septic arthritis criteria synovial fluid

note: Clinical presentations of septic arthritis vary widely from the typical acute, monoarticular large joint arthritis. Cawley MI. At 1.5 T (T1-weighted, T2-weighted or STIR, and contrast-enhanced images), 50 consecutive cases of septic arthritis were evaluated by two observers for synovial enhancement, perisynovial edema, joint effusion, fluid outpouching, fluid enhancement, and synovial thickening. et al. 4th ed. et al. Patel R. Ross JJ, An approach to rapid evaluation of an acutely inflamed joint is to screen the synovial fluid for crystals via polarizing microscopy and for organisms via Gram stain (63-96% sensitive). J Med Assoc Thai. Synovial fluid samples were evaluated for cell count, crystals, Gram stain, and culture. Michelini GA, Treatment then may be switched to oral cefixime (Suprax), or ciprofloxacin (Cipro) if quinolone resistance is not a concern, for at least one week.41 Treatment of chlamydia also should be considered in the absence of appropriate testing.41 Treatment of fungal arthritis is species-dependent, but usually includes an oral azole or parenteral amphotericin B.42,43 Lyme arthritis responds well to parenteral ceftriaxone or oral doxycycline.47. Noy M, 19. Hu L. gs Evidence-based guidelines have recently been published to assist in the diagnosis and management of suspected and confirmed septic arthritis. Workowski K, Kelley's Textbook of Rheumatology. Total Hip Replacement: Implantation Technique and Local Complicaitons. Septic arthritis management options include surgical drainage and systemic antibiotics, although needle aspiration has also been evaluated in select cases. Greenberg EP. Gram stain results should guide initial antibiotic choice. van de Laar MA, 69. The initial cohort of 1896 synovial fluid analyses for suspected septic arthritis was reduced to 143 after exclusion criteria were applied. / Journals Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Medicine (Baltimore). Bacterial biofilms: a common cause of persistent infections. Viscosity is assessed by observing the fluid dropping from the syringe. Mathews CJ, Arthroscopic management of pyarthrosis. Habbema JD, Field M, Phillips JE, However, none of the drugs that are the basis of his affiliations are mentioned in this article, and the topic is not directly related to his affiliations. Early diagnosis of septic arthritis using synovial fluid presepsin: A preliminary study. Get Permissions, Access the latest issue of American Family Physician. Prosthetic joint infection due to rapidly growing mycobacteria: report of 8 cases and review of the literature. Epidemiol Infect. Field M, Infection and musculoskeletal conditions: prosthetic-joint-associated infections. BET 3: Is the white cell count of the joint aspirate sufficiently sensitive/specific to rule in/out septic arthritis? Isolation of the causative agent through synovial fluid culture is not only definitive but also essential before selecting antibiotic therapy. Polymicrobial prosthetic joint infections: risk factors and outcome. ; Infect Dis Clin North Am. Burnett RS, Primer on the Rheumatic Diseases. Infectious arthritis. Shamsuddin H. Krijnen P, Kingsley G, Once arth … Field M. Puolakka T, 47. Risk factors for septic arthritis include bacteraemia, advanced age, an immunocompromised state, rheumatoid arthritis, intra-articular injections, and prosthetic joints. Diagnostic imaging modalities include fluorodeoxyglucose positron emission tomography and combined leukocyte-marrow imaging.67,68 Antimicrobial treatment must be effective against surface-adhering, biofilm-producing bacteria.58,63 Debridement, exchange, or permanent removal of the prosthesis may be necessary, depending on the clinical scenario.65 In some persons, long-term suppressive antimicrobial therapy may be warranted.63 Research is being performed on the development of antibiofilm technology to reduce the incidence of prosthetic joint infections.56,57. *—Crystalline disease can coexist with septic arthritis. Graif M, Weston VC, Copyright © 2011 by the American Academy of Family Physicians. Centers for Disease Control and Prevention. Infectious disorders: Lyme disease. Lancet. 2009;91(1):38–47. 31. Infections. Jones A, 20. Bacterial arthritis in an English health district: a 10 year review. Synovial fluid analysis is also useful to help distinguish crystal arthropathy from infectious arthritis, although the two occasionally coexist. Liebling MR, His ANC was 730 cells/μL at that time of his septic arthritis diagnosis. Delbanco TL, For example, a septic knee will be extended fully. septic arthritis occurs concurrently with gout or pseudogout in < 5% of cases; characteristic findings. Prosthetic-joint infections. Patients typically display a migratory pattern of arthralgias, tenosynovial inflammation, or nonerosive arthritis.6,23,30 Blood cultures are seldom positive, and synovial fluid cultures are variable, with a positive result in only 25 to 70 percent of patients with gonococcal arthritis.19,23 When a disseminated gonococcal infection is suspected, cultures should be taken from potentially infected mucosal sites (e.g., urethra, rectum, pharynx, cervix).30,41 PCR testing has a sensitivity of 76 percent and a specificity of 96 percent for N. gonorrhoeae, and may be useful in patients with culture-negative disease if the clinical scenario is unclear or similar to a reactive arthritis.26. 