Diagnosis Of Septic Arthritis Research Articles

Septic Arthritis of the Knee and Necrotizing Fasciitis in a Young Immunocompetent Adult: A Case Report

Septic arthritis is uncommon in immunocompetent young adults. It typically presents in individuals with underlying risk factors. Isolation of Group A Streptococcus (GAS) as the causative agent of septic arthritis is usually associated with autoimmune diseases, chronic skin infections or trauma. Here we report a case of a young lady who is immunocompetent without any prior history of trauma, who presented with an abrupt onset of left knee pain and swelling to the emergency department. An initial diagnosis of acute gout was made and she was treated with non-steroidal anti-inflammatory drug (NSAID). She presented again two days later to a primary care clinic with worsening knee pain and severe left calf pain. A clinical diagnosis of septic arthritis was suspected and the patient was urgently referred to the Orthopaedic team. Synovial fluid from the knee joint aspiration showed growth of GAS. A diagnosis of necrotizing fasciitis was also made as the culture taken from the left calf during incision and drainage (I&D) procedure showed a mixed growth. She eventually underwent surgical debridement twice, together with the administration of several courses of intravenous antibiotics leading to her full recovery after 45 days. This case demonstrates the challenge in making a prompt diagnosis of septic arthritis and probable Type II necrotizing fasciitis in an immunocompetent adult without underlying risk factors. Any delay in diagnosis and treatment would have increased the risk of damage to her knee joint and this may be fatal even in a previously healthy young adult.
 KEYWORDS: septic arthritis, immunocompetent, Group A streptococcus, necrotizing fasciitis

Factors associated with septic arthritis of the distal interphalangeal joint in beef cattle: A case-control study

Lameness in cattle is a welfare concern and is associated with important economic losses in beef cattle operations. Infection of the distal interphalangeal joint (DIJ) results in severe lameness and if left untreated carries a poor prognosis. Diagnosis of DIJ infection is challenging in the field. The aim of this study was to determine factors associated with septic arthritis of the DIJ in beef cattle. Thirty-nine beef cattle with a complaint of single-foot lameness were used in this study. History and lameness examination data were recorded and analyzed. Radiographic changes and cytology of synovial fluid of the affected DIJ were used to define the presence (cases) or absence (controls) of DIJ infection.Asymmetric swelling at the coronary band of the affected foot and a lameness score of ≥4/5 significantly increased the odds (odds ratio [OR]=63.2 and OR=120, respectively) of diagnosis of septic arthritis of the DIJ in beef cattle with a single-foot lameness compared to cattle with no asymmetry of the coronary band or lameness scores <3. Routine lameness examination findings could be used in the field to rapidly recognize infection of the DIJ in lame beef cattle.

Vancomycin presoaking of hamstring grafts removes the risk of infection in primary anterior cruciate ligament reconstruction

Background:Several strategies have been studied to decrease the rate of infection after hamstring autograft anterior cruciate ligament (ACL) reconstruction. Our group started presoaking grafts with Vancomycin in November 2015 to decrease this risk.Purpose:The objective of the study is to compare the success of this protocol against the immediate previous period in which we did not use the protocol.Study design:Retrospective cohort. Level III.Methods:Consecutive periods were studied: April 2013-October 2015 (pre Vancomycin protocol) and November 2015- May 2018 (Vancomycin protocol). All patients that underwent a hamstring autograft primary ACL reconstruction during the periods studied were included. The final outcome was the presence of postoperative septic arthritis in both groups. Diagnosis of septic arthritis was made using the clinical picture plus cytological analysis of a joint aspiration (cell count > 50.000/uL + > 90% neutrophils) Statistical analysis was made using the Fisher’s exact test. Significance was set in p < 0.05.Results:490 patients were included in the study, 230 in the pre Vancomycin protocol an 260 in the Vancomycin protocol. 4 postoperative septic arthritis were noted in the pre Vancomycin protocol (1.7%) while no septic arthritis was noted in the post Vancomycin protocol patients during the period studied. (p < 0.05) The 4 postoperative infections were presented at an average 21.7 days (range 16-25). Staphylococcus epidermidis was isolated in 2 of the cases, and in the other 2 no organism was isolated.Conclusion:Vancomycin presoaking of hamstring autografts in primary ACL reconstruction eliminated the risk of postoperative septic arthritis during the studied period compared to the immediate previous period, where no Vancomycin presoaking was used.

