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Clinical Management of Septic Arthritis

  • INFECTIONS AND ARTHRITIS (K WINTHROP, SECTION EDITOR)
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Abstract

Septic arthritis is a rheumatologic emergency as joint destruction occurs rapidly and can lead to significant morbidity and mortality. Accurate diagnosis can be particularly challenging in patients with underlying inflammatory joint disease. This review outlines the risk factors for septic arthritis and summarizes the causative bacterial organisms. We highlight advances in antibiotic management with a focus on new drugs for methicillin-resistant Staphylococcus aureus (MRSA) and discuss the use of adjunctive therapies for treatment of septic arthritis in adults.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Ross JJ. Septic arthritis. Infect Dis Clin North Am. 2005;19:799–817.

    Article  PubMed  Google Scholar 

  2. Geirsson AJ, Statkevicius S, Vikingsson A. Septic arthritis in Iceland 1990–2002: increasing incidence due to iatrogenic infections. Ann Rheum Dis. 2008;67:638–43.

    Article  PubMed  CAS  Google Scholar 

  3. Kaandorp CJ, Van Schaardenburg D, Krijnen P, et al. Risk factors for septic arthritis in patients with joint disease. A prospective study. Arthritis Rheum. 1995;38:1819–25.

    Article  PubMed  CAS  Google Scholar 

  4. Kellgren JH, Ball J, Fairbrother RW, et al. Suppurative arthritis complicating rheumatoid arthritis. Br Med J. 1958;1:1193–200.

    Article  PubMed  CAS  Google Scholar 

  5. Doran MF, Crowson CS, Pond GR, et al. Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum. 2002;46:2287–93.

    Article  PubMed  Google Scholar 

  6. Edwards CJ, Cooper C, Fisher D, et al. The importance of the disease process and disease-modifying antirheumatic drug treatment in the development of septic arthritis in patients with rheumatoid arthritis. Arthritis Rheum. 2007;57:1151–7.

    Article  PubMed  Google Scholar 

  7. Strangfeld A, Listing J. Infection and musculoskeletal conditions: Bacterial and opportunistic infections during anti-TNF therapy. Best Pract Res Clin Rheumatol. 2006;20:1181–95.

    Article  PubMed  CAS  Google Scholar 

  8. Dolganiuc A, Stavaru C, Anghel M, et al. The migratory and phagocytic activity of polymorphonuclear leukocytes in rheumatoid arthritis and osteoarthritis patients. Roum Arch Microbiol Immunol. 2000;59:43–53.

    PubMed  CAS  Google Scholar 

  9. Turner RA, Schumacher R, Myers AR. Phagocytic function of polymorphonuclear leukocytes in rheumatic diseases. J Clin Invest. 1973;52:1632–5.

    Article  PubMed  CAS  Google Scholar 

  10. Goldenberg DL. Infectious arthritis complicating rheumatoid arthritis and other chronic rheumatic disorders. Arthritis Rheum. 1989;32:496–502.

    Article  PubMed  CAS  Google Scholar 

  11. O'Connell PG, Milburn BM, Nashel DJ. Coexistent gout and septic arthritis: a report of two cases and literature review. Clin Exp Rheumatol. 1985;3:265–7.

    PubMed  Google Scholar 

  12. Yu KH, Luo SF, Liou LB, et al. Concomitant septic and gouty arthritis--an analysis of 30 cases. Rheumatology (Oxford). 2003;42:1062–6.

    Article  CAS  Google Scholar 

  13. Hamilton ME, Parris TM, Gibson RS, et al. Simultaneous gout and pyarthrosis. Arch Intern Med. 1980;140:917–9.

    Article  PubMed  CAS  Google Scholar 

  14. • Galloway JB, Hyrich KL, Mercer LK, et al. Risk of septic arthritis in patients with rheumatoid arthritis and the effect of anti-TNF therapy: results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis. 2011;70:1810–4. A prospective observational study evaluating the risk of septic arthritis in over 4,500 patients with rheumatoid arthritis treated with anti-TNF and non-biological disease-modifying antirheumatic drugs. This study demonstrated that anti-TNF therapy use in RA is associated with doubling the risk of septic arthritis.

    Article  PubMed  CAS  Google Scholar 

  15. Ostensson A, Geborek P. Septic arthritis as a non-surgical complication in rheumatoid arthritis: relation to disease severity and therapy. Br J Rheumatol. 1991;30:35–8.

