Diagnosis, Prevention and
Management:
Osteoarthritis
Rheumatoid Arthritis
Septic Arthritis
RaeAnne Fondriest, RN, BSN
Katie Kearney, RN, BSN
Michelle Nissen, RN, BSN
Angela Robinson, RN, BSN
Teresa Siefke, RN, BSN
Objectives
• Identify prevalence of arthritic conditions
• Discuss the pathophysiology of arthritic
conditions
• Recognize physical assessment attributes of
arthritic conditions
• Discuss current treatment guidelines for arthritic
conditions
• Identify preventative strategies of arthritic
conditions
• Outline needed follow up for the treatment of
arthritic conditions
Osteoarthritis
Pathophysiology
(Ling et al., 2009)
Causative Agents
• Old Age
• Obesity
• Improper joint alignment
• Direct or repetitive trauma
• Genetic abnormalities
(Keenan et al., 2012)
Prevalence
• Osteoarthritis affects 13.9% of the population
over the age of 25 and 33.6% over the age 65
• Job related costs from AO average 3.4 to 13.2
billion per year
• OA of the knee is one of the top 5 leading
causes of disability among adults
• Hospitalizations: OA accounts for 69.9% of
arthritis related hospitalizations
• The rate of total knee replacement and total hip
replacement increased by 187% and 86.2% from
1991 to 2007
• The estimated costs due to hospital expenditures
of TKR and THR average 28.5 billion and 13.7
billion in 2009
(Centers for Disease Control and Prevention, 2014)
Signs and Symptoms
Early stages of disease
• Early morning stiffness of less then 30
minutes
Middle stages of disease
• Pain with activity
• Improves with rest
Later Stage of Disease
• Pain with rest and sleep
• Limited Range of motion
(Ling et al., 2009)
Physical Assessment
• Subtle prominence of the finger
joints
• Herberden’s Nodes
• Bouchard’s Nodes
Adapted from: American College Of Rheumatology 2014 Osteoarthritis: Heberden’s and Bouchard’s Nodes, Fingers Retrieved
from http://http://images.rheumatology.org/viewphoto.php?albumId=77030&imageId=2897683 201411011813361594496608
Physical Assessment
• Effusion of the knee
• Bony prominence
• Joint laxity or unexpected mobility
• Mal-alignment of the joint
• Varus or valgus deformity
(Ling et al., 2009)
Differential Diagnosis
• Rheumatoid arthritis
• Crystalline diseases:
• Gout, calcium pyrophosphate deposition
disease and hyproxyappetite
• Seronegative spondyloarthropathy:
• Psoriatic arthritis and Rieter’s
• Polymyalgia rheumatica
• Bone disease:
• Osteomalacia, hypovitaminosis D and
Paget’s disease
• Malignancy:
• Myeloma and metastatic
(Ling et al., 2009)
Differential Diagnosis
• Infectious disease:
• Infectious arthritis, osteomyelitis and
sepsis syndrome
• Periarticular soft-tissue abnormalities:
• Tendonitis and bursitis
• Neuromuscular diseases:
• Neuropathy
• Systemic disease:
• Diabetes, autoimmune-lupus vasculitis
(Ling et al., 2009)
Diagnostic Criteria
• Conventional Radiology
• Optical Coherence Tomography
Hand
• Ultrasound
• MRI
Knee
Hip
Hand pain, aching or stiffness
Knee pain
Hip pain
and
and
and
Hand tissue enlargement of 2 or
more joints
Radiographic osteophytes
2 or more of the following:
Fewer than 3 swollen MCP joints
and
ESR <10 mm/h
and
1 or more of the following:
Radiographic femoral or
acetabular osteophytes
2 or more DIP joints with hand
tissue enlargement
Age ≥ 50
Radiographic joint space
narrowing
or
Morning stiffness <30 min
Deformity in 2 or more select joints
Creptus on motion
(Braun & Gold, 2012; Sinusas, 2012)
Treatment
(Sinusas, 2012)
Knee Surgery
• Transplantation of autologous chondrocytes:
• Used to repair discrete defects in articulate cartilage
• Arthroscopy with debridement:
• Allows visualization of the joint and is appropriate
for patients with mechanical problems such as
locking and giveaway weakness while awaiting
more definitive treatment.