Early diagnosis of septic arthritis using synovial fluid presepsin: A preliminary study.

Therapeutic outcomes for septic arthritis vary greatly depending on the span of time between disease-onset and surgery. The most important factor is making an early and definitive diagnosis; however, some cases may be difficult to diagnose. We investigated presepsin, a biomarker of sepsis, to determine whether or not presepsin in synovial fluid would be useful for the diagnosis of septic arthritis. We selected 18 patients with septic arthritis including periprosthetic joint infections (SA group) and 28 patients with osteoarthritis (OA group). We measured the concentrations of synovial fluid presepsin, blood presepsin and procalcitonin (PCT) in the two groups. We compared the sensitivities and specificities of synovial fluid presepsin, blood presepsin and PCT. Synovial fluid and blood presepsin and blood PCT were all significantly higher in the SA group. Synovial fluid presepsin exhibited both 100% sensitivity and 100% specificity in the SA group, which were higher rates than those for blood presepsin and PCT. We found that synovial fluid presepsin is markedly elevated in case of septic arthritis, and therefore, it has potential as a new biomarker of septic arthritis.

Corticosteroids for septic arthritis in children.

Septic arthritis is an acute infection of the joints characterised by erosive disruption of the articular space. It is the most common non-degenerative articular disease in developing countries. The most vulnerable population for septic arthritis includes infants and preschoolers, especially boys. Septic arthritis disproportionately affects populations of low socioeconomic status. Systemic corticosteroids and antibiotic therapy may be beneficial for treatment of septic arthritis. Even if the joint infection is eradicated by antibiotic treatment, the inflammatory process may produceresidual joint damage and sequelae. To determine the benefits and harms of corticosteroids as adjunctive therapy in children with a diagnosis of septic arthritis. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, Latin American Caribbean Health Sciences Literature (LILACS), the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/), ClinicalTrials.gov (www.ClinicalTrials.gov), and Google Scholar. We searched all databases from their inception to 17 April 2018, with no restrictions on language of publication. We included randomised controlled trials (RCTs) with patients from two months to 18 years of age with a diagnosis of septic arthritis who were receiving corticosteroids in addition to antibiotic therapy or as an adjuvant to other therapies such as surgical drainage, intra-articular puncture, arthroscopic irrigation, or debridement. Two review authors independently assessed eligibility, data extraction, and evaluation of risk of bias. We considered as major outcomes the presence of pain, activities of daily living, normal physical joint function, days of antibiotic treatment, length of hospital stay, and numbers of total and serious adverse events. We used standard methodological procedures expected by Cochrane. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table. We included two RCTs involving a total of 149 children between three months and 18 years of age who were receiving antibiotics for septic arthritis. The most commonly affected joints were hips and knees. These studies were performed in Costa Rica and Israel. In both studies, dexamethasone administered intravenously (ranging from 0.15 to 0.2 mg/kg/dose every six to eight hours) during four days was the corticosteroid, and the comparator was placebo. Trials excluded patients with any degree of immunodeficiency or immunosuppression. The longest follow-up was one year. Trials did not report activities of daily living nor length of hospital stay. Both studies used adequate processes for randomisation, allocation concealment, and blinding, and review authors judged them to have low risk of selection and performance bias. Losses to follow-up were substantive in both studies, and we judged them to have high risk of attrition bias and of selective outcome reporting. We graded all outcomes as low quality due to concerns about study limitations and imprecision.The risk ratio (RR) for absence of pain at 12 months of follow-up was 1.33, favouring corticosteroids (95% confidence interval (CI) 1.03 to 1.72; P = 0.03; number needed to treat for an additional beneficial outcome (NNTB) = 13, 95% CI 6 to 139; absolute risk difference 24%, 95% CI 5% to 43%).The RR for normal function of the affected joint at 12 months of follow-up was 1.32, favouring corticosteroids (95% CI 1.12 to 1.57; P = 0.001; NNTB = 13, 95% CI 7 to 33; absolute risk difference 24%, 95% CI 11% to 37%).We found a reduction in the number of days of intravenous antibiotic treatment favouring corticosteroids (mean difference (MD) -2.77, 95% CI -4.16 to -1.39) based on two trials with 149 participants.Researchers did not report length of hospital stay. One trial (49 participants) reported that treatment with dexamethasone was associated with a shorter duration of IV antibiotic treatment, leading to a shorter hospital stay, and although duration of hospitalisation was a primary outcome of the study, study authors did not provide data on the duration of hospitalisation. We downgraded the quality by one level for concerns about study limitations (high risk of attrition bias and selective reporting), and by another level for imprecision.In one trial of 49 participants, researchers followed 29 children for 12 months, and parents reported that no children demonstrated adverse effects of the intervention. Evidence for corticosteroids as adjunctive therapy in children witha diagnosisof septic arthritis is of low quality and is derived from the findings of two trials (N = 149). Corticosteroids may increase the proportion of patients without pain andthe proportionof patients withnormalfunction of the affected joint at 12 months, and may also reduce the number of days of antibiotic treatment. However, we cannot draw strong conclusions based upon these trial results. Additional randomised clinical trials in children with relevant outcomes are needed.

