Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP and SECOT / Resumen ejecutivo: Guía de diagnóstico y tratamiento de la artritis séptica en adultos y niños de GEIO (SEIMC), SEIP y SECOT

Infection of a native joint, commonly referred to as septic arthritis, is a medical emergency because of the risk of joint destruction and subsequent sequelae. Its diagnosis requires a high level of suspicion. These guidelines for the diagnosis and treatment of septic arthritis in children and adults are intended for use by any physician caring for patients with suspected or confirmed septic arthritis. They have been developed by a multidisciplinary panel with representatives from the Bone and Joint Infections Study Group (GEIO) belonging to the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Paediatric Infections (SEIP) and the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT), and two rheumatologists. The recommendations are based on evidence derived from a systematic literature review and, failing that, on the opinion of the experts who prepared these guidelines. A detailed description of the background, methods, summary of evidence, the rationale supporting each recommendation, and gaps in knowledge can be found online in the complete document.(AU)

La infección de una articulación nativa, generalmente denominada artritis séptica, constituye una urgencia médica por el riesgo de destrucción articular y las consecuentes secuelas. Su diagnóstico requiere un alto nivel de sospecha. Esta guía de diagnóstico y tratamiento de la artritis séptica en niños y adultos está destinada a cualquier médico que atienda pacientes con sospecha de artritis séptica o artritis séptica confirmada. La guía ha sido elaborada por un panel multidisciplinar en el que están representados el Grupo de Estudio de Infecciones Osteoarticulares (GEIO) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), la Sociedad Española de Infectología Pediátrica (SEIP) y la Sociedad Española de Cirugía Ortopédica y Traumatología (SECOT); además han participado dos reumatólogos. Las recomendaciones se basan en la evidencia proporcionada por una revisión sistemática de la literatura y, en su defecto, en la opinión de los expertos que han elaborado la presente guía. En el texto completo online se hace una descripción detallada de los antecedentes, métodos, resumen de la evidencia, fundamentos que apoyan cada recomendación y las lagunas de conocimiento existentes.(AU)

Consensus on the definition and criteria for failure of surgical treatment in bacterial arthritis of a native joint: An international Delphi study.

PURPOSE: The literature presents a wide range of success rates for a single surgical intervention of bacterial-septic-arthritis, and there is a lack of clear criteria for identifying treatment failure and making decisions about reintervention. This Delphi study aims to establish a consensus among an international panel of experts regarding the definition of treatment failure and the criteria for reintervention in case of bacterial arthritis. METHODS: The conducting and reporting Delphi studies (CREDES) criteria were used. Data from a systematic review was provided as the basis for the study. A list of 100 potential experts were identified. The study was designed and conducted as follows: (I) identification and invitation of an expert panel, (II) informing the participating expert panel on the research question and subject, and (III) conducting two or three Delphi rounds to reach consensus on explicit research items. Potential criteria were rated on a five-point Likert scale. RESULTS: Sixty orthopaedic experts from nine countries participated in this Delphi study, with 55 completing all three rounds. The mean experience as an orthopaedic surgeon was 15 years (SD ± 9). Strong (96%) consensus was reached on the definition of treatment failure: the persistence of physical signs of arthritis (e.g., pain and swelling) and/or systemic inflammation (e.g., fever and no improvement in CRP) despite surgical and antibiotic treatment. Furthermore, consensus (>80%) was reached on six criteria influencing the decision for reintervention; pain (81%), sepsis (98%), fever (88%), serum CRP (93%), blood culture (82%), and synovial fluid culture (84%). CONCLUSION: The definition of treatment failure for bacterial arthritis after a single surgical intervention was established through a three-round Delphi study. Additionally, consensus was reached on six criteria that are helpful for determining the need for reintervention. This definition and these criteria may help in the development of clinical guidelines, and will empower physicians to make more precise and consistent decisions regarding reintervention for patients, ultimately aiming to reduce over- and undertreatment and improve patient outcomes. LEVEL OF EVIDENCE: Level V.

Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP and SECOT.

Infection of a native joint, commonly referred to as septic arthritis, is a medical emergency because of the risk of joint destruction and subsequent sequelae. Its diagnosis requires a high level of suspicion. These guidelines for the diagnosis and treatment of septic arthritis in children and adults are intended for use by any physician caring for patients with suspected or confirmed septic arthritis. They have been developed by a multidisciplinary panel with representatives from the Bone and Joint Infections Study Group (GEIO) belonging to the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Paediatric Infections (SEIP) and the Spanish Society of Orthopaedic Surgery and Traumatology (SECOT), and two rheumatologists. The recommendations are based on evidence derived from a systematic literature review and, failing that, on the opinion of the experts who prepared these guidelines. A detailed description of the background, methods, summary of evidence, the rationale supporting each recommendation, and gaps in knowledge can be found online in the complete document.

