Bacterial Arthritis; Causes, Symptoms, Diagnosis, Treatment

Children (age 3 months to 14 years)

• No cause identified in one third of cases
• Staphylococcus aureus (27%)
• Streptococcus (14%) > Streptococcus Pyogenes & Streptococcus Pneumoniae
• HaemophilusInfluenzae (<3% of cases, much less common in U.S. since start of Hib Vaccine)
• Gram Negative Bacilli

Adults with STD risk

Neisseria gonorrhoeae (most common)

• Gonococcal Arthritis
• Gonorrrhea is a still a leading cause in young adults with Septic Arthritis
• More common in women by a factor 3-4
• Typically Migratory Arthritis
• Staphylococcus aureus
• Streptococcus
• Gram Negative Bacilli
• Syphilis

Adults with no STD risk

• Staphylococcus aureus (50%)
• Streptococcus species
• Gram-Negative Bacilli

Joint Trauma

• Gram-Negative Bacilli
• Anaerobic Bacteria
• Staphylococcus aureus

Joint prosthesis

• Early infection  >Staphylococcus epidermidis
• Late Infection > Gram-Positive Cocci & Anaerobic Bacteria

Umbilical catheter (UAC or UVC) use in the newborn

• Risk of septic hip

Diagnosis of Septic Arthritis

• Removal of joint fluid – This is done to examine for white blood cells and bacteria.
• Blood tests – These tests are done to detect bacteria.
• Phlegm, spinal fluid, and urine tests – These tests are done to detect bacteria and find the source of infection.
• X-ray – A diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film
• Bone scan – A nuclear imaging method to evaluate any degenerative and/or arthritic changes in the joints to detect bone diseases and tumors to determine the cause of bone pain or inflammation.
• Magnetic resonance imaging (MRI) – A diagnostic procedure that uses a combination of large magnets, radio frequencies, and a computer to produce detailed images of organs and structures within the body.
• Radionuclide scans – Nuclear scans of various organs to determine blood flow to the organs.

Erythrocyte Sedimentation Rate (ESR)

1. ESR typically > 25 mm/hour in pediatric Septic Arthritis

C-Reactive Protein (C-RP)

• C-RP typically >20 mg/L in pediatric Septic Arthritis
• Closely mirrors infectious, inflammatory process
• Test Sensitivity: 95% in children

Complete Blood Count

• WBC Count typically >12,000 in pediatric Septic Arthritis

Other tests in severe cases or as directed by history

• Blood Culture
  • Bacteremia is present in up to one-third of cases of Septic Arthritis
• Complete Metabolic Panel
  • Typically obtained in severe Septic Arthritis, to establish end-organ injury, Renal Dosing of antibiotics
  • May also evaluate Pseudogout
• Uric Acid
  • Evaluate differential diagnosis
• STD Testing
  • Gonorrhea (PCR from Urethra or Cervix, or Throat Culture)
  • Syphilis

Bacterial Arthritis

• Opaque to turbid Synovial Fluid
• Synovial Fluid WBC
  • Non-prosthetic joint: >50,000 White Blood Cells (or >90% PMNs)
    1. Likelihood Ratio: 4.7 for Septic Arthritis
  • Prosthetic joint: >1700 White Blood Cells per mm3 (or >65% PMNs)
• Gram Stain
  • Test Sensitivity: 29-60%
• Bacterial Culture
  • Test Sensitivity: 30-50% (75% if polyarticular)
  • Guides antibiotic therapy when positive
• Synovial lactate
  • Synovial lactate >10 mmol/L has a very high Likelihood Ratio for Septic Arthritis (rules in Septic Arthritis)
• Gonococcal Arthritis

Clear to opaque Synovial Fluid

• • Synovial Fluid WBC: 30,000 to 100,000 (>80% PMNs)
  • Gram Stain Positive in <25% of cases
  • Culture positive in <50% of cases
• Tuberculous Arthritis
  • Opaque Synovial Fluid
  • Synovial Fluid WBC: 10,000 to 20,000 (>50% PMNs)
  • Gram Stain Positive in <20% of cases
  • Culture positive in 80% of cases

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1. Early changes
   • Distention of joint capsule
   • Joint Dislocation
2. Late changes
   • Joint space destruction
   • Epiphyseal cartilage resorption
   • Metaphysis erosion

Joint Ultrasound

• Bedside Ultrasound using high frequency linear probe (9-15 MHz)
• Indentifies effusion
  • Have patient move joint to distinguish effusion (re-distributes) from synovial thickening (static)
• Guides aspiration
  • Especially helpful in Hip Joint evaluation and needle aspiration
  • See Hip Ultrasound (Anterior Hip in Long Axis or LAX)

1. Advanced imaging
   • CT or MRI joint for unclear diagnosis
   • CT-guided aspiration may also be considered if Ultrasound-guided aspiration results in dry tap

• Nuclear scan
  1. Negative Nuclear scan excludes septic prosthetic joint
• Pet Scan
• Avoid CT Scan or MRI in infected prosthetic joint
  1. Does not distinguish infected prosthetic joint from other causes of pain

• Rest your painful joint as directed. You may need to keep the joint still when it is painful to prevent more damage.
• Elevate the joint to reduce swelling and pain. Keep the joint above the level of your heart as often as possible.
• Apply ice to the joint to reduce swelling and pain. Ice may also help prevent tissue damage. Use a cold compress, or put crushed ice in a bag. Cover it with a towel and apply it to your joint for 15 to 20 minutes every hour, or as directed.
• Exercise as directed. Exercise may help keep your joints flexible and reduce pain. Ask your healthcare provider how much exercise to get each day and which exercises are best for you.

