1. Septic Arthritis Dr.noori/Rheumatologist

2. Infectious Arthritis
Septic Gonococcal Viral Fungal Tuberculous Lyme

3. Definition Acute joint infection due to bacterial agents
Medical emergency

4. Epidemiology Incidence: 40-68/100000/ yr in Prosthetic joint
28-38/ / yr in RA
5- 12/ / yr in Children
2-5/ / yr in GP

5. } SEPTIC ARTHRITIS Infection of synovium and synovial fluid
Seen in every ages
Hip joint in children
Knee in adults }
frequent

6. In Adult: 75% with risk factor

7. Risk factors: Systemic: Local: Old age (>65 Y) RA DM
Immunosuppressive
Hemodyalisis
Malignancy
Local: OA
Prosthetic joint

8. Etiology (microbiology)
Microbial agent:
Staphylococcus aureus: most common (75-80%)
Other organism in special patients:
Sexually active woman: Neisseria gonorrheae
Elderly, IV drug abuser, immunocompromised, UTI: Gram negative (p. aeruginosa and E.coli)
SLE: Salmonella
HIV:Pneumococci, Salmonella, H. influenzae
Alcoholism, Humeral immunity abnormality, Hemoglobinopathies: Pneumococcal infections
Primary immunoglobolin deficiency: Mycoplasma

9. ETIOLOGY S. aureus → in every ages H. influenzae → 6 mo-5 years
N. gonorrhoeae → >10 years, adults (in Western populations)
Gram negative bacilli → Immune deficiency, urinary or intestinal invasive procedures, elderly people, renal failure, chronic joint disorders and diabetes

10. PATHOGENESIS Hemotogenous spread Spread through adjacent tissues
Direct inoculation(aspiration/arthrotomy)
*Rheumatic diseases are underlying disorders for septic arthritis
-Structural abnormalities in the joint
-Steroid use (abnormal phagocytosis…)
*DM, immune def, hematological diseases, trauma, systemic infections…

12. Site of involvement: Mono (80-90%) Poly (more than 1 joint): RA
Knee: 50%
Hip: 13-20%
Shoulder:10-15 %-
Ankle: 5%
Wrist: 5%
Elbow: 5%
SC: 5%- IV drug abuser
SI: 2%- IV drug abuser
Small joints of the hand andFoot : 2%
Poly (more than 1 joint): RA

13. CLINICAL FEATURES
Usually, there is a history of recent trauma/infection
Frequently hip and knee joints
Sacroiliac joint is affected in brucellosis
Interphalangeal joints: human and animal bites
Fever, fatigue, anorexia, nausea…
Local findings of inflammation

14. Clinical manifestations
Fever (toxic):60-80%
Acute
Sever pain
Sever swelling of one joint
Sever tenderness
Warmth
Sever effusion
Sever limited ROM

15. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Synovial fluid sampling: > leukocytes/ml
(crystal arthropathies and RA)
Leukocytes <50.000/ml (Malignancy, steroid use)
Gram staining and culture
Gram-positive bacteria 60%, Gram-negative bacteria 40%

17. Diagnosis
Acute Monoarthritis
Sepsis workup
Biochemist
Synovial Fluid
Aspiration (rule)

21. کنتراندیکا سیونهای آرتروسنتز
سلولیت بروی مفصل مورد نظر
عفونت پوست مفصل
پلاکهای پسوریازیس بروی مفصل
باکتریمی(نسبی)
مصرف داروهای ضد انعقاد

22. Acute Monoarthritis
Sepsis workup
Biochemist
Synovial Fluid
Aspiration
Smear- Culture
Light microscope

23. Acute Monoarthritis Sepsis workup Synovial Fluid Biochemist Aspiration
Smear- Culture
Light microscope
Turbid - Purulent
Leukocyte> 50,000/ml
(> 90% PMN)
Damaged WBC
Crystal (-)