Failure rates in surgical treatment in adults with bacterial arthritis of a native joint: a systematic review of 8,586 native joints.

INTRODUCTION: Most adult cases of bacterial-septic-arthritis of a native joint are effectively managed with a single surgical debridement, but some cases may require more than one debridement to control the infection. Consequently, this study assessed the failure rate of a single surgical debridement in adults with bacterial arthritis of a native joint. Additionally, risk factors for failure were assessed. MATERIALS AND METHODS: The review protocol was registered on PROSPERO (CRD42021243460) before data collection and conducted in line with the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' (PRISMA) guidelines. Multiple libraries were systematically searched to identify articles including patients reporting on the incidence of failure (i.e. persistence of infection requiring reoperation) of the treatment of bacterial arthritis. The quality of individual evidence were assessed using the Quality in Prognosis Studies (QUIPS) tool. Failure rates were extracted from included studies and pooled. Risk factors for failure were extracted and grouped. Moreover, we evaluated which risk factors were significantly associated with failure. RESULTS: Thirty studies (8,586 native joints) were included in the final analysis. The overall pooled failure rate was 26% (95% CI 20 to 32%). The failure rate of arthroscopy and arthrotomy was 26% (95% CI 19 to 34%) and 24% (95% CI 17 to 33%), respectively. Seventy-nine potential risk factors were extracted and grouped. Moderate evidence was found for one risk factor (synovial white blood cell count), and limited evidence was found for five risk factors (i.e. sepsis, large joint infection, the volume of irrigation, blood urea nitrogen-test, and blood urea nitrogen/creatinine ratio). CONCLUSION: A single surgical debridement fails to control bacterial arthritis of a native joint in approximately a quarter of all adult cases. Limited to moderate evidence exists that risk factors associated with failure are: synovial white blood cell count, sepsis, large joint infection, and the volume of irrigation. These factors should urge physicians to be especially receptive to signs of an adverse clinical course.

Arthroscopic Treatment of the Septic Ankle.

Ankle joint sepsis is a relatively rare but potentially devastating pathologic process of the lower extremity that requires expeditious identification and management. Establishing the diagnosis of ankle joint sepsis is often challenging as it may present with concomitant pathologies and often lacks consistency in regard to classic clinical characteristics. Once a diagnosis has been established, prompt management is imperative to minimize the potential for long-term sequelae. The purpose of this chapter is to address the diagnosis and management of the septic ankle with a focus on arthroscopic treatment.

Clinical prediction rule for bacterial arthritis: Chi-squared automatic interaction detector decision tree analysis model.

Objectives: Differences in demographic factors, symptoms, and laboratory data between bacterial and non-bacterial arthritis have not been defined. We aimed to identify predictors of bacterial arthritis, excluding synovial testing. Methods: This retrospective cross-sectional survey was performed at a university hospital. All patients included received arthrocentesis from January 1, 2010, to December 31, 2020. Clinical information was gathered from medical charts from the time of synovial fluid sample collection. Factors potentially predictive of bacterial arthritis were analyzed using the Student's t-test or chi-squared test, and the chi-squared automatic interaction detector decision tree analysis. The resulting subgroups were divided into three groups according to the risk of bacterial arthritis: low-risk, intermediate-risk, or high-risk groups. Results: A total of 460 patients (male/female = 229/231; mean ± standard deviation age, 70.26 ± 17.66 years) were included, of whom 68 patients (14.8%) had bacterial arthritis. The chi-squared automatic interaction detector decision tree analysis revealed that patients with C-reactive protein > 21.09 mg/dL (incidence of septic arthritis: 48.7%) and C-reactive protein ⩽ 21.09 mg/dL plus 27.70 < platelet count ⩽ 30.70 × 104/µL (incidence: 36.1%) were high-risk groups. Conclusions: Our results emphasize that patients categorized as high risk of bacterial arthritis, and appropriate treatment could be initiated as soon as possible.

SPILF update on bacterial arthritis in adults and children.