The Limitations of Gram-stain Microscopy of Synovial Fluid in Concomitant Septic and Crystal Arthritis.

Rapid diagnosis of septic arthritis from Gram-stain microscopy is limited by an inherent false-negative rate of 25-78%. The presence of concomitant crystal arthritis in 5% of cases represents a particular diagnostic challenge. This study aims to investigate the effects that a concomitant crystal arthropathy has on the ability of Gram-stain microscopy of synovial fluid to diagnose a septic arthritis. This is a 22-year retrospective cohort study. Inclusion criteria were a positive synovial fluid culture result with a positive clinical diagnosis of septic arthritis. Results were correlated with the presence or absence of urate and calcium pyrophosphate crystals, and Gram-stain result. During this time our collection and analysis methods remained unchanged. All samples were collected in Lithium Heparin containers. Chi-squared test with a p value < 0.05 was considered significant. 602 synovial fluid samples were included. 162 cases of concomitant crystal arthritis were identified (27%). Of these, 16 (10%) had an initial negative Gram-stain. Out of the 440 samples with no crystals detected, 18 (4%) had an initial negative Gram-stain microscopy result (p < 0.05). The incidence of concurrent septic and crystal arthritis may be higher than previously thought. Synovial fluid samples in concomitant septic and crystal arthritis are significantly less likely to have a positive Gram-stain at microscopy than in cases of an isolated septic arthritis. We would advise the clinician to maintain a high index of suspicion for septic arthritis in these patients.

Multiplex Polymerase Chain Reaction and Microcalorimetry in Synovial Fluid: Can Pathogen-based Detection Assays Improve the Diagnosis of Septic Arthritis?

To prospectively evaluate automated multiplex PCR and isothermal microcalorimetry tests for rapid and accurate diagnosis of septic arthritis. Patients with acute arthritis were prospectively included from October 2014 to September 2015. In synovial fluid (SF), leukocyte count and differential, culture, PCR, and microcalorimetry were determined. Septic arthritis was diagnosed by positive SF culture or (1) local clinical signs and symptoms, (2) increased SF leukocyte count, and (3) exclusion of noninfectious causes of inflammatory arthropathy. The performance of individual tests was compared with McNemar's test. Among 57 patients, 22 (39%) were diagnosed with septic arthritis. SF culture grew a pathogen in 10 patients (46%), PCR was positive in 5 (23%), and microcalorimetry in 10 (46%). Compared to SF culture, 49 concordant pairs were found for both methods (PCR and microcalorimetry; 86% agreement). In SF, PCR failed to detect Staphylococcus aureus (2 patients), Streptococcus pneumoniae (1 patient), Streptococcus dysgalactiae (1 patient), and Clostridium clostridioforme (1 patient). Microcalorimetry failed to detect S. dysgalactiae (1 patient), Streptococcus agalactiae (1 patient), and C. clostridioforme (1 patient). No statistical differences between the performance of SF culture, and PCR and microcalorimetry, respectively, were found. The processing time for PCR was 5 h and for microcalorimetry a median of 8.8 h (range, 2.3-64 h), whereas cultures required a median of 4.5 days (range, 3-14 days). Performance of SF PCR was inferior while microcalorimetry was similar to culture but provided results considerably faster. [Clinical trial registration number (https://www.clinicaltrials.gov): NCT02530229].