Treatment by Drug

• Aspiration is a procedure used to drain fluid from your joint. Your healthcare provider may use a needle to drain the fluid.
• Antibiotics prevent or fight an infection caused by bacteria.

• Prescription pain medicine may be given. Ask your healthcare provider how to take this medicine safely.
• NSAIDs –  such as ibuprofen, help decrease swelling, pain, and fever. This medicine is available with or without a doctor’s order. NSAIDs can cause stomach bleeding or kidney problems in certain people. If you take blood thinner medicine, always ask your healthcare provider if NSAIDs are safe for you. Always read the medicine label and follow directions.
• Arthroscopy is a procedure used to remove infected lining from a joint.
• Septic Arthritis management requires two components
  • Thorough Joint Fluid drainage of purulent fluid
  • Antimicrobial management to cover the causative organisms

Antibiotics are started after obtaining joint culture and Blood Culture

• Septic Arthritis Causes for antibiotic considerations
• Gram Stain of fluid may assist antibiotic selection
• Empirically antibiotics based on age and risk factors (see below) until culture results available
• Antibiotics do not need to be injected into joints
• Joint cultures are recommended before antibiotics in most cases even if 24-48 hour antibiotic start delay
• Antibiotics may be considered prior to arthrocentesis ONLY if
  • Strong suspicion of Septic Arthritis AND
  • Consultant agrees that antibiotics should be started before the culture has been obtained AND
  • Procedure is delayed >24-48 hours
  • Difficult arthrocentesis requiring intervention radiology or rheumatology

• Adjunctive Corticosteroids
  • Discuss with consultant (orthopod)
  • Associated with decreased duration and Disability in studies of pediatric Septic Arthritis

Acute monoarticular without STD risk

Gram Stain Negative (2 drug regimen)

• Drug 1: Vancomycin 15-20 mg/kg IV q8-12 hours
• Drug 2: Choose one
  • Ceftriaxone 1 gram IV q24 hours or
  • Cefepime 2 grams IV q8 hours
  • Alternative: Ciprofloxacin 400 mg q12 hours or Levofloxacin 750 mg IV q24 hours

• Gram Stain with Gram Positive Cocci
  • Vancomycin 15-20 mg/kg IV q8-12 hours
• Gram Stain with Gram Negative Bacilli
  • Cefepime 2 grams q8 hours IV or
  • Meropenem 1 gram q8 hours iv
• Pseudomonas suspected
  • Cefepime OR
  • Piperacillin-Tazobactam
• Polyarticular Arthritis
  • Ceftriaxone 1 gram IV q24 hours

• Parenteral antibiotics for 2 to 4 weeks
• Oral antibiotics for 2 to 4 week

Home Remedies of  Bacterial Arthritis

Listed below are some effective arthritis home remedies which are found to be useful in arthritis cure and arthritis pain relief. Natural treatment for arthritis is also without side effects.

