Arthritis, infectious, bacterial

BASICS
DESCRIPTION:
Invasion of joints by live micro-organisms or their fragments. One of the few curable causes of arthritis. May allow
early recognition of systemic infection/disease.
System(s) affected: Musculoskeletal
Genetics: N/A
Incidence/Prevalence in USA:
Neisserial:
Responsible for 50% of infectious arthritis
Arthritis occurs in 0.6% of the 3% of women with gonorrhea
Arthritis occurs in 0.1% of the 0.7% of men with gonorrhea
Arthritis occurs in 7% of individuals with N. meningitidis
Non-Neisserial:
Perhaps half as frequent as Neisserial
Predominant age:
Neisserial:
Especially 15-40, can occur at any age
Non-Neisserial:
50% Prior to age 2: 27% Staphylococcus, 20% Streptococcus, 33% Haemophilus, and 13% other gram
negative rods
70% Age 2-14: 34% Staphylococcus, 29% Streptococcus, 13% Haemophilus, and 13 % other gram negative
rods
Adult: 34% Staphylococcus, 38% Streptococcus, 2% Haemophilus, and 26% other gram negative rods
Predominant sex:
Neisserial: Female > Male (4:1)
Non-Neisserial: Male > Female (2:1)
Subacute bacterial endocarditis-related: Male = Female

SIGNS AND SYMPTOMS:

Predominantly monoarticular (90%). (Haemophilus may be pauciarticular and Mycoplasma often presents as a
migratory polyarthritis).
Limited joint use/motion (especially in children)
Joint effusion, tenderness
Joint warmth - present in less than 50%
Joint redness- present in less than 50%
Loss of joint motion
Tenosynovitis
Sudden flare of one or two joints in a patient with underlying joint disease
Fever - in 90% at some time during the course of the infection
Chills, malaise
Cutaneous lesions
Peripheral neuropathy
Back pain - especially in subacute bacterial endocarditis (SBE)
Hypertrophic osteoarthropathy - rare, secondary to endocarditis
Fretfulness - especially in children
Dermato-arthritis - usually pustular skin lesions in gonorrhea - usually petechial rash in meningococcemia
Bacteremic phase - migratory polyarthritis, tenosynovitis, high fever, chills, pustules
Localized phase - usually monoarticular, low grade fever (80%)

CAUSES:
Hematogenous invasion by microorganisms (80-90%)
Contiguous spread (10-15%) from adjacent osteomyelitis in children
Direct penetration of micro-organisms secondary to trauma or joint injection

RISK FACTORS:
Young patient with venereal exposure
Concurrent extra-articular infection
Prior arthritis in infected joint
Trauma
Joint puncture or surgery
Prosthetic joint
Prior antibiotic, corticosteroid, or immunosuppressive therapy
Serious chronic illness (e.g., diabetes, liver disease, malignancy, primary immunodeficiency)
Defective phagocytic mechanisms (e.g., chronic granulomatous disease)
Intravenous drug abuse
Travel/habitat history
Sickle cell anemia

DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
Gout
Pseudogout (calcium pyrophosphate deposition disease)
Spondyloarthropathy (Reiter's syndrome, psoriatic arthritis, ankylosing spondylitis, the arthritis of inflammatory
bowel disease)
Juvenile rheumatoid arthritis
Type IIa hyperlipoproteinemia
Foreign body synovitis
Rheumatoid arthritis
Rheumatic fever
AIDS
Cellulitis
Palindromic rheumatism
Neuropathic arthropathy
Lyme arthritis
Sarcoidosis
Granulomatous arthritis

