Septic arthritis is an infection producing inflammation in a native or prosthetic joint or more than one joint. It can be acute or chronic. Prompt diagnosis and treatment of infectious arthritis can help prevent significant morbidity and mortality.
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- Staphylococcus aureus is the most frequent pathogen responsible for septic arthritis in any age group, mainly meticillin-sensitive strains.
- The incidence of disseminated gonococcal arthritis is 2.8 cases per 100,000 person-years. The disease is becoming increasingly common among the elderly with multiple morbidities and in the immunosuppressed.
- The incidence of prosthetic joint infection among all recipients ranges from 1.5-2.5% for primary interventions and up to 20% for revision procedures.
Risk factors for septic arthritis include:
- Increasing age.
- Diabetes mellitus.
- Prior joint damage - eg, rheumatoid arthritis, gout, systemic connective tissue disorders.
- Joint surgery.
- Hip or knee prosthesis.
- Skin infection in combination with joint prosthesis.
- Immunodeficiency - eg, infection with HIV
- The classic picture is a single swollen joint with pain on active or passive movement.
- Septic arthritis may present as polyarticular arthritis in a minority of patients.
- Fevers and rigors are present in the majority of cases but their absence does not exclude the diagnosis. Bacteraemia is a common finding and, when present, may cause prostration, vomiting or hypotension.
- Patients with septic arthritis of the sternoclavicular, acromioclavicular, sternocostal or manubrosternal joints may present with chest wall pain.
- Infection of the sacroiliac joint may present as buttock, hip or anterior thigh pain.
- Apart from pre-existing joint disease, associated conditions include immunosuppressive disease, recent steroid injection, sexually transmitted disease and intravenous drug use.
Septic arthritis is easily missed in children, as localising signs may be absent, and may be confused with more common conditions - eg, transient synovitis and trauma. It can occur at any age but most commonly in preschool infants and toddlers. The hip and knee represent a third of cases each, with other joints making up the remainder. Patients usually present with fever, joint pain and/or unwillingness to move the affected joint (eg, a limp or refusal to weight bear if the hip joint is affected).
The joint is usually swollen, warm, tender and exquisitely painful on movement. An effusion may be obvious. The knee is the most common joint involved (about half of cases), followed by the hip, shoulder, ankle and wrists.
Signs may be less marked or poorly localised in the elderly, in the immunocompromised, in drug abusers and in infections of the spine, hip and shoulder joints.
Infection of a prosthetic joint may show few signs until a drainage sinus develops. Occasionally, an abscess around the joint, or loosening of the implant, is indicated by pain.
- Primary rheumatological disorders (eg, rheumatoid arthritis, osteoarthritis), vasculitis, gout and pseudogout.
- Drug-induced arthritis.
- Reactive arthritis, post-infectious diarrhoeal syndrome, post-meningococcal and post-gonococcal arthritis, arthritis associated with intrinsic bowel disease.
- Lyme disease.
- Viral arthritis.
- Infective endocarditis.
Septic arthritis should always be the 1 last update 2020/07/02 considered in patients presenting with one or a few acutely inflamed joints. The most important differential diagnosis is the crystal arthropathies. Gout and pseudogout can also present with pain, inflammation and, occasionally, spiky fevers and chills.Septic arthritis should always be considered in patients presenting with one or a few acutely inflamed joints. The most important differential diagnosis is the crystal arthropathies. Gout and pseudogout can also present with pain, inflammation and, occasionally, spiky fevers and chills.
The triad of fever, pain and impaired range of motion is typical. Fevers are usually low-grade and rigors are only present in a minority of cases.
History and examination may not only yield clues as to the diagnosis of septic arthritis but also to the type of infection that is present. 85-90% of non-gonococcal suppurative arthritis affects one joint. S. aureus is the most common cause of polyarticular arthritis. Other causes include various viral infections, Lyme disease, gonococcal disease, reactive arthritis and various non-infective conditions.
- Infection of the sternoclavicular and sacroiliac joints is commonly caused by Group B streptococcal infection.
- Gonococcal disease usually presents with fever, arthralgia, multiple skin lesions (dermatitis-arthritis syndrome) and tenosynovitis of the hand joints, knees, wrists, ankles and elbows. However, it may also present as a monoarticular arthritis in which these other features are absent.
