Advances in the Management of Bacterial Septic Arthritis

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.

Authors and Disclosures

Myo M Lynn & Catherine J Mathews*

Queen Elizabeth Hospital, South London Healthcare NHS Trust, Stadium Road, Woolwich, SE18 4QH, London, UK

Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

Author for correspondence catherinemathews@nhs.net

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.