Septic arthritis State of the art

Transcription

1 Workshop on prosthetic Joint Infection Berlin Septic arthritis State of the art PD Dr. med. Anna Conen, MSc Senior consultant and deputy head physician Division of Infectious Diseases and Hospital Hygiene Kantonsspital Aarau, Switzerland

2 Septic arthritis = Emergency Preservation of joint integrity dependent on time between symptom start and adequate therapy Delay results in irreversible cartilage and joint damage (20-50%) Mortality: 5-15% Higher in case of polyarticular involvement Mathews et al. Lancet Smith et al. Arthritis Rheum Goldstein et al. Orthopedics Balabaud et al. Knee Surg Sports Traumatol Arthrosc Wirtz et al. Int Orthop Aïm et al. Orthop Traumatol Surg Res

3 Pathogenesis Hematogenous 60% Primary focus mainly skin, urogenital or pulmonary infections, infective endocarditis Synovia without protecting basement membrane Microorganisms easily pass from blood into joint space Direct inoculation After joint aspiration / infiltration Postoperatively, after arthroscopy Trauma Contiguous spread Osteomyelitis, bursitis, cellulitis 90% monoarticular 50% knee Kaandorp et al. Ann Rheuma Dis Mathews et al. Lancet Aïm et al. Orthop Traumatol Surg Res

4 Which microorganisms? Microorganism Frequency Staphylococcus aureus (MSSA > MRSA) 40 60% Streptococci - S. pyogenes, group B, C, G streptococci - Pneumococci 20 30% 3 6% Coagulase-negative staphylococci 4% Gram-negative bacilli Escherichia coli Pseudomonas aeruginosa, Salmonella spp., Haemophilus influenzae 4 20% Gonococci % Polymicrobial * Up to 8% * Open joint injury, VAC Goldenberg et al. Lancet Dubost et al. Ann Rheum Dis Morgan et al. Epidemiol Infect Ross et al. CID Maneiro et al. Clin Rheumatol Aïm et al. Orthop Traumatol Surg Res Murillo et al. Clin Microbiol Infect Ross et al. Infect Dis Clin N Am 2017.

5 Aspiration 2 goals 1. Diagnostic: Synovial fluid for analysis Cell count and differentiation (EDTA) Gram stain, culture (pediatric blood culture bottle, native) Crystals (native or EDTA) Cave: Presence of crystals does not rule out septic arthritis! 2. First provisional treatment Relief of joint distension Decrease of intraarticular concentration of cartilage destroying leucocytes, enzymes and bacteria Perry et al. Am J Orthop Mathews et al. Lancet Coakley et al. Rheumatology Soderquist et al. Scand J Infect Dis Gordon et al. Aust N Z Med O Connell et al. Clin Exp Rheumatol

6 Gram stain Problem: Low sensitivity 23-45% High specificity % Thus: Gram staining is an unreliable tool in early decision making Wrong security! Gram stain: positive in 50% Culture: positive in 80% Faraj et al. Acta Orthop Belg Chimento et al. JBJS Goldenberg et al. Am J Med Newman et al. J Rheumatol Bayer et al. Semin Arthritis Rheum 1977.

7 Diagnostic parameters in the synovial fluid 14 studies, 6242 patients, 653 septic arthritis cases Parameter Sensitivity (%) Specificity (%) Likelihood Ratio (95% CI) Positive Negative > Lc/µl ( ) 0.71 ( ) > Lc/µl ( ) 0.42 ( ) > Lc/µl ( ) 0.32 ( ) Polynuclear Lc 90% ( ) 0.34 ( ) Blood test (inflammation parameters): Good sensitivity, but low specificity Shmerling et al. JAMA Margaretten et al. JAMA 2007.

8 Synovial fluid: cell count Parameter Normal Group 1 (degenerative) Group 2 (inflammatory) Group 3 (infectious + crystal) Leucocytes /μl < > Neutrophils, % <25% 25 70% 70-90% >90% - Psoriasis - Rheumatoid arthritis/reactive arthritis - Collagenosis (SLE) - Low-grade prosthetic joint infection Shmerling et al. JAMA Margaretten et al. JAMA Conen A. et al. AOTrauma, Thiemeverlag, 2016: Principles of Orthopedic Infection Management. Chapter 11.1, pp : Septic arthritis. Kaandorp et al. Ann Rheum Dis McCutchan et al. Clin Orthop 1990.

9 Patient 2: 65 years old man Since 48 hours: Increasing swelling and excessive heat of left knee 1 week ago: Left knee joint puncture and infiltration with steroids cells/µl, detection of calciumpyrophosphate crystals Personal history: Metabolic syndrome Coronary heart disease Recurrent arthritis caused by calcium-pyrophosphate crystals (pseudogout)

10 Joint puncture 2

11 Microbiology 2 Gram stain without detection of microorganisms Postinterventional septic gonarthritis left with Staphylococcus lugdunensis

12 Patient 3: 79 years old man Since 4 days acute knee pain rightsided, no trauma No fever Personal history: Metastasizing prostatic cancer with bone metastasis Treatment with Alpharadin Metabolic syndrome Chronic renal failure egfr 40 ml/min.

