[Septic arthritis in rheumatoid polyarthritis. 24 cases and review of the literature]. / Les arthrites septiques au cours de la polyarthrite rhumatoïde. Vingt quatre observations et revue de la littérature.

Twenty-four cases of septic arthritis in rheumatoid arthritis patients were compared with 99 cases of septic arthritis in patients without rheumatoid arthritis. In addition, 238 previously published cases of septic arthritis with rheumatoid arthritis were analyzed. Fifteen percent of our patients with septic arthritis had rheumatoid arthritis, which was typically of long duration (mean 15 years), erosive, and seropositive. Fifty-four per cent (28% in the literature) and 9% of patients with and without rheumatoid arthritis, respectively, had pyarthrosis of multiple joints. The knee represented one-third of infected joints and the elbows and wrists were more often infected in patients with than without rheumatoid arthritis. S. aureus was recovered in 80% versus only 60% of patients with and without rheumatoid arthritis, respectively. The source of sepsis was often a skin lesion, in particular at the foot, emphasizing the need for early orthopedic treatment of deformities responsible for skin lesions. Monoarticular infection was more likely to be due to an intraarticular injection. Mortality rate was 17% in patients with rheumatoid arthritis (23% in the literature) versus 7% in patients without rheumatoid arthritis. Staphylococcal infection and infection of multiple joints were associated with higher mortality rates (35% and 49%, respectively). The mortality rate in polyarticular infections has failed to decline over the last 35 years. Initial failure to distinguish septic arthritis from an exacerbation of rheumatoid arthritis contributes to the high mortality rate. The diagnosis of septic arthritis rests on a high index of suspicion. Septic arthritis cannot be ruled out based on absence of local inflammation, fever, or hyperleukocytosis or on presence of inflammation of multiple joints. Joint fluid specimens should routinely be sent to the microbiological laboratory and should be inoculated in blood culture bottles at the least suspicion.

Polyarticular septic arthritis.

Twenty-five cases of polyarticular septic arthritis (PASA) were observed in our department over a 13-year period. They accounted for 16.6% of all septic arthritis (15% on average in the literature). A male predominance was noted in our patients, as well as in the literature. The knee was the most frequent location followed by the elbow, shoulder, and hip, in varying order depending on the series. An average of 4 joints was involved. The causative microorganism was Staphylococcus aureus in 20/25 of our patients and in about 50% of published cases. Other frequently causative organisms were streptococci and gram-negative bacteria. Blood cultures and joint aspirations were positive in 19/22 and 23/25 of our cases, respectively. Other septic lesions were noted in 10/25 of our cases. Fever and severe leukocytosis were absent at admission in 5/25 (literature, 37%) and 10/25 of our 25 patients, respectively. The underlying disease was rheumatoid arthritis in 13/25, while 9 of the other patients had immunodepression caused by drugs or by concurrent illness. Typically, rheumatoid arthritis was long-standing and erosive, patients having ulcerated calluses on the feet. This skin source was also noted in 23/36 published cases of PASA in rheumatoid arthritis. Systemic lupus erythematosus was an uncommon disease in PASA, but its presence promoted gram-negative infection. Despite effective therapy with 2 antibiotics, 8/25 patients died, a prognosis that is equally severe in cases reported in the literature (30%) and one that has remained surprisingly stable over the last 40 years. For comparison, the death rate was only 4% in our patients with MASA. Factors contributing to a poor prognosis were age greater than 50 years, rheumatoid arthritis as an underlying disease, and disease of staphylococcal origin. Septic polyarthritis should be considered even when the clinical picture is not florid--when patients have low fever and normal white blood cell counts. Nor should the simultaneous involvement of distant joints rule out infection. Indeed, the frequency of underlying rheumatic disease and its treatment may further confuse the clinical presentation. Joints suspected of harboring infection should be aspirated, including those previously affected by the concurrent rheumatism.

[Value of puncture-arthrography in the diagnosis of infection of total hip arthroplasty]. / Intérêt de la ponction-arthrographie de hanche dans le diagnostic d'infection sur prothèse totale.