In 2020 the French Society of Rhumatology (SFR) published an update of the 1990 recommendations for management of bacterial arthritis in adults. While we (French ID Society, SPILF) totally endorse this update, we wished to provide further information about specific antibiotic treatments. The present update focuses on antibiotics with good distribution in bone and joint. It is important to monitor their dosage, which should be maximized according to PK/PD parameters. Dosages proposed in this update are high, with the optimized mode of administration for intravenous betalactams (continuous or intermittent infusion). We give tools for the best dosage adaptation to conditions such as obesity or renal insufficiency. In case of enterobacter infection, with an antibiogram result "susceptible for high dosage", we recommend the requesting of specialized advice from an ID physician. More often than not, it is possible to prescribe antibiotics via the oral route as soon as blood cultures are sterile and clinical have symptoms shown improvement. Duration of antibiotic treatment is 6 weeks for Staphylococcus aureus, and 4 weeks for the other bacteria (except for Neisseria: 7 days).

Impact of a pediatric infectious disease consultation service on timely step-down to oral antibiotic treatment for bone and joint infections.

PURPOSE: In recent years an earlier step down to oral antibiotic therapy has been advocated for numerous infections. Trained infectious disease specialists regularly consulting their colleagues may speed up the implementation of such recommendations into clinical practice and thus may improve treatment. METHODS: We retrospectively analyzed bone and joint infections in children admitted to the University Hospital of Cologne between 2010 and 2021. We assessed clinical, imaging, and microbiological findings and treatment modalities. Additionally, we assessed both the impact of a newly implemented pediatric infectious diseases consultation service and publications on revised treatment recommendations by comparing antibiotic therapy in two periods (2010-2016 versus 2017 to 2021). RESULTS: In total, 29 children presented with osteomyelitis, 16 with bacterial arthritis and 7 with discitis. In period 2 (2017-2021) we observed shorter duration of intravenous treatment (p = 0.009) and a higher percentage of oral antibiotic treatment in relation to the total duration of antibiotics (25% versus 59%, p = 0.007) compared to period 1 (2010-2016). Yet, no differences were identified for the total length of antibiotic treatment. Additionally, biopsies or synovial fluid samples were retrieved and cultured in more children in period 2 (p = 0.077). The main pathogen identified in osteomyelitis and bacterial arthritis was Staphylococcus aureus (MSSA), diagnosis was confirmed predominantly with MRI. CONCLUSION: Recent guidelines addressing the safety of an earlier step-down (to oral) antibiotic therapy have influenced clinical practice in the treatment of bone and joint infections in our hospital. A newly implemented pediatric infectious diseases consultation service might have accelerated this progress resulting in a faster step down to oral treatment.

Polyarticular Sepsis Secondary to Staphylococcus aureus Bacteremia Post-acute Hemodialysis: A Case Report.

Polyarticular septic arthritis (PASA) is less common than monoarticular septic arthritis (MASA). There is a low incidence of PASA in immunocompetent patients. This case report describes the development of PASA after hemodialysis through the permcath after a single session.

Septic arthritis of the wrist: a retrospective review of 39 cases.

LEVEL OF EVIDENCE: III.

Gonococcal arthritis: case series of 58 hospital cases.

OBJECTIVES: Extra-genital manifestations of gonococcal infection are rare (0.5-3%). Among them, gonococcal arthritis (GA) is the most frequent, accounting for 30-90% of disseminated infections. Our study aimed to describe all hospital cases of GA in Reunion Island, a French overseas territory. METHODS: We conducted a retrospective, multicentric, observational study of all cases of certain, probable or possible GA from 2008 to 2020. RESULTS: We identified 58 cases of GA, mostly certain cases (n = 48). Sex ratio was balanced, but men were older than women (51 vs 27 years, p < 0.001). A total of 41% had travelled abroad during the previous 3 months, mostly in Madagascar or South-East Asia. The most frequently infected joint was the knee, followed by ankle, wrist and fingers or carpal joints. Only 16% of cases had genital symptoms, but 50% had another extra-genital manifestation, mainly skin lesions (40%). Positivity rate of joint puncture was 91%, with a purulent liquid. Only 58% had a positive culture, and 33% had only a positive PCR. There was no 3GC-resistant strain. In comparison with gonococcal infection without arthritis, patients were older and had fewer genital but more extra-genital symptoms. On discharge 60% had persistent articular symptoms. GA represented 18% of all hospitalised septic arthritis cases with microbial identification in 2019. CONCLUSIONS: GA is rare but it is important to make an early diagnosis and treat promptly, as joint destruction may be important, leading to persistent symptoms after discharge. PCR use in joint puncture is useful in cases with negative culture.