• Osteotomy:
• Transfers the load to the unaffected part of the
knee- high tibial osteotomy effective for OA for
patients with a single compartment of a varus
malaligned knee
• Arthroplasty:
• Including unicompartment, patellafemoral, total joint
in which they replace the damaged cartilage with
metal or plastic
(Ling et al., 2009)
Hip Surgery
• Arthroscopy:
• Used to debride labral tears, loose body removal,
osteophyte resection, biopsy, synovectomy , or
lengthening or releasing of iliopsoas or IT band
• Osteotomy:
• Cutting the bone of the femur or pelvis to realign
and fix the bone with plates or screws
• Resection arthroplasty:
• Complete resection of the femoral head without
replacement, salvage procedure for severe hip
infection resistant to antibiotics or failed total hip
arthroplasty with unreconstructable bone defects
(Srinivasan, Tolhurst, Vanderhave, & Doherty, 2010)
Hip Surgery
• Arthrodesis:
• realigns the hip to 5 to 10 degrees of
external rotation and 20 to 30 degrees of
flexion and neutral adduction,
• Total Hip and hemiarthroplasty:
• replacement of the femoral head and or
acetabulum with manufactured components
• Resurfacing arthroplasty:
• replacement of an acetabular component in
addition to resurfacing the femoral head with
resection of the entire femoral head
(Srinivasan, Tolhurst, Vanderhave, & Doherty, 2010)
Post Op Care
• Pain management with multimodal
strategies including
• Epidural or spinal analgesia
• Femoral nerve block
• Periarticular injections
• Patient controlled analgesia
• Oral analgesics
(Maheshwari, Blum, Shekhar, Ranawat, & Ranawat, 2009)
Post Op Care
• Deep Vein Prophylaxis
• Assess for history of bleeding disorders or
liver disease
• Discontinue all antiplatelet agents prior to
surgery
• Use of pharmacological and nonpharmacological devices with high risk
patients
• Mechanical compressive devices with low
risk patients and bleeding disorders
• Practice early mobilization following surgery
• Use epidural, intrathecal and spinal
anesthesia to limit blood loss
(Jacobs et al., 2011)
Post Op Care
• Infection prevention: Antibiotics within one
hour of surgical incision
• A first or second generation Cephalosporin –
cefazolin or cefuroxime with isoxazolyl penicillin
for a substitute
• Clindamycin or Vancomycin should be used in
patients with penicillin allergies
• Vancomycin should be used in patients who are
carriers for MRSA
• Patients with previous joint infections should be
treated with the same antibiotics effective for that
infection
• Patients should not receive antibiotics for more
than 24 hours post surgery
(Hansen et al., 2014)
Health Promotion
• Weight Loss
• Regular Exercise
• Diet
• Proper use of pain medication
• Smoking cessation
• Immunization status
(Stein, 2011)
Prevention
• Prevention of the need for surgery in
osteoarthritis
• Weight loss: Every one pound of weight
loss results in a fourfold reduction in the
load exerted on the knee per step (Ling et al., 2009)
• Prevention of joint injury: Improve
mechanical efficiency for occupations with
repetitive motion, and reduce joint injury in
recreational sports with proper technique
and education
• Estrogen deficiency: Replacement may
reduce the risk of OA
• C-reactive protein : higher levels increase
risk
(Centers for Disease Control and Prevention, 2014)
Outcomes
(Cushner, Agnelli, Fitzgerald, & Warwick, 2010)
Outcomes
• Statistics for total knee and hip arthroplasty
• 85-90% of patients report a good
outcome with absence of pain
• Periprosthetic joint infection rate 1.62.3%
• Pulmonary Embolism rate 0.5 to 0.9%
• Wound infection rates 0.3 to 1.0%
• Bleeding and hematoma 0.94 to 1.7%
• 90 day death rate 0.7 to 2.7%
(Agency For Health Care Research And Quality, 2014)
Follow Up
• Depends on the patient progression and
amount of external support the patient
receives in the way of physical therapy,
home nurse visits, home caregivers, and the
home environment
• First follow up visit in 10 to 14 days for suture
removal
• Total hip replacement follow up is at two
weeks, six weeks and 12 weeks
• Follow up yearly for all joint replacement for
first five years
(Skinner & McMahon, 2014)
Rheumatoid Arthritis
Prevalence of RA
• Affects approximately 1% of the world
population
• Women 1.06% vs men 0.61%
• Peak incidence in women 55-64 years of age
• Peak incidence in men 75-84 years of age
• Associated genetic link to RA
• Highest prevalence:
• American Indian
• Alaskan Indian tribes
(Carmona et al., 2002; U.S. Department of Health and Human Services, 2012)
Prevalence Globally of RA
(Shah & Clair, 2012)
Prevalence of Rheumatoid Arthritis
(Google Images, 2014)
Pathophysiology
• Systemic chronic autoimmune disease causing
inflammation of the connective tissue that affects
synovial tissue, cartilage and bones.