To study epidemiological pattern and clinical and radiological parameters of recovery of septic arthritis in nfants and neonates admitted in B.R.D medical college, Gorakhpur

Introduction: Prior to the antibiotic era and more enlighten surgical approaches, the occurrence of septic arthritis presented literal threat to life and limb. Despite potent antibiotics, Septic arthritis continues to be one of the most damaging and prevalent form of arthritis. Septic arthritis is bacterial infection of synovium and subsequently all the structure within the joint, which causes intense inflammatory reaction, possibly leading to destruction of articular cartilage and later of the complete Joints. Case Presentation: A diagnosis of septic arthritis was explicitly assigned when a patient had a positive Gram stain or culture finding of joint fluid, purulent joint aspiration drawn from a joint adjacent to a site with known osteomyelitis, focal joint involvement in the setting of bacteremia. If no growth was observed during culture, we presumed a diagnosis of septic arthritis when 2 of the major and 5 of the minor clinical criteria described by Morrey et al. were satisfied and the diagnosis was supported by ultrasonographic findings.Conclusion: The incidence of septic arthritis in children < 1 year is 1.65 per1000 children, 8.37 per 10,000 infants and in neonates its 2.80 per 1000. Males are most commonly affected with male: female being 3: 1. Hip is commonest involved joint. Commonest organism responsible for septic arthritis is Staphylococcus. The major cause of late presentation and/or delayed initiation of definitive management in septic arthritis is handling of the patients by non-orthopaedics specialist initially. Identified risk factors in this study are prematurity, perinatal hypoxia, septicemia, birth trauma and venous catheterization. Most of the clinical improvement occurs during first 6 weeks. Radiological improvement lags behind clinical improvement by 2-4 weeks. Most important prognostic factors for poor outcome are late presentation and /or delayed initiation of definative management.

Improved Diagnosis and Treatment of Bone and Joint Infections Using an Evidence-based Treatment Guideline.

Our institution created a multidisciplinary guideline for treatment of acute hematogenous osteomyelitis (AHO) and septic arthritis (SA) in response to updates in evidence-based literature in the field and existing provider variability in treatment. This guideline aims to improve the care of these patients by standardizing diagnosis and treatment and incorporating up to date evidence-based research into practice. The primary objective of this study is to compare cases before versus after the implementation of the guideline to determine concrete effects the guideline has had in the care of patients with AHO and SA. This is an Institutional Review Board-approved retrospective study of pediatric patients age 6 months to 18 years hospitalized between January 2009 and July 2016 with a diagnosis of AHO or SA qualifying for the guideline. Cohorts were categorized: preguideline and postguideline. Exclusion criteria consisted of: symptoms >14 days, multifocal involvement, hemodynamic instability, sepsis, or history of immune deficiency or chronic systemic disease. Cohorts were compared for outcomes that described clinical course. Data were included for 117 cases that qualified for the guideline: 54 preguideline and 63 postguideline. Following the successful implementation of the guideline, we found significant decrease in the length of intravenous antibiotic treatment (P<0.001), decrease in peripherally inserted central catheter use (P<0.001), and an increase in bacterial identification (P=0.040). Bacterial identification allowed for targeted antibiotic therapy. There was no change in length of hospital stay or readmission rate after the implementation of the guideline. Utilizing an evidence-based treatment guideline for pediatric acute hematogenous bone and joint infections can lead to improved bacterial diagnosis and decreased burden of treatment through early oral antibiotic use. Level III- retrospective comparative study.

Radiographic Study of Haematogenous Septic Arthritis in Dairy Calves.

