Bacterial septic arthritis in adults.
TL;DR: The changing epidemiology of septic arthritis of native joints in adults, encompassing the increasing frequency of the disorder and its evolving antibiotic resistance is reviewed, including the advent of novel and antibiotic-resistant causative microorganisms and within the current climate of increased immunosuppression.
About: This article is published in The Lancet.The article was published on 2010-03-06. It has received 492 citations till now. The article focuses on the topics: Septic arthritis & Arthritis.
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TL;DR: This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of S. aureus as a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections.
Abstract: Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.
3,054 citations
01 Oct 2012
TL;DR: This work will provide an overview of the mechanisms and factors involved in bacterial adhesion, the techniques that are currently being used studying bacterial-material interactions as well as provide insight into future directions in the field.
Abstract: Staphylococcus comprises up to two-thirds of all pathogens in orthopedic implant infections and they are the principal causative agents of two major types of infection affecting bone: septic arthritis and osteomyelitis, which involve the inflammatory destruction of joint and bone. Bacterial adhesion is the first and most important step in implant infection. It is a complex process influenced by environmental factors, bacterial properties, material surface properties and by the presence of serum or tissue proteins. Properties of the substrate, such as chemical composition of the material, surface charge, hydrophobicity, surface roughness and the presence of specific proteins at the surface, are all thought to be important in the initial cell attachment process. The biofilm mode of growth of infecting bacteria on an implant surface protects the organisms from the host immune system and antibiotic therapy. The research for novel therapeutic strategies is incited by the emergence of antibiotic-resistant bacteria. This work will provide an overview of the mechanisms and factors involved in bacterial adhesion, the techniques that are currently being used studying bacterial-material interactions as well as provide insight into future directions in the field.
569 citations
Cites background from "Bacterial septic arthritis in adult..."
...These factors include rheumatoid arthritis or osteoarthritis, joint prosthesis, low socioeconomic status, intravenous drug abuse, alcoholism, diabetes, previous intra-joint corticosteroid injection and cutaneous ulcers.(41) The yearly incidence of septic arthritis is between 2 and 10 in 100,000 in the general population but it may be as high as 30–70 per 100,000 in rheumatoid arthritis patients or recipients of prosthetic joints(42-44) and is more common in children than in adults, and in males rather than in females....
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...In all age and risk groups, the most frequent causative organisms identified are Staphylococcus aureus followed by other gram-positive bacteria, including streptococci.(40,41) Numerous different factors have been identified for developing of septic arthritis....
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TL;DR: Advances in antibiotic management with a focus on new drugs for methicillin-resistant Staphylococcus aureus (MRSA) and the use of adjunctive therapies for treatment of septic arthritis in adults are highlighted.
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.
111 citations
TL;DR: The high economic burden of BJIs was mostly associated with more frequent and prolonged hospitalizations, high morbidity, and complexity of care, whereas diabetes and ulcer sores were significantly associated with native infections.
110 citations
Cites result from "Bacterial septic arthritis in adult..."
...There was an overall BJI prevalence of 54 per 100,000, which is in the range of other studies.(9,10,14) BJI prevalence was age and sex dependent, increasing six-fold from those aged <50 years to those aged >70 years....
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Journal Article•
TL;DR: In the absence of peripheral leukopenia or prosthetic joint replacement, synovial fluid white blood cell count in patients with septic arthritis is usually greater than 50,000 per mm3, and Gram stain results should guide initial antibiotic choice.
Abstract: Prompt diagnosis and treatment of infectious arthritis can help prevent significant morbidity and mortality. The acute onset of monoarticular joint pain, erythema, heat, and immobility should raise suspicion of sepsis. Constitutional symptoms such as fever, chills, and rigors are poorly sensitive for septic arthritis. In the absence of peripheral leukopenia or prosthetic joint replacement, synovial fluid white blood cell count in patients with septic arthritis is usually greater than 50,000 per mm3. Isolation of the causative agent through synovial fluid culture is not only definitive but also essential before selecting antibiotic therapy. Synovial fluid analysis is also useful to help distinguish crystal arthropathy from infectious arthritis, although the two occasionally coexist. Almost any microorganism can be pathogenic in septic arthritis; however, septic arthritis is caused by nongonococcal pathogens (most commonly Staphylococcus species) in more than 80 percent of patients. Gram stain results should guide initial antibiotic choice. Vancomycin can be used for gram-positive cocci, ceftriaxone for gram-negative cocci, and ceftazidime for gram-negative rods. If the Gram stain is negative, but there is strong clinical suspicion for bacterial arthritis, treatment with vancomycin plus ceftazidime or an aminoglycoside is appropriate. Evacuation of purulent material with arthrocentesis or surgical methods is necessary. Special consideration should be given to patients with prosthetic joint infection. In this population, the intraarticular cutoff values for infection may be as low as 1,100 white blood cells per mm3 with a neutrophil differential of greater than 64 percent.
94 citations
Cites background from "Bacterial septic arthritis in adult..."
...Although septic arthritis is usually monoarticular, up to 20 percent of cases are oligoarticular.(1) In native joints, the knee is the most commonly affected, followed by the hip, shoulder, ankle, elbow, and wrist....
