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Septic arthritis treatment antibiotic guidelines,how to get rid of dog urine in grass 07,how to get rid of a viral infection in the eye 007 - Good Point

Septic arthritis, commonly termed as infectious or bacterial arthritis is a serious medical condition marked by inflammation of the joint owing to the development of an infection. Bacterial species, mostly Staphylococcus aureus gain access to the joint area, either through the bloodstream (commonly seen in children), resulting from a wound injury or a rare complication of joint surgery. The clinical features of septic arthritis initiate at a quick pace, resulting in severe pain, swollen joints, fever, along with development of chills, localized rise in temperature and significantly restricted movement of the infected joint. Initial antibiotic treatment must be initiated empirically without any delay (even prior to the results of blood culture). In case of infection caused by Methicillin resistant Staphylococcus aureus, a prolonged treatment consisting of antibiotic administration via the intravenous route is recommended for a duration of four weeks.
In uncomplicated cases of septic arthritis, drainage can be performed using needle aspiration.
In many cases, immobilization of the affected joint (for the purpose of pain management) is not required after the initial few days. Majority of patients who are being treated for infectious arthritis may require aggressive physiotherapy so as to facilitate maximum functionality of the joint. AbstractSeptic arthritis is the most rapidly destructive joint disease, but its early diagnosis remains challenging; delayed or inadequate treatment, even by expert physicians, can lead to irreversible joint destruction. The infection of a joint can occur in different ways, (I) via injection or during joint operation through direct colonization, (II) by direct contact with a neighboring infected site, or (III) by haematogenous or lymphogenous seed of the pathogen.
If bacteria reach into the joint they can bind to a large number of different binding molecules.
A differentiation of arthritis is practicable by examination of typical laboratory medicine and microbiology characteristics in joint fluid. Infection serologyIn reactive arthritis the cultural detection of pathogens is often not possible. The therapeutic approach has to be selected in accordance with the mode of infection (NJI, PJI, RA), the expected or found pathogens, and their resistance. Acute native joint infectious arthritisEssential for sufficient treatment of acute septic arthritis is the fast and aggressive therapy with the combined application of antimicrobial medication and joint lavage. Prosthetic Joint InfectionIn the treatment of PJI virtually every conceivable form was tried out, antibiotics alone or in combination with debridement and intraarticular lavage, the ex- and reimplantation of the prosthesis in one or two stages, the arthrodesis or as a last option the amputation.
Antibiotic prophylaxisThe perioperative antibiotic prophylaxis is one of the procedures, which clearly demonstrates the reduction of infection rate after joint surgery [22,23]. There are only a few interfaces in medicine of such high importance like the interaction between surgeons, physicians and microbiologists in the preanalytical, analytical and postanalytical phases in the diagnosis and treatment of joint infections. Herrmann M, Vaudaux PE, Pittet D, Auckenthaler R, Lew PD, Schumacher-Perdreau F, Peters G, Waldvogel FA. Atkins BL, Athanasou N, Deeks JJ, Crook DW, Simpson H, Peto TE, McLardy-Smith P, Berendt AR.
Correspondence to: Udo Geipel, MD, Institute of Medical Microbiology and Hygiene, University of Saarland Hospital, Kirrberger Strasse, Bldg 43, 66421 Homburg, Germany. Microbial invasion of the anatomical space in the joints (mostly caused by bacteria) usually targets a single, large joint in the human body; for example knee or hip joint.
Other foreign invaders that may cause this type of arthritis include viruses (such as hepatitis A, B, C, herpes virus etc) and fungi. Mostly, young children and older people are at an escalated risk of developing this uncommon form of arthritis.
The choice of antibiotic drug depends on a number of factors, such as the age of the patient, potential portal of infection, medical history of diabetes etc, as well as the dubious pathogen responsible for septic arthritis. It has been observed that antibiotic therapy succeeds in controlling the spread of infection, which can be concluded by the reduction in the number of white blood cells that fight infective organisms. Aspiration of the fluid accumulated in the joint space prevents further damage to the joint and tissues, whilst antibiotic coverage works in clearing off the infective agent. Aspiration of the joint is carried out two or three times in a day, especially during the initial days of treatment. Following this procedure, the limb needs to be kept at a slight elevation, and adequate rest may also be recommended by the doctor for the purpose of quicker healing.
As the condition of the patient improves (about 5-7 days after initiation of treatment), gently mobilization of the joint can be attempted. Such therapy consists of different types of passive exercises that improve and maintain range of motion.