• As part of the dietary regimen, it is imperative that patients of arthritis choose a diet that will contribute to the alkaline content of blood. Diet rich in raw vegetables, sprouts, and juicy fruits should be opted for in place of one rich in animal protein, carbohydrate and fat.
• Sometimes in course of therapy, patients are recommended diet solely consisting of raw vegetables and fruits.
• Seawater has been found effective in relieving painfulness and stiffness of the affected joints. The iodine content of sea water not only helps to balance the pH of the body but also positively influences the thyroid functioning. Thus bathing in seawater can be recommended for patients struck by arthritis.
• As an alternative, the patient may be advised to take a dip into warm water enriched with common salt.
• Special care should be taken to expose oneself to sunlight and ambiance marked by proper ventilation.
• Drinking water stored in copper content proves to be beneficial from the point of view of arthritis patients as traces of copper accumulation making its way to the system contributes to strengthening the skeletal and muscular system.
• Calcium supplements, as well as calcium, is taken as ‘calcium lactate’ serves to strengthen bones and muscles.
• Garlic with its multi-sided medicinal qualities is also useful for arthritis. Consumption of two to three cloves of garlic work wonders against inflammation leading to aching joints.
• Besides garlic, ginger is also effective from the point of view of rheumatic arthritis. Consumption of at least thirty to fifty grams of ginger serves to reduce the painful conditions.
• Juice extracted from potato is similarly beneficial if consumed before breakfast. One may also soak sliced potato along with its peel in a bowl filled with water for drinking the water used for soaking potato slices.
• Water soaking sesame seeds can be had early in the morning along with the seed being soaked. The remedy will make your joint pains infrequent.
• Pineapple juice is also an effective natural option on account of its ‘bromelain’ content which serves to reduce swelling and pain.
• Though animal protein is not recommended the Omega3 fatty acids of certain oily fish proves to be beneficial from the viewpoint of arthritis. Supplements of the same or food rich in Omega 3 fatty acid can be taken.
• One tablespoon measure of cod liver oil may be added to a glass filled with orange juice. The said mixture will assure you of the requisite nutrients in forms of Vitamin C and Omega 3 fatty acid.
• Juice extracted from raw vegetables such as celery, spinach, and carrot blended in equal measure is also one of the healthy options which serve to clear the blood of the accumulated deposits.
• Coconut water and milk of the same are equally beneficial as natural remedial measures
• While the consumption of tea and coffee should be reduced, as an alternative option you may go for herbal tea. Herbal tea based on alfalfa has been found to be beneficial from the point of view of arthritis.
• Regular consumption of banana is also beneficial because Vitamin B content of the fruit acts against the stiffness of joints.
• Soup made out of green gram is another of your naturally nourishing options which work wonders if consumed regularly with crushed cloves of garlic.
• For soothing and instantaneous relief from joint pains; application of tolerably warm coconut or mustard oil enriched with crushed camphor proves to be relieving.
• Circulation around the affected tissues can be enhanced with the help of massaging of herbal oils such as lemon, rosemary, lavender, and chamomile. Thus gentle massaging of the mentioned oils will prove to be relieving.
• Gentle massaging of castor oil is also similarly beneficial.
• Applying mildly hot compresses of apple vinegar before pushing off to bed can also serve to keep your joints warm and soothing.

Homeopathic Remedies of Septic Arthritis

Aconite

• Sudden onset after exposure to cold dry air. Pains, with formication and numbness.
  Rheumatic inflammation of joints; pains intolerable. Intense bright-red swelling of parts. Sensitive to contact. High fever. Worse at night. With the rheumatism anxiety, fear, restlessness is well marked in aconite. Arthritic and rheumatic drawing and tearing pains, especially in the limbs. Acute and violent pulling in the joints and the bones, mitigated by the heat of a bed. The greater the suffering the greater the anguish, restlessness and fear of death. Mentally restless, but physically too weak to move. Indicated by its periodicity and time aggravation: after mid-night, and from 1-2 a.m. And by its intense restlessness, mental and physical: its anxiety and prostration.

Belladonna

• Joints swollen, red, hot, shining. Exquisitely sensitive to touch or jar. Red streaks radiate from inflamed joint. Recurrent fever with pains attacking nape of neck.
  Pains in the joints and bones. Rheumatic pains (in the joints) flying from one place to another. The pains are aggravated, chiefly at night, and in the afternoon towards three or four o’clock. The least touch, and sometimes also the slightest movement, aggravates the sufferings. Some of the symptoms are aggravated, or make their appearance after sleep. Jerking in the limbs, muscular palpitations and shocks of the tendons. St.Vitus dance. Sensation in the muscles, as if a mouse were running over
  them.

Bryonia

• Over-sensitiveness of the senses to external impressions. Rheumatic and gouty pains in the limbs, with tension, worse from motion and contact. Tension, drawing pains, acute pullings and shootings, especially in the limbs, and chiefly during movement, with insupportable pains on being touched, sweat of the part affected, and trembling of that part when the pains diminish. Stiffness and shootings in the joints, on being touched and when moved. In the evening, pain, as from fatigue, in the limbs, with paralytic weakness.

Causticum

• Arthritic and rheumatic drawing and tearing pains, especially in the limbs. Acute and violent pulling in the joints and the bones, mitigated by the heat of a bed. Contraction of the tendons, and stiffness in the flexor muscles of the limbs. Cramp-like Contraction of several limbs.

Risk factors of Septic Arthritis

Risk factors for septic arthritis include

• Existing joint problems. Chronic diseases and conditions that affect your joints — such as osteoarthritis, gout, rheumatoid arthritis or lupus — can increase your risk of septic arthritis, as can an artificial joint, previous joint surgery and joint injury.
• Taking medications for rheumatoid arthritis. People with rheumatoid arthritis have a further increase in risk because of medications they take that can suppress the immune system, making infections more likely to occur. Diagnosing septic arthritis in people with rheumatoid arthritis is difficult because many of the signs and symptoms are similar.
• Skin fragility. Skin that breaks easily and heals poorly can give bacteria access to your body. Skin conditions such as psoriasis and eczema increase your risk of septic arthritis, as do infected skin wounds. People who regularly inject drugs also have a higher risk of infection at the site of injection.
• Weak immune system. People with a weak immune system are at greater risk of septic arthritis. This includes people with diabetes, kidney and liver problems, and those taking drugs that suppress their immune systems.
• Joint trauma. Animal bites, puncture woods or cuts over a joint can put you at risk of septic arthritis

References