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Clin Rheumatol (2011) 30:707710 DOI 10.

1007/s10067-010-1672-3

BRIEF REPORT

What are we doing about septic arthritis? A survey of UK-based rheumatologists and orthopedic surgeons
Usman Butt & Maame Amissah-Arthur & Fazal Khattak & Chris F. Elsworth

Received: 4 October 2010 / Revised: 9 December 2010 / Accepted: 13 December 2010 / Published online: 11 January 2011 # Clinical Rheumatology 2011

Abstract This study aims to determine the current practices and beliefs of United Kingdom (UK)-based rheumatologists and orthopedic surgeons (OS) in managing septic arthritis (SA) and to determine awareness levels of national guidance. Two-hundred OS and 200 rheumatologists were sent a link to a web-based survey tool via email. Questions posed related to the management of SA, including the respondents views on antibiotic therapy, joint drainage, which specialty should manage these cases, and also the clinicians evidence base. There were 354 functioning addresses with 182 responses (51%). One hundred fifty-one (77 OS, 74 rheumatologists) (43%) responses were complete and included for analysis. Eighty percent of rheumatologists and 82% of OS recommended 6-weeks total antibiotic therapy. Seventy-three percent in each group recommended 12 weeks intravenous therapy initially followed by oral continuation therapy. In patients at risk of methicillin-resistant Staphylococcus aureus (MRSA), 25% rheumatologists and 14% OS would ensure MRSA cover. Seventy-seven percent of rheumatologists and 66% of OS recommended surgical joint drainage; 22% and 27%, respectively, recommended repeated closed needle aspiration as their chosen method of joint drainage. Sixtysix percent of rheumatologists and 65% of OS believed OS should manage SA. Twenty-three percent of rheumatologists and 22% of OS quoted published guidance as their main evidence base in the treatment of SA. Only 24% of
U. Butt (*) : C. F. Elsworth Pennine Acute Trust, Royal Oldham Hospital, Rochdale Road, Oldham OL1 2JH, UK e-mail: usmanbutt02@yahoo.co.uk M. Amissah-Arthur : F. Khattak Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK

rheumatologists and 34% of OS quoted British Society of Rheumatology (BSR) guidance when asked if they were aware of any guidelines. Views of rheumatologists and OS are not that dissimilar in managing SA. Surprisingly, rheumatologists are more aggressive regarding the recommendation for surgical joint drainage. Within both groups, significant variation in management principles exists often discrepant to recommendations laid out by the BSR. There are poor awareness levels of the BSR guidelines. Keywords Infective arthritis . Joint infection . Septic arthritis . Survey

Introduction Septic arthritis (SA), though relatively uncommon, is a clinical emergency which should be identified early and treated promptly, as it can lead to rapid and irreversible articular cartilage destruction. It is associated with a significant mortality risk with reported figures as high as 11% for monoarticular sepsis and 50% in polyarticular cases [1, 2]. Given the varied causes of a hot swollen joint, obtaining a firm diagnosis can often be difficult even for experienced clinicians. Early referral for specialist assessment and management is imperative if SA is suspected. This is often carried out by rheumatologists or orthopedic surgeons (OS) depending upon local policies. To facilitate standardized care, guidelines for the management of hot swollen joints were introduced in 2006 by a multi-disciplinary working party set up by the British Society for Rheumatology (BSR), which comprised of the British Orthopaedic Association (BOA), the British Society for Antimicrobial Chemotherapy, and the Royal College of General Practitioners [3]. These laid out clear