LABORATORY:
Synovial fluid usually cloudy with > 50,000 WBC/HPF (high power field), but may have fewer white blood cells
present or over 100,000. (Caveat - cell count must be performed within 1 hour of obtaining specimen to be valid).
Synovial fluid white count can be recognized as elevated (in presence of trauma) if RBC:WBC ratio significantly
less than 700
Polymorphonuclear leukocytes usually predominate in synovial fluid
Synovial fluid glucose often more than 40 mg/dL (2.22 mmol/L) less than in a simultaneously obtained serum
glucose value (in fasting patient). However, arthrocentesis should not be delayed simply to obtain fasting synovial
fluid glucose level.
Westergren erythrocyte sedimentation rate - often elevated, but normal in 20%
Rheumatoid factor positive in 50% - if endocarditis present and in viral arthritis
Anti-teichoic acid antibodies - with Staphylococcus infection
Elevated peripheral white blood cell count (in 50-90%)
Cryoglobulins
Immune complexes
Febrile agglutinins (to include Brucella and rickettsial-related titers)
Antistreptolysin O (ASO) titer is usually normal, exclusive of streptococcal infections
Depressed synovial fluid and occasionally depressed serum levels of complement
Microscopic hematuria in subacute bacterial endocarditis (SBE)
Presence of crystals (e.g., urate or calcium pyrophosphate) does not exclude infectious arthritis
Drugs that may alter lab results: Antibiotics
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS:
Synovial biopsy will reveal polymorphonuclear leukocytes and possibly the causative organism

SPECIAL TESTS:

Joint fluid - for gram stain (positive in 50%); culture (positive in 50-70%)
Serum cidal level assessment of antibiotic adequacy is suggested with virulent organisms or therapeutic
unresponsiveness (tenfold margin suggested)
Blood, orifice, urine cultures. "Bedside culture" is recommended to enhance isolation of fastidious organisms.
All cultures should be preserved and observed for at least 3 days and preferably 2 weeks. Observing synovial
fluid cultures for at least 3 days allows isolation of fastidious organisms such as those of rat bite fever
(Streptobacillus moniliformis and Spirillum minus).
Neisserial infection generally requires use of special agars (e.g., chocolate or Thayer Martin) and relative
anaerobic culturing conditions
Countercurrent immunoelectrophoresis or complement fixation for specific bacterial antigens
Polymerase chain reaction for specific bacterial DNA

IMAGING:
X-ray
Soft tissue swelling
Juxta-articular osteoporosis
Radiolucent area (gas) in a joint space from gas forming organisms. (Caveat - may also occur normally as a
"vacuum phenomenon").
Effacement of the obturator fat pad (with hip involvement)
X-ray changes are usually a late phenomenon
Rarefaction of subchondral bone may occur as early as 2-7 days
Joint space loss (secondary to cartilage destruction) may be seen as early as 4-10 days
Erosions
Joint destruction with ankylosis may occur as early as 2 weeks
Other imaging techniques
Technetium joint scans - reveal distribution of inflammation
Gallium or Ceretec WBC scan-Indium scans - reveal inflammation as well as infection
CT - to identify sequestration
MRI - effusion, perhaps early cartilage damage, osteomyelitis

DIAGNOSTIC PROCEDURES:
Arthrocentesis with gram stain and culture - only positive in 50-70%. Must be done in all patients when
possibility of infectious arthritis is considered. Arthrocentesis should probably be performed within 12 hours of
suspicion.
Arthrocentesis approach must avoid contaminated tissue (e.g., overlying cellulitis)

TREATMENT
APPROPRIATE HEALTH CARE:
Hospitalization for parenteral therapy
Rarely an extremely compliant patient with a very sensitive organism might be treated as an outpatient

GENERAL MEASURES:
Repeat arthrocentesis to drain the joint, as fluid re-accumulates
Avoid adding anti-inflammatory therapy so as not to compromise assessment of therapeutic response to antibiotic
If a joint prosthesis is present in an infection, the infection is very difficult to eradicate, without removal of the
prosthesis
Treatment is continued for 1-2 weeks after total resolution of all signs of inflammation, 3-4 weeks for gram
negative organisms, and 6-8 weeks if the joint was previously diseased (e.g., involved by arthritis)
Intra-articular antibiotics are not required and may actually aggravate the arthritis

SURGICAL MEASURES:
Arthrotomy indicated only if fluid accumulated is loculated and/or not amenable to needle drainage

ACTIVITY:
Limit activity or splint the joint initially. Continuous passive motion may be used as an alternative approach.