• Early disease
• Synovium becomes markedly hyperplastic and
edematous.
• Progression of RA
• Activation and recruitment of T cells into the joint
result in a complex cascade of inflammatory
responses.
• Accumulation of inflammatory cells, panus
formation, localized osteoporosis, bony erosions,
and destruction of periarticular structures.
(Young, 2009)
Pathophysiology
• Rheumatoid synovitis is accompanied by the
accumulation of inflammatory joint fluid with
elevated white cell count
• Proteins that have been implicated in the
inflammatory process:
• Proinflammatory cytokines interleukins
• Tumor necrosis factor
• Metalloproteinases transforming growth factor-β
• Granulocyte colony-stimulating factor
• Activated complement components
(Young, 2009)
Pathophysiology
(Google Images, 2014)
2010 Joint Classification Criteria
(Aletaha et al., 2010)
2010 Joint Classification Criteria
• At least 1 joint with definite
clinical synovitis (swelling)
• Synovitis not better
explained by another
disease
• A score of 6/10 is needed
for RA classification
(Aletaha et al., 2010; Google Images, 2014)
Early Disease Presentation
• Common symptoms:
• Morning stiffness > 60 minutes
• ROM improves with activity
• Fatigue
• Low-grade fevers
• Symmetric arthritis
• Rheumatoid nodules
• Radiographic changes
• Mild weight loss
• Most frequently involved joints:
• Wrist
• Metacarpophalangeal (MCP)
• Proximal interphalangeal (PIP)
(Shah & St. Clair, 2012; Google Images, 2014)
Physical Assessment
• Progressive deformity and
decrease in ROM
• Joint swelling and/or
tenderness
• Early manifestations usually
start in the small bones:
• Hands
• Feet
• Flexor tendon tenosynovitis
• Reduced grip strength and
ROM
• “Trigger Finger”
(Shah & St. Clair, 2012; Google Images, 2014)
Progression of Physical Assessment
• Late manifestations progress to
larger bone involvement and
increased debility
• Temporal mandibular joint
• Atlantoaxial cerval spine
• Compressive myelopathy and
neurological dysfunction
• Compression of C1 on C2
• These complications have
decreased significantly due to
treatment
(Shah & St. Clair, 2012)
Extraarticular Manifestations
• Arise in active, untreated or inadequately
treated disease
• Affects multiple organ systems
• Can occur prior to arthritic symptoms
• Occurs more in smokers
• Early onset disability
• Will test positive for serum rheumatoid factor
(Shah & St. Clair, 2012)
Extraarticular Manifestations
(Shah & St. Clair, 2012)
Extraarticular Manifestations
•
•
•
•
•
•
•
•
•
Skin: nodules - extensor surfaces, pressure points
Bone: osteoporosis
Blood: anemia, Felty’s syndrome, lymphoma, leukemia
Eyes: scleritis, episcleritis, keratoconjunctivitis sicca –
secondary Sjögren syndrome
Heart: CAD, atherosclerosis, MI, pericarditis, myocarditis,
cardiomyopathy, mitral regurgitation
Peripheral neuropathy
Rheumatoid vasculitis
Neuro: cervical myelopathy
Endocrine: hypoandrogenism
(Shah & St. Clair, 2012)
Extra-articular Manifestations
Lungs:
• Interstitial lung disease
• Bilateral infiltrates
• Honeycomb pattern
•
•
•
•
PFTs – Restrictive pattern
Fibrosis
Bronchiectasis/Bronchiolitis
Rheumatoid nodules
• Solitary
• Multiple
• Often in conjunction with
cutaneous nodules
• Exudative pleural effusions
(Shah & St. Clair, 2012; Google Images, 2014)
Differential Diagnosis
•
•
•
•
•
•
•
•
•
Infectious arthritis
Parvovirus B19 (Fifth disease)
Hepatitis B or C
Infective endocarditis
Mycobacterium tuberculosis
Septic arthritis
Lyme disease
Reactive arthritis
Multicentric reticulocytosis
(Shah & St. Clair, 2012)
Differential Diagnosis
•
•
•
•
•
•
•
•