Diagnosis is made by analysis of fluid that has been removed from the joint, including microscopic examination and culture.
Between 25% and 50% of patients develop irreversible loss of joint function, which is especially concerning in elderly patients.
Another classification of bacterial arthritis distinguishes acute, chronic and reactive forms, which differ in their type of joint infection and their triggering bacteria. Especially fibrinogen, extracellular matrix proteins and glycosaminoglycans, including fibronectin and laminin, are components of the blood plasma, the bacteria use adhesion to [4,5]. This makes serological analysis to a method principally necessary to detect antibodies against the causing bacteria. It should be remembered that the slowed growth of bacteria in a biofilm on surfaces of joint prosthesis may additionally reinforces antibiotic resistance [18,19]. In all, however, the prolonged antibiotic therapy is a crucial factor.An algorithm has been described, suggesting the surgical management as a function of the time period from surgical intervention till onset of PJI, the type of infection, the implant and soft tissue situation and existing co-morbidities [20]. Also, diabetics, cancer patients or those with sexually transmitted diseases, like gonorrhea have increased susceptibility of incurring septic arthritis.
In most cases, antibiotics are given via the parenteral route, especially in the initial phases of the antibiotic regime (for a minimum span of two weeks). The joint, however, must not be subjected to increased weight till the clinical signs resolve entirely.
To understand the factors influencing the outcome of septic arthritis, the authors reviewed patients aged older than 50 years who had undergone debridement surgery for primary septic arthritis at their institution between 1998 and 2008. Native joint infections of the hip are less common than infections after implantation of prosthetic devices. Reactive arthritis is a postinfectious complication with no need of presence for viable pathogens in the joint.
A large number of bacteria specific receptors (adhesins) and adhesion factors have been described.
The antibody detection has a great diagnostic value also due to the reduced sensitivity of bacterial culture in joint infections caused by Borrelia or Brucella. Responsible for such an increase against antibacterial substances are changes in cell wall synthesis, which limits the effect of beta-lactam antibiotics and glycopeptides, and the occurrence of bacterial variants with modifications of other metabolic activities, with implications for the action of quinolones, aminoglycosides, and tetracyclines. The most widely used antibiotics in orthopedic surgery are cephalosporins of the first or second generation, like Cefazolin or Cefuroxime.
Conclusions must be made for the samples to be investigated, their required numbers and volumes, the sample collection method, time and mode of transport, and the communication of laboratory results. Ninety-two patients (92 knees) were enrolled in the study; 14 did not meet inclusion criteria and were excluded from the final analysis.
Difficulties in prosthetic joint infections are, (I) a higher age of patients, and, thus an associated presence of other medical risk factors, (II) often long courses of treatment regimes depending on the bacterium and its antibiotic resistance, (III) an increased mortality, and (IV) a high economic burden for removal and reimplantation of an infected prosthetic device. While reactive arthritis often simultaneously affect several joints, the presence of polyarthritic types of non reactive arthritis occur infrequently and then mostly as a result of several bacteriaemic phases.Among joint infections, the hip is the second most frequent localization after the knee joint.
The intra- and interspecific variation of the expression of these bacterial pathogenity factors can be correlated with the inherent bacterial virulence [6,7]. Beside the inflammatory parameters, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell count, which are nonspecific and do not provide location-related information, the synovial fluid leukocyte count is a simple, rapid and accurate test. For a medically and economically adequate evaluation in serologic diagnosis the sensitivity and specificity of the various methods must be considered.


In principle, the spectrum of available antibiotics is limited by the specific pharmacokinetic requirements in the treatment of joint infections. For initial therapy in the presence of clustered gram positive cocci in microscopic examination and, therefore, most likely an infection with S. Beneficial characteristics are bactericidal action, effective bone and tissue concentrations, opportunity for oral sequential therapy, and no adverse side effects.
Of the 78 included patients, 7 underwent arthrodesis, 22 underwent total knee arthroplasty, 19 were indicated for total knee arthroplasty for severe knee joint osteoarthritis but did not undergo surgery by the end of this study, and the remaining 30 had no or mild symptoms of osteoarthrosis and did not receive any surgical procedure.
The pathogenic mechanisms responsible for articular infections are well studied only for some bacteria, e.g.
Basically, there are no differences in the bacterial spectrum between hip joint infections and those of other large joints. Staphylococcus aureus has dominance in acute purulent arthritis while coagulase-negative staphylococci can be found mainly in periprosthetic infections and after diagnostic arthroscopies.
