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Septic Arthritis

Dr Swapnil Pawar January 15, 2022 43


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    Septic Arthritis
    Dr Swapnil Pawar

Blog Written by Dr Ashley Liu

Septic Arthritis

Differentials for Mono-arthritis
Infective (i.e. septic arthritis) History:

·   Hot, swollen singular joint

·   Constitutional symptoms (high-grade fever, malaise, weight loss)

Exam:

·   Inability to weight bear

Diagnostic investigation: Joint aspirate

·   Macroscopic: Turbid purulent fluid

·   Microscopic: Elevated WCC with >70% PMN

·   Culture: Positive

Crystallopathy (i.e. gout, pseudogout) History:

·   Severe pain, redness, warmth and swelling usually worst within 12-24h from onset

·   Involvement of first MTP or knee

·   History of self-limiting attacks of arthritis

Exam:

·   Presence of tophi

Diagnostic investigation: Joint fluid aspirate (crystallopathy), MRI

·   Gout: negatively birefringence + yellow needle shape

·   Pseudogout: positively birefringence + rod-shaped

Haemarthrosis (i.e. clotting disorders) History:

·   Minimal trauma swelling

·   History of coagulopathy

Exam:

·   Hot, swollen joint

·   ± limited range of motion

Diagnostic investigation: Joint fluid aspirate

·   Macroscopic: tinged red

·   Microscopic: xanthochromia

·   Culture: negative

Trauma (i.e. fracture, meniscal tear, soft tissue injury) History: Trauma preceding joint pain

Exam: Pain on active and/or passive movement + limited range of motion

Diagnostic investigation: X-Ray (fracture), MRI (soft-tissue injury)

Systemic rheumatic disease (i.e. Rheumatoid arthritis, spondyloarthritis, SLE, sarcoidosis) History:

·   “Morning stiffness” that worsens with immobility

·   Multi-system involvement (fatigue, rash, adenopathy, alopecia, oral ulcers, pleuritic chest pain, Raynaud phenomenon, dry eyes and mouth)

·   Family history of rheumatic diseases

Exam:

·   Eye & skin involvement

·   Joint swelling and deformity (swelling of MCP, swan neck deformity)

Diagnostic investigation: Diagnostic criteria that usually involves clinical, laboratory and imaging results

Tumour History:

·   Localised pain or swelling for a few weeks-months

·   Possible noticed following minor trauma

Exam:

·   Distinct soft tissue mass

·   Firmly attached to bone and tender to palpation

Diagnostic investigation: Needle biopsy or operative biopsy

Osteoarthritis History:

·   Joint pain and stiffness that worsens with mobility but improves with rest

·   History of progressive pain

Exam:

·   Usually involving knees, hips

·   Joint deformity (subluxation of thumb)

Diagnostic investigation: Clinical + X-Ray

 

Helfgott SM. (2021) Monoarthritis in adults: Etiology and evaluation. In:  UpToDate, M. R. Curtis (Ed), UpToDate. Retrieved January 15 2022, from https://www.uptodate.com.acs.hcn.com.au/contents/monoarthritis-in-adults-etiology-and-evaluation

Antibiotic regimen for Septic Arthritis

The suggested duration for antibiotic therapy (adults) is recommended to be for a total of 4 weeks (2 weeks IV). However, these treatment durations do not apply to gonococcal arthritis, which should be treated for 7 days.

Organism Antibiotic Regimen
Staphylococcal species (gram-positive)

 

Flucloxacillin 2g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly

If non-severe hypersensitivity to penicillin, cefazolin 2g IV q8hrly

MRSA (suspected or increased risk of MRSA) Vancomycin IV

OR depending on local guidelines

Clindamycin 600mg IV q8hly or Lincomycin 600mg IV 8hly

Streptococcal OR

Gram-negative septic arthritis

Ceftriaxone 2g (child: 50 mg/kg up to 2 g) intravenously daily

OR

Cefotaxime 2g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly

 

Septic Arthritis [published 2019 April]. In: Therapeutic Guidelines [digital]. Melbourne: Therapeutic Guidelines Limited; 2022 Jan. <https://www.tg.org.au>

 

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