25. مایع مفصل سپتیک در 3 مورد WBCخیلی بالا نیست :
1)بیماران ایمنوساپرس
2)مصرف آنتی بیوتیک
3)اوایل عفونی شدن مفصل

26. Acute Monoarthritis Sepsis workup Synovial Fluid Biochemist Aspiration
Smear- Culture
Light microscope
Positive Gram stain:
75% in s. aureus
30-50% in gram (-)
Positive Fluid culture: 90%
PCR: partially treated or culture negative

27. Acute Monoarthritis Sepsis workup Synovial Fluid Biochemist Aspiration
Positive B/C :
50-70%
Smear- Culture
Light microscope
Leukocytosis
ESR & CRP
Positive Gram stain:
75% in s. aureus
30-50% in gram (-)
Positive Fluid culture: 90%
PCR: partially treated or culture negative

28. Radiography Early:(1-7d) (baseline/exclude contiguous osteomyelitis)
Soft tissue swelling Joint space widening
Late (2-3 w):
Erosion
Joint space narrowing
Periosteal new bone formation

32. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
PLAIN X-RAY
-Expansion in joint space
-Edema around the joint
-Late structural findings
Ultrasound
-Collection of fluid in the joint and aspiration CT
- Detection of associated osteomyelitis, joint fluid MR
- Pyogenic sacroiliitis and spread of joint infection to surrounding structures

33. DIFFERENTIAL DIAGNOSIS
Rheumatic fever
Acute juvenile arthritis
RA, gout, reactive arthritis
Viral arthritis
Fungal arthritis
Tuberculous arthritis
Osteomyelitis
Cellulitis
Bleeding into the joint (hemarthrosis)

34. TREATMENT
Antibiotic
Joint Drainage

35. TREATMENT Antibiotic Joint Drainage Empiric (IV): Smear
Age or Risk factors
Extra articular site

36. Empirical antibiotic Gram stain result: Gram positive cocci:
Oxacillin or Naficillin (2g /q 4h)
Vancomycin (1g /q 12h) if methycillin-resistant S. aureus
Gram Negative:
Ampicillin or Cephalosporin
No organism:
In healthy, sexually active: Cefotaxime or ceftriaxone
In elderly debilitated patients: antistaphylococcal + Aminoglycoside + antipseudomonal penicillin or a third generation cephalosporin

37. TREATMENT Antibiotic Joint Drainage Empiric (IV): Smear
Age or Risk factors
Extra articular site
Definitive therapy;
based on culture

38. Definitive therapy S. aureous: 4 weeks Oxacillin Naficillin Vancomycin
Pneumococal and streptococcal inf : 2 weeks
Penicillin G, 2mU /q 4h
H. influenzae and s. pneumoniae resistant to penicillin: 2 weeks
Cefotaxime or Ceftriaxone
Enteric gram negative: 3-4 w
Second or Third Gen cephalosporin
Fluoroquinolone (levofloxacin 500mg IV or Po every 24h)
P. aeruginosa: 4 weeks
Combination of AG + mezlocillin or ceftazidime (IV) 2 weeks
Ciprofloxacin 750mg twice daily (oral) 2 weeks

39. TREATMENT Antibiotic Joint Drainage Empiric (IV): Closed needle
Smear
Age or Risk factors
Extra articular site
Closed needle
Aspiration
Arthrotomy:
Hip, Shoulder
Definitive therapy;
based on culture

40. TREATMENT Antibiotic Joint Drainage Empiric (IV): Closed needle
Smear
Age or Risk factors
Extra articular site
Closed needle
Aspiration
Arthrotomy:
Hip, Shoulder
Arthroscopic Drainage:
Symptom
S. fluid volume
S. fluid WBC
S. fluid smear & culture
Definitive therapy;
based on culture

41. Frequent passive motion Until removal of inflammation signs
TREATMENT
Antibiotic
Joint Drainage
No weight bearing
Frequent passive motion
Until removal of inflammation signs