    Article  PubMed  CAS  Google Scholar 

  16. Albert C, Brocq O, Gerard D, et al. Septic knee arthritis after intra-articular hyaluronate injection. Two case reports. Joint Bone Spine. 2006;73:205–7.

    Article  PubMed  Google Scholar 

  17. • Smith RM, Schaefer MK, Kainer MA, et al. Fungal Infections Associated with Contaminated Methylprednisolone Injections - Preliminary Report. N Engl J Med. 2012. A preliminary report on the multistate outbreak of fungal infections associated with injections of methylprednisolone acetate purchased from a single compounding pharmacy.

  18. Ryan MJ, Kavanagh R, Wall PG, et al. Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period. Br J Rheumatol. 1997;36:370–3.

    Article  PubMed  CAS  Google Scholar 

  19. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford). 2001;40:24–30.

    Article  CAS  Google Scholar 

  20. Dubost JJ, Soubrier M, De Champs C, et al. No changes in the distribution of organisms responsible for septic arthritis over a 20 year period. Ann Rheum Dis. 2002;61:267–9.

    Article  PubMed  CAS  Google Scholar 

  21. Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. 2006;26:703–8.

    Article  PubMed  Google Scholar 

  22. Martinez-Aguilar G, Avalos-Mishaan A, Hulten K, et al. Community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children. Pediatr Infect Dis J. 2004;23:701–6.

    Article  PubMed  Google Scholar 

  23. Fridkin SK, Hageman J, McDougal LK, et al. Epidemiological and microbiological characterization of infections caused by Staphylococcus aureus with reduced susceptibility to vancomycin, United States, 1997–2001. Clin Infect Dis. 2003;36:429–39.

    Article  PubMed  Google Scholar 

  24. Lu JJ, Lee SY, Hwa SY, et al. Septic arthritis caused by vancomycin-intermediate Staphylococcus aureus. J Clin Microbiol. 2005;43:4156–8.

    Article  PubMed  Google Scholar 

  25. • Allison DC, Holtom PD, Patzakis MJ, et al. Microbiology of bone and joint infections in injecting drug abusers. Clin Orthop Relat Res. 2010;468:2107–12. A retrospective review describing the microbiology of bone and joint infections in 215 patients with a history of IVDU from the years 1998 to 2005. S. aureus remained the predominant organism with an increased proportion of MRSA infections over the study period.

    Article  PubMed  Google Scholar 

  26. Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in a single UK Health District 1982–1991. Ann Rheum Dis. 1999;58:214–9.

    Article  PubMed  CAS  Google Scholar 

  27. Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. 2002;15:527–44.

    Article  PubMed  Google Scholar 

  28. Schelenz S, Bramham K, Goldsmith D. Septic arthritis due to extended spectrum beta lactamase producing Klebsiella pneumoniae. Joint Bone Spine. 2007;74:275–8.

    Article  PubMed  Google Scholar 

  29. O'Brien JP, Goldenberg DL, Rice PA. Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. Medicine (Baltimore). 1983;62:395–406.

    Article  Google Scholar 

  30. Prevention CfDCa. Sexually Transmitted Disease Surveillance. 2002 [cited 2003]; Available from: www.cdc.gov.

  31. Kaandorp CJ, Dinant HJ, van de Laar MA, et al. Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis. 1997;56:470–5.

    Article  PubMed  CAS  Google Scholar 

  32. Gardner GC, Weisman MH. Pyarthrosis in patients with rheumatoid arthritis: a report of 13 cases and a review of the literature from the past 40 years. Am J Med. 1990;88:503–11.

    Article  PubMed  CAS  Google Scholar 

  33. Newman JH. Review of septic arthritis throughout the antibiotic era. Ann Rheum Dis. 1976;35:198–205.

    Article  PubMed  CAS  Google Scholar 

  34. Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet. 2010;375:846–55.

    Article  PubMed  Google Scholar 

  35. Margaretten ME, Kohlwes J, Moore D, et al. Does this adult patient have septic arthritis? JAMA. 2007;297:1478–88.

    Article  PubMed  CAS  Google Scholar 

  36. Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology (Oxford). 2006;45:1039–41.

    Article  CAS  Google Scholar 

  37. Gupta MN, Sturrock RD, Field M. Prospective comparative study of patients with culture proven and high suspicion of adult onset septic arthritis. Ann Rheum Dis. 2003;62:327–31.