(1) To develop an evaluation grid to provide a systematic interpretation of calves' articular radiographs, (2) to describe radiographic lesions of septic arthritis in dairy calves less than 6 months of age, (3) to investigate potential associations between demographic data or synovial bacteriological culture results and radiographic lesions (4) to determine whether an association is present between radiographic lesions, their severity and the long-term outcome. Medical records of 54 calves less than 180 days old treated for septic arthritis between 2009 and 2014 with radiographic images performed in the first 2 days after admission were reviewed. Most common radiographic findings were increased articular joint space height (n = 49), irregularity of the articular surfaces (n = 24) and subchondral bone lysis (n = 24). The number of lesions observed and their severity were associated with older calves (p = 0.02), increased time between onset of clinical signs and admission (p = 0.0001) and the culture of Trueperella pyogenes within the joint (p = 0.02). The radiographic lesions associated with negative long-term prognosis were reduction in the joint space height (p = 0.01) and subchondral bone lysis on weight-bearing surfaces (p = 0.02). An evaluation grid designed for veterinarians can facilitate systematic reading of articular radiographs and can be used for dairy calves with a presumptive diagnosis of septic arthritis. This diagnostic tool may aid in establishing a prognosis and decision-making process in terms of treatment.

Ultrasound-guided synovial biopsy improves diagnosis of septic arthritis in acute arthritis without enough analyzable synovial fluid: a retrospective analysis of 176 arthritis from a French rheumatology department.

To assess the diagnostic value of ultrasound-guided (US-guided) synovial biopsy in routine clinical practice in cases of acute and chronic arthritis. A retrospective, single-center study of US-guided synovial biopsies between 2003 and 2013. The clinical, laboratory, radiographic, synovial fluid, and histological and bacteriological results of synovial biopsies were analyzed. Arthritis was classified according to disease duration < 6weeks (AA) or ≥ 6weeks (CA). Synovial biopsy success rate was defined by the rate of capsular and/or synovial tissue analyzed. The diagnostic efficiency was defined by synovial biopsy success rate multiplied by the clinical utility (validation of a diagnostic hypothesis leading to a specific therapy). One hundred seventy-six US-guided synovial biopsies (51 AA and 125 CA) were analyzed. Synovial biopsy success rate was 82.4%. The diagnostic efficiency was 19.9%. Among the acute arthritis cases, 11 were septic. Only three patients had a positive biopsy culture while the synovial fluid puncture was of insufficient quantity to allow bacteriological analysis. The perivascular infiltration of neutrophils (PMN) had a sensitivity of 81.8%, a specificity of 84.2%, and a positive likelihood ratio of 5.2 for the septic arthritis diagnosis. Among the chronic arthritis cases, no case of pyogenic septic arthritis was found. No histological lesions, examined separately, were specific to a type of chronic inflammatory joint disease. US-guided synovial biopsies remain relevant for the diagnosis of septic arthritis, in cases of acute arthritis when joint aspiration is not possible.

Clinical Features and Outcomes of Children with Culture-Negative Septic Arthritis.

Septic arthritis is a serious infection, but the results of blood and joint fluid cultures are often negative in children. We describe here the clinical features and management of culture-negative septic arthritis in children at our hospital and their outcomes. We performed a retrospective review of a cohort of children with septic arthritis who were hospitalized at Children's Hospital of Philadelphia between January 2002 and December 2014. Culture-negative septic arthritis was defined as a joint white blood cell count of >50000/μL with associated symptoms, a clinical diagnosis of septic arthritis, and a negative culture result. Children with pretreatment, an intensive case unit admission, Lyme arthritis, immunodeficiency, or surgical hardware were excluded. Treatment failure included a change in antibiotics, surgery, and/or reevaluation because of a lack of improvement/worsening. We identified 157 children with septic arthritis. The patients with concurrent osteomyelitis (n = 28) had higher inflammatory marker levels at presentation, had a longer duration of symptoms (median, 4.5 vs 3 days, respectively; P < .001), and more often had bacteremia (46.4% vs 6.2%, respectively; P < .001). Among children with septic arthritis without associated osteomyelitis, 69% (89 of 129) had negative culture results. These children had lower C-reactive protein levels (median, 4.0 vs 7.3 mg/dL, respectively; P = .001) and erythrocyte sedimentation rates (median, 39 vs 51 mm/hour, respectively; P = .01) at admission and less often had foot/ankle involvement (P = .02). Among the children with culture-negative septic arthritis, the inpatient treatment failure rate was 9.1%, and treatment failure was more common in boys than in girls (17.1% vs 3.8%, respectively; P = .03). We found no association between treatment failure and empiric antibiotics or patient age. No outpatient treatment failures occurred during the 6-month follow-up period, although 17% of the children discharged with a peripherally inserted central catheter line experienced complications, including 3 with bacteremia. The majority of septic arthritis infections at our institution were culture negative. Among patients with culture-negative infection, empiric antibiotics failed for 9% and necessitated a change in therapy. More sensitive diagnostic testing should be implemented to elucidate the causes of culture-negative septic arthritis in children.

