] - [[vancomycin]] <ref name="AFP2011" /><ref name=":1" />
* Gram negative [[Coccus|cocci]] - [[Ceftriaxone]] <ref name="AFP2011" />
* Gram negative [[bacilli]] - [[Ceftriaxone|Ceftrioxone]], [[cefotaxime]], or [[ceftazidime]] <ref name=":1" />
* Gram stain negative AND immunocompetent - [[vancomycin]] <ref name=":1" />
* Gram stain negative AND immunocompromised - [[vancomycin]] + third generation [[Cephalosporin|cephalosphorin]] <ref name=":1" />
* [[Drug injection|IV drug]] use (possible pseudomonas aeruginosa) - [[ceftazidime]] +/- an [[aminoglycoside]] <ref name=":1" /><ref name=":0" />
Once [[Microbiological culture|cultures]] are available, antibiotics can be changed to target the specific organism. <ref name=":1" /><ref name=":0" />
After a good response to intravenous antibiotics, patients can be switched to oral antibiotics. The duration of oral antibiotics varies, but is generally for 1-4 weeks depending on the offending organism. <ref name="AFP2011" /><ref name=":0" /><ref name=":1" />
In infection of a [[Joint replacement|prosthetic joint]], a [[biofilm]] is often created on the surface of the prosthesis which is resistant to antibiotics.<ref>{{Cite web|url=https://www.uptodate.com/contents/prosthetic-joint-infection-epidemiology-clinical-manifestations-and-diagnosis|title=Prosthetic joint infection: Epidemiology, clinical manifestations, and diagnosis|last=Berbari|first=Elie|last2=Baddour|first2=L. M.|date=2017|website=UpToDate|publisher=UpToDate Inc|location=Waltham, MA|archive-url=|archive-date=|dead-url=|access-date=}}</ref> [[Debridement|Surgical debridement]] is usually indicated in these cases.<ref name=":6">{{Cite web|url=https://www.uptodate.com/contents/prosthetic-joint-infection-treatment|title=Prosthetic joint infection: Treatment|last=Barbari|first=Elie|last2=Baddour|first2=L. M.|date=2017|website=UpToDate|publisher=UpToDate, Inc|location=Waltham, MA|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name="AFP2011" /> A replacement prosthesis is usually not inserted at the time of removal to allow antibiotics to clear infection of the region.<ref name=":4" /><ref name=":6" /> Patients that cannot have surgery may try long-term antibiotic therapy in order to suppress the infection. <ref name=":4" />
Close follow up with [[Physical examination|physical exam]] & labs must be done to make sure patient is no longer feverish, pain has resolved, has improved [[range of motion]], and lab values are normalized. <ref name=":1" /><ref name="AFP2011" />
== Outcomes ==
Risk of permanent impairment of the joint varies greatly.<ref name=":1" /> This usually depends on how quickly treatment is started after symptoms occur as longer lasting infections cause more destruction to the joint. The involved organism, age, preexisting arthritis, and other [[Comorbidity|comorbidities]] can also increase this risk.<ref name=":4" /> Gonococcal arthritis generally does not cause long term impairment. <ref name=":0" /><ref name=":1" /><ref name=":4" />
[[Mortality rate|Mortality]] rates generally range from 10-20%.<ref name=":4" /> These rates increase depending on the offending organism, older age, and comorbidities such as [[rheumatoid arthritis]] <ref name=":1" /><ref name=":3" /><ref name=":4" />
==References==
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