DIET:

No special diet

PATIENT EDUCATION:
Rothschild, B.: Diagnosing and treating infectious arthritis. Geriatric Consultant. 5:14-15, 1986
Arthritis Foundation pamphlet

MEDICATIONS
DRUG(S) OF CHOICE:
Neisserial
Ceftriaxone 1 gm IM or IV every day for 14 days (but at least 7 days after symptoms resolve)
or
Spectinomycin 2 gm IM every 12 hours for 10 days
Non-Neisserial:
Gram positive cocci in chains or clumps - nafcillin 150 mg/kg/day q 4-6 h IV/IM
Gram positive diplococci - penicillin G 1.4 million units q6h
Gram negative bacilli: In neonates - penicillin and gentamicin; in children age 6 months to 4 years cefuroxime; in adult - penicillin or cephalosporin plus gentamicin, all at full dose. Add clindamycin, at full dose, in
the presence of retroperitoneal or pelvic abscess.
Gram negative pleomorphic organisms - clindamycin at full dose (clindamycin has gram negative activity only
against anaerobes)
No bacteria seen on smear - penicillin or cephalosporin plus gentamicin, all at full dose
Contraindications:
Tetracycline: not for use in pregnancy or children < 8 years.
Precautions:
Observe for allergic reactions/serum sickness
Tetracycline: may cause photosensitivity; sunscreen recommended.
Significant possible interactions:
Tetracycline: avoid concurrent administration with antacids, dairy products, or iron.
Broad-spectrum antibiotics: may reduce the effectiveness of oral contraceptives; barrier method recommended.

ALTERNATIVE DRUGS:
Non-Neisserial
In children age 6 months to 4 years - ampicillin [Chloramphenicol may be required to cover resistant
Haemophilus]
Infectious disease consult strongly advised to supplement rheumatologist input for Haemophilus infections
Quinolones (e.g., ciprofloxacin)

FOLLOW UP
PATIENT MONITORING:
Recurrent arthrocentesis, as fluid re-accumulates - to verify sterilization of the joint and to verify reversion of
inflammatory signs to normal
If no definitive improvement within 48 hours, re-evaluate completely
Complete blood count, liver and kidney function and urinalysis twice a week, while on antibiotics (perhaps with
creatinine every other day when gentamicin used)
Gentamicin levels
It is essential to followup one week and a month after stopping antibiotics to detect any relapse

PREVENTION/AVOIDANCE:
Prophylaxis in presence of predisposing joint condition
Condoms and discretion for STD protection

POSSIBLE COMPLICATIONS:
Death (9-33% in elderly)
Limited joint range of motion
Flail or fused or dislocated joint
Carpal tunnel syndrome

Septic necrosis
Sinus formation
Ankylosis
Osteomyelitis
Postinfectious synovitis
Shortening of the limb (in children)

EXPECTED COURSE AND PROGNOSIS:

Early treatment should allow cure
Delayed recognition/treatment complicated by morbidity and mortality

MISCELLANEOUS
ASSOCIATED CONDITIONS:
Systemic infection; infection elsewhere
Immunodeficiency; immunosuppression
Rheumatoid arthritis

AGE-RELATED FACTORS:
Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY:
N/A

SYNONYMS:
Suppurative arthritis
Septic arthritis

ICD-9-CM:
711.00 Pyogenic arthritis, site unspecified

SEE ALSO:
Reiter's syndrome
Lyme disease
OTHER NOTES:
N/A

ABBREVIATIONS:
N/A

REFERENCES
Kelly WW, Harris ED Jr, Rudd S, Sledge CB: Textbook of Rheumatology. Philadelphia, W.B. Saunders Co., 1997
Garcia, Porrax, et al: The clinical spectrum of severe septic bursitis in Northwestern Spain. J Rheum
1999;26:663-667
Berbari EF, et al: Risk factors for prosthetic joint infection. Clin Infect Dis 1998;27:1247-1254
Wilkinson NZ, Kingsley GH, Jones HW, Sieper J, Braun J, Ward ME. The detection of DNA from a range of
bacterial species in the joints of patients with a variety of arthritides using a nested, broad-range polymerase chain
reaction. Rheumatology 1999;38:260-266.
Gershwin ME, Robbins DL: Musculoskeletal Diseases of Children, New York, Grune & Stratton, 1983

Rothschild BM: Infectious Arthritis. Fairlawn, CT, Clinical AV, 1982

Rothschild BM, Martin L: Paleopathology: Disease in the Fossil Record. London, CRC Press, 1993

Web citations:
University of Washington - Infectious Arthritis
American College of Rheumatology (ACR)
Author(s):
Bruce M. Rothschild, MD

IMAGES
Illustrations:
N/A