Early diagnosis of septic arthritis in immunocompromised patients.

Septic arthritis results in rapid joint destruction if not properly diagnosed and treated. A work up for septic arthritis includes a peripheral white blood cell count, inflammatory markers, and a joint aspiration. In the general population, the interpretation of these labs has been well-defined by prior studies. To this point, no study has determined how immunosuppressive states affect this work up. Patients with immunosuppressive conditions who received a joint aspiration for a painful joint were retrospectively identified. Laboratory results from their work up were gathered and analyzed. 216 patients were included in the study, 21 of whom were diagnosed with septic arthritis. The average aspiration WBC count was 74,190 with 88% PMNs. 81% had a positive gram stain. Laboratory values for immunosuppressed patients with septic arthritis were similar to those associated with septic arthritis in historical general population controls.

Validating an Algorithm to Predict Adjacent Musculoskeletal Infections in Pediatric Patients With Septic Arthritis.

Septic arthritis is frequently associated with adjacent infections including osteomyelitis and subperiosteal and intramuscular abscesses. While often clinically indiscernible from isolated septic arthritis, the diagnosis of adjacent infections is important in determining the need for additional surgical intervention. MRI has been used as the diagnostic gold standard for assessing adjacent infection. Routine MRI, however, can be resource-intensive and delay surgical treatment. In this context, there is need for additional diagnostic tools to assist clinicians in determining when to obtain preoperative MRI in children with septic arthritis. In a previous investigation by Rosenfeld et al., an algorithm, based on presenting laboratory values and symptoms, was derived to predict adjacent infections in septic arthritis. The clinical applicability of the algorithm was limited, however, in that it was built from and applied on the same population. The current study was done to address this criticism by evaluating the predictive power of the algorithm on a new patient population. (1) Can a previously created algorithm used for predicting adjacent infection in septic arthritis among pediatric patients be validated in a separate population? Records for all pediatric patients (1-18 years old) surgically treated for suspected septic arthritis during a 3-year period were retrospectively reviewed (109 patients). Of these patients, only those with a diagnosis of septic arthritis confirmed by synovial fluid analysis were included in the study population. Patients without confirmation of septic arthritis via synovial fluid analysis, Gram stain, or culture were excluded (34 patients). Patients with absence of MRI, younger than 1 year, insufficient laboratory tests, or confounding concurrent illnesses also were excluded (18 patients), resulting in a total of 57 patients in the study population. Five variables which previously were shown to be associated with risk of adjacent infection were collected: patient age (older than 4 years), duration of symptoms (> 3 days), C-reactive protein (> 8.9 mg/L), platelet count (< 310 x 10 cells/µL), and absolute neutrophil count (> 7.2 x 10 cells/µL). Adjacent infections were determined exclusively by preoperative MRI, with all patients in this study undergoing preoperative MRI. MR images were read by pediatric musculoskeletal radiologists and reviewed by the senior author. According to the algorithm we considered the presence of three or more threshold-level variables as a "positive" result, meaning the patient was predicted to have an adjacent infection. Comparing against the gold standard of MRI, the algorithm's accuracy was evaluated in terms of sensitivity, specificity, positive predictive value, and negative predictive value. In the new population, the sensitivity and specificity of the algorithm were 86% (95% CI, 0.70-0.95) and 85% (95% CI, 0.64-0.97), respectively. The positive predictive value was determined to be 91% (95% CI, 0.78-0.97), with a negative predictive value of 77% (95% CI, 0.61-0.89). All patients meeting four or more algorithm criteria were found to have septic arthritis with adjacent infection on MRI. Critical to the clinical applicability of the above-mentioned algorithm was its validation on a separate population different from the one from which it was built. In this study, the algorithm showed reproducible predictive power when tested on a new population. This model potentially can serve as a useful tool to guide patient risk stratification when determining the likelihood of adjacent infection and need of MRI. This better-informed clinical judgement regarding the need for MRI may yield improvements in patient outcomes, resource allocation, and cost. Level II, diagnostic study.