13 Joint puncture 3

14 Microbiology 3 Gram stain without detection of microorganisms Hematogenous septic gonarthritis right with Streptococcus milleri

15 Patient 4: 55 years old man Since 72 hours: Fever, redness, swelling and pain in the left elbow Personal history: Rheumatoid arthritis (under prednisone) Recurrent elbow infections leftsided with S. aureus, last 9/2009 Multiple prosthetic joints (hip and knee both sided)

16 Joint puncture 4 Hematogenous septic elbow arthritis left with Staphylococcus aureus with - Extensive involvement of soft tissue - Radiological osteomyelitis

17 Treatment Surgery Antibiotics No randomized controlled trials available Early and aggressive treatment start: better results 1. Joint decompression: Ubi pus ibi evacua Mechanical cleaning: Removal of cytokines, proteases, granulocytes; reduction of bacterial load Arthroscopy, arthrotomy, repetitive aspiration 2. Rapid joint sterilization: systemic antibiotics 3. Functional healing: early mobilisation, physiotherapy Mathews et al. Lancet Vispo et al. Arch Orthop Trauma Surg Coakley et al. Rheumatology Smith et al. CMI Shirtliff et al. Clinical Microbiology Reviews Kusma et al. Unfallchirurg Aïm et al. Orthop Traumatol Surg Res

18 Bacterial arthritis: Gächter stages Arthroscopic and radiological classification, but can be used in open surgery Stage Criteria 1 Synovitis, cloudy fluid, possible petechiae, no radiological changes 2 Highly inflammatory synovitis, clumps of fibrin, pus, no radiological changes Arthroscopy 3 Thickening (subtotal of synovectomy the synovial membrane only in stage (possibly 3) several centimeters), adhesion with pouch formation, no radiological changes visible 4 Pannus formation, proliferation of aggressive synovitis Arthrotomy on and later beneath the cartilage (subchondral erosions), radiological changes visible Gächter et al. Inform Arzt 1985.

19 Arthroscopic treatment: Gächter stages 1-3 The earlier the operation and the lower the Gächter stage, the better will be the outcome! Stutz et al. Knee Surg, Sports Traumatol, Arthrosc Aïm et al. Orthop Traumatol Surg Res Kirchhoff et al. International Orthopaedics (SICOT) 2009.

20 Antimicrobial treatment Start immediately after microbiological diagnostic Systemic high dose and bactericidal antibiotic therapy Empirically: amoxicillin/clavulanate i.v. Targeted: according to microbiological results Treatment duration: 2-6 weeks Dependent on microorganism, clinical response and concomitant osteomyelitis * (Gächter stage IV) With osteomyelitis: 6 weeks S. aureus, gram-negative bacilli: 4 weeks Streptococci, Haemophilus spp.: 2-3 weeks Gonococci: 7 days of therapy Usually 1 to 2 weeks of intravenous therapy Followed by another 1 to 4 weeks of oral therapy Normalization of clinical and laboratory findings Zimmerli et al. Arthroskopie Smith et al. CID Mathews et al. Lancet Coakley et al. Rheumatology Kowalski et al. Infection 2014.

21 Targeted oral antimicrobial therapy Microorganism Antimicrobial therapy S. aureus (MSSA and MRSA) Levofloxacin 2x500 mg plus Rifampicin* 2x450 mg p.o. Cotrimoxazol forte 3x1 (2x2) Tbl. +/- Rifampicin* 2x450 mg p.o. Doxycyclin 2x100mg plus Rifampicin* 2x450 mg p.o. Fusidic acid 3x500mg plus Rifampicin* 2x450 mg p.o. Rifampin only, if large weight bearing joints are affected and no prosthetic joint is planned within 12 months Streptococci Coagulase-negative staphylococci Gram-negative bacilli Pseudomonas aeruginosa Neisseria gonorrhoeae Amoxicillin 3x mg p.o. (Clindamycin 3x600 mg p.o.) Cotrimoxazol double strength 3x1 or 2x2 Tbl. p.o. (Clindamycin 3x600 mg p.o.) 1. Ciprofloxacin 2x750 mg p.o. (2. Cotrimoxazol double strength 3x1 or 2x2 Tbl. p.o.) Ciprofloxacin 2x750 mg p.o. 1. Ciprofloxacin 2x750 mg p.o. 2. Amoxicillin 3x mg p.o.

22 Summary Emergency! % monoarticular - 50% knee Irreversible joint damage Predominant pathogens: - Staphylococci - Streptococci Conen A. et al. AOTrauma, Thiemeverlag, 2016: Principles of Orthopedic Infection Management. Chapter 11.1, pp : Septic arthritis.