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instructions for the assessment and management of SA. Diagnostic recommendations stated that the affected joint must be aspirated and synovial fluid sent for analysis (including crystals) and culture, before commencing antibiotics where possible. Gram-stain analysis of synovial fluid gives quick results and can facilitate early, targeted antibiotic therapy. Specificity approaches 100% for this test, however sensitivity is in the region of 5070% making a negative result particularly unreliable [2, 4]. Where clinical suspicion is high, it is imperative to treat it as infection. Guidelines stipulate that aspiration of the joint should be followed by antibiotic administration, and complete drainage of pus by means of arthroscopic washout or closed needle aspiration is regarded essential. Arthrotomy was not considered in the guidelines. The working party acknowledged insufficient evidence in the literature to suggest any additional benefit of surgical drainage over closed needle aspiration in the majority of cases and deemed either as acceptable. However, in cases of unsatisfactory response to medical management, the presence of thick, inspissated pus, or hip involvement, surgical intervention is required [3]. There is a scarcity of evidence to guide antibiotic choice and duration. There are no randomized controlled trials in the literature. It is acknowledged that local policies may be developed, but as a general guide, flucloxacillin is first choice with or without the addition gentamicin, as 60% or more of cases of SA are due to Staphylococcus organisms. Clindamycin or cephalosporins (2nd or 3 rd generation) are used in cases of penicillin allergy. Where there is a risk of gram-negative organisms, cephalosporins are advised. If there is a risk of methicillinresistant Staphylococcus aureus (MRSA) (known case, recent inpatient, nursing home resident, leg ulcers or catheters, or other risk factors determined locally), then vancomycin is advised in addition to cephalosporins. Discussion with a microbiologist is recommended for complex cases such as those involving intravenous drug users or intensive care patients [3]. Despite the lack of solid evidence for certain aspects in the treatment of SA, the BSR guidelines provided a welcome step toward standardizing care for patients with SA. Four years on from this publication, we conducted a survey to determine the current trends and beliefs surrounding the management of SA among OS and rheumatologists. We hypothesized that there would not only be a consistent divide in management, but also reticence from the surgical community to acknowledge the option of non-surgical management. In addition, we sought to ascertain the evidence base for the clinicians management principles and assess awareness levels of the BSR guidelines.

Method Two-hundred consultant OS and 200 rheumatologists were identified using the BOA and the BSR handbooks, respectively. A link to an online questionnaire, using a web-based survey tool [5], was emailed to the doctors with a covering letter from the first two authors in three phases (November 2009, December 2009, and February 2010). The doctors were asked to confirm their grade and specialty and whether they routinely managed cases of SA. A short clinical scenario was presented of a patient with a strong working diagnosis of a septic knee joint. Initial questioning focused on early, commonly encountered, management decisions in cases of presumed SA. Respondents were asked about choice of antibiotic therapy including their views on MRSA cover. Views on the need and methods of joint drainage were determined, and also whether the clinicians management would alter on the basis of a negative rather than positive gram-stain result. The final section of questioning addressed the evidence base for the clinicians practice, including their knowledge of any published guidelines. Beliefs relating to the role for surgery and which hospital specialty should manage SA were also enquired about.

Results From 400 emails sent out in phase 1, a total of 46 (23 rheumatology and 23 orthopedic) addresses were nonfunctional, leaving a sample of 354. By the end of phase 3, there were 182 responses (51%). Of these, 151 (43%) completed the survey in its entirety and were included for analysis77 (51%) were OS and 74 were rheumatologists (49%). Antibiotic therapy The duration of antibiotic cover the respondents would advise varied, but the majority of doctors recommended at least 12 weeks of intravenous therapy, or would consult a microbiologist for advice (Fig. 1). Regarding total duration of antibiotic treatment (including oral continuation therapy), most would continue for a minimum of 6 weeks (82% OS and 80% rheumatologists); 6% OS and 14% rheumatologists advised a total of 4 weeks antibiotic therapy. A small proportion of each group stated some other duration (4% OS answered 2 weeks only); 4% OS would rely on microbiology advice; 4% OS and 7% rheumatologists would continue until inflammatory markers had normalized. None of the OS questioned would routinely cover for MRSA infection, compared with 4 (6%) rheumatologists

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Discussion Regarding empirical antibiotics, rheumatologists were more likely to provide MRSA cover, though a sizeable proportion of each group, not unsurprisingly, said they would be guided by microbiology advice. MRSA is increasingly being recognized as the causative organism in a range of invasive infections, both community and hospital acquired [6, 7]. A large amount of current literature and commentary on SA, written mainly by rheumatologists, would suggest no additional benefit of surgery in uncomplicated cases of a septic knee [1, 2, 812]. It was therefore interesting to find the overwhelming majority of rheumatologists (76%) recommended arthroscopic joint washout as the method of choice for joint drainage, an even larger proportion than the OS surveyed (65%). Furthermore, a smaller proportion of rheumatologists than OS (22% vs 27%) recommended closed needle aspirations repeated as required. The expected observation that OS would be more likely to recommend that surgery was not realized. One prospective observational study of 75 patients found that 83% of patients undergoing surgical management were orthopedic patients compared with only 17% patients on non-surgical wards [11]. This sample did however include prosthetic joint infections and hip infections, which, as previously mentioned, are inevitably managed surgically. As such, any inference regarding management preferences between different specialists is difficult to make from that particular study. To further re-enforce the notion that surgery is not an inevitability whilst under the care of an OS, and in keeping with the question regarding joint drainage, a larger proportion of rheumatologists (50% vs 43%, respectively) agreed with the position that non-surgical management had no place in the management of cases of SA such as that described. Most rheumatologists (66%) also suggested orthopedics was the most appropriate specialty to manage such cases. Interestingly, these views were virtually mirrored by the OS (65%). As regards antibiotic duration, in line with guidance, the vast majority of OS and rheumatologists would use intravenous antibiotics for a minimum of 12 weeks and continue with oral antibiotics for a minimum of 6 weeks in total. Less than one quarter of both OS and rheumatologists quoted published guidelines as their primary evidence base in managing SA. The most likely reason for this is the relatively low levels of awareness of the BSR guidelines in our sample. Only 34% OS and 24% rheumatologists were aware of the guidance (43% and 40% respectively were aware of any published guidance at all). Likewise, in a survey of trainee doctors conducted by Ravindran et al.,