•
•
Osteoarthritis
Gout/Pseudogout
Psoriatic arthritis
Ankylosing spondylitis
Inflammatory bowel disease
Fibromyalgia
Lupus
Hypothyroidism
Polymyalgia rheumatica
Sarcoidosis
(Shah & St. Clair, 2012)
Diagnostic Laboratory Studies
• Anti-cyclic citrullinated peptide antibody
(ACPA or anti-CCP)
• Helps confirm diagnosis and prognosis, high
sensitivity, positive earlier than RF
• Rheumatoid factor (RF)
• Useful in differentiating RA from other chronic
inflammatory arthritides
• C-reactive protein and erythrocyte sedimentation rate
• Assess disease activity
• Synovial aspirate
• Inflammatory changes and white blood cells
(Nicoll,2012)
Treatment and Monitoring
• NSAIDS and High Dose Salicylates
• Pain and mild inflammation, do not alter
disease course
• Monitor:
• Bleeding
• Renal toxicity
• GI distress
• Avoid in pregnancy
(The Medical Letter, 2012)
Treatment and Monitoring
• Disease Modifying Antirhematic Drugs
(DMAD)
• Corticosteroids
• Methotrexate (Trexall), leflunomide (Arava)
sulfasalazine (Azulfidine)
• Hydroxychloroquine (Plaquenil) - Antimalarial
• Monitor:
• GI Distress
• Increased risk for infection
• Heptotoxicity
• Aplastic anemia
• Agranulocytosis
• Steven’s Johnson’s Syndrome
(The Medical Letter, 2012)
Treatment and Monitoring
• Biologic Response Modifiers
(TNF - inhibitors)
• Newer class that target pathways
responsible for progression and symptoms
of RA
• Etanercept (Enbrel), Inflixmab (Remicade),
Adalimumab (Humira)
• Montior:
• TB
• Hep B
• Infection
• Avoid in heart failure
• Avoid in demyelinating disease
• Avoid in pregnancy
(The Medical Letter, 2012)
Health Promotion and Prevention
• Immune system suppression awareness
• Must check for TB prior to drug initiation
• Routine assessment for infection, hypertension,
hepatic dysfunction and pulmonary abnormalities
• Vision screening
• Pregnancy screening prior to treatment
• Plaquenil only DMAD approved in pregnancy
• Vaccination
• Must immunize against influenza, pneumonia,
hepatitis B and herpes zoster
• Live vaccines should be given one month prior to
treatment
(The Medical Letter, 2012)
Health Promotion and Prevention
• Routine assessment:
• Cardiac
• 40% of RA patients die from
cardiovascular disease
• Increased risk for MI and stroke due
endothelial dysfunction
• Pulmonary
• Skin
• Osteoporosis
• Smoking cessation
• Weight management
(Dhawan & Quyyumi, 2008)
Outcomes and Follow Up
• Routine monitor of LFTs, CBC and
Creatinine
• Monitor once a month for first 6
months, then every 6 to 8 weeks
• Monitor general health concerns,
comorbidities and quality of life
• Assess medication doses and monitor for
side effects
(Dhawan & Quyyumi, 2008)
Septic Arthritis
Pathophysiology
• Bacterial deposits cause an inflammatory
reaction of the synovial membrane
• Synovium does not have a basement
membrane
• Becomes hyperemic and infiltrated with
rapidly progressing inflammatory cells
• Inflammation develops from acute to
chronic within a few weeks
(Mascioli & Park, 2013)
Pathophysiology
• Inflammatory and infectious cascade that can
begin depleting the matrix within 2 days after
inoculation
• Hyperplasia develops in 5-7 days
• Degradation of the matrix appears within 4-6
days resulting in destruction of articular
cartilage
• The articular cartilage can have complete
destruction in approximately 4 weeks
(Abelson, 2009; Mascioli & Park, 2013; Matteson & Osmon, 2012)
Etiology
• Hematogenous spread: carried by the
bloodstream (e.g. indwelling catheters)
• Inoculation or direct invasion: trauma,
accidents, bites, surgery or adjacent
infection invading the joint (e.g.
osteomyelitis)
• Rarely inoculation from arthroscopy or
arthrocentesis
(Abelson, 2009; Matteson & Osmon, 2012)
Etiology
(Kherani & Shojania, 2007, p. 1606)
Causative Organisms
• Staphylococcus aureus
• Most common cause of infection
• Contain collagen receptors, which are thought to
contribute to the infection of the joints
• Expression of adhesions, microbial surface
proteins, help form biofilms that coat prostheses
and make effective treatment more difficult
• Increase expression of protein A, which
interferes with the host immune opsonization
and phagocytosis
• Group A streptococcus
• Enterobacter
(Mascioli & Park, 2013; Raukar & Zink, 2014)
Causative Organisms
• Neisseria gonorrhoeae
• Cause of about 75% in healthy, sexually
active young adults
• Although septic arthritis develops in only 3%
of those infected with N. gonorrhoeae
• Presents differently
• often polyarticular and may have papular
rash
• joint cultures are usually negative,
however cultures from pharynx or urethra
may be positive
• Polymerase chain reaction (PCR) may be
helpful
(Mascioli & Park, 2013)
Causative Organisms
• Haemophilus influenza was a common
cause for children, but has declined
drastically since the use of H. influenza b
vaccine
• Decreased by 70-80%
• Other:
• Mycobacteria and fungi
• Gram-negative bacilli often in neonates,
elderly, & immunocompromised patients
(Abelson, 2009)
Causative Organisms
• Kingella kingae may be more common than
originally thought
• Difficult to recover on solid media by joint
culture
• Salmonella
• Increased likelihood in Systemic lupus
erythematosus
• Pseudomonas
• In those with history of IVDU
(Mascioli & Park, 2013)
Causative Organisms
(Raukar & Zink, 2014, p. 1834)
Prevalence
• General population: 2-10 per 100,000
(Abelson, 2009)
• 20,000 cases per year in the United
States (Cho, Burke, & Lee, 2014)
• 8%-27% present as bacterial acute
monoarthritis (Cho, Burke, & Lee, 2014)
• Rheumatoid arthritis population: 30-70 per
100,000 (Abelson, 2009)
• 50% of cases involve the knee joint (Abelson,
2009)
Risk Factors
•
•
•
•
•
•
•
•
Diabetes
Alcoholism
Cirrhosis
Uremia
Cutaneous ulcers
Skin infections
IV drug use
Indwelling IV
catheters
• RA
• OA
• Low socioeconomic
status
• Advanced age
• Cancer
• Immunosuppressive
therapies
• Prosthetic joints
• Corticosteroid
injections
Charcot Foot
http://trufitusa.com/files/Patient_Education_PICS/patient_ed/CharcotFoot1.png
http://contentwithpictures.com/wp-content/uploads/2013/04/charcot-foot.png
Corticosteroid Injections
(Murdoch & McDonald, 2007, p. 2)
Signs & Symptoms
• Usually monoarticular but as many as 22%
can be polyarticular
• Hot, swollen, tender joint with decreased
range of motion
• Fever is an unreliable sign
• Chills are uncommon
• Symptoms are diminished in the elderly,
immunocompromised, and IV drug abusers
• Symptoms typically less than 2 weeks
although can be delayed by low virulence
organisms
(Cho, Burke, & Lee, 2014; Mathews, et al., 2008)
Signs & Symptoms
• More common in large
joints
• 60% affecting the hip or
knee
• About 50% cases involve
the knee
• Multiple joints occur in
15% of cases
http://www.onmedica.com/getresource.aspx?resourceid=0f058d22e44f-42cb-8907-b32acf83a1af
(Mathews, et al., 2008)
Other Joints Infected
• Nondiarthrodial joints, are
usually associated with IV
drug abuse or IV
catheters for medical
treatments
• Symphysis pubis is
associated with prior UTI,
pelvic malignancy, IV
drug use, or vigorous
weight bearing physical
activity such as longdistance running in
females
(Matteson & Osmon, 2012; Google Images, 2014)
Physical Assessment
• The joint is held in the position that allow for
maximal joint space
• Accommodate for increased fluid
• Increased pain with movement
• regardless of passive or active ROM
(Cho, Burke, & Lee, 2014)
Diagnostic Tests Per Guidelines
• Aspirate synovial fluid:
• gram stain and culture prior to initiation
of antibiotics (anticoagulation therapy is
not a contra-indication)
• Prosthetic joint: always refer to orthopedic
surgeon
• Polarizing microscopy to evaluate crystals
in all synovial fluid
(Mathews, et al., 2008)
Diagnostic Tests
• “Neither the absence of organisms on Gram
stain, nor a negative subsequent synovial
fluid culture, excludes the diagnosis of
septic arthritis” (Mathews, et al., 2008, p. 2)
• Key point: if high clinical suspicion of septic
arthritis based on clinical presentation, treat
as septic arthritis until proven otherwise!
(Mathews, et al., 2008; Weston & Coakley, 2006)
Additional Tests
• Blood cultures should always be drawn at the same
time as joint aspiration
• White cell count (WCC), erythrocyte sedimentation
rate (ESR), C-reactive protein (CRP)
• Again, the absence of elevated WCC, ESR, or
CRP does NOT exclude the diagnosis
• Urea, electrolytes, liver function measurements for
detection of end organ damage (a poor prognostic
indicator) and renal function tests that may influence
antibiotic treatment
• Other tests as indicated by H&P: genitourinary,
respiratory tract, cervical, urethral, or other infection
(Mathews, et al., 2008)
Imaging
• Plain radiographs
• no benefit in diagnosis, however does
provide baseline for future joint damage
• Scintigraphy and magnetic resonance imaging
(MRI): distinguish sepsis from OA but cannot
differentiate sepsis and inflammation
• not recommended for a hot swollen joint
• MRI is preferred for advanced imaging to detect
osteomyelitis that may require surgical
treatment
• Ultrasound or CT may be needed to aspirate
septic joints such as the hip
(Mathews, et al., 2008)
(Abelson, 2009, p. 1159)
Recommend joint aspiration to dryness as often as required
(Abelson, 2009, p. 1159; Mathews, et al., 2008)
http://www.dealwitharthritis.com/wp-content/uploads/2013/10/septic-arthritis-treatment.jpeg
Synovial Fluid
(Kherani & Shojania, 2007, p. 1607
(Cho, Burke, & Lee, 2014, p. 497)
Differential Diagnoses
• Crystal-induced arthritis (gout, calcium
oxalate, pseudogout, hydroxyapatite crystals)
• Calcium Pyrophosphate Deposition Disease
• Infectious arthritis (bacterial, fungal,
mycobacterial, spirochetes, virus)
• Rheumatic fever
• Inflammatory arthritis (Behcet syndrome,
rheumatic arthritis, sarciod, systemic lupus,
erythematosus, still disease, seronegative
spondyloarthropathy, ankylosing spondylitis,
psoriatic arthritis, reactive arthritis,
inflammatory bowel disease-related to arthritis,
systemic vasculitis)
(Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011)
Differential Diagnoses
•
•
•
•
•
•
•
Osteoarthritis
Avascular necrosis
Fracture
Hemarthrosis
Hyperlipoproteinemia
Meniscal tear
Systemic infection (bacterial endocarditis,
HIV)
• Tumor (metastasis, pigmented villonodular
synovitis)
(Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011)
Nongonococcal Arthritis
Treatment
•
•
•
•
•
•
•
Nongonococcal arthritis
Gram-positive Cocci
80% of patients, primarily older adults
Acute in nature
Synovial fluid are 90% positive
Blood cultures are only positive 50%
Staphylococcus aureus 40% and
streptococcus 28% most identified GPO
• Typically associated with IVDU, cellulitis,
abscesses, endocarditis, and chronic
osteomyelitis
(Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011)
Nongonococcal Arthritis
Treatment
• MRSA
• CA-MRSA is emerging, ranges between 525% of bacterial infections
• Tend to affect older people, primarily shoulder
joints
• Gram-negative bacilli
• Causative organisms pseudomonas
aeruginosa and E. coli
• 14% to 19% of septic arthritis patients
• Mostly related to invasive urinary tract
infections, IVDU, older population,
immunocompromised patients, and skin
conditions
(Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011; Mathews et al., 2008)
Nongonococcal Arthritis
Treatment
• Recommended IV antibiotic therapy for Grampositive and negative cocci:
• Vancomycin 15mg/kg IV every 12 hours and
ceftriaxone 1 gm IV every 24 hours are good
initial treatment
• If pseudomonas is suspected, Cefepime 2 gm
is given in place of ceftriaxone
• Treatment for Nongonococcal infections, IV
antibiotic therapy for at least two weeks,
followed by one to two weeks of oral
antibiotics, tailored to the patent response
(Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011; Mathews et al., 2008)
Gonococcal Arthritis Treatment
• Disseminated neisseria gonorrhoeae
• Young, healthy, sexually active adults
• Various clinical musculoskeletal clinical
presentation, with or without associated skin
conditions
• 25-70% of blood cultures positive, when
compared Nongonococcal infections
• If Gonococcal infections are suspected,
cultures should be taken from infected source
(urethra, rectum, cervix, pharynx)
• PCR test has a high specificity 96%, this may
be beneficial in culture negative patients, but
present with a septic arthritis picture
(Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011; Mathews et al., 2008)
Gonococcal Arthritis Treatment
• Treatment of Gonococcal arthritis
• IV antibiotics for one to three days, thirdgeneration cephalosporin (usually ceftriaxone
1-2 gm daily)
• If the patient responds well, IV therapy can be
switched to oral antimicrobial therapy for
seven to 14 days
• Cefixime 400 mg po BID or amoxicillin 500 to
850 mg po BID
• Doxycycline and or azithromycin can be
considered if the patient is positive for
chlamydia
(Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011; Mathews et al., 2008)
Other Types of Exposure to Septic Arthritis
http://www.aafp.org/afp/2011/0915/p653.pdf
Pathogen Specific History and Organisms
(https://www.med.unc.edu/tarc/events/event-files/septic%20arthritis%20management.pdf)
Other Types of Treatment
• Treatment of fungal arthritis includes an azole
or parental amphotericin B six to 12 weeks
(Brusch, 2014)
• Lyme arthritis responds well to ceftriaxone IV
or oral doxycycline
• Repeat of joint aspiration is successful during
the first five days of treatment to monitor WBC
count, polymorphonuclear cell count, Gram
stain, and cultures
• Arthroscopic drainage increases outcomes
and reduces morbidity
• Consult Rheumatologist or Orthopedic
surgeon
(Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011; Mathews et al., 2008)
Treatment Algorithm
https://www.med.unc.edu/tarc/events/event-files/septic%20arthritis%20management.pdf
Health Promotion/ Prevention
• Inform your doctor and dentist about a
prosthetic joint prior to any type of procedure
• Educate the patient of signs of infections
• HIV or immunocompromised patients require a
therapeutic relationship with their PCP to
discuss antibiotics prior to a procedure,
regular visits to monitor for joint or skin
infections, and any slow healing cuts or sores.
• Up to date vaccinations
• Traveling out of the country or to another
state; you may be exposed to different insects
or require vaccinations
(CDC, 2014)
Health Promotion/Prevention
• IVDU- this is the most common way to
introduce a foreign bacteria into your body,
which can lead to infective arthritis. IVDU are
at higher risk for developing recurrent joint
infections. Bacteremia can increase the risk for
infective arthritis
• Weight management and balanced diet
• Practice safe sex, use protection
• Ensure patients have access and availability to
evidenced-based arthritis interventions
addressing basic information, weight
management, injury prevention, and physical
activity tips
(CDC, 2014)
Outcomes for Septic Arthritis
• Mortality rates ranges 10-20%, depending
upon comorbidities
• Greater than 65 years or older and infection in
shoulder, elbow, or multiple sites are factors
associated with increased mortality
• Pneumococcal septic arthritis patients
mortality rates ~ 20%, but regain almost full
function of their joint
• S. aureus causative agents only regain 4650% of their baseline joint function upon
completion of antimicrobial therapy
(Shirtliff & Mader, 2002; Horowitz, Katzap, Horowitz, & Barilla-LaBarca, 2011)
Outcomes for Septic Arthritis
• The high rate has not changed significantly
over the past 40 years due to the difficultness
of the diagnosis
• Treatment initiated after seven days or more
demonstrate a worse outcome
• Prompt diagnosis and initiation of empiric
antimicrobial therapy is utmost importance to
improve quality of life and outcomes
• Early involvement in therapy and aggressive
movement of the joint increases optimal
outcomes
• An extended time > 6 days required to sterilize
the joint is another indicator of poor prognosis
(Shirtliff & Mader, 2002)
Follow-up
• Follow-up appointments are pertinent to
maintain to monitor for improved or worsening
of the joint
• Laboratory data will be monitored weekly for
adverse reactions secondary to IV antibiotics
(CBC, BMP, LFT’s, CRP, ESR)
• Most Patients will have an indwelling PICC
line, which increases an individuals risk for
bacteremia, close monitoring of site and
presence of cord
• Discuss any questions or concerns with your
ACNP to ensure understanding of the disease
Question #1
All of the following regarding OA are true
EXCEPT:
A: Evidence of bilateral swelling and warmth
affecting only the wrists
B: Joint space narrowing and osteophytes at the
proximal and distal interphalangeal joints on xray
C: Pain that becomes worse when preparing
meals
D: Stiffness that is worse after brief periods of rest
with occasional locking of the more affected
joints
Question #1 Answer
A: Evidence of bilateral swelling
and warmth affecting only the
wrists
• Joints of the hands are most commonly
affected, but the wrist is uncommon
• OA can also occur in the hips, knees, cervical
and lumbosacral spine
• Pain occurs with joint use and relieves with
rest
• Joint stiffness usually occurs after periods of
rest
Question #2
47 y.o. female presents complaining of pain in
her hands in the mornings. She drops things
and feels she has difficulty maintaining her
grip. X-ray reveals bilateral soft tissue
swelling of her metacarpals. The ACNP
knows additional testing findings will include:
A: Rheumatoid Factor (RF) +
B: Heberden’s nodes +
C: Anti-CCP Antibodies +
D: Antinuclear antibody (ANA +)
Question #2 Answer
C: Anti-CCP Antibodies
• Anti-CCP has a higher sensitivity than RF,
and is more likely to be positive early in
disease.
• Heberden’s nodes are present in
osteoarthritis.
• ANA is not positive in RA.
Question #3
Which of the follow statements is NOT true
regarding RA?
A: RA results in joint degeneration, which causes
deterioration of bone formation at the joint
surfaces.
B: Patients with RA have on average an onset of
cardiovascular disease 10 years earlier than
those without RA
C: Morning stiffness and joint pain are
characteristic symptoms
D: RA is a chronic inflammatory disease of the
synovial joint and tendon sheath
Question #3 Answer
A: RA results in joint
degeneration, which causes
deterioration of bone formation
at the joint surfaces.
• Joint degeneration is consistent with
osteoarthritis, not RA.
Question #4
66 y.o. with a history of RA and pseudogout
presents with night sweats and a 2-day history of
left knee pain. Temp is 101.5. WBC is 16,000.
Tap of knee shows 168,000 WBCs, 99%
neutrophils and crystals. Gram stain shows gram
+ cocci.
Management for this patient includes all of the
following EXCECPT:
A: Blood cultures
B: Glucocorticoids
C: Needle aspiration of joint fluid
D: Orthopedic surgery consult
E: Vancomycin
Question #4 Answer
B: Glucocorticoids
• Crystals are suggestive of active pseudogout
• Septic arthritis (SA) is the patient’s major
problem with a joint leukocyte count >100,000
and a positive gram stain.
• SA should be treated aggressively with
antibiotics, a surgical consult should be
completed for possible joint drainage and
cultures should be sent to assess for
bacteremia.
Question #5
• 24 y.o. admitted with fever, swollen and painful
right knee.
• 3 weeks earlier she had systemic symptoms:
fever, chills and migratory joint pains. Rash over
her chest and hands.
• She has no significant history. Clean
arthrocentesis.
A: Bacterial cultures of the cervix
B: Bacterial cultures of the synovial fluid
C: Blood cultures
D: Rheumatoid factor
Question #5 Answer
A: Bacterial cultures of the cervix
• The patient’s history is consistent with septic
arthritis due to a gonococcal infection.
• Diagnostic procedure is to culture the infected
mucosal site, including the cervix, urethra or
pharynx.
• Neisseria gonorrhoeae is responsible for about
70% of acute arthritis infections in patients
younger than 40.
• Patients usually present with fever, chills,
migratory arthralgias and a rash 3 weeks prior to
monoarticular septic arthritis.
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