Patient Presents With Acute Increase In Pain +/- Swelling In One Or More Joints. G.P. History Examination. Inflammatory arthritis Crystal arthritis Haemarthrosis Trauma Bursitis/Cellulitis Treat as appropriate. No definite alternative diagnosis but could be septic.
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Patient Presents With Acute Increase In Pain +/- Swelling In One Or More Joints
Treat as appropriate
No definite alternative diagnosis but could be septic
Definite alternative diagnosis
Clinical impression septic arthritis
Self referral to A&E
Refer for urgent A&E or specialist assessment
MUST ASPIRATE and other investigations
Seek rheumatology or orthopaedic advice if in doubt
Diagnosis SEPTIC ARTHRITIS
Empirical antibiotic treatment (as per local protocol)
Alter if necessary once results available
Examination In One Or More Joints
EXAMINATION In One Or More Joints
Joint Effusion / heat / erythema / restriction of movement - if all 4 signs are present then sepsis is likely
Large joints more commonly affected than small joints.
The majority of joint sepsis occurs in the hip or knee
1st MTP only joint affected – consider gout.
Joints involved monoarticular/polyarticular - 22% septic arthritis affects >1 joint
Pyrexia May be absent in 50% of patients with septic arthritis and present in cases of crystal arthritis
- Signs of systemic involvement: pulse, BP
- Sites of infection
Skin lesions - blisters/pustules suggest gonococcal arthritis
- tophi suggest gout
Bursitis/cellulitis suggested by local warmth and erythema without joint effusion and without restriction of joint movement
INVESTIGATION OF SYNOVIAL FLUID In One Or More Joints
Synovial fluid must be aspirated prior to starting antibiotics, Gram stained andcultured
(If affected joint is prosthetic seek orthopaedic advice)
Send specimen fresh to the laboratory for immediate microscopy and culture
Polarising microscopy to evaluate crystals must be carried out on all synovial fluid samples. The samples should be fresh and the microscopy performed by a microscopist experienced in crystal identification. (If unable to process samples immediately they should be stored at room temperature overnight to prevent artefactual crystal formation)
Neither the absence of organisms on Gram stain, nor a negative synovial fluid culture excludes the diagnosis of septic arthritis, although they make it less likely and alternative diagnoses should be considered
Patient Group In One Or More Joints
No risk factors for atypical organisms
Flucloxacillin 2g qds iv. Local policy may be to add gentamicin iv.
If penicillin allergic, Clindamycin 450-600mg qds iv. or 2nd or 3rd generation cephalosporin iv.
High risk of Gram –ve sepsis (elderly, frail, recurrent UTI, recent abdominal surgery)
2nd or 3rd generation cephalosporin eg cefuroxime 1.5g tds iv. Local policy may be to add flucloxacillin iv to 3rd generation cephalosporin. Discuss allergic patients with microbiology-Gram stain may influence antibiotic choice
MRSA risk ( known MRSA, recent inpatient, nursing home resident, leg ulcers or catheters, or other risk factors determined locally)
Vancomycin iv. plus 2nd or 3rd generation cephalosporin iv.
Suspected gonococcus or meningococcus
Ceftriaxone iv. or similar dependent on local policy / resistance
iv drug users
Discuss with microbiologist
ITU patients, known colonisation of other organs (eg cystic fibrosis)
Discuss with microbiologist
Summary of recommendations for initial empirical antibiotic choice in suspected septic arthritis
Antibiotic choice will need to be modified in the light of results of Gram stain and culture. This table is based on expert opinion, and should be reviewed locally by microbiology
IV antibiotics should be used and continued for at least 2 weeks
Repeat joint aspiration/surgical intervention may be required – all patients should be referred for a rheumatological or orthopaedic opinion
Joints should be aspirated to dryness as often as is required
Further treatment with oral antibiotics for at least 4 weeks. Do not stop antibiotics until symptoms and signs resolve, and ESR/CRP are returning to normal