    Article  PubMed  CAS  Google Scholar 

  38. Fenollar F, Roux V, Stein A, et al. Analysis of 525 samples to determine the usefulness of PCR amplification and sequencing of the 16S rRNA gene for diagnosis of bone and joint infections. J Clin Microbiol. 2006;44:1018–28.

    Article  PubMed  CAS  Google Scholar 

  39. Yang S, Ramachandran P, Hardick A, et al. Rapid PCR-based diagnosis of septic arthritis by early Gram-type classification and pathogen identification. J Clin Microbiol. 2008;46:1386–90.

    Article  PubMed  CAS  Google Scholar 

  40. Stengel D, Bauwens K, Sehouli J, et al. Systematic review and meta-analysis of antibiotic therapy for bone and joint infections. Lancet Infect Dis. 2001;1:175–88.

    Article  PubMed  CAS  Google Scholar 

  41. Brancos MA, Peris P, Miro JM, et al. Septic arthritis in heroin addicts. Semin Arthritis Rheum. 1991;21:81–7.

    Article  PubMed  CAS  Google Scholar 

  42. Limbago B, Fosheim GE, Schoonover V, et al. Characterization of methicillin-resistant Staphylococcus aureus isolates collected in 2005 and 2006 from patients with invasive disease: a population-based analysis. J Clin Microbiol. 2009;47:1344–51.

    Article  PubMed  Google Scholar 

  43. Naimi TS, LeDell KH, Como-Sabetti K, et al. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA. 2003;290:2976–84.

    Article  PubMed  CAS  Google Scholar 

  44. Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in Staphylococcus aureus. Glycopeptide-Intermediate Staphylococcus aureus Working Group. N Engl J Med. 1999;340:493–501.

    Article  PubMed  CAS  Google Scholar 

  45. •• Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011;52:285–92. Evidence-based guidelines for the management of MRSA infections.

    Article  PubMed  Google Scholar 

  46. Kutscha-Lissberg F, Hebler U, Muhr G, et al. Linezolid penetration into bone and joint tissues infected with methicillin-resistant staphylococci. Antimicrob Agents Chemother. 2003;47:3964–6.

    Article  PubMed  CAS  Google Scholar 

  47. Rana B, Butcher I, Grigoris P, et al. Linezolid penetration into osteo-articular tissues. J Antimicrob Chemother. 2002;50:747–50.

    Article  PubMed  CAS  Google Scholar 

  48. Moise PA, Forrest A, Birmingham MC, et al. The efficacy and safety of linezolid as treatment for Staphylococcus aureus infections in compassionate use patients who are intolerant of, or who have failed to respond to, vancomycin. J Antimicrob Chemother. 2002;50:1017–26.

    Article  PubMed  CAS  Google Scholar 

  49. Howden BP, Ward PB, Charles PG, et al. Treatment outcomes for serious infections caused by methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility. Clin Infect Dis. 2004;38:521–8.

    Article  PubMed  CAS  Google Scholar 

  50. Manfredi R, Sabbatani S, Chiodo F. Severe staphylococcal knee arthritis responding favourably to linezolid, after glycopeptide-rifampicin failure: a case report and literature review. Scand J Infect Dis. 2005;37:513–7.

    Article  PubMed  Google Scholar 

  51. Rao N, Ziran BH, Hall RA, et al. Successful treatment of chronic bone and joint infections with oral linezolid. Clin Orthop Relat Res. 2004; 67–71.

  52. Wu VC, Wang YT, Wang CY, et al. High frequency of linezolid-associated thrombocytopenia and anemia among patients with end-stage renal disease. Clin Infect Dis. 2006;42:66–72.

    Article  PubMed  Google Scholar 

  53. De Vriese AS, Coster RV, Smet J, et al. Linezolid-induced inhibition of mitochondrial protein synthesis. Clin Infect Dis. 2006;42:1111–7.

    Article  PubMed  Google Scholar 

  54. Lawrence KR, Adra M, Gillman PK. Serotonin toxicity associated with the use of linezolid: a review of postmarketing data. Clin Infect Dis. 2006;42:1578–83.

    Article  PubMed  CAS  Google Scholar 

  55. Rouse MS, Piper KE, Jacobson M, et al. Daptomycin treatment of Staphylococcus aureus experimental chronic osteomyelitis. J Antimicrob Chemother. 2006;57:301–5.