Distinguishing Contamination from Infection in Suspected Septic Arthritis

For a diagnosis of septic arthritis (SA), isolation of bacteria from synovial fluid (SF) is the gold standard. However, if an SF culture gets

Pathogen or contaminant? Distinguishing true infection from synovial fluid culture contamination in patients with suspected septic arthritis.

Isolation of bacteria from synovial fluid (SF) is the gold standard for diagnosis of septic arthritis (SA). Contamination results in misdiagnosis and mismanagement. This study identifies clinical characteristics, microbiology, and outcomes of patients with contaminated SF and compares them with patients with true SA. We conducted a retrospective study including all patients aged 18 and older admitted to a single, tertiary-care hospital between 1998 and 2015 with suspected SA and positive SF cultures. Contamination cases were determined by infectious disease specialists involved in the patients' care and a clinical course inconsistent with SA. 398 patients with true SA and 22 with contaminated SF were identified. The SA group was younger (60.9 vs. 75.6years; p<0.01), had higher peripheral polymorphonuclear lymphocytes (78.0 vs. 69.4%; p<0.01) and SF white blood cell count (91.7 vs. 25.6K/mL; p=0.02), and longer mean length of stay (10.9 vs. 6.7days; p=0.02). The average time to positive culture was longer in the contaminated group (3.62 vs. 1.4days; p<0.01). The SA group was less likely to receive a new rheumatologic diagnosis within 1year (3.0 vs. 36.4%; p<0.01). This is the first study of its kind looking at clinical features and outcomes of patients with contaminated SF. These patients present with less severe disease, have better outcomes, and receive new rheumatologic diagnoses in more than a third of cases within 1year. We recommend a conservative approach for patients with suspected contaminated SF, mild symptoms, and no bacterial growth within the first 48h.

Acute osteomyelitis and septic arthritis in children : Areferral hospital-based study in Iran.

Information concerning the epidemiology of acute osteomyelitis (OM), septic arthritis (SA) and concurrent OM and SA in children is limited. The aim of this study was to describe the epidemiology of OM, SA and concurrent OM and SA in children. During the 4years of the study, 63,999 patients were admitted to the Children's Hospital, Tehran, Iran. We identified 111 patients with OM and/or SA during the 4‑year period. There were 72cases of OM (11cases per 10,000 children) and 90cases of SA (11cases per 10,000 children). Concurrent OM and SA accounted for 0.17% of all cases (n= 51). The erythrocyte sedimentation rate and C‑reactive protein were elevated in the majority of both infections. Staphylococcus aureus was the most frequent pathogen responsible for both OM and SA in any age group. The lower limb was the most frequently affected (femur: 33/72, 46%; tibia or fibula: 22/72, 31%; foot: 5/72, 7%). The most frequent involved joints were hips (n= 31, 34%) and knees (n= 31, 34%). The present study showed high frequency of patients with concurrent SA and OM. Therefore, prompt recognition and proper diagnosis of pediatric OM and SA is highly recommended.

Septic arthritis associated with systemic sepsis.

Septic arthritis presents with good joint function, but sometimes leads to poor outcomes. Concurrent systemic sepsis has been regarded as the poor outcome, and the exact cause remains unclear. This paper was performed to identify factors associated with concurrent systemic sepsis and to research results to predict poor outcomes in patients with septic arthritis. Laboratory and medical data were reviewed for 137 adults with acute septic arthritis who underwent open or arthroscopic surgical debridement at our institution between January 2005 and December 2014. The patients were divided according to whether they had septic arthritis alone (Group A) or in combination with systemic sepsis (Group B). Systemic sepsis was defined as two more systemic inflammatory signs in response to an infectious process. Patient characteristics, laboratory findings, synovial fluid findings and cultures, and surgical results were compared between two groups. Of the 137 patients, 41 (29.9%) had initial systemic sepsis at the diagnosis of septic arthritis. Independent t test revealed that duration of prodromal symptom (p=0.012), serum neutrophil percent (p=0.008), C-reactive protein (p=0.001), Charlson comorbidity index (p=0.001), positive culture in synovial fluid (p=0.001), and methicillin-sensitive Staphylococcus aureus (MSSA) isolate in synovial fluid (p=0.001) had significant correlations with the group B. Repeated debridement was performed for those who had recurrence of infection, and this procedure was more often in group B (23 versus 21 joints, 23.9 versus 51.2%, p=0.012). Progression of arthritis occurred more often in group B (16 versus 17 joints, 16.7 versus 41.5%, p=0.001). Septic arthritis combined with systemic sepsis was related to duration of prodromal symptom, serum neutrophil percent, C-reactive protein, Charlson comorbidity index, positive culture in synovial fluid, and a MSSA isolate in synovial fluid. Concurrent systemic sepsis led to poor outcomes in patients with septic arthritis in terms of recurrence of infection and progression of arthritis. III Case control study.