Arthrography with hip aspiration was performed in 143 patients with hip arthroplasties to determine its effectiveness as a technique for diagnosing infection. Thirty-three cases of infection were found. On 26 occasions the germ responsible was isolated in the joint fluid. In six other cases infection was revealed from cytologic or arthrographic findings, or from both. Only once was a diagnosis of infection not arrived at. In this series of patients, except in cases of evolutive inflammatory rheumatism, cytologic examination of the joint fluid was a discriminative factor in diagnosis. Hip aspiration arthrography had a sensitivity of 79 per cent for the diagnosis of infection in arthroplasty with isolation of the germ and a specificity of 100 per cent. The sensitivity of the diagnosis rose to 91% when any one of the following features was observed: leucocytosis of the joint fluid higher than 10,000 elements/mm3; presence of a fistula or of fistulization on arthrography; isolation of the germ in the joint fluid or the rinsing liquid.

[Our experience with ofloxacin in the treatment of osteoarticular infections]. / Notre expérience de l'ofloxacine dans le traitement des infections ostéo-articulaires.

Twenty patients with osteoarticular infections, fourteen post-arthroplasty and six with osteitis, were treated with ofloxacin, usually in combination. Sixteen staphylococcus strains including eight aureus and eight coagulase negative (modal MIC and MBC: 0.5 micrograms/ml), three Escherichia coli (modal MIC and MBC: 0.06 micrograms/ml) and one Peptococcus (MIC: 0.25, MBC: 0.5) were isolated. Treatment was given at a mean dose of 9.81 +/- 2.46 mg/kg for a mean duration of 100 days. The serum concentration of ofloxacin was measured at 3.73 +/- 2.13 micrograms/ml for a dosage of 8.23 +/- 0.94 mg/kg (25 assays) and 7.42 +/- 4 micrograms/ml for 11.46 +/- 1.3 mg/kg (23 assays). Bacteriological control was carried out nineteen times; in one case of staphylococcal osteitis, a relapse occurred on the 43rd day of treatment when the strain isolated was resistant to ofloxacin. Three patients presented adverse effects: two cases of bone and muscle pain and one cutaneous allergic reaction: treatment was withdrawn after two restarts. The antibacterial action, the good tolerance and the easy administration of ofloxacin make it a useful antibiotic in the treatment of osteoarticular infections, where a dosage of 8 mg/kg appears to be necessary, particularly in infections due to staphylococci.

[Diffusion of ceftriaxone in human bone tissue]. / Diffusion de la ceftriaxone dans le tissu osseux humain.

Ceftriaxone diffusion into spongious and cortical bone after single 2 g dose by intravenous injection was studied in 40 patients undergoing total hip replacement. Serum and tissue assays were performed by HPLC and microbiological method 2, 4, 12 and 24 hours after administration. Both methods produced similar results. Antibiotic levels (HPLC) were 19.3 +/- 7.3; 16.9 +/- 9.2; 11.2 +/- 4.7 and 5.6 +/- 2.7 micrograms/g in spongious bone at hours 2, 4, 12 and 24, and 6.5 +/- 1.6; 3.1 +/- 0.7; 3.3 +/- 1.1 and 2.2 +/- 0.4 micrograms/g in cortical bone at the same times. The tissue/serum ratios were 14% for spongious bone and 5% for cortical bone after 2 hours. At hour 24 these ratios were 21% and 8% in spongious and cortical bone respectively. These tissue levels remain higher than ceftriaxone MIC for most Enterobacteriaceae strains until hour 24.

Rifampicin in the treatment of osteoarticular infections due to staphylococci.

Rifampicin is a suitable drug for treating staphylococcal bone and articular infections, because high levels are obtained in the human tissues. The best oral dose is 600 mg 12 hourly. The serum levels range from 10 to 15 mg/l at the peak concentration and from 0.2 to 0.6 mg/l 8 h after oral administration of 600 mg. The ratio for cancellous bone/serum is 0.41 at 3 h and 0.39 at 12 h, and for cortical bone/serum is 0.20 at 3 h after a dose of 600 mg. In every case, tissue levels paralleled serum levels; cancellous bone levels are greater than the MIC of Staphylococcus aureus strains until 12 h after a dose of 600 mg. Rifampicin is always used in combination with another antibacterial substance. Results are excellent in most cases. The average duration of antibiotic treatment is 3 months for osteo-arthritis, 6 months for spondylitis and osteitis.