    Article  PubMed  CAS  Google Scholar 

  56. Forrest GN, Donovan BJ, Lamp KC, et al. Clinical experience with daptomycin for the treatment of patients with documented gram-positive septic arthritis. Ann Pharmacother. 2008;42:213–7.

    Article  PubMed  CAS  Google Scholar 

  57. Lalani T, Boucher HW, Cosgrove SE, et al. Outcomes with daptomycin versus standard therapy for osteoarticular infections associated with Staphylococcus aureus bacteraemia. J Antimicrob Chemother. 2008;61:177–82.

    Article  PubMed  CAS  Google Scholar 

  58. Papadopoulos S, Ball AM, Liewer SE, et al. Rhabdomyolysis during therapy with daptomycin. Clin Infect Dis. 2006;42:e108–10.

    Article  PubMed  Google Scholar 

  59. Lal Y, Assimacopoulos AP. Two cases of daptomycin-induced eosinophilic pneumonia and chronic pneumonitis. Clin Infect Dis. 2010;50:737–40.

    Article  PubMed  Google Scholar 

  60. Kazory A, Dibadj K, Weiner ID. Rhabdomyolysis and acute renal failure in a patient treated with daptomycin. J Antimicrob Chemother. 2006;57:578–9.

    Article  PubMed  CAS  Google Scholar 

  61. Drew RH, Perfect JR, Srinath L, et al. Treatment of methicillin-resistant staphylococcus aureus infections with quinupristin-dalfopristin in patients intolerant of or failing prior therapy. For the Synercid Emergency-Use Study Group. J Antimicrob Chemother. 2000;46:775–84.

    Article  PubMed  CAS  Google Scholar 

  62. Chambers HEG, Gilbert D, Moellering R, Saag M. In: Sanford JC, editor. The Sanford Guide to Antimicrobial Therapy. Sperryville, VA: Antimicrobial Therapy, Inc; 2011.

    Google Scholar 

  63. Lin JC, Aung G, Thomas A, et al. The use of ceftaroline fosamil in methicillin-resistant Staphylococcus aureus endocarditis and deep-seated MRSA infections: a retrospective case series of 10 patients. J Infect Chemother. 2012.

  64. Twilla JD, Gelfand MS, Cleveland KO, et al. Telavancin for the treatment of methicillin-resistant Staphylococcus aureus osteomyelitis. J Antimicrob Chemother. 2011;66:2675–7.

    Article  PubMed  CAS  Google Scholar 

  65. Kaushal R, Hassoun A. Successful treatment of methicillin-resistant Staphylococcus epidermidis prosthetic joint infection with telavancin. J Antimicrob Chemother. 2012;67:2052–3.

    Article  PubMed  CAS  Google Scholar 

  66. •• Prasad P, Sun J, Danner RL, et al. Excess deaths associated with tigecycline after approval based on noninferiority trials. Clin Infect Dis. 2012;54:1699–709. A metaanalysis of 13 randomized trials comparing outcomes of tigecyline with other control antibiotics demonstrated an increase in mortality and increased noncure rates associated with tigecycline use.

    Article  PubMed  CAS  Google Scholar 

  67. CDC. Sexually Transmitted Diseases Treatment Guidelines 2010; Gonococcal Infections. 2011; Available from: http://www.cdc.gov/std/treatment/2010/gonococcal-infections.htm.

  68. Goldenberg DL, Sexton, D.J. Disseminated Gonococcal Infection. UpToDate; 2012 [updated Novemer 16 2012].

  69. Gerald L, Mandell JEB, Raphael D. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill, Livingstone, Elsevier; 2010.

    Google Scholar 

  70. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351:1645–54.

    Article  PubMed  CAS  Google Scholar 

  71. •• Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases society of america. Clin Infect Dis. 2013;56:e1–25. Evidence-based and opinion-based recommendations on the management of prosthetic joint infections.

    Article  PubMed  Google Scholar 

  72. Zimmerli W, Widmer AF, Blatter M, et al. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA. 1998;279:1537–41.

    Article  PubMed  CAS  Google Scholar 

  73. Ravindran V, Logan I, Bourke BE. Medical vs surgical treatment for the native joint in septic arthritis: a 6-year, single UK academic centre experience. Rheumatology (Oxford). 2009;48:1320–2.

    Article  Google Scholar 

  74. Goldenberg DL, Brandt KD, Cohen AS, et al. Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage. Arthritis Rheum. 1975;18:83–90.

