Infectious Arthritis

Septic or infectious arthritis occurs when a joint becomes infected. Infections are most often caused by bacteria, but can also be caused by fungus or yeast. Viral infections can occur, but this is quite rare. Fortunately, septic arthritis is relatively uncommon, but does occur in about 26,000 Americans each year.

Bacteria can gain entry into a joint in several ways. Trauma can introduce bacteria into the joint. This can range from large traumatic injuries which tear tissues away and expose the joint, to very small injuries, such as punctures by a nail or staple.

Bacteria can also spread to a joint by traveling though the blood (bacteremia). Small amounts of bacteria can enter the blood during dental procedures (even teeth cleaning). Bacteria frequently enter the blood in patients who have pneumonia or other serious infections. Even minor bladder infections can cause bacteremia.

Surgical procedures can also create an opportunity for bacteria to enter a joint, although modern surgical techniques, modern antibiotic therapy, and the filtered air in modern operating rooms has dramatically reduced the likelihood of this problem. For example, the frequency of a joint infection following a hip replacement or knee replacement 30 years ago was about 10%. Today, the frequency is less than 0.5 %, about one chance in 200.

Almost half of the infections that do occur following hip and knee replacement occur long after surgery. These late infections most likely occur after episodes of bacteremia, during which bacteria seed into the area of the joint replacement. As a result, all patients who receive joint replacements are instructed to take preventative antibiotic therapy before and after any dental or surgical procedures which may cause a bacteremia. They are also encouraged to seek prompt attention anytime they have a suspected infection.

Who is at Risk for Septic or Infectionous Arthritis

• Patients with chronic rheumatoid arthritis.
• Patients with certain systemic infections, including gonorrhea and HIV infection. Women and male homosexuals are at greater risk for gonorrheal arthritis than are male heterosexuals.
• Patients with certain types of cancer.
• IV drug abusers and alcoholics.
• Patients with artificial (prosthetic) joints.
• Patients with diabetes, sickle cell anemia, or systemic lupus erythematosus (SLE).
• Patients with recent joint injuries or surgery, or patients receiving medications injected directly into a joint.

Symptoms of Infectious Arthritis

Septic Arthritis usually is easily recognized by the findings of a hot, swollen, and painful joint which develops rapidly and without obvious trauma. However, some infections can be indolent, developing slowly and only causing mild symptoms of swelling and stiffness.

The most difficult aspect of recognizing a joint infection is determining when a hot painful joint is not infected. Several other conditions can cause these symptoms, including gout, pseudogout (chondrocalcinosis), inflammatory arthritis (such as Rheumatoid Arthritis), occult fractures, or tumors. The evaluating physician needs to consider all of these possibilities.

Over 50% of cases occur in a knee joint, although children more commonly get hip infections. A diagnosis is usually made by testing fluid which is aspirated from the joint.

Causes Infectious Arthritis

In general, infectious arthritis is caused by the spread of a bacterial, viral, or fungal infection through the bloodstream to the joint. The disease agents may enter the joint directly from the outside as a result of an injury or a surgical procedure, or they may be carried to the joint by the blood from infections elsewhere in the body. The specific organisms vary somewhat according to age group. Newborns are most likely to acquire gonococcal infections of the joints from a mother with gonorrhea. Children may also acquire infectious arthritis from a hospital environment, often as a result of catheter placement. The organisms involved are usually either Haemophilus influenzae (in children under two years of age) or Staphylococcus aureus. In older children or adults, the infectious organisms include Streptococcus pyogenes and Streptococcus viridans as well as Staphylococcus aureus. Staphylococcus epidermidis is usually involved in joint infections related to surgery. Sexually active teenagers and adults frequently develop infectious arthritis from Neisseria gonorrhoeae infections. Older adults are often vulnerable to joint infections caused by gram-negative bacilli, including Salmonella and Pseudomonas.

Infectious arthritis often has a sudden onset, but symptoms sometimes develop over a period of three to 14 days. The symptoms include swelling in the infected joint and pain when the joint is moved. Infectious arthritis in the hip may be experienced as pain in the groin area that becomes much worse if the patient tries to walk. In 90% of cases, there is some leakage of tissue fluid into the affected joint. The joint is sore to the touch; it may or may not be warm to the touch, depending on how deep the infection lies within the joint. In most cases the patient will have fever and chills, although the fever may be only low-grade. Children sometimes develop nausea and vomiting.

