SEPTIC JOINT IN ADULTS AND PAEDIATRICS ,,,.pptx

septic

1. Septic arthritis (Pediatric and adult

2. A 15-month-old boy presents to the ED with sudden onset of fever to 39.5°C, left knee swelling, and refusal to bear weight. His mother reports that the boy fell 2 days prior. He had a minor abrasion with some mild swelling to the left knee, but he was walking normally. Case 1

3. -You order acetaminophen for the persistent fever . **You begin to think: -What labs will you send? -plain radiography? -Do you need to obtain additional imaging studies? -What procedures should be performed?

4. -This is a previously healthy 4-year old female who is brought to the ED by her mother because of fever and right leg pain since the previous night. -She was taken to an ED because she had difficulty walking. She was diagnosed with a hip sprain and was sent home on ibuprofen. - Her fever and leg pain worsened to the point that she was no longer able to ambulate, prompting a return to the ED. Case 2

5. What would you do?

6. -The most common causative organisms for septic arthritis, based on patient age. -Key aspects of the history and physical examination that will help to narrow the differential diagnosis. -Which laboratory markers are better predictors and which can be used to effectively monitor a response to treatment. What to learn from this lecture

7. -To use the Kocher criteria to distinguish between septic arthritis and transient synovitis . -Which imaging studies should be ordered first and which can be used if the initial studies are inconclusive. -Recommendations for which antibiotics to administer as well as the appropriate duration for antibiotic treatment.

8. Definition - Simply it’s infection of a joint by microorganism. - bacterial invasion of the synovium and joint space followed by an inflammatory process. - can threaten both life and limb due to its potential for rapid destruction of the joint, causing significant disability within hours to days.

9. -Early diagnosis and treatment of septic arthritis cannot be overemphasized. -Fibrous deposition and lysosomal enzymes from polymorphonuclear leukocytes in synovial fluid can rapidly damage cartilage. -Permanent damage will occur in only a few days if the diagnosis and treatment are delayed.

10. -Pediatric patients with septic arthritis (SA) commonly present to the emergency department (ED) with vague and nonspecific complaints, but fever and joint pain are usually present.  -Presenting symptoms vary based on age. Presenting symptoms

11. Neonates and infants -signs of septicemia -Cellulitis -fever without a source Older children -Fever -joint pain -limited range of motion around the affected joint -refusal to bear weight

12. Physical exam *Physical exam:  -inspection -erythema  -effusion -extremity tends to be in position of maximum joint volume: hip would be in FABER position (flexed, abducted, externally rotated)

13. -Peak incidence in the pediatric population is between 2 and 3 years of age. -Boys are more commonly affected than girls. - it has a reported annual incidence of 1 to 37 cases per 100,000 children per year, although there is variation in different geographic areas. Incidence

14. *Most commonly affected joints in descending order: -knee (~ 50% of cases) -hip -shoulder -elbow -ankle - sternoclavicular joint * NOTE : in pediatric septic joint -hip joint involved in 35% of all cases of septic arthritis -knee joint involved in 35% of all cases of septic arthritis Location

15. Causative organisms 0 to 3 months

16. 3 months to 3-5 years

17. Age more than 3-5 years

18. -Staphylococcus aureus  is definitely the most frequent pathogen responsible for osteomyelitis and septic arthritis in any age group, mainly methicillin-sensitive strains (MSSA), and it is responsible for up to 70%–90% of confirmed cases.