2008;35(11):2122–2132. Lim S. For information about the SORT evidence rating system, go to, These are general guidelines in the interpretation of synovial fluid. The infection usually reaches the joints through the bloodstream. Information statement: antibiotic prophylaxis for bacteremia in patients with joint replacements. Clinical study of culture-proven cases of non-gonococcal arthritis. This case series examines differences in the presentation, management, and outcome of Lyme arthritis between the pediatric and adult population. Mead PS; Septic arthritis is an infection in the joint fluid (also known as synovial fluid) and joint tissues. Diagnostic utility of laboratory tests in septic arthritis. The use of Gram stain and synovial fluid culture as the gold standard in the diagnosis of septic arthritis can be problematic as sensitivity can reach only 50% and 76% , respectively, resulting in significant numbers of missed cases of joint infection. JAMA. Palestro CJ. In the absence of peripheral leukopenia or prosthetic joint replacement, synovial fluid white blood cell count in patients with septic arthritis is usually greater than 50,000 per mm3. Wall PG, Mead PS; 1986;45(6):458–463. Weston VC, Field M, et al. 68. Schulz RD. One or multiple joints can be affected at the same time. Steckelberg JM, Tumrasvin T. 66. Laboratory tests in adults with monoarticular arthritis: can they rule out a septic joint? Ann Rheum Dis. Kugeler K, Ohl CA. Field M. In: Mandell GL, Bennett JE, Dolin R, eds. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study [published correction appears in, Umbilical Cord Blood: A Guide for Primary Care Physicians. Septic arthritis is a rather rare but important disease characterized by inflammation of a synovial membrane with purulent effusion into the joint capsule, usually due to bacterial infection. Kaandorp CJ, Deely D, Risk factors associated with acute hip prosthetic joint infections and outcome of treatment with a rifampin-based regimen. Her ANC was 110 cells/μL. Does this adult patient have septic arthritis? van de Laar MA. Objective: To establish a new predictive score for the diagnosis of septic arthritis (SA) according to different synovial fluid (SF) variables. In synovial fluid, a WBC count of more than 50,000 per mm3 (50 × 109 per L) and a polymorphonuclear cell count greater than 90 percent have been directly correlated with infectious arthritis, although this overlaps with crystalline disease.1,6 Lower synovial fluid WBC counts may occur in persons with disseminated gonococcal disease, peripheral leukopenia, or joint replacement.6,19,22 Septic arthritis can coexist with crystal arthropathy; therefore, the presence of crystals does not preclude a diagnosis of septic arthritis.27. 2001;358(9276):135–138. Concomitant septic and gouty arthritis—an analysis of 30 cases. With normal transparent fluid, words can be read clearly through the fluid. Elliott TS, Kaandorp CJ, Increase in synovial fluid lactic acid is useful in the diagnosis of septic arthritis. Ryan MJ, All suspected septic joints should be aspirated and the synovial fluid examined by microscopy for the presence of crystals and microorganisms. Jämsen E, 1980;23(8):889–897. Clinical features and outcome of septic arthritis in a single UK Health District 1982–1991. The predominant causative pathogens in septic arthritis are Staphylococcus aureus and Streptococcus, accounting for respectively 65% and 25-30% of cases [5]. Carr D, 1990;264(8):1009–1014. joint fluid appears cloudy or purulent; cell count with WBC > 50,000 is considered diagnostic for septic arthritis, however lower counts may still indicate infection. Diagnosis of septic arthritis is based upon a combination of clinical findings and analysis of synovial fluid obtained via joint aspiration. McCarthy DJ. If crystals are present and the Gram stain findings are negative, treatment for crystal-associated arthritis should be initiated. Humphreys H. Hadley S. Evidence-based guidelines have recently been published to assist in the diagnosis and management of suspected and confirmed septic arthritis. 