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...The incidence of septic arthritis ranges widely, between four and 29 cases per 100,000 person-years, and depends on population variables and preexisting structural joint abnormalities.(1) Because of the lack of a limiting basement plate in synovial tissues, the most common route of entry into the joint is hematogenous spread during bacteremia....
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...Because pathogenesis may be hematogenous, blood cultures are positive in 25 to 50 percent of patients with septic arthritis.(1,9,20)...
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...Failure to initiate appropriate antibiotic therapy within the first 24 to 48 hours of onset can cause subchondral bone loss and permanent joint dysfunction.(1,2) The incidence of septic arthritis ranges widely, between four and 29 cases per 100,000 person-years, and depends on population variables and preexisting structural joint abnormalities....
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...In synovial fluid, a WBC count of more than 50,000 per mm(3) (50 × 10(9) per L) and a polymorphonuclear cell count greater than 90 percent have been directly correlated with infectious arthritis, although this overlaps with crystalline disease.(1,6) Lower synovial fluid WBC counts may occur in persons with disseminated gonococcal disease, peripheral leukopenia, or joint replacement....
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References
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TL;DR: Staphylococcus aureus can colonize the host to initiate infection by adhering to components of the extracellular matrix by distinct mechanisms that are being investigated at the molecular level.
1,022 citations
TL;DR: Dramatic shifts have occurred in the prevalence and types of extended-spectrum beta-lactamases (ESBLs) in Europe, and changing patterns present major therapeutic and infection control challenges, with the public health intervention points unclear.
Abstract: Since around 2000—earlier in Poland and Spain and later in France and the UK—dramatic shifts have occurred in the prevalence and types of extended-spectrum b-lactamases (ESBLs) in Europe. Before this watershed, most producers were nosocomial isolates, often Klebsiella spp. or Enterobacter spp. from specialist care units, and had mutant TEM or SHV ESBLs. Subsequently, CTX-M ESBLs have become dominant, with much greater penetration into Escherichia coli, and with many infections in ‘complicated community’ patients, usually with underlying disease, recent antibiotic usage, or healthcare contact. The degree of clonality among producers varies with the country, as does the enzyme type produced, with group 9 (CTX-M-9 and -14) enzymes dominant in Spain and group 1 enzymes (particularly CTX-M-3 and -15) dominant elsewhere. Irrespective of the particular enzyme, most producers are multiresistant. These changing patterns present major therapeutic and infection control challenges, with the public health intervention points unclear.
924 citations
TL;DR: Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis, but the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septicthritis before the Gram stain and culture test results are known.
Abstract: ContextIn patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality.ObjectiveTo review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis.Data SourcesStructured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity.Study SelectionStudies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis.Data ExtractionThree authors independently abstracted data from the included studies.Data SynthesisFourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts 50 000/μL: LR, 7.7; 95% CI, 5.7-11.0; and for counts >100 000/μL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47).ConclusionsClinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.
468 citations
TL;DR: These evidence-based guidelines have been produced after a literature review of the treatment and prophylaxis of methicillin-resistant Staphylococcus aureus (MRSA) infection.
Abstract: These evidence-based guidelines have been produced after a literature review of the treatment and prophylaxis of methicillin-resistant Staphylococcus aureus (MRSA) infection. The guidelines were further informed by antibiotic susceptibility data on MRSA from the UK. Recommendations are given for the treatment of common infections caused by MRSA, elimination of MRSA from carriage sites and prophylaxis of surgical site infection. There are several antibiotics currently available that are suitable for use in the management of this problem and potentially useful new agents are continuing to emerge.
449 citations
TL;DR: These results confirm the importance of obtaining synovial fluid and blood for culture before starting antimicrobial treatment and suggest that important predictors of death are: confusion at presentation, age ⩾65 years, multiple joint sepsis or involvement of the elbow joint, and of morbidity.
Abstract: AIMS To determine the clinical features of a large number of unselected UK hospital patients with confirmed septic arthritis and to determine those features associated with a poor outcome. STUDY DESIGN Retrospective, case-note survey. SETTING A single English Health District. PATIENTS All patients admitted to hospital in Nottingham during the period 1 January 1982 to 31 December 1991 with confirmed septic arthritis were included. OUTCOME MEASURES Death, osteomyelitis and recorded functional impairment. RESULTS The spectrum of causative organisms remains similar to that seen in previous studies with the Gram positive organisms Staphylococcus aureus and Streptococci responsible for 74% of cases, gonococcal infections though were less common. Culture of joint aspirates and or blood were positive in 82% of cases, with the Gram stain demonstrating the causative organism in 50% of cases. Pre-existing joint disease was evident in 35% of cases. The mortality remains high at 11.5% with a significant additional morbidity of 31.6%. Multivariate analysis suggests that important predictors of death are: confusion at presentation, age ⩾65 years, multiple joint sepsis or involvement of the elbow joint, and of morbidity are: age ⩾ 65 years, diabetes mellitus, open surgical drainage, and Gram positive infections other than S aureus. CONCLUSIONS Septic arthritis continues to be associated with a considerable degree of morbidity and mortality. These results confirm the importance of obtaining synovial fluid and blood for culture before starting antimicrobial treatment. The apparent poorer outcome found with surgical intervention is in line with some previous suggestions but should be interpreted with caution in light of the retrospective nature of this study.
423 citations