Epidemiology, general characteristics and clinical evolution SEPTIC ARTHRITIS Epidemiology, general characteristics and clinical evolution Enrique Sandoval Orthopaedic Surgery Bone and Joint Infection Unit FJD. Madrid, Spain

definition Synovial joint. Clinical and microbiological criteria. Catastrophic consequences. Up to 11% in monoarticular disease and 50% in poliarticular.

pathogenesis Direct contamination. Haematogenous spread. Contiguous focus.

epidemiology Annual incidence of 230 (after de first 2 years of implantation) PJI per 100,000 inhabitants vs 1.6 native joint infections per 100.000 inhabitants.

etiology

diagnosis Clinical. Blood test. Synovial fluid. Microbiological.

clinical presentation Fever. Pain. Joint effusion.

clinical presentation Non-gonococcal: 80-90% Gonococcal: 3%. Other: mycobacteria, fungi, etc. Clinical presentations can be broadly grouped into three categories: nongonococcal, gonococcal, and other (e.g., Lyme disease, mycobacterial, fungal).

clinical presentation

blood tests Leukocyte elevation (PMN). RCP. ESR. Blood cultures positive in 25 – 50%.

synovial fluid White blood cell count (PMN). Gram stain. Culture. Crystal analysis. Measuring synovial fluid glucose or protein is not useful because results are neither sensitive nor specific for septic arthritis.6 Polymerase chain reaction (PCR) testing may help isolate less common organisms, such as Borrelia species and should be ordered if there is a high level of clinical suspicion.

synovial fluid

differential diagnosis Crystal arthritis. Trauma, haemarthrosis. Systemic inflammatory arthritis.

treatment Surgical débridement: Empiric antibiotical treatment: Arthrotomy. Arthroscopic lavage. Empiric antibiotical treatment: Non-gonococcal: vancomycin + ceftazidim/aminoglycoside. Gonococcal: ceftriaxone. 4-6 weeks of etiological treatment. Empiric treatment based on clinical suspicion and gram stain

clinical evolution Before antibiotics: 60-70% mortality. Today: 10-20% mortality. Age over 65 years. Infection site (shoulder, elbow, multiple). Comorbidity: Cardiac, renal disease. Immunosupresion.

clinical evolution Functional outcome: Morbidity: 30-40% cases. 50% of baseline joint function in infections caused by S. aureus. 95% of baseline joint function in infections caused by S. pneumoniae. Morbidity: 30-40% cases. Severe cartilage damage. Amputation. Systemic involvement. Morbidity (e.g., amputation, arthrodesis, prosthetic surgery, severe functional deterioration) occurs in one-third of patients with bacterial arthritis, usually affecting older patients, those with preexisting joint disease

clinical evolution

clinical evolution

what’s new Modern antibiotics and vaccines may have modified the epidemiology.

what’s new Chronic diseases and treatments are more prevalent. Population over 65 in 2006

what’s new ARE CLASSICAL STATISTICS STILL RELIABLE?

epidemiology

epidemiology Retrospective review 2005-2012. Positive bacterial cultures (synovial fluid, synovial biopsy). Any type of orthopaedic implants were excluded.

epidemiology Retrospective review 2005-2012. Positive bacterial cultures (synovial fluid, synovial biopsy). Data recorded: Clinical characteristics. Laboratory examinations. Medical and surgical treatment. Outcomes. Any type of orthopaedic implants were excluded.

epidemiology Results: 41 patients (25 male, 16 female). Mean age 61 years old. One child (2 year-old girl). Poliarticular: 6 cases (7.4%). All patients presented with fever, pain and joint effusion

epidemiology Any type of orthopaedic implants were excluded.

epidemiology Any type of orthopaedic implants were excluded.

epidemiology Microorganisms: Staphylococcus aureus: 58.5%. Streptococcus sp: 22%. Escherichia coli: 12.2%. Mycobacterium tuberculosis: 4.9%. Other: 7.3%. 3 of 4 were S. agalactiae

epidemiology Laboratory parameters: Leukocytes: 12,286 ± 5,725 c/μl (PMN 71.8%). CRP: 13.44 ± 12.19 mg/dl. ESR: 55 ± 31.35 mg/dl.

epidemiology Treatment: Surgical débridement + antibiotics: 33 patients. Antibiotics only: 8 patients. Preferred combination: cloxacillin/vancomycin + ciprofloxacin 6-12 weeks.

epidemiology Outcomes: 1.5 ± 1 years follow-up. Poor outcome in 15 cases: Persistent pain - osteoarthritis (12 cases): 41.2% of S. aureus cases. Septic shock (3 cases).

epidemiology Conclusions: No major changes over time in: Microorganisms (except Haemophilus influenzae) Treatment strategy. Special attention to: Comorbitidity. Early diagnosis. Historically, Haemophilus influenzae infection has occurred more often in children although this may be tempered by wide- spread H. influenzae type b vaccination. 13 patients had at least one comorbidity.

epidemiology

take home SEPTIC ARTHRITIS incidence is expected to increase due to: Life expectancy. Chronic diseases – treatments. Little changes in etiology: Haemophilus. Mycobacteria. Early diagnosis and treatment are mandatory. Historically, Haemophilus influenzae infection has occurred more often in children although this may be tempered by wide- spread H. influenzae type b vaccination. 13 patients had at least one comorbidity.

take home Etiologic diagnosis strongly desirable. S. aureus: methicillin resistance. S. epidermidis: methicillin and glycopeptide resistance. Enterobacteriaceae: extended-spectrum beta-lactamases, carbapenemases. Pseudomonas aeruginosa: carbapenemases, quinolone resistance. Enterococcus sp.: glycopeptide resistance Others.

take home Work together. Orthopaedics Microbiology Infectious diseases

epidemiology 75% cases Staphylococcus aureus MICROBIOTA ASSOCIATION Typical Staphylococcus aureus 75% cases Atypical Neisseria gonorrhoeae STD Group B Streptococci (agalactiae) Neonatus Haemophilus influenzae Children under 5 years Enterobacteriaceae, Pseudomonas aeruginosa, fungi Opportunists

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