Rce Educationguide Ch65 Septicarthritis

© ©
Does This Adult Patient Have Septic

Arthritis?
The Rational Clinical Examination

Copyright © American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.
Overview ©
• Case Scenarios • Hands On!

• Context • Back to the
Case Scenarios
• The Evidence
• The Bottom Line
• Populations
• Prior Probability
• Reference Standard
• Test Characteristics

Case Scenario 1 ©
• A 48-year-old woman with rheumatoid

arthritis (RA) is treated with long-term
low-dose prednisone
• Presents to the ED with swollen, tender,
red left knee for 2 days
• No prior swelling, rash, or uveitis
• No recent trauma, surgery, illegal drug
use, or risky sexual behavior

Case Scenario 1 ©
Physical examination
• Afebrile
• Left knee effusion
Laboratory results
• WBC 11 000/μL
• ESR 55 mm/hr
Should you do an arthrocentesis?

Case Scenario 1 ©
• Arthrocentesis performed
• Gram stain negative
• Synovial WBC 48 000/μL
• Culture pending

Case Scenario Questions ©
• What is the likelihood that this patient

has septic arthritis?
• What are the other possible causes for
her symptoms?
• How useful are clinical findings and
results of laboratory tests for making a
diagnosis of septic arthritis?

Case Scenario 2 ©
• An 81-year-old man with diabetes

mellitus and hypertension presents to
clinic with 2 days of left ankle pain
• He has difficulty walking and notes an
exquisitely tender ankle
• Prior episode was clinically diagnosed
as gout

Case Scenario 2 ©
• Febrile to 38.2° C
• Swelling and extreme tenderness of the
dorsal aspect of the midfoot and ankle
• Direct pressure over the ankle confirms
extreme tenderness and swelling

Case Scenario Questions ©

• Can gout and septic arthritis occur
together?
• Should an arthrocentesis be performed
and how will it help with making a
diagnosis?

Why Is Diagnosis Important? ©
Nongonococcal bacterial
arthritis
• The most dangerous and destructive
type of acute arthritis
• May result in irreversible joint damage
within days of onset
• Mortality 7%-15% of hospitalized
patients despite antibiotic
administration

Differential Diagnosis ©
Gonococcal arthritis
• Most common infectious arthritis
• 2-3 times more common in women
• Often with migratory tenosynovitis
• Gram stain positive in <10% and
culture is often negative
• Less destructive than nongonococcal
arthritis; usually rapid, complete
response to treatment
Differential Diagnosis ©
Systemic illnesses
• RA
• Systemic lupus erythematosus
• Reactive arthritis
Many less destructive arthritides

• Crystal induced arthritis: gout and
pseudogout
• Trauma
• Osteoarthritis
Pathogenesis ©
Joint invasion
• Bacteria enter the joint space and
deposit in the synovial membrane
• Spread then occurs to synovial fluid,
leading to inflammation
Microbiological findings
• Streptococci and staphylococci most
common nongonococcal bacteria
• Viruses, other bacteria, fungi
mycobacteria, spirochetes are rare
Clinical Presentation ©
Many conditions mimic presentation

• Nonspecific features of joint pain,
swelling, and stiffness
• Acute onset
• Chills and fever may be present
Which joints?
• Most often monoarticular
• Large joints, especially the knee,
most common

Who Should Be Evaluated? ©
Populations to evaluate for septic arthritis

• Patients with acutely swollen joints
unrelated to trauma
• Important risk factors
• Recent joint surgery
• Age >80 years
• Diabetes mellitus or RA
• History of hip or knee replacement
• Skin infection
Prior Probability ©
• In patients with an acutely swollen and

painful joint, the probability of septic
arthritis is 8%-27%.

Reference Standard ©
• Synovial fluid culture is the generally

accepted reference standard but is
imperfect (sensitivity 75%-95%)
• Clinical standard used in practice
• Positive Gram stain or blood culture in
patient with acutely painful, swollen joint
• Aspiration of pus from the joint space
• Response to antibiotics sometimes used

Test Characteristics ©
• Sensitivity
• SnN(–)out: Negative tends to rule out
• Specificity
• SpP(+)in: Positive tends to rule in

Test Characteristics ©
• Likelihood Ratio (LR)

• Determined for a particular test result
• Conceptually related to how much more (LR > 1)

or less (LR < 1) likely the disease is, given a
particular test result
• LR = 1 will not change your assessment of the

likelihood of disease, given a particular test result

Using Likelihood Ratios ©
Values of Likelihood Ratio: How much do

they affect probability of disease?
• LR = 1 No effect on likelihood
• LR = 3-10 Disease More Likely

