Septic Arthritis Definition: Septic arthritis is the purulent invasion of a joint by an infectious agent which produces arthritis.

The infection can be caused by bacteria, viruses, fungi, or parasites. Joint infection caused by fungi or parasites is much less common than that caused by bacteria or viruses. Typically, septic arthritis affects a single large joint, such as the knee or hip, but it is possible for several joints to be infected. Causes of Septic Arthritis: The infection can originate anywhere in the body. The infection may also begin as the result of an open wound, surgery, or unsterile injection. Whatever the initial source of infection, septic arthritis occurs when the infective organism travels through the bloodstream to the joint. Points of Interest About Septic Arthritis: The most common type of bacteria involved in septic arthritis is Stahylococcus aureus, usually referred to as Staph. The bacteria that causes gonorrhea used to be a common cause of septic arthritis, but safe sex has made it less common. When viruses attack joints, it is called viral arthritis, and the condition usually resolves on its own. Joint infection caused by a fungus, known as fungal arthritis, is considered very rare. A.K.A. Septic arthritis is also referred to as infectious arthritis and pyogenic arthritis. Septic arthritis is considered a medical emergency because of the serious damage that can occur to bone and cartilage. Septic arthritis can cause septic shock, which can be fatal. The term "suppurative arthritis" is a near synonym for septic arthritis. ("Suppurative" refers to the production of pus, without necessarily implying sepsis.) 3. Incidence rate Frequency United States Approximately 20,000 cases of septic arthritis occur each year in the United States (7.8 cases per 100,000 person-years).4 The incidence of arthritis due to disseminated gonococcal infection is 2.8 cases per 100,000 person-years. Septic arthritis is becoming increasingly common among people who are immunosuppressed and elderly persons; these groups are more likely to have various comorbid disease states. The incidence of PJI among all prosthesis recipients ranges from 2-10%. International The incidence of septic arthritis in Europe is identical to that in the United States. Mortality/Morbidity The primary morbidity of septic arthritis is significant dysfunction of the joint, even if treated properly. The mortality rate depends primarily on the causative organism. N

gonorrhoeae septic arthritis carries an extremely low mortality rate, while that of S aureus can approach 50%.14 Race Septic arthritis has no recognized racial predisposition. Sex Fifty-six percent of patients with septic arthritis are male. Age Forty-five percent of people with septic arthritis are older than 65 years. Septic arthritis can affect anyone at any age -- including infants and children. In adults, weightbearing joints (hips, knees, ankles) are most affected. In children, shoulders, hips, and knees are commonly affected. As the population ages, doctors are seeing more patients with septic arthritis. 4. risk/predisposing factors Septic arthritis develops when bacteria spreads through the bloodstream to a joint. It may also occur when the joint is directly infected with bacteria during injury or surgery. Acute septic arthritis tends to be caused by organisms such as staphylococcus, streptococcus pneumoniae and group B streptococcus. Chronic septic arthritis (which occurs less frequently) is caused by organisms such as Mycobacterium tuberculosis and Candida albicans. The knee and the hip are the most commonly infected joints. The following increase your risk for septic arthritis: Artificial joint implants Bacterial infection Chronic illness or disease Intravenous (IV) drug abuse Medications that suppress the immune system Recent joint trauma Recent joint arthroscopy or other surgery Rheumatoid arthritis Sickle cell disease Septic arthritis may be seen at any age. In children, it occurs most often in those less than 3 years old. The hip is a frequent site of infection in infants. Septic arthritis is uncommon from age 3 to adolescence. Children with septic arthritis are more likely than adults to be infected with group B streptococcus and Haemophilus influenza

5. Manifestations The onset of the symptoms is usually rapid with joint swelling, intense joint pain, and low-grade fever. Symptoms in newborns or infants: Unable to move the limb with the infected joint (pseudoparalysis)

Cries when infected joint is moved (example: diaper change causes crying if hip infected) Irritability Fever Symptoms in children and adults: Intense joint pain Joint swelling Joint redness Unable to move the limb with the infected joint Low-grade fever Chills may occur, but are uncommon