19. * Hematogenous spread: -75% of the cases. -patients with indwelling catheters and immunocompromised patients. * Direct inoculation: - accidents, surgery, bites. * Contiguous spread: - Extension from infected bone into an adjacent joint space. Pathogenesis

20. Bacteria causing septic arthritis produce an acute inflammatory reaction in the synovial membrane . Synovial hyperplasia and inflammatory cell immigration . Release of pro-inflammatory and cartilage-destroying cytokines and proteases . Pathophysiology

21. Irreversible cartilage destruction in an involved joint. Damage to the cartilage and bone . **NOTE: Cartilage injury can occur by 8 hours

22. Diagnosis Imaging Blood cultures Synovial fluid arthrocentesis Serum labs

23. - MRI: *Useful to determine whether there is associated osteomyelitis and in cases of diagnosis uncertainty. *Imaging: - Plain radiography: * SHOULD be performed to evaluate the surrounding bones and joint space and to provide a baseline for comparison after therapy is completed.

24. *Serum labs: 1) WBC >12K with left shift 2) ESR >30 -ESR is often elevated but may be normal early in process -rises within 2 days of infection and can rise 3-5 days after initiation of appropriate antibiotics, and returns to normal 3-4 weeks 3)CRP >5 - most helpful - best way to judge efficacy of treatment, as CRP rises within few hours of infection, and may normalize within 1 week of treatment

25. **probability of septic arthritis may be as high as 99.6% when all four criteria below are present (Kocher Criteria): 1) WBC > 12,000 cells/µl of serum 2) inability to bear weight 3)fever > 101.3° F (38.5° C) 4)ESR > 40 mm/h *Kocher criteria in pediatrics septic arthritis: *NOTE: order of sensitivity of above criteria: fever > CRP > ESR > refusal to bear wieght > WBC (1) Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. Caird MS 1 ,  Flynn JM ,  Leung YL ,  Millman JE ,  D'Italia JG ,  Dormans JP  

26. - Blood cultures are positive in up to 50% of patients with bacterial septic arthritis. - SHOULD be obtained in all patients in whom this diagnosis is suspected. *Blood cultures:

27. 1) IV antibiotics 2) operative irrigation and drainage of the joint Treatment ***considered an orthopaedic surgical emergency***

28. *outcomes : treatment can be monitored by following serum WBC, ESR, and CRP levels during treatment

29. Treatment is started without delay after synovial fluid and blood samples have been obtained.  Empiric treatment primarily targets  S. aureus  and takes into account its resistance to antibiotics .

30. After a short 2–4 day intravenous course, the antibiotic may be administered orally if the patient is recovering and CRP level is declining.

31. Risk Management Pitfalls in the Management of Pediatric Septic Arthritis “The patient presented with vague/nonspecific pain. I didn’t consider a bone or joint infection.” - Pediatric SA initial symptoms may be vague and nonspecific so it is important to maintain a high index of suspicion. A complete musculoskeletal examination should be completed and imaging should be obtained in order to fully assess the joint/bone involved.

32. “I wanted to tailor the antibiotics to the specific microbial pathogen, so I decided to wait for culture results prior to starting antibiotic therapy.” - Ideally, empiric antibiotic therapy should be started after obtaining a reliable culture sample. - but the initiation of antibiotics should not be delayed while awaiting results of culture samples. - The antibiotics are geared toward the organisms known to be the most likely cause of SA.

33. “I instructed my patient to continue antibiotics at least until his symptoms improved.” -Incomplete antibiotic treatment duration and/or microbial coverage can attribute to antibiotic resistance and recurrence of symptoms. -SA require initial inpatient parenteral antibiotic therapy followed by oral antibiotic therapy lasting several weeks.

34. In Adults

35. - Septic arthritis due to needle arthrocentesis -Septic arthritis due to arthroscopy (less than 1 in 10,000 procedure) (4 cases per 1000-10,000 procedures)

36. *Knee- lateral para -patellar approach: Arthrocentesis

37. *Elbow- lateral approach:

38. *Ankle joint:

39. Adults management algorith

40. Take home messages Septic arthritis is an orthopedics emergency that you should not miss during your practice! Always aspirate the joint if you suspect septic arthritis as it’s the gold standard for diagnosis. The results and prognosis of septic joint is bad so always use sterile instruments during any procedure involving the joint.