Management of septic arthritis: a systematic review.

OBJECTIVE: To evaluate the existing evidence on the diagnosis and management of septic arthritis in native joints. DESIGN: Systematic review. DATA SOURCES: Cochrane Library, Medline, Embase, National Electronic Library for Health, reference lists, national experts. REVIEW METHODS: Systematic review of the literature with evaluation of the methodological quality of the selected papers using defined criteria set out by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians. RESULTS: 3291 citations were initially identified. Of these, 189 full text articles were identified for potential selection. Following review of these full text articles, 80 articles were found to fulfil the inclusion criteria and were included in the final list. Conclusions were drawn on the diagnosis, investigation and management of septic arthritis. DISCUSSION: Little good quality evidence exists to guide the diagnosis and management of septic arthritis. Overall, no investigation is more reliable in the diagnosis of septic arthritis than the opinion of an experienced doctor. Aspiration and culture of synovial fluid is crucial to the diagnosis, but measurement of cell count is unhelpful. Antibiotics are clearly required for a prolonged period, but there are no data to indicate by which route or for how long. Key unanswered questions remain surrounding the medical and surgical management of the infected joint.

Methicillin-resistant Staphylococcus aureus incidence and outcome in patients with neck of femur fractures.

Since the 1980s, methicillin-resistant Staphylococcus aureus (MRSA) has been identified as a significant infectious agent with an increasing incidence within both hospitals and the community. The aim of this study was to measure the incidence of MRSA colonization in patients admitted with a neck of femur fracture requiring implant surgery and to assess the outcome of these cases. We also sought to identify any risk factors associated with MRSA colonization, and to assess the need for any prophylactic treatment to prevent postoperative MRSA infection. Nasal, perineal and (where present) wound site swabs were taken on a sequential series of patients admitted with a neck of femur fracture who required a surgical implant. The presence of MRSA isolates from these swabs and the presence of a significant postoperative infection in both the colonized and non-colonized patients were recorded. A total of 66 patients were enrolled in the study, of whom 63 had surgical treatment for their fracture. A total of four patients were found to be colonized with MRSA. Of the study group, 27 patients had been admitted to hospital in the previous year, three of whom were found to be colonized with MRSA. Four of the patients were noted to have a postoperative infection-all of these cases were in the non-colonized group. The incidence of MRSA colonized patients in this series was 6%-a figure broadly consistent with previous studies. This does not appear to justify the routine screening of all neck of femur fracture admissions, though the results do suggest that a selective policy of screening only those who patients who had been admitted to hospital within the last year may be profitable. Our study does not appear to show any correlation between MRSA colonization and postoperative infection however. This is consistent with previous studies and does not support the adoption of an aggressive strategy for detection or eradication of MRSA prior to neck of femur fracture surgery.

Listeria monocytogenes meningitis in a penicillin-allergic paediatric renal transplant patient.

Currently in many centres the extended spectrum cephalosporins (e.g. cefotaxime and ceftriaxone) are being used empirically for patients with suspected bacterial meningitis. We present a case of meningitis in a penicillin allergic paediatric renal transplant patient from whose cerebrospinal fluid (CSF) Listeria monocytogenes was cultured, despite four days of cefotaxime therapy. The patient was successfully treated with meropenem but required neuro-endoscopic intervention for hydrocephalus.

Management of septic arthritis: a systematic review.

OBJECTIVE: To evaluate the existing evidence on the diagnosis and management of septic arthritis in native joints. DESIGN: Systematic review. DATA SOURCES: Cochrane Library, Medline, Embase, National Electronic Library for Health, reference lists, national experts. REVIEW METHODS: Systematic review of the literature with evaluation of the methodological quality of the selected papers using defined criteria set out by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians. RESULTS: 3291 citations were initially identified. Of these, 189 full text articles were identified for potential selection. Following review of these full text articles, 80 articles were found to fulfil the inclusion criteria and were included in the final list. CONCLUSIONS: were drawn on the diagnosis, investigation and management of septic arthritis. DISCUSSION: Little good quality evidence exists to guide the diagnosis and management of septic arthritis. Overall, no investigation is more reliable in the diagnosis of septic arthritis than the opinion of an experienced doctor. Aspiration and culture of synovial fluid is crucial to the diagnosis, but measurement of cell count is unhelpful. Antibiotics are clearly required for a prolonged period, but there are no data to indicate by which route or for how long. Key unanswered questions remain surrounding the medical and surgical management of the infected joint.