    Article  PubMed  CAS  Google Scholar 

  75. Sammer DM, Shin AY. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. J Bone Joint Surg Am. 2009;91:1387–93.

    Article  PubMed  Google Scholar 

  76. Abdel MP, Perry KI, Morrey ME, et al. Arthroscopic management of native shoulder septic arthritis. J Shoulder Elbow Surg. 2012.

  77. Nusem I, Jabur MK, Playford EG. Arthroscopic treatment of septic arthritis of the hip. Arthroscopy. 2006;22:902 e1–3.

    Google Scholar 

  78. Garcia-Arias M, Balsa A, Mola EM. Septic arthritis. Best Pract Res Clin Rheumatol. 2011;25:407–21.

    Article  PubMed  Google Scholar 

  79. Butt U, Amissah-Arthur M, Khattak F, et al. What are we doing about septic arthritis? A survey of UK-based rheumatologists and orthopedic surgeons. Clin Rheumatol. 2011;30:707–10.

    Article  PubMed  Google Scholar 

  80. Sakiniene E, Bremell T, Tarkowski A. Addition of corticosteroids to antibiotic treatment ameliorates the course of experimental Staphylococcus aureus arthritis. Arthritis Rheum. 1996;39:1596–605.

    Article  PubMed  CAS  Google Scholar 

  81. Odio CM, Ramirez T, Arias G, et al. Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children. Pediatr Infect Dis J. 2003;22:883–8.

    Article  PubMed  Google Scholar 

  82. Harel L, Prais D, Bar-On E, et al. Dexamethasone therapy for septic arthritis in children: results of a randomized double-blind placebo-controlled study. J Pediatr Orthop. 2011;31:211–5.

    Article  PubMed  Google Scholar 

  83. Wysenbeek AJ, Leitman M, Amit M, et al. Experimental septic arthritis in rabbits treated by a combination of antibiotic and steroid drugs. Clin Exp Rheumatol. 1996;14:507–12.

    PubMed  CAS  Google Scholar 

  84. Wysenbeek AJ, Volchek J, Amit M, et al. Treatment of staphylococcal septic arthritis in rabbits by systemic antibiotics and intra-articular corticosteroids. Ann Rheum Dis. 1998;57:687–90.

    Article  PubMed  CAS  Google Scholar 

  85. Verdrengh M, Carlsten H, Ohlsson C, et al. Addition of bisphosphonate to antibiotic and anti-inflammatory treatment reduces bone resorption in experimental Staphylococcus aureus-induced arthritis. J Orthop Res. 2007;25:304–10.

    Article  PubMed  CAS  Google Scholar 

  86. Sharp JT, Lidsky MD, Duffy J, et al. Infectious arthritis. Arch Intern Med. 1979;139:1125–30.

    Article  PubMed  CAS  Google Scholar 

  87. Goldenberg DL, Brandt KD, Cathcart ES, et al. Acute arthritis caused by gram-negative bacilli: a clinical characterization. Medicine (Baltimore). 1974;53:197–208.

    CAS  Google Scholar 

  88. Kratz A, Greenberg D, Barki Y, et al. Pantoea agglomerans as a cause of septic arthritis after palm tree thorn injury; case report and literature review. Arch Dis Child. 2003;88:542–4.

    Article  PubMed  CAS  Google Scholar 

  89. Freiberg AA, Herzenberg JE, Sangeorzan JA. Thorn synovitis of the knee joint with Nocardia pyarthrosis. Clin Orthop Relat Res. 1993; 233–6.

  90. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999;340:85–92.

    Article  PubMed  CAS  Google Scholar 

  91. Hu L. Lyme arthritis. Infect Dis Clin North Am. 2005;19:947–61.

    Article  PubMed  Google Scholar 

  92. Ohl CA. Infectious Arthritis of Native Joints. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill Livingstone; 2010. p. 1443–56.

    Chapter  Google Scholar 

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Katie A. Sharff declares that she has no conflict of interest.

Eric P. Richards declares that he has no conflict of interest.

John M. Townes declares that he has no conflict of interest.

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This article is part of the Topical Collection on Infections and Arthritis

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Sharff, K.A., Richards, E.P. & Townes, J.M. Clinical Management of Septic Arthritis. Curr Rheumatol Rep 15, 332 (2013). https://doi.org/10.1007/s11926-013-0332-4

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