- Lyme disease (caused by infection with Borrelia burgdorferi) may cause swelling disproportionate to the level of pain. It should be suspected in patients with a history of tick bite or who have travelled to endemic areas and present with transient polyarthralgia, typical erythema chronicum migrans and systemic symptoms. Joint inflammation may present many months after initial infection and occurs in 60% of untreated patients, mainly affecting the large joints - commonly the knee.
- Hip joint infection may cause pain which does not localise directly and swelling which may not be obvious.
- Sacroiliac joint infection often presents as buttock, anterior thigh or hip pain. Direct pressure may elicit tenderness.
- Reactive arthritis (including Reiter''boggy''blood''s age and sexual activity become major determinants as to the likelihood of a gonococcal infection.
- The antibiotic should at least cover S. aureus and Streptococcus spp. A microbiologist should also be consulted, as the choice of therapy should be based on resistance patterns in the local hospitals and community.
- Antibiotics are given intravenously initially (usually for 2-3 weeks) before being switched to oral (often for at least a further 2-4 weeks).
- Recommended antibiotic treatments include:
- Seek specialist advice if prostheses are present.
- Flucloxacillin for 4-6 weeks (longer if infection complicated); if penicillin-allergic then use clindamycin instead.
- If meticillin-resistant S. aureus (MRSA) is suspected, vancomycin (teicoplanin may also be used) for 4-6 weeks (longer if infection complicated)
- If gonococcal arthritis or Gram-negative infection is suspected, cefotaxime (ceftriaxone may also be used). Treat Gram-negative infections for 4-6 weeks (longer if infection complicated). Treat gonococcal infection for two weeks.
MRSA is becoming an increasing problem, as is penicillin resistance in Group B streptococcal infection. Penicillin plus gentamicin, or later-generation cephalosporins, are often used. Treatment is generally administered intravenously for 3-4 weeks, except in the case of gonococcal infection, where a switch to oral antibiotics is often made after two weeks.
There is no benefit in injecting antibiotics intra-articularly. Antibiotics have good penetration across the synovial membrane and intra-articular injection has the potential for causing a chemical synovitis.
causes of arthritis flare ups fingershow to causes of arthritis flare ups fingers for Other medical therapy
If the condition fails to respond to five days of treatment with an appropriate antibiotic (as evidenced by persistent fever, positive cultures or synovial purulence), the therapeutic approach should be reassessed. Synovial fluid should be re-examined for crystals, and Lyme disease serology should be arranged. Consideration should be given to synovial biopsy (to exclude fungal or mycobacterial infection) and to the possibility of reactive arthritis requiring the use of non-steroidal anti-inflammatory drugs.
Chondral damage is one of the major sequelae of septic arthritis, occurring even after prompt treatment of a septic joint. Corticosteroids are known to have beneficial effects on the rate and extent of cartilage destruction in arthritis. Investigation into sepsis at other sites has suggested improved outcomes with corticosteroid use despite the theoretical risks. However, there is currently a lack of reliable data regarding the safety and efficacy of corticosteroids in septic arthritis.
- Repeated percutaneous aspiration may be required if the infection does not respond to antibiotic treatment.
- Joints difficult to access (eg, hip, shoulder and sacroiliac joints) may require ultrasound-guided needle aspiration or open arthrotomy.
- Surgical drainage may be required in any infected joint which does not respond to medical treatment.
The limb should be splinted in the position of function (knees in extension, elbows at 90°, wrists in neutral to slight extension, hips in balanced suspension in neutral rotation). Once the infection is under control, immediate joint mobilisation will promote healing of the articular cartilage and prevent contractures.
The prosthetic joints to get infected most commonly are the elbow, shoulder and ankle joints, followed by hips and knees. Early infection (less than 12 weeks after implantation) is usually caused by skin pathogens such as coagulase-negative Staphylococcus spp. It can often be cured medically, providing there is no evidence of periarticular soft tissue involvement or joint instability.
Late-onset infections (more than one year after implantation) are usually caused by haematogenous spread of common organisms such as Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus epidermis and S. aureus.