Septic arthritis is considered a medical emergency because of the damage it causes to bone as well as cartilage, and its potential for creating septic shock, which is a potentially fatal condition. Staphylococcus aureus is capable of destroying cartilage in one or two days. Destruction of cartilage and bone in turn leads to dislocations of the joints and bones. If the infection is caused by bacteria, it can spread to the blood and surrounding tissues, causing abscesses or even blood poisoning. The most common complication of infectious arthritis is osteoarthritis.

Diagnosis of Infectious Arthritis

The diagnosis of infectious arthritis depends on a combination of laboratory testing with careful history-taking and physical examination of the affected joint. It is important to keep in mind that infectious arthritis can coexist with other forms of arthritis, gout, rheumatic fever, Lyme disease, or other disorders that can cause a combination of joint pain and fever. In some cases, the doctor may consult a specialist in orthopedics or rheumatology to avoid misdiagnosis.

Patient historyof Infectious Arthritis

The patient's history will tell the doctor whether he or she belongs to a high-risk group for infectious arthritis. Sudden onset of joint pain is also important information.

Laboratory tests for Infectious Arthritis

Laboratory testing is necessary to confirm the diagnosis of infectious arthritis. The doctor will perform an arthrocentesis, which is a procedure that involves withdrawing a sample of synovial fluid (SF) from the joint with a needle and syringe. SF is a lubricating fluid secreted by tissues surrounding the joints. Patients should be warned that arthrocentesis is a painful procedure. The fluid sample is sent for culture in the sealed syringe. SF from infected joints is usually streaked with pus or looks cloudy and watery. Cell counts usually indicate a high level of white cells; a level higher than 100,000 cells/mm3 or a neutrophil proportion greater than 90% suggests septic arthritis. A Gram's stain of the culture obtained from the SF is usually positive for the specific disease organism.

Doctors sometimes order a biopsy of the synovial tissue near the joint if the fluid sample is negative. Cultures of other body fluids, such as urine, blood, or cervical mucus, may be taken in addition to the SF culture.

Diagnostic imaging of Infectious Arthritis

Diagnostic imaging is not helpful in the early stages of infectious arthritis. Destruction of bone or cartilage does not appear on x rays until 10-14 days after the onset of symptoms. Imaging studies are sometimes useful if the infection is in a deep-seated joint.

Treatment of Infectious Arthritis

Infectious arthritis requires usually requires several days of treatment in a hospital, with follow-up medication and physical therapy lasting several weeks or months.

Medications for Infectious Arthritis

Because of the possibility of serious damage to the joint or other complications if treatment is delayed, the patient will be started on intravenous antibiotics before the specific organism is identified. After the disease organism has been identified, the doctor may give the patient a drug that targets the specific bacterium or virus. Nonsteroidal anti-inflammatory drugs are usually given for viral infections.

Intravenous antibiotics are given for about two weeks, or until the inflammation has disappeared. The patient may then be given a two- to four-week course of oral antibiotics.

Surgery for Infectious Arthritis

In some cases, surgery is necessary to drain fluid from the infected joint. Patients who need surgical drainage include those who have not responded to antibiotic treatment, those with infections of the hip or other joints that are difficult to reach with arthrocentesis, and those with joint infections related to gunshot or other penetrating wounds.

Patients with severe damage to bone or cartilage may need reconstructive surgery, but it cannot be performed until the infection is completely gone.

Monitoring and supportive treatment for Infectious Arthritis

Infectious arthritis requires careful monitoring while the patient is in the hospital. The doctor will drain the joint on a daily basis and remove a small sample of fluid for culture to check the patient's response to the antibiotic.

Infectious arthritis often causes intense pain. Patients are given medications to relieve pain, together with hot compresses or ice packs on the affected joint. In some cases the patient's arm or leg is put in a splint to protect the sore joint from accidental movement. Recovery can be speeded up, however, if the patient practices range-of-motion exercises to the extent that the pain allows.

Prognosis of Infectious Arthritis

The prognosis depends on prompt treatment with antibiotics and drainage of the infected joint. About 70% of patients will recover without permanent joint damage. However, many patients will develop osteoarthritis or deformed joints. Children with infected hip joints sometimes suffer damage to the growth plate. If treatment is delayed, infectious arthritis has a mortality rate between 5% and 30% due to septic shock and respiratory failure.

Prevention of Infectious Arthritis

Some cases of infectious arthritis are preventable by lifestyle choices. These include avoidance of self-injected drugs; sexual abstinence or monogamous relationships; and prompt testing and treatment for suspected cases of gonorrhea. Patients receiving corticosteroid injections into the joints for osteoarthritis may want to weigh this treatment method against the increased risk of infectious arthritis.