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Septic arthritis, also known as infectious arthritis, may represent a direct invasion of joint space by various microorganisms, most commonly caused by a variety of bacteria. However, viruses, mycobacteria, and fungi have been implicated

TYPES Arthritis: Gonococcal Septic

Most common pathogen(75% of cases) in younger sexually active individuals. Non-gonococcal Septic Arthritis: STAPHYLOCOCCUS AUREUS INFECTION Adults and children older than 2 years Prosthetic joints Immunosupressive agents 80% of joints affacted by rheumatoid arthritis STREPTOCOCCAL SPECIES 20% of cases AEROBIC GRAM NEGATIVE RODS 20-25% of cases Very young, very old Immunosupressed Intravenous drug abusers PSEUDOMONAS AUREGINOSA/SERRATIA Intavenous drug abusers

AEROMONAS Leukemia POLYMICROBIAL JOINT INFECTIONS and ANAEROBES Trauma Abdominal infection BORRELIA BURGDORFERI (Lyme Disease)
Non-suppurative joint infection VIRUSES Non-suppurative joint infection Prosthetic Joint Infection Early: within 3 months of implantation; staphylococcus aureus; acquired in the operatimg room

Delayed: 3-24 months of implantation; coagulase negative staphylococcus aureus (CoNS); acquired in the operating room Late: >24 months of implantation; hematogenous spread from infectious foci

PATHOPHYSIOLOGY
Routes of invasion:

Direct Contiguous spread Hematogenous (most common)

PATHOGENIC INVASION

Previously damaged joints, especially those damaged by rheumatoid arthritis, are the most susceptible to infection. The synovial membranes of these joints exhibit neovascularization and increased adhesion factors; both conditions increase the chance of bacteremia, resulting in a joint infection. Some microorganisms have properties that promote their tropism to the synovium. S aureus readily binds to articular sialoprotein, fibronectin collage, elastin, hyaluronic acid, and prosthetic material via specific tissue adhesion factors (microbial surface components recognizing adhesive matrix molecules [MSCRAMMs]). In adults, the arteriolar anastomosis between the epiphysis and the synovium permits the spread of osteomyelitis into the joint space.

The major consequence of bacterial invasion is damage to articular cartilage. This may be due to the particular organism's pathologic properties, such as the chondrocyte proteases of S aureus, as well as to the host's polymorphonuclear leukocytes response. Infection with N gonorrhoeae induces a relatively mild influx of white blood cells (WBCs) into the joint, explaining, in part, the minimal joint destruction observed with infection with this organism relative to destruction associated with S aureus infection.

Large effusions, which can occur in infections of the hip joint, impair the blood supply and result in aseptic necrosis of bone. as early as 3 days into the course of untreated infection.

PROSTHETIC JOINT INFECTION

The most common and challenging type of septic arthritis encountered by most clinicians. The incidence of prosthetic joint infection (PJI) among all prosthesis recipients ranges from 2% to 10%. Intraoperative contamination (60-80% of cases) bacteremias (20-40% of cases) The bacteremias may be spontaneous (ie, gingival disease) or secondary to various manipulations. Delayed wound healing is a major factor behind early prosthetic joint infection. Until the fascia has healed, the usual tissue barriers to infection of the implant are not present. Eventually, the implanted hardware becomes less susceptible to infection by hematogenous spread, because the pseudocapsule develops around it. The biofilm of coagulase-negative S aureus (CoNS) protects the pathogen from the host's defenses, as well as from various antibiotics. Polymethylmethacrylate cement inhibits WBC and complement function.

The most common organisms of prosthetic joint infections are CoNS (22% of cases) and S aureus (22% of cases). Enteric gram-negative organisms account for 25% of isolates. Streptococci, including S viridans, enterococci, and the beta-hemolytic streptococci, cause 21% of cases. Anaerobes are isolated from 10% of patients.