Fig. 1 Duration of initial intravenous antibiotic therapy

who would. Eleven (14%) OS compared with 19 (25%) rheumatologists said they would cover if there were risk factors for MRSA. Microbiology advice must always be sought when there is uncertainty or an unusual organism is being treated. Additional measures (Joint drainage) In a presumed case of SA, 50 (65%) OS and 56 (76%) rheumatologists would recommend an arthroscopic joint washout as their preferred method of joint drainage, with 21 (27%) OS and 16 (22%) rheumatologists recommending closed needle aspiration repeated as required. Three OS and one rheumatologist recommended open joint washout. Three OS and one rheumatologist would use antibiotics alone. Fifty-three (69%) OS reported there would be no change in their management plan if the gram-stain result was negative, whereas 24 (31%) OS said that their management would alter mainly by deferring surgery. Sixteen (22%) rheumatologists would alter their management in light of a negative gram-stain result most commonly by deferring surgery; 58 (78%) rheumatologists would not change their management plan.

Evidence base Less than one quarter of either rheumatologists or OS quoted published guidelines as the main evidence base for their practice (22% OS and 23% rheumatologists). The remaining doctors across both specialties answered that their practice was primarily based on personal experience, senior recommendation or general reading. When asked if they were aware of any published guidelines and asked to say what the source of these were, only 34% of OS and 24% of rheumatologists quoted the BSR guidelines.

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Clin Rheumatol (2011) 30:707710 Disclosures None.

only 42% (13 of 31 surveyed) were aware of the BSR guidelines [13]. The poor awareness level they reported was exemplified by a lack of compliance with the guidelines in their own trust audit, the findings of which were presented in the same article. Other similar audits have been carried out which likewise show variable and often poor adherence to the BSR guidelines with a general lack of awareness of their existence [1418]. Useful recommendations from these audits include the introduction of a hot joint pack containing a management algorithm and specimen bottles for patients presenting with a hot swollen joint [16]. At the very least, this could improve the diagnosis and early management of infected joints along with the recognition amongst doctors that guidance exists for this condition. Ravindran et al. suggested that clinical audits themselves provide a vehicle for wider dissemination of the BSR guidance and could help in optimizing care [13]. Contrary to our initial hypothesis, the views of rheumatologists and OS are not that dissimilar. If anything, rheumatologists were more aggressive regarding the recommendation for surgical joint drainage. However, it is apparent that within both groups, significant variation in management principles exists which is discrepant to the recommendations laid out in the BSR guidelines. The guidelines were comprehensive and produced by experts, but nevertheless a poor evidence base was acknowledged in the document for certain aspects in the management of SA. This coupled with poor awareness levels offers some explanation for variable adherence to the guidance. A stronger body of evidence in the form of a large-scale randomized controlled trial with cost-analysis would ultimately help to reduce variation in treatment strategy that continues to be based largely on personal preferences. It is recognized that these trials are logistically difficult to carry out and so in the absence of such, wider dissemination of current guidance is an essential measure to ensure standardization and appropriate care. Publication of guidance in journals accessed by the many specialties involved in caring for those with SA, particularly including microbiologists, rheumatologists, OS, emergency and general physicians, is paramount. Regular multidisciplinary audits and presentations at both local and national levels would ensure that this important condition receives appropriate attention and consideration by both policy makers and those involved at the frontline of patient care across all levels of seniority.

References

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