6. type None 7. pathophysiology Organisms may invade the joint by direct inoculation, by contiguous spread from infected periarticular tissue, or via the bloodstream (the most common route) When joint infection occurs as a result of bacteremia, the initial growth of microorganisms is either in the synovial membrane or in the adjacent bone. In either case, an inflammation of the synovial membrane is quickly established and results in a marked increase in leukocytes in the synovial fluid, even though the fluid itself is sterile. When the microorganisms have spread into the joint fluid, culture of the fluid reveals the etiology of the infection. The pathologic findings are varied and depend on the duration of the infection, the organism and the resistance of the host. Early in the infection, only inflammatory changes in the synovium are seen. Late in the course of untreated septic arthritis, destruction of joint structures is marked. Articular cartilage is particularly vulnerable because it is an avascular tissue. In acute, pyogenic arthritis, the cartilage characteristically dissolves first at points of articular contact to expose the underlying bone. As destructive changes occur several abnormalities appear in the synovial fluid: Increased pressure Low pH Low concentration of glucose Activation of proteolytic enzymes Increased turbidity Presence of mucin precipitate 8. dx studies How is septic arthritis diagnosed? Prompt diagnosis of septic arthritis is necessary to prevent permanent damage to the joint. In addition to a complete medical history and physical examination, diagnostic procedures for septic arthritis may include:

removal of joint fluid - to examine for white blood cells and bacteria. blood tests - to detect bacteria. phlegm, spinal fluid, and urine tests - to detect bacteria and find the source of infection. x-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. bone scan - a nuclear imaging method to evaluate any degenerative and/or arthritic changes in the joints; to detect bone diseases and tumors; to determine the cause of bone pain or inflammation. magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body. radionuclide scans - nuclear scans of various organs to determine blood flow to the organs

9. management Medical Care Medical management of infective arthritis focuses on adequate and timely drainage of the infected synovial fluid, administration of appropriate antimicrobial therapy, and immobilization of the joint to control pain. Acute PJI (<3 wk in duration) can be cured medically if it is of the early type or secondary to hematogenous spread without any evidence of periarticular soft-tissue involvement or joint instability.5 In native joint infections, antibiotics usually need to be administered parenterally for at least 2 weeks. However, each case must be evaluated independently. Infection with either methicillin-resistant S aureus (MRSA) or methicillinsusceptible S aureus (MSSA) requires at least 4 full weeks of intravenous antibiotic therapy. Orally administered antimicrobial agents are almost never indicated in the treatment of S aureus infections. Gram-negative native joint infections with a pathogen that is sensitive to quinolones can be treated with oral ciprofloxacin for the final 1-2 weeks of treatment. As a rule, a 2-week course of intravenous antibiotics is sufficient to treat gonococcal arthritis. Initial antibiotic choices must be empirical, based on the sensitivity pattern of the pathogens of the community. Consider the rise of resistance among potential bacteria when choosing an initial antibiotic regimen. If local incidence of MRSA is high (in particular, marked increase in the resistance of the pneumococcus), prescribe alternate antibiotics initially. Because many isolates of group B streptococci have become tolerant of penicillin, use a combination of penicillin and gentamicin or a later-generation cephalosporin. MRSA is becoming established outside of the hospital. Enterobacteriaceae and P aeruginosa are becoming more resistant to multiple antibiotics. Knowing the resistance patterns in the community, as well as in the hospital, is most important. Preferably, the antibiotic should be bactericidal with some effect against the slowgrowing organisms that are protected within a biofilm (eg, CONS). Rifampin fulfills these requirements. It should never be used alone because of the rapid development of bacterial resistance to the drug.

The choice of the type of drainage, whether percutaneous or surgical, has not been resolved completely.19,20 In general, use a needle aspirate initially, repeating joint taps frequently enough to prevent significant reaccumulation of fluid. Aspirating the joint 2-3 times a day may be necessary during the first few days. If frequent drainage is necessary, surgical drainage becomes more attractive. If, after 5 days of therapy, the joint shows some degree of improvement, consider an empirical trial of an anti-inflammatory agent. If the joint fails to respond after 5 days of appropriate antibiotic therapy (eg, presence of clinically significant fever, continued synovial purulence, persistently positive findings on culture), reassess the therapeutic approach. Reculture the fluid and reexamine for crystals. Perform appropriate serologies for diagnosis of Lyme disease. If these are positive, treat per current guidelines. If fungal or mycobacterial infection is possible, consider obtaining a synovial biopsy. Consider the possibility of reactive arthritis. Nonsteroidal inflammatory agents are the primary therapeutic agents for reactive arthritis. Perform imaging studies, either radiographs or an MRI, to rule out periarticular osteomyelitis. The use of fluoroquinolones for an extended period should be considered when the removal of an infected prosthesis is not possible. Cure rates as high as 62% have been documented in relatively small series. Generally, such prolonged therapy is seen as suppressive and not curative.

