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Arthritis, Septic

Arthritis, Septic is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Infection due to bacterial invasion of the joint space
  • Systems affected: musculoskeletal
  • Synonyms: suppurative arthritis; infectious arthritis; pyarthrosis; pyogenic arthritis; bacterial arthritis

Epidemiology

  • May occur at any age; incidence is higher in very young and in the elderly.
  • Prevalence: 27% of patients presenting with monoarticular arthritis have nongonococcal septic arthritis (1).
  • Gender differences:
    • Gonococcal: female > male
    • Nongonococcal: male > female

Etiology and Pathophysiology

  • Multiple pathogens
  • Nongonococcal:
    • Staphylococcus aureus (most common in adults)
      • MRSA risk increased in elderly, intravenous drug users (IVDU), postsurgical
    • Streptococcus spp. (second most common in adults)
    • Gram-negative rods (GNR): IVDU, trauma, extremes of age, immunosuppressed
  • Neisseria gonorrhoeae (most common in young, sexually active adults)
  • Other: rickettsial (e.g., Lyme), fungal, mycobacterial
  • Risk by specific age (2):
    • <1 month: S. aureus, group B streptococcus (GBS), GNR
    • 1 month to 4 years: S. aureus, Streptococcus pneumoniae, Neisseria meningitidis
    • 16 to 40 years: N. meningitidis, S. aureus
    • >40 years: S. aureus
  • Specific high-risk groups:
    • Rheumatoid arthritis (RA): S. aureus
    • IVDU: S. aureus, GNR, opportunistic pathogens
    • Neonates: GBS
    • Immunocompromised: gram-negative bacilli, fungi
    • Trauma patients with open injuries: mixed flora
  • Pathogenesis:
    • Hematogenous spread (most common)
    • Direct inoculation by microorganisms secondary to trauma or iatrogenesis (e.g., joint surgery)
    • Adjacent spread (e.g., osteomyelitis)
  • Pathophysiology:
    • Microorganisms initially enter through synovial membrane and spread to the synovial fluid.
    • Resulting inflammatory response releases cytokines and destructive proteases leading to systemic symptoms and joint damage.

Risk Factors

  • Age >80 years
  • Low socioeconomic status, alcoholism
  • Cellulitis and skin ulcers
  • Violation of joint capsule
    • Prior orthopedic surgery
    • Intra-articular steroid injection
    • Trauma
  • History of previous joint disease
    • Inflammatory arthritis (RA: 10-fold increased risk)
    • Osteoarthritis
    • Crystal arthritides
  • Systemic illness
    • Diabetes mellitus, liver disease, HIV, malignancy, end-stage renal disease/hemodialysis, immunosuppression, sickle cell anemia
  • Risks for hematogenous spread
    • IVDU, severe sepsis/systemic infection

General Prevention

  • Prompt treatment of skin and soft tissue infections.
  • Control risk factors.
  • Immunization (S. pneumoniae, N. meningitidis)

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Citation

Stephens, Mark B., et al., editors. "Arthritis, Septic." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816409/2.1/Arthritis_Septic.
Arthritis, Septic. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816409/2.1/Arthritis_Septic. Accessed June 24, 2019.
Arthritis, Septic. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816409/2.1/Arthritis_Septic
Arthritis, Septic [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 June 24]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816409/2.1/Arthritis_Septic.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Arthritis, Septic ID - 816409 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816409/2.1/Arthritis_Septic PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -