1. ANA Testing Carrie Marshall 1/18/08

2. Septic Arthritis RRC R heumatology R esearch C enter

3. Infectious Arthritis SepticGonococcalViralFungalTuberculousLyme

4. Definition Acute joint infection due to bacterial agents Acute joint infection due to bacterial agents Medical emergency Medical emergency

5. Epidemiology Incidence: Incidence: 40-68/100000/ yr in Prosthetic joint 40-68/100000/ yr in Prosthetic joint 28-38/ 100000/ yr in RA 28-38/ 100000/ yr in RA 5- 12/ 100000/ yr in Children 5- 12/ 100000/ yr in Children 2-5/ 100000/ yr in GP 2-5/ 100000/ yr in GP

6. In Adult: 75% with risk factor In Adult: 75% with risk factor

7. Risk factors: Risk factors: Systemic: Systemic: Old age (>80 Y) Old age (>80 Y) RA RA DM DM Immunosuppressive Immunosuppressive Hemodyalisis Hemodyalisis Malignancy Malignancy Local: Local: RA RA OA OA Prosthetic joint Prosthetic joint

8. Etiology (microbiology) Microbial agent: Microbial agent: Staphylococcus aureus: most common (75-80%) Staphylococcus aureus: most common (75-80%) Other organism in special patients: Other organism in special patients: Sexually active woman: Neisseria gonorrheae Sexually active woman: Neisseria gonorrheae Elderly, IV drug abuser, immunocompromised, UTI: Gram negative (p. aeruginosa and E.coli) Elderly, IV drug abuser, immunocompromised, UTI: Gram negative (p. aeruginosa and E.coli) SLE: Salmonella SLE: Salmonella HIV: Pneumococci, Salmonella, H. influenzae HIV: Pneumococci, Salmonella, H. influenzae Alcoholism, Humeral immunity abnormality, Hemoglobinopathies: Pneumococcal infections Alcoholism, Humeral immunity abnormality, Hemoglobinopathies: Pneumococcal infections Primary immunoglobolin deficiency: Mycoplasma Primary immunoglobolin deficiency: Mycoplasma

9. Root of infection: Root of infection: Blood stream Blood stream Contiguous infection Contiguous infection Direct inoculation: Direct inoculation: Injection: 0.0002 Injection: 0.0002 Arthroscopic surgery: < 0.005 Arthroscopic surgery: < 0.005 Animal or human bite Animal or human bite

11. Site of involvement: Site of involvement: Mono (80-90%) Mono (80-90%) Knee: 55% Knee: 55% Ankle: 10% Ankle: 10% Wrist: 9% Wrist: 9% Shoulder: 7% Shoulder: 7% Hip: 5% Hip: 5% Elbow: 5% Elbow: 5% SC: 5%- IV drug abuser SC: 5%- IV drug abuser SI: 2%- IV drug abuser SI: 2%- IV drug abuser Foot joints: 2% Foot joints: 2% Poly (more than 1 joint): RA Poly (more than 1 joint): RA

12. SYNOVIAL FLUID SYNOVIUM Cartilage

13. Pathogenesis Microbial Factors: virulence Microbial Factors: virulence Host Factors: Immune response Host Factors: Immune response

14. Fibronectin binding protein Collagen Bindidng protein Protein A Coagulase Enterotoxin B TSST-1 alfa Toxin

15. Immune response: Immune response: Synovial cell: Synovial cell: IL1- IL6 (influx of immune cell) IL1- IL6 (influx of immune cell) Immune cells: Immune cells: Early cytokines: Clearance of organism Early cytokines: Clearance of organism Late cytokines: may amplify the destruction Late cytokines: may amplify the destruction

16. SYNOVIUM

18. Clinical manifestations Fever (toxic) Fever (toxic) Acute Acute Sever pain Sever pain Sever swelling of one joint Sever swelling of one joint Sever tenderness Sever tenderness Warmth Warmth Sever effusion Sever effusion Sever limited ROM Sever limited ROM

20. Acute Monoarthritis Sepsis workup Biochemist Synovial Fluid Aspiration (rule) Diagnosis

22. Acute Monoarthritis Synovial Fluid Aspiration Light microscope Smear- Culture Sepsis workup Biochemist

23. Acute Monoarthritis Synovial Fluid Aspiration Light microscope Smear- Culture Turbid - Purulent Leukocyte> 50,000/ml (> 90% PMN) Damaged WBC Crystal (-) Sepsis workup Biochemist

25. Acute Monoarthritis Synovial Fluid Aspiration Light microscope Smear- Culture Positive Gram stain: 75% in s. aureus 30-50% in gram (-) Positive Fluid culture: 90% PCR: partially treated or culture negative Sepsis workup Biochemist

26. Acute Monoarthritis Synovial Fluid Aspiration Light microscope Smear- Culture Positive Gram stain: 75% in s. aureus 30-50% in gram (-) Positive Fluid culture: 90% PCR: partially treated or culture negative Positive B/C : 50-70% Leukocytosis ESR & CRP Sepsis workup Biochemist

27. Radiography Early: Early: Soft tissue swelling Joint space widening Soft tissue swelling Joint space widening Predisposing agent Predisposing agent Late (2-3 w): Late (2-3 w): Erosion Erosion Joint space narrowing Joint space narrowing

33. AntibioticJoint Drainage TREATMENT

34. AntibioticJoint Drainage TREATMENT Empiric (IV): Smear Age or Risk factors Extra articular site

35. Empirical antibiotic Gram stain result: Gram stain result: Gram positive cocci: Gram positive cocci: Oxacillin or Naficillin (2g /q 4h) Oxacillin or Naficillin (2g /q 4h) Vancomycin (1g /q 12h) if methycillin-resistant S. aureus Vancomycin (1g /q 12h) if methycillin-resistant S. aureus Gram Negative: Gram Negative: Ampicillin or Cephalosporin Ampicillin or Cephalosporin No organism: No organism: In healthy, sexually active: Cefotaxime or ceftriaxone In healthy, sexually active: Cefotaxime or ceftriaxone In elderly debilitated patients: antistaphylococcal + Aminoglycoside + antipseudomonal penicillin or a third generation cephalosporin In elderly debilitated patients: antistaphylococcal + Aminoglycoside + antipseudomonal penicillin or a third generation cephalosporin

36. AntibioticJoint Drainage TREATMENT Empiric (IV): Smear Age or Risk factors Extra articular site Definitive therapy; based on culture

37. Definitive therapy S. aureous: 4 weeks Oxacillin Naficillin Vancomycin Pneumococal and streptococcal inf : 2 weeks Penicillin G, 2mU /q 4h H. influenzae and s. pneumoniae resistant to penicillin: 2 weeks Cefotaxime or Ceftriaxone Enteric gram negative: 3-4 w Second or Third Gen cephalosporin Fluoroquinolone (levofloxacin 500mg IV or Po every 24h) P. aeruginosa: 4 weeks Combination of AG + mezlocillin or ceftazidime (IV) 2 weeks Ciprofloxacin 750mg twice daily (oral) 2 weeks

38. AntibioticJoint Drainage Empiric (IV): Smear Age or Risk factors Extra articular site Closed needle Aspiration Arthrotomy: Hip, Shoulder TREATMENT Definitive therapy; based on culture

39. AntibioticJoint Drainage Closed needle Aspiration Arthroscopic Drainage: Symptom S. fluid volume S. fluid WBC S. fluid smear & culture Arthrotomy: Hip, Shoulder TREATMENT Empiric (IV): Smear Age or Risk factors Extra articular site Definitive therapy; based on culture

40. AntibioticJoint Drainage TREATMENT Frequent passive motion Until removal of inflammation signs No weight bearing