Septic Arthritis

Septic arthritis, which is sometimes called septic arthritis is a suppurative inflammation within a joint space, most commonly due to haematogenous spread, but sometimes due to direct spread from a penetrating wound or a neighbouring infection, for example chronic osteomyelitis.

Most commonly affected are children, premature neonates, the elderly and the immune suppressed.

Generally, this disease is monoarticular, and occurs often in the knee and the hip, but may involve any joint. In infants there can be multiple joint involvement. Note that septic arthritis of the hip may present as pain in the knee and vice-versa.

Information about Septic Arthritis

Septic arthritis can occur in any age group, including newborns and children. In adults, it usually affects the wrists or one of the patient's weight-bearing joints--most often the knee--although about 20% of adult patients have symptoms in more than one joint. Multiple joint infection is common in children and typically involves the shoulders, knees, and hips.

Some groups of patients are at greater risk for developing Septic arthritis. These high-risk groups include:

• 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 Septic Arthritis

Symptoms of septic arthritis occur suddenly and are characterized by severe pain, swelling in the affected joint along with acute pain. Chills and fever are also common symptoms. Septic arthritis in the hip may be experienced as pain in the groin area that becomes much worse if the patient tries to walk. In the majority of cases, there is some leakage of tissue fluid into the affected joint. The joint is sore to the touch, and may or may not be warm to the touch, depending on how deep the infection lies within the joint. Children sometimes develop nausea and vomiting.

Causes of Septic Arthritis

In general, Septic 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 Septic 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 Septic arthritis from Neisseria gonorrhoeae infections. Older adults are often vulnerable to joint infections caused by gram-negative bacilli, including Salmonella and Pseudomonas.

Septic 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. Septic 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 Septic arthritis is osteoarthritis.

Diagnosis of Septic Arthritis

Your doctor will diagnose septic arthritis based upon your symptoms, your medical history, a complete physical exam, and synovial fluid and blood tests. After numbing the area, he or she will withdraw a sample of synovial fluid from the affected joint. This fluid will be tested for white blood cells, which are usually high, and for bacteria and other organisms. Some of the joint fluid will be placed in a special container in which many types of bacteria can grow and be identified.

The doctor may perform an arthrocentesis, which is a procedure that involves withdrawing a sample of synovial fluid from the joint with a needle and syringe for testing. The doctor may also perform a culture of blood and urine to rule out other causes such as gout, acute rheumatic fever, rheumatoid arthritis, Lyme disease and 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.   Because septic arthritis can quickly destroy a joint unless treated, your doctor may also order x-rays to assess any joint damage.

Laboratory testing is necessary to confirm the diagnosis of Septic 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 is not helpful in the early stages of Septic 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 Septic Arthritis

Septic arthritis must be diagnosed quickly and treated with antibiotics. Your doctor may first give these antibiotics intravenously (through a vein) to make sure the infected joint receives medication to kill the bacteria as quickly as possible. Then, the remaining course of antibiotics is taken orally.

The doctor may also need to drain the fluid from the infected joints if it rapidly reaccumulates and causes symptoms. Immediate surgical drainage is reserved for septic arthritis of the hip, because that site is inaccessible for repeated fluid removal. For most other joints, surgical drainage is used only if medical therapy fails over two to four days to alleviate symptoms.  Hot compresses and splinting the joint to provide it with rest and support can help relieve pain. After a period of rest, your doctor will recommend gentle exercise to prevent stiffness. If septic arthritis occurs in an artificial joint, antibiotic treatment may need to be followed by surgery to replace the joint. Most patients with no other serious underlying disease recover fully from septic arthritis with antibiotic therapy.

Recovery from septic arthritis is usually good with most patients undergoing treatment, although many patients will develop osteoarthritis or deformed joints. Children with infected hip joints sometimes suffer damage to the growth plate. Patients with severe damage to bone or cartilage may need reconstructive surgery, but it cannot be performed until the infection is completely gone.

Medications for Septic 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 Septic 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 Septic arthritis

Septic 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.

Septic 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 Septic 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, Septic arthritis has a mortality rate between 5% and 30% due to septic shock and respiratory failure.

Prevention of Septic arthritis

Some cases of Septic 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 Septic arthritis.