In this large microbiological and infectiological field a lot of research is done for Staphylococcus aureus. An overview of the bacteria that most commonly trigger reactive arthritis is listed in Table 3.
Even if these aspects should be included in the selection of the drug of choice, the finding is, however, that (I) for many of these parameters (e.g. In hospitals with high prevalence of MRSA Vancomycin is also used.Haematogenous infections of the joint prosthesis may be due to transient bacteremia. An initially chosen antimicrobial therapy has to be adapted on the results of diagnostic procedures, the infectious agent detected or most probable, and the planned surgical procedure. Staphylococcus aureus was the most common pathogenic agent (38%), followed by mixed bacterial infection (10%). Hip joint infections, however, are aggravated by the fact that they can exist over a long time with only poor symptoms. Other gram-positive bacteria as causative agents for hip joint infections are streptococci, especially Streptococcus pyogenes, Enterococcus faecalis and Corynebacteria species.A large number of different gram-negative rods act as infectious agents on joints. This is also substantiated by the production of various cytotoxins and the presence of highly effective signaling mechanisms [3]. For gram positive chainlike cocci, thus highly suspicious for a streptococcal infection, penicillin G is empirically given.
Thus, antibiotic prophylaxis during dental procedures or genitourinary tract and gastrointestinal tract interventions are useful in order to prevent late-onset prosthetic infection [24]. The bacterial culture in the microbiological laboratory, especially for PJI and other infections probably due to slow-growing bacteria require an extended period of 7 to 14 days. Several factors negatively influenced the final clinical outcome, including delayed treatment, advanced macroscopic staging made during debridement surgery, performing multiple debridement surgeries, and a larger Lysholm score difference pre- and posttreatment.
An increased rate of infection occurs in the pre-damaged joint and is also associated with particular predispositions of the patients (Table 1) [1,2,3]. Another bacterial feature is the formation of a biofilm, a polymeric matrix of saccharides, primarily described in the colonization of foreign material. Thus, joint fluid or intraarticular tissue must be obtained before antibiotic therapy is started. Most of the gram negative rods have their effective therapy initially with a quinolone or a second or third generation cephalosporin.
For infections with staphylococci particularly antibiotic combinations with Rifampicin possesses high cure rates. More antibiotics administered, longer duration of antibiotic treatment, and more pathogenic agents present were also significantly correlated with poor outcome.
Salmonella enterica, Shigella species, and Yersinia species are classically described as pathogens for purulent and reactive forms of arthritis. Swabs, also from intraoperative sites should not be sent into the laboratory due to the small quantity of carried material. Finally it should be noted that the occurrences of postoperative joint infections should be combined with investigations regarding their epidemiological value (e.g.
Also swabs or tissue from superficial wounds or fistula often show the growth of skin flora and not the relevant bacteria.
Cefazolin, Cefuroxime), possibly in combination with an anti-staphylococcal penicillin (e.g. Also in this constellation Rifampicin plays in staphylococcal infections a prominent role [21]. On the other hand the implanted foreign material causes in addition to the severe joint disease present an additional reduction in local resistance, which facilitates haematogenous infections. It was also shown that bacteria inside the biofilm have an increased resistance to the local host defenses and to antibiotics [8]. The prosthetic materials are also additional binding sites for various bacteria, and act as a starting point for prosthetic infections.
In otherwise healthy people it is associated with iatrogenic modes of infection during diagnostic procedures. Additionally, through the conversion into so-called small colony variants (Figure 2) additional modifications of bacterial cells develop [9], while significantly reducing treatment efficiency and triggering chronic processes. Extending this repertoire with newer antibiotics, especially Linezolid, Daptomycin and Tigecyclin were introduced for PJI therapy.
Thus, in addition to the local conditions, the bacterial properties and their specific pathogenity have to be considered for understanding the whole mechanism of infection.
Campylobacter species, however, are classic agents of reactive arthritis, as well as the obligate intracellular bacteria Chlamydia trachomatis, Mycoplasma pneumoniae, and Ureaplasma urealyticum. The formation of an inflammatory response, with the local generation of cytokines and reactive bacterial and host specific metabolic products leads to a joint injury, not seldom to irreversible destruction. Especially in PJI an operational approach is useful to obtain and examine several materials. A valid rating for the newest (lipo)glycopeptides Oritavancin, Dalbavancin, Telavancin, and for the cephalosporins Ceftobiprol and Ceftarolin in treatment of methicillin-resistant staphylococci is currently not possible. Its yearly incidence in Western Europe is 4 to 10 per 100,000, but can be higher among those with diabetes mellitus and previous joint pathology, especially rheumatoid arthritis.1–4The diagnosis of septic arthritis can be challenging because the differential diagnosis of 1 or more hot, swollen joints can indicate various conditions.