Evaluation of the sensitivity of a rapid polymerase chain reaction for detection of group B streptococcus.

The objective of this study was to compare detection of group B streptococcal (GBS) carriage using 'real-time' polymerase chain reaction (PCR) and microbiological standard culture. The study design was a test accuracy study comparing a novel molecular technique against the standard microbiological cultural technique in normal pregnant women. The setting and population consisted of 143 pregnant women with pre-labour rupture of the membranes, recruited from two large teaching hospitals in the UK. The study examined the efficacy of a polymerase chain reaction (PCR) assay for screening pregnant women who presented with term rupture of the membranes. Low vaginal specimens were obtained from the women. The specimens were tested for GBS by conventional culture and with a GBS-specific real-time PCR assay. The main outcome measure was the sensitivity and specificity of the PCR assay with 95% confidence intervals (CI) compared with the standard culture. The length of time to obtain a result was also reported for both methods. Among the 143 women, the results of the culture were positive (at least one colony) for GBS in 20 women (14%). The PCR assay detected GBS carriage in 10 women (7%). As compared with the culture method, the sensitivity and specificity of the PCR assay were 45% and 99%, respectively. The positive and negative predictive values of the PCR assay were 90% and 92%, respectively. The length of time required to obtain results for the majority of women (94%) was <2.5 h for the PCR assay and at least 24 h for culture. While a rapid result (within 3 h) of carriage of GBS can be obtained by the PCR assay, at present, it cannot replace conventional culture without further optimisation of the DNA extraction method. The sensitivity may further be improved by testing both low vaginal and rectal specimens.

Streptococcus pneumoniae spinal infection in Nottingham, United Kingdom: not a rare event.

Pneumonia and meningitis are the most frequent manifestations of Streptococcus pneumoniae infection. Spinal infection is considered to be a rarity. Between 1985 and 1997, 8 patients with spinal infection (vertebral osteomyelitis, 3; spinal epidural abscess, 1; both, 4) due to S. pneumoniae were seen at University Hospital (Nottingham, U.K.). Predisposing factors for pneumococcal infection were documented for five patients and included diabetes mellitus, alcoholism, and corticosteroid therapy. One patient presented with concomitant meningitis and endocarditis. Clinical features of note were prolonged symptoms and a lack of febrile response. S. pneumoniae was isolated from the blood of five patients. Magnetic resonance imaging was used to localize the spinal infection in five patients. Two cases were managed medically. Three patients died after a protracted illness. A literature search revealed 20 other cases of spinal infections due to S. pneumoniae. The salient features of the cases are summarized.

Twenty year surveillance of invasive pneumococcal disease in Nottingham: serogroups responsible and implications for immunisation.

AIMS: To evaluate the incidence, spectrum of clinical manifestations, and outcome of invasive pneumococcal disease (IPD) in children. To determine the major serogroups of Streptococcus pneumoniae responsible for invasive disease and the potential coverage by the new pneumococcal conjugate vaccines. METHODS: Analysis of prospectively recorded information of all children admitted to two teaching hospitals in Nottingham with IPD between January 1980 and December 1999. RESULTS: A total of 266 episodes of IPD in children were identified; 103 (39%) were aged <1 year and 160 (60%) <2 years. Major clinical presentations were meningitis in 86 (32%), pneumonia in 82 (31%), and bacteraemia without an obvious focus in 80 (30%). The age specific mean annual incidence rates of IPD overall among children aged <1, <2, and <5 years were 47.1, 37.8, and 20 per 100 000 population, respectively. Mortality rates for children with meningitis and non-meningitic infection were 20% and 7%, respectively. Neurological sequelae following meningitis were documented in 16 (26%) of the 61 survivors assessed. The potential coverage rates in children between the ages of 6 months and 5 years are 84% by the 7-valent, 91% by the 9-valent, and 95% by the 11-valent conjugate vaccines. CONCLUSION: This study indicates that inclusion of a pneumococcal conjugate vaccine in the primary immunisation programme in the UK would have a considerable effect on the mortality and morbidity associated with IPD.

