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Septic Arthritis Treatment & Management

  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Oct 08, 2015
 

Approach Considerations

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 prosthetic joint infection (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.[7]

Overall, the mean length of hospitalization for septic arthritis is 11.5 days. However, outpatient antibiotic therapy in stable patients can significantly reduce hospital stays.[27]

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.

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Antibiotic Therapy

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 methicillin-susceptible 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.

In MSSA, MRSA, and CoNS prosthetic joint infections in the setting of retained hardware, rifampin should always be used because of its unique ability to penetrate the biofilm in which these pathogens reside.

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.[25] Because of the high worldwide resistance rates to the quinolones (20%-100%), they should be used only when the particular isolate is sensitive to this class of antimicrobial.[28]

In addition, patients with gonococcal arthritis should receive concurrent therapy for chlamydia, such as one dose of 2 g of azithromycin or 7 days of doxycycline twice a week.

Antibiotic selection

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 setting. 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 slow-growing organisms that are protected within a biofilm (eg, coagulase-negative S aureus [CONS]). Rifampin fulfills these requirements; however, this agent should never be used alone because of the rapid development of bacterial resistance to the drug.

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, as follows:

  • 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 (NSAIDs) are the primary therapeutic agents for reactive arthritis
  • Perform imaging studies, either radiographs or magnetic resonance imaging (MRI), to rule out periarticular osteomyelitis.

Antibiotics have a role in suppressing associated chronic osteomyelitis and chronically infected prosthetic material that cannot be removed for various reasons.

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.[29]

Oral antibiotics are usually used in treating gonococcal joint infections.

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Joint Immobilization and Physical Therapy

Usually, immobilization of the infected joint to control pain is not necessary after the first few days. 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.

Initial physical therapy consists of maintaining the joint in its functional position and providing passive range-of-motion exercises. The joint should bear no weight until the clinical signs and symptoms of synovitis have resolved. Aggressive physical therapy is often required to achieve maximum therapy benefit.

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Synovial Fluid Drainage

The choice of the type of drainage, whether percutaneous or surgical, has not been resolved completely.[20, 30] 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.

Gonococcal-infected joints rarely require surgical drainage.

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)
  • 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.

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Surgical Intervention in Prosthetic Joint Infection

Debridement and retention of the prosthesis should be considered in patients who develop prosthetic joint infection within 30 days of implantation or who present within 3 weeks of the development of symptoms if the prosthesis appears to be well fixed and is without a sinus tract.[22]

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.

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.

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Infection Prevention

Strictly adhere to sterile procedures whenever the joint space is invaded (eg, in aspiration or arthroscopic procedures).

Antibiotic prophylaxis with an antistaphylococcal antibiotic has been demonstrated to reduce wound infections in joint replacement surgery. Polymethylmethacrylate cement impregnated with antibiotics may decrease perioperative infections.

Using antibiotic prophylaxis on the same theoretic basis as that for cardiac valvular disease has been advocated. Whenever a sustained bacteremia may be encountered, be aware of the possibility of joint involvement, especially for prosthetic joints. Consideration should be given to more prolonged treatment of the bacteremia to cover the possibility of very early joint infection (secondary prophylaxis). The implanted hardware most likely is at greatest risk of bacteremia infection within a few months of placement. The risk probably decreases as a pseudocapsule evolves. During this time, prophylaxis is probably most beneficial. A recent well-designed study refutes the recommendation that all joint replacement patients require antibiotic prophylaxis prior to dental procedures.[31]

Treat any infection promptly to lessen the chance of bloodstream invasion. In addition, decreasing the incidence of underlying infections best prevents reactive arthritis.

Patient education

Instruct patients with a prosthetic joint in place to recognize early signs of joint infection and, more importantly, to recognize bacterial infections in other parts of their bodies to prevent associated bacteremias.

For patient education information, see Arthritis Center as well as Knee Pain and Ticks.

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Contributor Information and Disclosures
Author

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Aaron Glatt, MD Chief Administrative Officer, Executive Vice President, Mercy Medical Center, Catholic Health Services of Long Island

Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American Association for Physician Leadership, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Maria D Mileno, MD Associate Professor of Medicine, Division of Infectious Diseases, The Warren Alpert Medical School of Brown University

Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine, Sigma Xi

Disclosure: Nothing to disclose.

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A 30-year-old man who was taking steroids presented with a joint effusion and knee pain. Anteroposterior view of the knee demonstrates patchy demineralization of the tibia and femur and joint-space narrowing. This was caused by tuberculoid infection of the joint.
Septic arthritis. Anteroposterior view of the shoulder demonstrates subchondral erosions and sclerosis in the humeral head. These are relatively late findings of septic arthritis. Periosteal reaction due to coincident osteomyelitis is present adjacent to the surgical neck of the humerus.
During the progression of infectious arthritis of the hip, this image was obtained early in the disease and shows only concentric joint-space loss.
Table 1. Clinical Features of Viral Septic Arthritis
Virus Clinical Features of Viral Septic Arthritis
Parvovirus B19 Occurs in adult women with erythema infectiosum, often an itchy rash
Hepatitis A Muscle aches and rash in 10% of cases
Hepatitis B Onset in the preicteric phase; usually resolves as jaundice develops; chronic arthritis possible in patients with chronic hepatitis B infection
Hepatitis C History similar to hepatitis B joint infection
Rubella (natural infection and vaccine related) Onset is possible before, during, or after the appearance of the rash; usually resolves in a few weeks; may recur and, more commonly, may persist
Human immunodeficiency virus [HIV] (2 types occur, both with noninflammatory, sterile joint fluid) Develops over several days, and severe knee or ankle pain is characteristic; excellent response to nonsteroidal anti-inflammatory agents (NSAIDS)
Sudden onset of severe pain in the shoulders and elbows, closely resembling an acute gouty attack; Opiates often necessary to control pain
Mumps Occurs in adult men 2 weeks after the presentation of parotitis
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