PROGNOSIS

Primary morbidity: significant dysfunction of the joint, even if treated properly. Fifty percent: sequelae of decreased range of motion or chronic pain after infection. Thirty percent: become chronic. Complications: dysfunctional joints, osteomyelitis, and sepsis. The mortality rate depends primarily on the causative organism. N gonorrhoeaeseptic arthritis carries an extremely low mortality rate, whereas that of S aureus can approach 50%.

Predictors of poor outcome in suppurative arthritis:

Age older than 60 years

Infection of the hip or shoulder joints

Underlying rheumatoid arthritis Positive findings on synovial fluid cultures after 7 days of appropriate therapy

Delay of 7 days or longer in instituting therapy

HISTORY

Acuteness of onset of the joint pain pain superimposed on chronic pain Previous history of joint disease or trauma, whether accidental or iatrogenic (eg, infection complicates 0.4% of arthrocenteses) monoarticular or polyarticular?; which joints are involved? extra-articular symptoms? Catheterizations? or intravenous drug abuse? History of STDs Exposure to ticks Immunosupressive drugs and diseases Underlying joint disease (rheumatoid arthritis) Joint trauma Needle aspiration or injection of corticosteroids to the joint

SYMPTOMS

fever (40-60% of cases): low-grade pain (75% of cases), and

impaired range of motion

LYME DISEASE

Months after untreated infection 60% of patients develop swelling and pain chiefly affecting 1 to 2 of the large joints at a time the knee is involved most commonly The distinguishing pattern is attacks extending from a few weeks to months and separated by periods of complete remission. The rate of recurrence lessens by about 15% per year. A small percentage of individuals develop chronic arthritis (ie, inflammation of a joint lasting 1 y). Swelling may be disproportionate to the level of pain (Baker Cyst)

Most commonly involved joints:

knee (50% of cases) hip (20%) shoulder (8%) ankle (7%) wrists (7%) The elbow, interphalangeal, sternoclavicular, and sacroiliac joints each make up 1-4% of cases.

Pattern of joint involvement

Mono-articular: Non-gonococcal (85-90%) Poly-articular: gonococcal disease viral infections Lyme disease reactive arthritis noninfectious processes

Gonococcal Arthritis
Dermatitis-arthritis syndrome(60%): Fever, arthralgias of multiple joints, and multiple skin lesions tenosynovitis of asymmetric distribution Typically, hand joints are involved most often, as well as those of the knee, wrist, ankle, and elbow. Skin lesions are multiple but seldom number more than 12, (whereas lesions associated with meningococcemia may number more than 100). Findings on cultures of blood and mucosal surfaces are often positive; findings on cultures of joint fluid are usually negative

WORKUP
Joint fluid analysis and culture: leukocyte count appearance on Gram stain polarizing microscopy examination Culture Blood and other cultures: Obtain at least 2 sets of blood cultures to rule out a bacteremic origin of the septic joint. In the setting of possible gonococcal infection, obtaining cultures from the patient's rectum, cervix, urethra, and pharynx and from any skin lesions is most helpful. Polymerase Chain Reaction (PCR): PCR has led to diagnosis of infective arthritis due toYersinia species, B burgdorferi, Chlamydia species, N gonorrhoeae, and Ureaplasma species Radiography and ultrasonography Plain radiography is limited to the findings of soft tissue swelling and peri-articular osteoporosis. Ultrasonography may be used to diagnose effusions in chronically distorted joints (secondary to trauma or rheumatoid arthritis).

CT scanning and MRI more sensitive for distinguishing osteomyelitis, periarticular abscesses, and joint effusions. does not justify the increased cost most helpful in patients with sacroiliac or sternoclavicular joint infection to rule out extension into the mediastinum or pelvis. MRI is preferred because of its greater ability to image soft tissue.

Imaging in Prosthetic Joint Infection

Plain radiography can reveal new subperiosteal bone growth and transcortical sinus tracts.(findings are specific for infection) Arthrography can demonstrate loosening of the prosthesis and abscesses. Nuclear scans of all types are of limited diagnostic use in patients with prosthetic joint infection, and MRIs are limited by the type of implanted material (this diagnostic modality can safely image only titanium or tantalum devices). However, CT scans are useful in ascertaining the state of the surrounding soft tissue.