Pseudoseptic Arthritis in a Patient With Psoriasis.

A 42-year-old male with a history of untreated psoriasis and a previous episode of presumed left knee septic arthritis developed sudden onset of left knee pain, swelling, and a moderate effusion. The pathogen could not be isolated despite extensive inflammation seen in synovial fluid (SF) and synovial tissue biopsy. Whether this is culture-negative septic arthritis or pseudo-septic arthritis is the enigma, given the limited sensitivity of current available SF microbiologic testing. We present a challenging and stimulating case with no current guidelines for an optimal empiric antibiotic regimen or anti-inflammatory therapy.

What are the best diagnostic tests for diagnosing bacterial arthritis of a native joint? : a systematic review of 27 studies.

AIMS: This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint? METHODS: We performed a search of PubMed, Embase, and Cochrane libraries for relevant studies published between January 1980 and April 2020. Of 3,209 identified studies, we included 27 after full screening. Sensitivity, specificity, area under the curve, and Youden index of diagnostic tests were extracted from included studies. We grouped test characteristics per diagnostic modality. We extracted the definitions used to establish a definitive diagnosis of bacterial arthritis of a native joint per study. RESULTS: Overall, 28 unique diagnostic tests for diagnosing bacterial arthritis of a native joint were identified. The following five tests were deemed most useful: serum ESR (sensitivity: 34% to 100%, specificity: 23% to 93%), serum CRP (sensitivity: 58% to 100%, specificity: 0% to 96%), serum procalcitonin (sensitivity: 0% to 100%, specificity: 68% to 100%), the proportion of synovial polymorphonuclear cells (sensitivity: 42% to 100%, specificity: 54% to 94%), and the gram stain of synovial fluid (sensitivity: 27% to 81%, specificity: 99% to 100%). CONCLUSION: Diagnostic methods with relatively high sensitivities, such as serum CRP, ESR, and synovial polymorphonuclear cells, are useful for screening. Diagnostic methods with a relatively high specificity, such as serum procalcitonin and synovial fluid gram stain, are useful for establishing a diagnosis of bacterial arthritis. This review helps to interpret the value of various diagnostic tests for diagnosing bacterial arthritis of a native joint in clinical practice. Cite this article: Bone Joint J 2021;103-B(12):1745-1753.

Bacterial arthritis of native joints can be successfully managed with needle arthroscopy.

PURPOSE: To assess the feasibility of needle arthroscopy for management of suspected bacterial arthritis in native joints. METHODS: During a pilot period, patients presenting with symptoms suggestive of native joint bacterial arthritis were eligible for initial management with needle arthroscopy. Procedures were performed in the operating theatre or at the patient bedside in the emergency department or inpatient ward. As our primary outcome measure, it was assessed whether needle arthroscopic lavage resulted in a clear joint. In addition, the need for conversion to standard arthroscopy or arthrotomy, the need for conversion from local to general anaesthesia, complications and the need for additional surgical intervention at follow-up during admission were recorded. RESULTS: Eleven joints in 10 patients (four males, age range 35 - 77) were managed with needle arthroscopy. Needle arthroscopic lavage resulted in a clear joint in all cases. Conversion to standard arthroscopy or arthrotomy was not needed. Seven procedures were performed at the patient bedside using local anaesthesia. These procedures were well tolerated and conversion to general or spinal anaesthesia was not required. There were no procedure complications. One patient received multiple needle arthroscopic lavages. No further surgical interventions beside the initial needle arthroscopic lavage were required for successful management in other cases. CONCLUSIONS: Needle arthroscopy can be a feasible tool in the initial management of complaints suggestive for native joint bacterial arthritis, providing an effective, quick and well-tolerable intervention in the operating theatre or at the patient bedside, with the potential to relief health systems from need for scarce operating theatre time.

Septic polyarthritis with Mycoplasma salivarium in a patient with common variable immunodeficiency: case report and review of the literature.

Mycoplasma salivarium is a common mycoplasma usually isolated from human oropharynx, particularly from individuals with periodontal disease. It is also among the more common mycoplasmal contaminants of eukaryotic cell cultures. Although M. salivarium has been isolated occasionally from abscesses and other sterile sites, to our knowledge, only three cases of septic arthritis have been documented in the past due to this organism, all in patients with humoral immunodeficiency. We now report a fourth case of septic polyarthritis in a patient with profound hypoimmunoglobulinemia who had experienced dental abscesses within the preceding 2 years. Our case highlights the importance of considering invasive mycoplasmal infection in hypogammaglobulinemic patients. It is likely of significance that the patient had suffered recurrent dental abscesses as a source of infection with M. salivarium .

