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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 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

    • Many different 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 gonorrhea (most common in young, sexually active adults)
    • Other: rickettsial (e.g., Lyme), fungal, mycobacterial
    • Risk by specific age (2):
      • <1 month: Streptococcus aureus, Group B strep (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: 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 (rheumatoid 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/all/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/all/Arthritis__Septic. Accessed April 25, 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/all/Arthritis__Septic
    Arthritis, Septic [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 25]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816409/all/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/all/Arthritis__Septic PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -