There is no need to inject antibiotic into the joint: most antibiotics penetrate well from the bloodstream.Įnsure adequate drainage of weight-bearing joints to avoid damage to cartilage. Otherwise, removal of the prosthesis (in a one- or two-stage procedure) is usually needed for cure.Īspirate the jointfor diagnosis: order crystal search, Gram stain and culture for bacteria and fungi.īase initial antibiotic choice on likely causes (see below). Infections of prosthetic joints may be cured without removal of the prosthesis if (1) the prosthesis was placed less than 3 months earlier (or infection is the result of hematogenous spread) (2) the symptoms have been present for not more than 3 weeks and (3) the organism is susceptible to bactericidal antibiotics. Hematogenous infection of joints should raise a question of endocarditis. Obtain urine test for chlamydia and stool cultures for bacterial pathogens if reactive arthritis is a possibility, even in the absence of genital or intestinal symptoms.Įnsure adequate drainagefor weight-bearing joints: unrelieved pressure causes necrosis of cartilage. Obtain urine tests for Neisseria gonorrhoeae if gonococcal arthritis is a possibility. Obtain cultures of blood and other potential sources of infection (e.g., urine) if hematogenous infection is likely. Note that Gram stains of joint fluid are positive in only about 50% of cases of bacterial arthritis, although cultures are positive (in the absence of antibiotics) in about 90%. In patients with a systemic noninfectious arthritic condition (e.g., rheumatoid arthritis), bacterial infection (rather than a flare-up of the underlying condition) is suggested by increased pain and swelling in one joint with little change in the inflammatory process in other joints.ĭetermine that the infection involves the joint(s) and not a bursa or other periarticular tissues by clinical examination, imaging, andĭistinguish infectious from gouty arthritis or pseudogout by analysis of joint fluid. Plain x-rays may show swelling of periarticular tissues. These symptoms and signs may be subtle in patients with prosthetic joint infection. The clinical features of infections of native joints are usually straightforward with pain, swelling, warmth of the periarticular tissues and restriction of range of motion. Gram-negative bacilli: Enteric and other organisms are infrequent causes of infections of prosthetic joints. Gram-positive bacilli: Diphtheroids (especially in shoulder prostheses) Staphylococcus aureus coagulase-negative staphylococci The causative agents are similar to those that infect native joints except that organisms of low virulence (coagulase-negative staphylococci diphtheroids) play a large role. “Reactive” (sterile) arthritis, formerly known as Reiter’s syndrome, may occur following chlamydial genital infection or bacterial gastroenteritis caused by campylobacter, salmonella, and other agents. Rarely, fungi or viruses (parvovirus, rubella, mumps, hepatitis B virus) can cause acute arthritis. gonorrhoeae in patients with genital gonococcal infection Neisseria meningitidis in patients with meningococcemia Gram-negative bacilli: enteric bacilli from urinary tract or intestinal or other infection environmental gram-negative bacilli (e.g., Pseudomonas aeruginosa) after trauma Staphylococcus aureus, streptococci - these are by far the most common causes The most common agents are bacterial and include: Hematogenous spread (in the course of bacteremia or fungemia): the most common routeĭirect inoculation (surgical, injections of joints, or accidental trauma)Ĭontiguous spread (e.g., from adjacent osteomyelitis): rare
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