Serum procalcitonin levels as a diagnostic marker for septic arthritis: A meta-analysis

BackgroundThe aim of this study was to assess the value of serum procalcitonin (PCT) levels as a diagnostic marker for septic arthritis (SA) via meta-analysis. MethodsWe searched PubMed, Embase and the Cochrane Library, as well as the reference lists of relevant articles, for studies published up to May 21, 2015 and did not impose language restrictions. We selected original studies reporting the usefulness of PCT or C-reactive protein (CRP) as a diagnostic marker for SA. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic curves, and bivariate random effects models. Prespecified subgroup analyses and meta-regression analyses were also performed. ResultsThis meta-analysis comprised 10 studies including 838 patients. The overall sensitivity of serum PCT levels for the diagnosis of SA in these studies was 0.54 (95% CI, 0.41–0.66), and the specificity of PCT was 0.95 (95% CI, 0.87–0.98). The positive likelihood ratio (LR) was 10.97 (95% CI, 4.65–25.89); the negative LR was 0.49 (95% CI, 0.38–0.62); and the area under ROC curve (AUROC) was 0.82 (95% CI, 0.78–0.85). Six studies also examined the usefulness of CRP levels as a marker for the diagnosis of SA. The sensitivity and specificity of CRP were 0.45 (95% CI, 0.35–0.55) and 0.079 (95% CI, 0.0.021–0.25), respectively, and the positive LR, negative LR and AUROC curve were 0.48 (95% CI, 0.39–0.61), 6.79 (95% CI, 2.04–23.81), and 0.30 (95% CI, 0.26–0.34), respectively. ConclusionPCT is more valuable than CRP for distinguishing SA from non-SA.

Dorsal costo-vertebral joint as a rare localization of Staphylococcus aureus sepsis

BackgroundSeptic arthritis of the costovertebral thoracic joint is a rare site infection. We report an isolated case of septicarthritis of the 10th costo-vertebral right joint withosteitis due to Staphylococcus aureus. Case presentationA 59year old Tunisian man presented with a 2months history of dorsal spinal pain with fever, associated with asthenia, anorexia and loss of weight. There was a raised C-reactive protein (176mg/L) and erythrocyte sedimentation rate (100mm/1sth). Tests for tuberculosis and brucellosis were negative. In the present patient, the clinical symptoms were unspecific with lack of obvious predisposing factors. He had neither history of taking immunosuppressors nor of any disease indicative of immunodeficiency. Thoraco-abdominal computed tomography (CT) showed a lytic lesion centered on the 10th costo-vertebral right joint and histo-pathologic exam of the costo-vertebral puncture confirmed chronic active osteitis and bacteriologic culture allowed identifying methicillin-sensitive Staphylococcus aureus. The patient was treated with ciprofloxacin 1500mg/day, associated with daily rifampin (20mg/kg) for total treatment duration of 12weeks after consulting infectious disease specialists. After a follow-up of 6months, the patient remained asymptomatic and the markers of inflammation negative. ConclusionSeptic arthritis of costovertebral joints should be considered when a patient presents with back pain, fever and elevated inflammatory markers. The diagnosis of septic arthritis of costovertebral joints remain a challenge to clinicians. CT is important to confirm a diagnosis and guide costovertebral biopsy and culture. Early and appropriate antibiotic therapy is important for a required outcome.