Advances in the Management of Bacterial Septic Arthritis

Myo M Lynn; Catherine J Mathews

Int J Clin Rheumatol. 2012;7(3):335-342.

Current Treatment of Bacterial Septic Arthritis

Prompt initiation of appropriate antibiotic therapy and drainage of purulent material remains the mainstay of treatment of bacterial septic arthritis.^[16] As there are no randomized controlled trials regarding the duration and choice of antibiotic regimen to date, most published guidelines on the initial empirical choice of antibiotic therapy depend on the individual risk factors for the patient, local drug resistance and the geographic variation of pathogens.^[16] Treatment regimes need to be modified depending on subsequent identification of organisms. In the UK, 2 weeks duration of initial antibiotic therapy is recommended with follow-up of at least 4 weeks of oral antibiotics. Antibiotics are advised to be continued until symptoms and signs resolve and the inflammatory markers normalize.^[23] Table 1 shows a summary of current UK recommendations for initial antibiotic choice in suspected septic arthritis.^[23]

In a recent survey of UK-based rheumatologists and orthopedic surgeons (74 rheumatologists and 77 orthopedic surgeons, total 151), the vast majority of clinicians (80% of rheumatologists and 82% of orthopedic surgeons) reported that they would use antibiotics for a minimum of 6 weeks including 2 weeks of intravenous therapy in the treatment of bacterial septic arthritis. The majority would seek microbiological advice to guide their treatment. However, only 7% of rheumatologists and 4% of orthopedic surgeons would continue antibiotics until inflammatory markers normalized.^[43]

Combined with antibiotics, removal of septic material from the joint space is mandatory in the management of septic arthritis.^[16,44] Either arthroscopic washout, open drainage or repeated closed needle aspiration can be used. According to the UK survey already quoted, 76% of rheumatologists and 65% of orthopedic surgeons would prefer to employ an arthroscopic washout. 22% of rheumatologists and 27% of orthopedic surgeons would prefer closed-needle aspiration. Only a minority of doctors would prefer an open joint washout.^[43] In reality, so far, there is no randomized controlled trial with results that can identify which method is superior.^[45]

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Abstract and Introduction
Epidemiology & Pathogenesis of Bacterial Septic Arthritis
Diagnosis of Bacterial Septic Arthritis
Current Treatment of Bacterial Septic Arthritis
Future Developments
Summary
References
Sidebar

Table 1. Summary of UK recommendations for initial antibiotic choice in suspected septic arthritis.
Patient group	Antibiotic choice
No risk factors for atypical organism	Intravenous flucloxacillin (2 g four-times a day). Local policy might add oral fusidic acid (500 mg three-times a day) or intravenous gentamycin. If allergic to penicillin, use clindamycin (450–600 mg four-times a day) or second- or third-generation cephalosporin
High risk of Gram-negative sepsis (elderly or frail individual, recurrent urinary tract infection, recent abdominal surgery)	Second- or third-generation cephalosporin (e.g., cefuroxine 1.5 g three-times a day). Local policy might add flucloxacillin. Discuss strategy for patients allergic to specific antibiotics with microbiologist. Gram stain could affect antibiotics choice
MRSA risk (known MRSA, recent inpatient, nursing home resident, leg ulcers or catheters, or other risk factors)	Vancomycin plus second- and third-generation cephalosporin
Suspected gonococcus and meningococcus	Ceftriaxone or similar, dependent on local policy or resistance
Intravenous drug abusers	Discuss with microbiologist
Patients in intensive care unit, known colonization of other organs (e.g., cystic fibrosis)	Discuss with microbiologist

Antibiotic choice will need to be modified after results of Gram stain and culture, and should be reviewed locally by a microbiology department.
MRSA: Methicillin-resistant Staphylococcus aureus.

Sidebar

Executive Summary

Clinical Presentation of Septic Arthritis

The clinical presentation of a patient with one or more hot, swollen joints is a common one, however, the most serious potential cause is bacterial septic arthritis although differential diagnosis is broad.
The management of bacterial septic arthritis relies on early recognition, diagnosis and timely drainage of purulent material together with prompt administration of antibiotic therapy.

Epidemiology & Pathogenesis

The annual incidence of septic arthritis remains four to ten cases per 100,000 patient-years per year in western Europe. The estimated incidence of septic arthritis in industrialized countries is six per 100,000 of the population per year. The incidence increases to approximately 30–60 per 100,000 of the population per year in patients with underlying joint disease and prosthetic joints.
There are two main routes by which pathogens can enter the joint: by direct inoculation into the joint or, more commonly, by hematogenous spread following a septicemic or bacteremic episode.
Staphylococcus aureus and other Gram-positive organisms, such as streptococci, remain the most common pathogenic organisms. The emergence of antibiotic-resistant strains as well as increasingly atypical organisms has made the management of septic arthritis a real challenge.
There are patient groups that are more at risk of harboring atypical organisms, such as elderly patients, immunocompromized patients and intravenous drug abusers.

Diagnosis of Bacterial Septic Arthritis

The initial suspicion of the diagnosis of septic arthritis comes with the typical clinical presentation of a short, 1–2 week duration of an acutely hot and swollen joint (or joints).
Any acute hot swollen joint should be always aspirated before the initiation of antibiotics and sent for urgent Gram stain and culture.

Current Treatment of Bacterial Septic Arthritis

Prompt initiation of appropriate antibiotic therapy and drainage of purulent material remains the mainstay of treatment of bacterial septic arthritis.
There are no randomized controlled trials regarding the duration and choice of antibiotic regimen to date.
Initial empirical choice of antibiotic therapy depends on the individual risk factors, local drug resistance and the geographic variation of pathogens.

Future Development

Concomitant dexamethasone therapy had a favorable outcome compared with those without dexamethasone in pediatric studies, however, there are no equivalent studies conducted in adult patients.
In animal models, use of intraperitoneal bisphosphonates has been shown to be effective in the reduction of bone destruction.
Combination of anti-TNF-α (etanercept) therapy and antibiotic treatment (cloxacillin) has been shown to be beneficial on the outcome of staphylococcal arthritis and sepsis in a recent animal study from 2011.
Whether these novel targeted therapies could reduce the disease burden in adult bacterial septic arthritis in humans remains to be seen.

Summary

The key to preventing the morbidity and mortality associated with bacterial septic arthritis depends on awareness of risk factors, early diagnosis, timely investigation and management of patients suspected of having joint sepsis.

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Advances in the Management of Bacterial Septic Arthritis

Current Treatment of Bacterial Septic Arthritis

Tables

References

Authors and Disclosures

Authors and Disclosures

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