1. 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

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

3. pathogenesis Direct contamination. Haematogenous spread.
Contiguous focus.

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

5. etiology

6. diagnosis
Clinical.
Blood test.
Synovial fluid.
Microbiological.

7. clinical presentation
Fever.
Pain.
Joint effusion.

8. 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).

9. clinical presentation

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

11. 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.

12. synovial fluid

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

14. 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

16. 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.

17. 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

18. clinical evolution

19. clinical evolution

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

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

22. what’s new
ARE CLASSICAL STATISTICS STILL RELIABLE?

23. epidemiology

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

25. 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.

26. 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

27. epidemiology
Any type of orthopaedic implants were excluded.

28. epidemiology
Any type of orthopaedic implants were excluded.

29. 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

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

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

32. 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).

33. 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.

34. epidemiology

35. 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.

36. 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.

37. take home
Work together.
Orthopaedics
Microbiology Infectious diseases

38. 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

39. THANK YOU