Inflammatory cytokine mRNA and protein levels in the synovial fluid of Mycoplasma arthritis calves.

Bovine Mycoplasma arthritis (MA) is caused by Mycoplasma bovis and exhibits severe clinical symptoms. However, the pathophysiology of bovine MA is incompletely understood. In this study, we examined the cytokine mRNA expression of synovial fluid (SF) cells and cytokine concentrations in the SF of MA calves. The SF was isolated from five clinically healthy (control) and seven MA calves. mRNA and protein levels of interleukin (IL)-1ß, IL-6, IL-8, IL-12, and IL-17 in the SF from MA calves were significantly higher than those from control calves. Our results indicate that SF cells produce inflammatory cytokines, which mainly contribute to the severe inflammatory response in the joints of the MA calves.

[Septic arthritis of the native joint and after ligamentoplasty : Diagnosis and treatment]. / Septische Arthritis des nativen Gelenkes und nach Bandplastik : Diagnostik und Behandlung.

BACKGROUND: Septic arthritis is an acute emergency. It occurs more frequently in patients with pre-existing degenerative or chronic inflammatory joint diseases than in the general population. The causative microorganisms can be introduced in various ways. DIAGNOSTICS: A rapid diagnosis is of great importance for the success of the therapy. In the clinical examination, the typical signs of inflammation are noticeable. The gold standard is the aspiration of synovial fluid and the subsequent laboratory and microbiological investigation. THERAPY: A prerequisite for successful therapy is the early initiation of an antimicrobial pathogen-specific treatment and the surgical alleviation of the joint.

Emphysematous Osteomyelitis: Review of the Literature.

This article presents a detailed review of the 49 reported cases of emphysematous osteomyelitis. Infection of the bones and joints usually developed in various locations of patients with concomitant diseases. The treatment includes antibiotic therapy and minor surgery, usually drainage.

[Recurrence of septic arthritis of the wrist by Pseudomonas aeruginosa due to colonization of a central venous indwelling catheter]. / Rezidiv einer septischen Arthritis des Handgelenks durch Pseudomonas aeruginosa bei Besiedelung eines zentralvenösen Verweilkatheters.

A diabetic patient, wearer of a port and with a history of gonarthritis due to Pseudomonas aeruginosa presented with subacute arthritis of a wrist. After a protracted interval P. aeruginosa was detected by microbial culture from the explanted port and the affected joint. This case shows that in patients with unclear arthritis of the wrist, a history of septic arthritis with P. aeruginosa and risk factors for hematogenous spread, a recurrent infection should be excluded. The treatment consisted of explantation of the port, débridement with synovectomy of the joint and adequate antibiotic treatment.

Determination of diagnostic value (validity) leukocyte esterase (urine dipstick strip) in differentiating inflammatory arthritis from bacterial arthritis.

BACKGROUND: The current diagnostic cornerstone for septic arthritis contains gram stains, bacterial culture, and cell count with a differential of aspirated synovial fluid. Recently, a synovial leukocyte esterase (LE) test has been used for diagnosing septic arthritis. Since this test measures the esterase activity of leukocytes, there is always a dilemma for using this test in patients with inflammatory arthritis. METHODS: We collected the synovial fluid specimens as part of the general diagnostic protocol for patients suspected of Juvenile Idiopathic Arthritis (JIA) or Septic Arthritis (SA). Each group included 34 patients. We compared the result of the synovial LE test with the result of the culture of each patient. RESULTS: The mean ages of patients were 64.14 ± 31.27 and 50.88 ± 23.19 months in the JIA group and septic arthritis group, respectively. The LE test results were positive in 30 specimens, trace in 3 and negative in one in the first-time test and were positive in 31 specimens and trace in 3 in the second-time test, while it was negative in all patients with JIA. Hence, the sensitivity of the synovial LE test was 80.8%, the specificity, PPV, and NPV were 78.6, 70.0, 86.8% respectively based on a positive culture. CONCLUSION: The leukocyte esterase strip test can be used as a rapid, bedside method for diagnosing or excluding bacterial infections in different body fluids. The synovial LE test can be used as an accurate test to rapidly rule in or out an acute articular bacterial infection, even in patients with concurrent inflammatory arthritis.