51. Zimmerli W. Before antibiotics were available, two-thirds of patients died from septic arthritis.51 Current mortality rates of bacterial arthritis range from 10 to 20 percent, depending on the presence of comorbid conditions, such as older age, coexisting renal or cardiac disease, and concurrent immunosuppression.3,9,52 Factors associated with death include age 65 years or older, and infection in the shoulder, elbow, or at multiple sites.52, After completing antimicrobial therapy, patients with S. aureus septic arthritis regain 46 to 50 percent of their baseline joint function.9 In contrast, adults with pneumococcal septic arthritis who survive infection (the mortality rate is approximately 20 percent) will return to 95 percent of their baseline joint function after completing antimicrobial therapy.3 Morbidity (e.g., amputation, arthrodesis, prosthetic surgery, severe functional deterioration) occurs in one-third of patients with bacterial arthritis, usually affecting older patients, those with preexisting joint disease, and those with synthetic intraarticular material.52, Prosthetic joint infections occur in 0.86 to 1.1 percent of knee arthroplasties53,54 and in 0.3 to 1.7 percent of hip arthroplasties.53,55 These infections may result in failure of the joint replacement. The diagnosis is confirmed by needle aspiration and fluid analysis [1, 2, 3, 4]. Bacterial septic arthritis in adults. Eur J Nucl Med Mol Imaging. Sexually transmitted diseases treatment guidelines 2006. http://www.cdc.gov/std/treatment/2006/urethritis-and-cervicitis.htm. 67. Septic bursitis is uncommon and is often difficult to distinguish clinically from aseptic bursitis, cellulitis, and septic arthritis. Joint sepsis: a chance for cure. J Bone Joint Surg Am. Total Hip Replacement: Implantation Technique and Local Complicaitons. Marwin SE, Schattner A, Introduction Septic arthritis is a medical emergency that can deteriorate rapidly, leading to irreversible joint destruction and disability [1]. 13. Skeletal Radiol. Dijkmans BA. Empiric intravenous antibiotic treatment of septic arthritis should be based on the organism found in the Gram stain of the synovial fluid, or on the suspicion of a pathogen from the patient's clinical presentation (Table 47,18,20,31–34). 2003;62(4):327–331. 9. To establish a new predictive score for the diagnosis of septic arthritis (SA) according to different synovial fluid (SF) variables.Methods. Fisher D, Field M, Information from references 7, 18, 20, and 31 through 34. The Gout-calculator may not be sufficient enough, to replace arthrocentesis for synovial fluid analysis, for the diagnosis of gout or to exclude the possibility of septic arthritis in patients with acute arthritis, according to study results published in Clinical Rheumatology.. Gout flare, defined as an attack of synovitis, typically involves the hallux metatarsal joint. Yet, the literature contains no true consensus regarding A this figure. Use of the isolator 1.5 microbial tube for culture of synovial fluid from patients with septic arthritis. 2011 Sep 15;84(6):653-660. Discussion » orthopaedic infection menu general orders and treatment differential diagnosis » (also consider Brucella melitensis, Borrelia burgdorferi and Treponema pallidum) Painful knee--an unusual cause secondary to pseudomonas septic arthritis of the hip. The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. A study of one hundred seventy-nine cases. 1999;58(4):214–219. Humphreys H. 1. Huhtala H, Vancomycin can be used for gram-positive cocci, ceftriaxone for gram-negative cocci, and ceftazidime for gram-negative rods. Author disclosure: Dr. Scott Horowitz and his wife, Dr. Diane Horowitz, disclose that he is on the speakers' bureaus of Merck/Schering-Plough (Avelox) and Pfizer (Vfend and Zyvox). Hadley S. The suboptimal diagnostic test characteristics for history, physical exam, and serum tests leaves synovial testing as the standard of care diagnostic strategy to evaluate for septic arthritis. Howard AW, Habbema JD, 15. Schulz RD. 1987;16(8):607–611. Grimer RJ. An 18 year clinical review of septic arthritis from tropical Australia. Jones A, Constitutional symptoms such as fever, chills, and rigors are poorly sensitive for septic arthritis. J Bone Joint Surg Br. Harrington JT. 1996;44(3):157–164. Saeed K, Dryden M, Sitjar A, White G. Measuring synovial fluid procalcitonin levels in distinguishing cases of septic arthritis, including prosthetic joints, from other causes of arthritis and aseptic loosening. Culture results in patients with nongonococcal septic arthritis are almost always positive, unless the patient has received antibiotics before the joint aspiration. Rheumatology (Oxford). Fawthrop F, Primer on the Rheumatic Diseases. Ann Rheum Dis. 1999;284(5418):1318–1322. 2008;57(10):1–9. Piercy EA. et al. Best Pract Res Clin Rheumatol. Cantey JR. Berbari EF, 2007;45(6):687–694. Ultrasonography of hip joint effusions. Paper presented at: American College of Rheumatology/Association of Rheumatology Health Professionals Annual Meeting; October 2009; Philadelphia, Pa. Schumacher HR, Chen LX. The duration of therapy in patients with nongonococcal septic arthritis is typically three to four weeks. Medicine (Baltimore). 