The child with a non-blanching rash: how likely is meningococcal disease?

AIMS: To examine a number of simple clinical features and investigations in children with a non-blanching rash to see which predict meningococcal infection. METHODS: A total of 233 infants and children up to 15 years of age presenting with a non-blanching rash were studied over a period of 12 months. Clinical features and laboratory investigations were recorded at presentation. The ability of each to predict meningococcal infection was examined. RESULTS: Eleven per cent had proven meningococcal infection. Children with meningococcal infection were more likely to be ill, pyrexial (>38.5 degrees C), have purpura, and a capillary refill time of more than two seconds than non-meningococcal children. Five children with meningococcal disease had an axillary temperature below 37.5 degrees C. No child with a rash confined to the distribution of the superior vena cava had meningococcal infection. Investigations were less helpful, although children with meningococcal infection were more likely to have an abnormal neutrophil count and a prolonged international normalised ratio. No child with a C reactive protein of less than 6 mg/l had meningococcal infection. CONCLUSIONS: Most children with meningococcal infection are ill, have a purpuric rash, a fever, and delayed capillary refill. They should be admitted to hospital and treated without delay. Children with a non-blanching rash confined to the distribution of the superior vena cava are very unlikely to have meningococcal infection. Measurement of C reactive protein may be helpful-no child with a normal value had meningococcal infection. Lack of fever at the time of assessment does not exclude meningococcal disease.

Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991.

AIMS: To determine the clinical features of a large number of unselected UK hospital patients with confirmed septic arthritis and to determine those features associated with a poor outcome. STUDY DESIGN: Retrospective, case-note survey. SETTING: A single English Health District. PATIENTS: All patients admitted to hospital in Nottingham during the period 1 January 1982 to 31 December 1991 with confirmed septic arthritis were included. OUTCOME MEASURES: Death, osteomyelitis and recorded functional impairment. RESULTS: The spectrum of causative organisms remains similar to that seen in previous studies with the Gram positive organisms Staphylococcus aureus and Streptococci responsible for 74% of cases, gonococcal infections though were less common. Culture of joint aspirates and or blood were positive in 82% of cases, with the Gram stain demonstrating the causative organism in 50% of cases. Pre-existing joint disease was evident in 35% of cases. The mortality remains high at 11.5% with a significant additional morbidity of 31.6%. Multivariate analysis suggests that important predictors of death are: confusion at presentation, age > or = 65 years, multiple joint sepsis or involvement of the elbow joint, and of morbidity are: age > or = 65 years, diabetes mellitus, open surgical drainage, and Gram positive infections other than S aureus. CONCLUSIONS: Septic arthritis continues to be associated with a considerable degree of morbidity and mortality. These results confirm the importance of obtaining synovial fluid and blood for culture before starting antimicrobial treatment. The apparent poorer outcome found with surgical intervention is in line with some previous suggestions but should be interpreted with caution in light of the retrospective nature of this study.

Septic arthritis due to Streptococcus pneumoniae in Nottingham, United Kingdom, 1985-1998.

Pneumonia and meningitis are the 2 most frequent manifestations of Streptococcus neumoniae infection. Pneumococcal septic arthritis is considered to be relatively uncommon. Between 1985 and 1998, 32 (8. 2%) of 389 cases of septic arthritis seen in the 2 hospitals in Nottingham, United Kingdom, were due to S. pneumoniae. Six of 7 children with pneumococcal septic arthritis were aged <2 years. Of the 25 adults, 20 (80%) were aged >60 years, 11 (44%) had concomitant pneumococcal infection elsewhere, and 23 (92%) had articular or nonarticular diseases and/or other risk factors. In the elderly, a lack of febrile response was striking. S. pneumoniae was isolated from blood and joint cultures in >70% of cases, and gram-positive diplococci were seen in the joint fluids of 90% of patients. The mean duration of antimicrobial therapy for adults was twice as long as that for children. Eight (32%) of the adults died.