Pyogenic Arthritis (Septic Arthritis)
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Acute infection of a single joint (usually a large joint), commonly affecting children.
Cause
- Usually haematologenous spread from a primary focus following bacteraemia (e.g. septic skin lesions, sinus infections, throat infections, abrasions, wounds, pressure sores, and osteomyelitis)
- Commonly involved in acute arthritis: Staphylococcus aureus and Gram negative bacilli, e.g., Salmonella spp, Streptococcus spp, Gonococcus
- In chronic septic arthritis: Brucella, tuberculosis
Clinical features
- Swollen and warm joint
- Severe pain, reduced or abolished movement, temporary loss of limb function (pseudoparalysis)
- Localised heat and tenderness
- Systemic symptoms: fever (neonates may not show fever but refuse to feed), general malaise
- Complications: irreversible joint damage if immediate treatment is not established
Differential diagnosis
- Inflammatory joint disease
- Intra-articular haemorrhage, e.g., haemophilia and other bleeding disorders
- Trauma
- Osteomyelitis of neighbouring bone
Investigations
- Blood: Full blood count, C&S, ESR (usually elevated)
- Joint fluid: Aspirate for C&S; in case of failure to get pus by aspiration, use arthrotomy (in theatre)
- Joint fluid: Gram stain
ManagementTreatment
- Provide pain relief, e.g., paracetamol, or ibuprofen
- Immobilise the involved limb, try splinting
- REFER URGENTLY to HC4, or hospital
- Aspirate articular fluid for gram stain, and C&S if available (use local skin and subcutaneous anaesthesia if indicated)
- Repeat daily until no further pus is obtained
- Use diazepam 2.5 mg rectal for sedation in children
- Or open drainage in theatre
- Continue pain relief, use paracetamol, ibuprofen
- Or diclofenac 50 mg every 8 hours
- Child: 0.3-2 mg/kg rectally every 6-8 hours (max 150 mg)
- Or indomethacin 25-50 mg every 8 hours
- Child: 0.5-1 mg/kg every 12 hours
- Or diclofenac 50 mg every 8 hours
Antibiotics: if possible, get guidance from gram stain, and culture and sensitivity results
If Gram positive at gram stain, or negative stain but immunocompetent adult patient:
- Cloxacillin 500-1 g IV every 6 hours
- Child: 50 mg/kg IV every 6 hours
- Give IV for 2 weeks, then if better, switch to oral to complete 4 weeks
- Alternative/second line: Chloramphenicol 500 mg IV every 6 hours for at least 2 weeks
- Child: 12.5 mg every 6 hours
If Gram negative at gram stain
- Ceftriaxone 1 g IV for 2-4 weeks
Alternatives
- Ciprofloxacin 500 mg every 12 hours for 3 weeks
In adults with negative stain and underlying conditions (suspect gram negative, e.g. Salmonella in Sickle Cell Disease), and all children with negative stain, or underlying conditions
- Cloxacillin + ceftriaxone
If suspicion of gonococcal (e.g. in sexually active adolescents)
- Ceftriaxone 1 g IV daily for 1 week