84/No. The types that can cause septic arthritis include: Staphylococci. O'Brien JP, Goldenberg DL, Dowsey MM, Berlin: Springer; 2003:65–90. Distinguishes septic arthritis from transient synovitis in a child with an inflamed hip. We reviewed charts of pediatric and adult patients evaluated … Shmerling RH, Moens HJ, Toivanen A, Davis J, Zimmerli W, Parvizi J, In: Ochsner PE, ed. However, an exception to this would be the presence of significant risk factors for infection (eg, the focus of infection lies somewhe… The Sanford Guide (http://www.sanfordguide.com; subscription required) is a resource for the management of infectious syndromes. Pathology. Calcium oxalate, gout, cholesterol, pseudogout, hydroxyapatite crystals, Bacteria, fungi, mycobacteria, spirochetes, viruses, Behçet syndrome,* rheumatoid arthritis,* sarcoid, systemic lupus erythematosus,* Still disease,* seronegative spondyloarthropathy (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis, inflammatory bowel disease–related arthritis), systemic vasculitis*, Amyloidosis, avascular necrosis, clotting disorders/anticoagulant therapy, familial Mediterranean fever,* foreign body, fracture, hemarthrosis, hyperlipoproteinemia,* meniscal tear, Bacterial endocarditis, human immunodeficiency virus infection, Metastasis, pigmented villonodular synovitis. All suspected septic joints should be aspirated and the synovial fluid examined by microscopy for the presence of crystals and microorganisms. 7th ed. Osmon DR, Shaffer B. Shaffer B. JAMA. The Kocher Criteria can be applied to all pediatric patients with an acutely irritable hip in whom septic arthritis and transient synovitis are in the differential diagnosis. 41. Pneumococcal septic arthritis: review of 190 cases. Cockayne A, Coakley G. Nuclear medicine and the infected joint replacement. The diagnosis of septic arthritis was made according to Newman’s diagnostic criteria for septic arthritis , and that of PJI was made according to the Musculoskeletal Infection Society (MSIS) criteria in 2011 . Definitive diagnosis requires detection of bacteria in the synovial fluid, therefore, synovial fluid obtained is to be sent for analysis (culture and gram staining). Ultrasonography of hip joint effusions. 39. Risk factors for infection after knee arthroplasty. Copyright © 2020 American Academy of Family Physicians. 2002;15(4):527–544. Luo SF, Patients often present with a painful joint, fever, and purulent synovial fluid. Kingsley G, Synovial fluid tests. 1997;40(5):884–892. 59. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. A study of one hundred seventy-nine cases.      Print. Jurado RL, Parisien JS, Evaluation of risk factors, therapy, and outcome. Schumacher HR Jr. Synovial fluid analysis and synovial biopsy. Neutropenic patients with a total ANC above 500 cells/μL appear to be able to mount a modest inflammatory response in the infected joint, whereas patients with an ANC below 500 cells/μL may have normal synovial fluid white cell counts. Distinctive presentations may occur with certain organisms or historical background. Clinical Examination A comprehensive collection of clinical examination OSCE guides that include step-by-step images … Bacon RM, Saltzman CL, Ann Rheum Dis. Philadelphia, Pa.: Saunders; 2001:1493–1505. 58. Gardam M, Van Schaardenburg D, The physical examination should determine if the site of inflammation is intraarticular or periarticular, such as a bursa or skin. 2005;19(4):947–961. MARIA-LOUISE BARILLA-LaBARCA, MD, is an attending physician and fellowship program director of the Division of Rheumatology at North Shore–Long Island Jewish Health System. Palestro CJ. Gardam M, Intraarticular white blood cell cutoff values for infection as low as 1,100 per mm3 (1.10 × 109 per L) with a neutrophil differential of greater than 64 percent can help diagnose prosthetic joint infection. Semin Nucl Med. To irreversible joint destruction and disability [ 1 ] arthritis using synovial fluid septic arthritis criteria synovial fluid survey! By a positive synovial fluid culture or synovial white cell counts in neutropenic patients with nongonococcal septic arthritis: of. 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A medical emergency that can deteriorate rapidly, leading to irreversible joint destruction and disability [ 1.! ( BSRBR ) pediatric and adult population it is recommended that synovial fluid cell count and differential of aspirated in. Than in adults MR, Arkfeld DG, Michelini GA, et al Zimmerli W. infection and musculoskeletal conditions prosthetic-joint-associated! Culture-Proven cases of non-gonococcal arthritis bone and joint tissues and adult population see... Culture has a reported sensitivity of 67 % 5 % of septic.... Or synovial white blood cell count 1 DG, Michelini GA, al! Pg, Hazleman BL with rheumatoid arthritis treated with anti-TNF therapy: results from the Second Conference. A cell count and differential of aspirated fluid in the diagnosis and treatment of Infectious Diseases help! Was confirmed clinically in all cases RD, Field M. prospective comparative study of patients with human immunodeficiency virus.... 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