Basically, a too late or not sufficiently cured joint infection can cause trophic and functional limitations or can even be the starting point of a progressive infection spreading in continuity, lymphogenic or haematogenic.
Thus, effective therapy strategies must combine calculated antibiotic regimes with local surgical interventions.Joint replacement surgery increases the risk of infections due to intraoperative bacterial wound contamination, leading to an early onset of the typical symptoms.
Although molecular techniques have a high value as a diagnostic procedure, only bacterial cultures can complete the diagnostic testing by antibiograms.
As a consequence, delayed or inadequate treatment can lead to irreversible joint destruction, even in expert hands. In general, the detection and treatment of acute infectious arthritis is an acute emerging situation, in which a delay may progress to further septic inflammation [2]. Less commonly identified organisms for joint infections often accompanied with osteitis or osteomyelitis are Brucella species and Mycobacterium tuberculosis. The material of the joint prosthesis is also covered by host proteins such as fibrinogen and fibronectin, which in turn facilitates bacterial colonization, leading to a delayed type of PJI. Anaerobes, such as Bacteroides fragilis, are rarely found and are usually part of a polymicrobial infection.
The foreign material allows not only a surface colonization; it is also responsible for a reduction of the local defense mechanisms. Slow-growing bacteria as a pathogen in question, the presence of bacteria modificated by antibiotic pretreatment, SCV or biofilm production need an extended culture period [16].


Past clinical experience has shown progression of degeneration after acute knee joint infection.6 To the authors’ knowledge, no previous study has focused on the elderly population. Both, joint defect formation and chronification, if NJI, are not treated quickly and efficiently, and increasing mortality, high economic burden for removal of infected joint prosthesis and implant renewing [17] always require the increased effort in sampling and microbiological analysis. Therefore, the purpose of this study was to review a database of elderly patients with knee joint infection who were treated and followed up at the authors’ institution.Materials and MethodsThe clinical data of patients diagnosed with a knee joint infection at the authors’ institution between 1998 and 2008 were reviewed.
A total of 92 patients (92 knees) were enrolled in the study.Each patient’s general condition was evaluated at admission. The immunological mechanism of the frequent association with HLA-B27 is not yet fully understood. Using immunological and molecular biological procedures bacterial antigens can be detected in synovial fluid and synovial membrane [11].
The patients’ underlying disease and surgical history were obtained after septic arthritis diagnosis.
Although in some studies viable bacteria could be detected [12], in an overview of research results it can be concluded that bacterial antigenetic material or antigen-antibody complexes are haematogenous deposited in the joint.
This triggers a local inflammatory immune reaction, even without local bacterial proliferation [3,13]. The causes of infection were recorded and analyzed along with the final outcome.Delay Before TreatmentDelays before treatment were recorded for each patient. The relationship between the delays and final outcomes was analyzed.Surgery and Antibiotic TreatmentAll patients underwent surgical debridement, either by arthroscopy or the traditional open method. The macroscopic appearance of joint destruction was classified according to the 4-stage classification system reported previously by Vispo Seara et al (Table 1).8 Surgical debridement was performed thoroughly, with all infected materials and bony fragments being removed carefully. The antibiotic route of administration was changed to oral if C-reactive protein levels and white blood cell counts had returned to normal levels.
In these cases, oral antibiotics were continued for a minimum of 4 weeks until the joint fluid was clear and C-reactive protein levels tended to remain within the normal range. Repeat surgical debridement was performed if symptoms persisted and lab data showed no clinical improvement after antibiotic treatment.Macroscopic staging was associated with the final outcome using Fisher’s exact test.
The number of infective pathogens present, number of debridement surgeries performed, number of antibiotics administered, and duration of antibiotic treatment were also associated with final outcome by using the Kruskal-Wallis test.
The number of infective pathogens was correlated with the number of debridement surgeries using Spearman’s correlation.Image and Clinical Performance EvaluationImaging data, functional performance, subjective functional performance by Lysholm knee scoring scale,9,10 and range of motion (ROM) were compared pre- and posttreatment.
The results were analyzed using Spearman’s correlation.Biplanar imaging studies were performed. The Kellgren-Lawrence classification of knee joint osteoarthrosis was applied to evaluate the degree of knee joint osteoarthrosis (Table 2).11 The change in osteoarthrosis degree was calculated. The medical history of each patient was recorded, and the number of patients per medical condition was calculated (Figure 1).