Surgical Care Surgical drainage is indicated when one or more of the following occur: the appropriate choice of antibiotic and vigorous percutaneous drainage fails to clear the infection after 5-7 days, the infected joints are difficult to aspirate (eg, hip), or adjacent soft tissue is infected. Routine arthroscopic lavage is rarely indicated. However, drainage through the arthroscope is replacing open surgical drainage. With arthroscopic drainage, the operator can visualize the interior of the joint and can drain pus, debride, and lyse adhesions. Gonococcal-infected joints rarely require surgical drainage. In cases of PJI that require surgery for cure (see above), successful treatment requires appropriate antibiotic therapy combined with removal of the hardware. Despite appropriate antibiotic use, the success rate is only about 20% if the prosthesis is left in place. A 2-stage approach is the most effective technique. o First, remove the prosthesis and follow with 6 weeks of antibiotic therapy. Then, place the new joint, impregnating the methylmethacrylate cement with an anti-infective agent (ie, gentamicin, tobramycin). Antibiotic diffusion into the surrounding tissues is the goal. The success rate for this approach is approximately 95% for both hip and knee joints. o An intermediate method is to exchange the new joint for the infected joint in a 1-stage surgical procedure with concomitant antibiotic therapy. This

method, with concurrent use of antibiotic cement, succeeds in 70-90% of cases. Consultations In general, obtain a consultation with an orthopedic surgeon or rheumatologist. If the initial treatment response is poor or the etiology of the synovitis remains unknown, consult with an infectious disease specialist. Activity If the patient's condition responds adequately after 5 days of treatment, begin gentle mobilization of the infected joint. Most patients require aggressive physical therapy to allow maximum postinfection functioning of the joint. Medication The empirical choice of antibiotic therapy is based on results of the Gram stain and the clinical picture and background of the patient. When the Gram stain fails to reveal any microorganisms (40-50% of cases), the individual's age and sexual activity become the major determinants to differentiate gonococcal from nongonococcal arthritis. When no evidence suggests infection elsewhere, antibiotics must cover S aureus, streptococcal species, and gonococci (in patients who are sexually active). Evidence shows that earlier initiation of an appropriate antibiotic regimen produces better functional results. Generally, treatment is administered intravenously for 3-4 weeks. The major exception to this is in the case of joints with gonococcal infection, for which total therapy is approximately 2 weeks, with switch to oral therapy. No indication exists for direct installation of antibiotics into the joint cavity. Such practice may increase the degree of inflammation. 10. Nursing dx a. Acute pain related to inflammation of joints b. Impaired physical mobility related to musculoskeletal impairment c. Risk for infection related to inadequate primary and secondary defenses d. Risk for activity intolerance related to presence of musculoskeletal problem e. Anxiety related to threat to health roles 11. Nursing responsibilities: a. Effective nursing management requires scrupulous attention to the clients position, exercise and rehabilitation. In the acute phase, the client is likely to hold joint in slight to moderate flexion as a position of comfort. Because this can lead to flexion, deformities, slings, immobilizers or splints may be used temporarily to hold the joint in an optimal position. b. As inflammation begins to resolve, passive ROM exercises are initiated to preserve joint function. CPM has also been used. c. Active motion and weight bearing may not be initiated until clinical manifestations and inflammation have almost totally disappeared. d. Pain management is also important for the client with septic arthritis to provide comfort and to allow greater ease in exercise participation

12. Illustrations

Septic arthritis with associated soft tissue abscess. Coronal T2-weighted fat-saturated MRI of the shoulder demonstrates a joint effusion, bone marrow edema, and marked adjacent soft tissue inflammation with a fluid collection in the infraspinatus muscle.

Septic arthropathy right hip with joint space loss and loss of the subchondral line in the tectum of the acetabulum

Figure 1 Septic arthiritis of the right hip joint

13. References: www.wikipedia.com, arthritis.about.com, mayoclnic.com,