[Dibekacin in the treatment of urinary infections in the elderly]. / La dibékacine dans le traitement de l'infection urinaire du sujet âgé.

Urinary tract infections in the elderly are severe and intractable, often justifying the use of aminoglycosides. We studied the effects of dibekacin in 28 patients, with no vesical catheter, whose average age was 78 +/- 6.1 years. The drug was given for ten days, in an average dose of 2.1 mg/kg/day divided into two injections. Serum concentration was measured after one hour on day 1 and after eight hours on days 1 and 10. Causative pathogens, all susceptible to dibekacin, were: 18 E. coli, 3 Proteus mirabilis, 3 Klebsiella, 1 Enterobacter cloacae, 1 Citrobacter and 2 Staphylococci. MIC and MBC of dibekacin were determined for each microorganism. Dibekacin was discontinued in four cases on day three because of persistent bacteriuria. Ten days after treatment end, 19 patients were cured, 4 had a relapse and 1 was reinfected. Average serum concentration of dibekacin, measured after eight hours, increased from 0.77 +/- 0.48 micrograms/ml on day 1 to 1.78 +/- 1.22 microgram/ml on day 10 (t = 4.42; p less than 0.0005), while, over the same period, there was no significant change in serum creatinine.

[Diffusion of fosfomycin into bone tissue in man]. / Diffusion de la fosfomycine dans le tissu osseux chez l'homme.

Fosfomycine diffusion into spongious and cortical bone was studied in 20 patients undergoing total replacement of the hip after an intravenous infusion of 4 g (1 g/h). The serum and bone samples were collected 1 h and 3 h after administration of the drug. Concentrations at 1 h were 105.0 +/- 12.4 micrograms/ml, 19.6 +/- 4.8 micrograms/g and 13.3 +/- 3.7 micrograms/g in serum, spongious bone and cortical bone respectively; at 3 h these concentrations had become respectively 67.8 +/- 15.9 micrograms/ml, 10.0 +/- 4.2 micrograms/g and 8.2 +/- 3.6 micrograms/g. Antibiotic levels in bone tissue decreased in direct ratio to corresponding serum values, the mean tissue/serum ratio remaining at 15 +/- 4%.

[Diffusion of rifampicin into spongy and compact bone tissue during total hip prosthesis operation]. / Etude de la diffusion de la rifampicine dans le tissu osseux spongieux et compact au cours de prothèses totales de hanche.

Sixty eight patients received either an oral single dose of 300 mg (or 300 mg/12 h), or an oral single dose of 600 mg (or 600 mg/24 h) of rifampicin. In every case samples of serum and bone were collected 3 h, 12 h, and 24 h after the last oral dose. Rifampicin levels measured at 3 h and 12 h in cortical bone samples increased significantly with the dose of the drug. The only dose which determines activity in cortical bone at the 3rd hour was the dose of 600 mg. When the dose was increased from 300 mg/12 h to 600 mg/24 h the ratio spongious bone/serum increased from 0.19 to 0.41 at 3d h and from 0.24 to 0.29 at the 12th hour; the ratio cortical bone serum was 0.20 at the 3rd hour after a dose of 600 mg. In any case tissue levels varied in a parallel direction to serum levels and were superior in spongious bone to the MIC of S. aureus sensitive strains until 12 h after the 600 mg dose. According to these results, it appears that the best dose for treating S. aureus bone infection seems to be 600 mg/12 h.

[Rifampicin in the treatment of Staphylococcus arthritis]. / La rifampicine dans le traitement des arthrites à Staphylocoques.

Rifampicin is used for treating 20 Staphylococcus septic arthritis, in combination with another antibiotic. The former is chosen for its striking bone diffusion. The average duration of the whole antibiotic treatment is 3 months. Rifampicin is usually prescribed, in daily doses of 1 200 mg for 60 days, after one month of parenteral antibiotherapy. The bactericidal activity is controlled regularly by measuring serum inhibitory titre. For 2 patients, the administration of rifampicin is suspended after 12 and 25 days respectively, due to digestive disorders. Results are evaluated at the end of a period averaging 18 months. Articular infection has been cured in all patients. Taking these results into account, we are able to emphasize that the inclusion of rifampicin in the antibiotic scheme is of great value in treating bone and articular infections.

