Elsevier

The Lancet

Volume 375, Issue 9717, 6–12 March 2010, Pages 846-855
The Lancet

Seminar
Bacterial septic arthritis in adults

https://doi.org/10.1016/S0140-6736(09)61595-6Get rights and content

Summary

Symptoms and signs of septic arthritis are an important medical emergency, with high morbidity and mortality. We review the changing epidemiology of septic arthritis of native joints in adults, encompassing the increasing frequency of the disorder and its evolving antibiotic resistance. We discuss various risk factors for development of septic arthritis and examine host factors (tumour necrosis factor α, interleukins 1 and 10) and bacterial proteins, toxins, and enzymes reported to be important determinants of pathogenesis in mouse models. Diagnosis of disease is largely clinical, guided by investigations and the opinion of skilled clinicians. We emphasise the need for timely medical and surgical intervention—most importantly, through diagnostic aspiration of relevant joints, choice of suitable antibiotic, and appropriate supportive measures. Management is growing in complexity with the advent of novel and antibiotic-resistant causative microorganisms and within the current climate of increased immunosuppression. Findings from animal models and patients are shedding light on disease pathogenesis and the possibility of novel adjunctive treatments, including systemic corticosteroids, cytokines and anticytokines, and bisphosphonates.

Introduction

The presentation of a patient with one or more hot swollen joints is a common medical emergency. Such symptoms have a broad differential diagnosis, and, although not the most typical, the most serious cause is septic arthritis. This disease has substantial morbidity and mortality.

Diagnosis of septic arthritis can be challenging even for doctors skilled in the management of musculoskeletal disease. Usually, patients present in the primary-care or emergency-room setting, and doctors working in these areas could have had little training in rheumatic disease. Delayed or inadequate treatment can lead to irreversible joint destruction and, even in expert hands, case-fatality is generally around 11%. This frequency is raised in polyarticular disease, with estimates as high as 50%.1 Moreover, resistance to conventional antibiotics is a growing difficulty.

Section snippets

Epidemiology

Accurate information about the epidemiology of septic arthritis is limited by several factors. First, data are mainly from retrospective cohorts, because the uncommon nature of the disorder makes prospective studies logistically difficult. Second, case-definitions generally restrict cases to those that are proven bacteriologically. Although this approach has nosological advantages, there are practical limitations. In patients in whom septic arthritis is strongly suspected clinically, the

Pathogenesis

Infection can be introduced into a joint either as a result of haematogenous spread or by direct inoculation, occurring with trauma or iatrogenically. Bacteraemia is more likely to arise in immunosuppressed individuals and patients admitted to hospital, particularly those who have invasive procedures, intravascular devices, or urinary catheters. Infection will most probably become established if the patient is immunosuppressed or the joint is damaged.4

Beyond traditional risk factors for sepsis,

Clinical features

Ideally, septic arthritis is confirmed by detection of bacteria in synovial fluid, but predominantly, diagnosis is clinical, depending on informed integration of history, examination, and results of investigations.2 Most studies are hospital-based and include individuals in whom synovial fluid culture fails to grow bacteria but in whom clinical suspicion is high. This situation often arises when patients present with acute arthritis and evidence of infection elsewhere.5, 33, 34

Individuals with

Prognosis

Mortality for septic arthritis varies in different studies, but seems to be around 11% for monoarticular sepsis.36 In one study, a poor functional outcome was recorded in 24% and osteomyelitis in a further 8%, emphasising the need for both early diagnosis and improvements in current management strategies.5

Management

In view of the 11% mortality rate for septic arthritis, patients should be admitted to hospital for prompt assessment, supportive care, and intravenous antibiotic treatment, along with measures to aspirate pus from the joint. If evidence indicates septic shock or organ failure, patients should be treated in appropriate critical-care facilities.

Future developments

Even when antimicrobial treatment for septic arthritis is timely and appropriate, it is not always sufficient to prevent permanent joint damage and overwhelming sepsis. Therefore, novel therapeutic options are warranted. Development of experimental models of bacterial arthritis has led to important progress in understanding of disease pathogenesis. These animal models have not only shed light on the pathogenic mechanisms underlying disease development but also presented potential targets for

Search strategy and selection criteria

We did a systematic search of work published in English in the following databases: Cochrane Library, Medline (1951 to Aug 31, 2008), Embase (1974 to Aug 31, 2008), and the National Electronic Library for Health. Selection of papers for full-text review depended on adherence to defined inclusion and exclusion criteria (outlined in detail in reference 41, search updated to Aug 31, 2008). In brief, we used search terms including: “infectious arthritis”, “meta-analysis”, “randomised

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