In 13 (14%) patients, no microorganism was identified, but in 11 of them, antibiotics had been administered at another hospital prior to culture. These patients were included in the current study because they presented with clinical symptoms, laboratory blood values, and histological findings compatible with joint infection.
In 12 of these patients, gram-negative bacterial infection was found: 4 (5%) cases of Pseudomonas aeruginosa, 4 (5%) cases of Escherichia coli, 2 (2%) cases of Klebsiella pneumoniae, and 2 (2%) cases of Salmonella enteritidis. Six patients died within 3 months after initial diagnosis due to late-stage cancer or severe infection. Seven patients underwent arthrodesis, 22 underwent total knee arthroplasty (TKA), 19 patients were indicated for TKA for severe knee joint osteoarthritis but did not undergo TKA by the conclusion of this study, and the remaining 30 patients had no or mild symptoms of osteoarthrosis and did not receive any surgical procedures (Table 3). The imaging series performed pre- and posttreatment and at final outcome are shown in Figures 3 through 6. Thirty-three patients underwent arthroscopic debridement surgery and 45 underwent open debridement surgery. Anteroposterior (C) and lateral (D) radiographs 2 months posttreatment showing severe joint space narrowing, osteophyte formation, and flexion contracture.
Anteroposterior (C) and lateral (D) radiographs 5 months posttreatment showing the affected site with severe cartilage destruction and severe joint space narrowing.
Anteroposterior (E) and lateral (F) radiographs 3 years posttreatment and after the patient had undergone total knee arthroplasty.
Postoperatively, the patient developed septic arthritis of the left knee resulting from compartment syndrome of the lower left leg. Anteroposterior (C) and lateral (D) radiographs 4 months posttreatment showing progression of cartilage destruction and joint space narrowing. Anteroposterior (C) and lateral (D) radiographs 6 months posttreatment showing a mild progression of knee joint degeneration. Anteroposterior (E) and lateral (F) radiographs 5 years posttreatment showing a mild degree of degeneration.The etiology of infection was associated with the final outcome (Table 3). In the arthrodesis group, trauma- or injury-related knee joint infection was noted in 5 (71%) patients; this percentage was significantly higher than in the other 3 groups.
However, no significant correlation existed between the cause of infection and the final outcome. The percentage of those having no specific cause of infection was higher in the TKA group (45%). Hematogenous infection was more common in those indicated for TKA (42%) and in those with mild sequelae (43%). No statistically significant correlation existed between the etiology of infection and the clinical outcome.Delay Before TreatmentDelay before treatment was recorded (Table 4). The number of patients who began treatment more than 3 weeks after the onset of clinical symptoms was 6 (86%) in the arthrodesis group, 18 (82%) in the TKA group, and 18 (79%) in the indicated for TKA group. No patient in these 3 groups began treatment within the first week after the onset of the symptoms. In the indicated for TKA group, fewer patients had severe degeneration; 7 (37%) patients each were stages III and IV, respectively, and the remaining 5 (26%) were stage II. In the mild symptoms group, 7 (23%) patients were stage IV, 10 (33%) were stage III, 12 (40%) were stage II, and 1 (3%) was stage I. A delay in treatment of more than 3 weeks resulted in a significant decrease in knee joint ROM and increased the possibility of joint replacement or arthrodesis (Figure 11; Table 4).
Recent infection of other sites, including cutaneous infection, may also increase the risk of knee joint sepsis.
According to Kaandorp et al,16 knee joint sepsis may result from direct inoculation of bacteria from trauma or hematogenous transmission of the pathogen.
Trauma of the affected limb accounted for 26% of cases in the current study, and the percentage of patients with recent infections of the body was as high as 34.6%.
Bacteria may be introduced during joint surgery, fluid aspiration, or local corticosteroid injection,1,6,17 but this route was less common in the current study (9%).
No definite predisposing factor exists for the development of septic arthritis, but previous infection of the knee joint is a good candidate.In the current study, staphylococci were the most common causative pathogens. This is in agreement with a previous study that showed that Staphylococcus aureus was responsible for primary septic arthritis in 37% to 56% of patients.17–19 Gram-negative bacilli was common in intravenous drug users, elderly patients, and seriously immunocompromised patients4,5 and accounted for 14% of all pathogens in the current study. Mycobacterium tuberculosis, although uncommon in bacterial arthritis, was found in 3% of the current cases.



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22.03.2014, author: admin


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