Prosthetic joint for 1 last update 2020/07/02 infections are often managed by surgical treatment of irrigation and debridement in acute infections, and 1-stage or 2-stage exchange arthroplasty in chronic infections.Prosthetic joint infections are often managed by surgical treatment of irrigation and debridement in acute infections, and 1-stage or 2-stage exchange arthroplasty in chronic infections.
- Mortality rates of bacterial arthritis range from 10-20%, depending on the presence of comorbid conditions, such as older age, co-existing renal or cardiac disease and concurrent immunosuppression.
- Factors associated with death include age 65 years or older, and infection in the shoulder, elbow, or at multiple sites.
- After completing antimicrobial therapy, patients with S. aureus septic arthritis regain 45-50% of baseline joint function.
- Adults with pneumococcal septic arthritis who survive infection (the mortality rate is approximately 20%) will return to 95% of baseline joint function after completing antimicrobial therapy.
- Morbidity (eg, amputation, arthrodesis, prosthetic surgery, severe functional deterioration) occurs in one third of patients with bacterial arthritis, usually affecting older patients, those with pre-existing joint disease and those with synthetic intra-articular material.
causes of arthritis flare ups fingershow to causes of arthritis flare ups fingers for Further reading and references
causes of arthritis flare ups fingershow to causes of arthritis flare ups fingers for Horowitz DL, Katzap E, Horowitz S, et al; Approach to septic arthritis. Am Fam Physician. 2011 Sep 1584(6):653-60.
Castellazzi L, Mantero M, Esposito S; Update on the Management of Pediatric Acute Osteomyelitis and Septic Arthritis. Int J Mol Sci. 2016 Jun 117(6). pii: E855. doi: 10.3390/ijms17060855.
Mathews CJ, Weston VC, Jones A, et al; Bacterial septic arthritis in adults. Lancet. 2010 Mar 6375(9717):846-55.
Cataldo MA, Petrosillo N, Cipriani M, et al; Prosthetic joint infection: recent developments in diagnosis and management. J Infect. 2010 Dec61(6):443-8. doi: 10.1016/j.jinf.2010.09.033. Epub 2010 Oct 7.
Septic Arthritis; Cleveland Clinic, August 2010
Lenski M, Scherer MA; Diagnostic potential of inflammatory markers in septic arthritis and periprosthetic joint infections: a clinical study with 719 patients. Infect Dis (Lond). 2015 Jun47(6):399-409. doi: 10.3109/00365548.2015.1006674. Epub 2015 Mar 6.
McGillicuddy DC, Shah KH, Friedberg RP, et al; How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis? Am J Emerg Med. 2007 Sep25(7):749-52.
causes of arthritis flare ups fingershow to causes of arthritis flare ups fingers for Lamagni T; Epidemiology and burden of prosthetic joint infections. J Antimicrob Chemother. 2014 Sep69 Suppl 1:i5-10. doi: 10.1093/jac/dku247.
Chen AF, Heller S, Parvizi J; Prosthetic joint infections. Surg Clin North Am. 2014 Dec94(6):1265-81. doi: 10.1016/j.suc.2014.08.009. Epub 2014 Sep the 1 last update 2020/07/02 30.Chen AF, Heller S, Parvizi J; Prosthetic joint infections. Surg Clin North Am. 2014 Dec94(6):1265-81. doi: 10.1016/j.suc.2014.08.009. Epub 2014 Sep 30.
Wall C, Donnan L; Septic arthritis in children. Aust Fam Physician. 2015 Apr44(4):213-5.
British National the 1 last update 2020/07/02 Formulary (BNF); NICE Evidence Services (UK access only)British National Formulary (BNF); NICE Evidence Services (UK access only)
Farrow L; A systematic the 1 last update 2020/07/02 review and meta-analysis regarding the use of corticosteroids in septic arthritis. BMC Musculoskelet Disord. 2015 Sep 516:241. doi: 10.1186/s12891-015-0702-3.Farrow L; A systematic review and meta-analysis regarding the use of corticosteroids in septic arthritis. BMC Musculoskelet Disord. 2015 Sep 516:241. doi: 10.1186/s12891-015-0702-3.
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