[Association of streptococcal spondylitis and endocarditis. 2 new cases]. / Association de spondylodiscite à streptocoque et d'endocardite. Deux nouvelles observations.

Two new cases of spondylitis associated with endocarditis are reported. Approximately 30 cases have already been published in the medical literature. Although this association is infrequent, the possibility of its occurrence calls for repeated auscultation in patients with spondylitis and focal roentgenograms in patient with bacterial endocarditis who develop vertebral pain.

[Penetration of cloxacillin into human bone tissue after oral administration (author's transl)]. / Diffusion de la cloxacilline dans le tissu osseux humain après administration par voie orale.

Cloxacillin diffusion into spongious and cortical bone was studied in 20 patients undergoing total replacement of the hip, after an oral single-dose of 1 g (10 patients) or an oral dose of 1 g every 8 hours (10 patients). Serum and bone samples were collected 2 and 3 hours after the last dose and assayed for antibiotic concentration by a microbiological method. Bone levels were similar in any group of patients, but significantly higher in spongious bone than in cortical bone. The bone/serum concentration ratios were 0.15 for spongious bone and 0.10 for cortical bone. Calculations from these data showed that adequate local levels inhibitory to Staphylococcus aureus, would be achieved by cloxacillin administration of 1 g dose every 4 hours orally.

[Sciatica caused by disk herniation in children. Apropos of 4 cases]. / Sciatiques par hernie discale de l'enfant. A propos de 4 observations.

The authors report 4 cases of sciatica from disk herniation occurring in children under 16. It happens rarely in this age range, as is shown in the review of the literature performed for this article. The symptomatology is similar to that in adults. The physical signs are much more prominent than the functional signs. An original traumatism, sometimes severe, is often encountered. The standard X-ray examination is of little use in diagnosis, while contrast studies (opaque myelography, phlebography) clearly show the lesions of compression. Surgical treatment is frequent but not compulsory, following the same rules than in the adults. The post-operative results are usually excellent.

[Osteoarticular infections due to Gram-negative bacilli]. / Les infections ostéo-articulaires à bacilles Gram négatif.

An enquiry carried out on 20 French rheumatology units led us to find, out of a total of 1,202 cases of non-tuberculous osteo-arthritis of the adult, 137 gram negative bacillary infections. These were 64 cases of spondylodiscitis and 73 cases of septic arthritis, due mainly to Escherichia Coli, Pseudomonas and other enterobacteria. The frequency of gram-negative bacilli was 11.4% i.e. 9.2% in the case of arthritis and 15.6% in the case of spondylodiscitis. It is higher than in the middle of this century but does not seem to be progressing now. However, the seventy of this type of infection, which may cause important functional sequelae and numerous deaths (8 patients) justifies the routine search for these bacilli in appropriate culture media, in order to test their sensitivity to antibiotics.

[The use of antibiotic treatment in osteoarticular infections]. / L'utilisation du traitment antibiotique dans les infections ostéo-articulaires.

The authors emphasise the interest of identification of the germ during bone and joint infections, and recall the main data, often fragmentary, one the diffusion of antibiotics into bone. Concerning the practical use of antibiotics, they emphasise the necessity of basing their treatment on bacteriological examinations before choosing an association of two antibiotics, the effect of which will be regularly assessed by a study of the bactericidal power of the serum.

[Non-tuberculous infectious coxitis in adults]. / Les coxites infectieuses non tuberculeuses de l'adulte.

A multicentric study permitted us to report 94 cases of non-tuberculous infections of the hip joint in the adult (13.4% of the cases of septic arthritis observed over the same period). A local predisposing factor (37.2%) and/or general predisposing factors (22.6%) were frequently noted. The routine search for bacteria permits identification of the latter in 71.3% of cases; the germ was usually a staphylococcus, arthritis due to Gram negative bacilli were found in 12% of the cases. The authors emphasize the interest of daily joint aspiration and traction on the lower limb associated with bactericidal antibiotic therapy which are the only means able, in their view, to improve the poor functional prognosis in these cases of hip joint infections.