• LR = 0.3-0.1 Disease Less Likely
• LR > 10 Disease More Likely

• LR < 0.10 Disease Less Likely

LR: Impact on Likelihood of Disease ©
LR = 0.01 LR = 100
LR = 0.1 LR = 10
Less Less
LR = 0.2 LR = 5
More
More
Less LR = 0.3 LR = 3 More
Likely Likely Likely Likely
Likely Less More Likely
0 Likely Likely 
Increasing impa ct increasi ng impac t
LR = 1
No
Impact on
Likelihood of
Disease
LR: Impact on Likelihood of Disease ©
LR = 0.01 LR = 100
LR = 0.1 LR = 10
More More
LR = 0.2 LR = 5
More
More
More LR = 0.3 LR = 3 More
Impact Impact LR = 1 Impact Impact
Impact More More Impact

No
0 Impact Impact
Increasing impact
Impact
increasi ng impac t

Nongonococcal Septic Arthritis ©
Risk Factors LR (95% CI)

Skin infection with joint 15 (8.1-28)
prosthesis
Recent joint surgery 6.9 (3.8-12)
Age >80 years 3.5 (1.8-7.0)
Hip or knee prosthesis 3.1 (2.0- 4.9)
Skin infection 2.8 (1.7-4.5)
Diabetes mellitus 2.7 (1.0-6.9)
Rheumatoid arthritis 2.5 (2.0-3.1)
Likelihood Ratio ©
Clinical Finding Sensitivity %

(95% CI)
Joint pain 85 (78-90)
History of joint swelling 78 (71-86)
Fever 57 (52-62)
Sweats 27 (20-34)
Rigors 19 (15-24)

Likelihood Ratio ©
Clinical Finding LR (95% CI)

Presence of fever 0.67 (0.43-1.0)
Absence of fever 1.7 (1.0-3.0)
Serum Laboratory Value
CRP > 100 mg/L 1.6 (1.1-2.5)
CRP ≤ 100 mg/L 0.44 (0.24-0.82)
Peripheral WBC >10 000/μL 1.4 (1.1-1.8)
ESR > 30 mm/h 1.3 (1.1-1.6)
Likelihood Ratio ©
Synovial Fluid Cell Count LR (95% CI)

(/μL)
WBC > 100 000 28 (12-66)
WBC > 50 000 7.7 (5.7-11)
WBC > 25 000 2.9 (2.5-3.4)
WBC < 25 000 0.32 (0.23-0.43)
PMNs ≥ 90% 3.4 (2.8-4.2)

PMNs < 90% 0.34 (0.25-0.47)

Hands On! ©

Nomogram for Interpreting LR ©
• Plot patient’s pretest

probability on left
• Draw straight line
through LR for
given test result
• Line points to
posttest probability

Return to Case Scenario 1 ©
• A 48-year-old woman with RA is treated

with long-term low-dose prednisone
• Presents to the ED with swollen, tender,
red left knee for 2 days
• No prior swelling, rash, or uveitis
• No recent trauma, surgery, illegal drug
use, or risky sexual behavior

• Afebrile
• Left knee effusion
Laboratory results
• WBC 11 000/μL
• ESR 55 mm/hr
Shuold you do an arthrocentesis?

• Arthrocentesis performed
• Gram stain negative
• Synovial WBC 48 000/μL
• Culture pending

Case 1 Questions ©

• What are the other possible causes for
her symptoms?
• How useful are clinical findings and
results of laboratory tests for making a
diagnosis of septic arthritis?

Can You Come Up With an LR? ©
• Yes
• History of RA: LR, 2.5 (2.0-3.1)
• Synovial WBC > 25 000/μL: LR, 2.9 (2.5-

3.4)
• Fever: LR, 1.7 (1.0-3.0)
• Elevated ESR: LR, 1.3 (1.1-1.6)

Likelihood Ratio ©
History of RA,
LR = 2.5
18% Pretest ~36% Posttest

probability of septic probability
arthritis

Range of Prior Probability ©
History of RA,
LR = 2.5
18%-48% Posttest
probability
8%-27% Pretest
probability of
septic arthritis

Likelihood Ratio ©
Synovial fluid
WBC > 25 000/μL,
LR+ = 2.9 ~62% Posttest
probability
36% Pretest
probability of septic
arthritis

Resolution Case Scenario 1 ©
• This patient presents with an acute

monoarthritis
• Underlying RA increases her probability
of having septic arthritis
• This, combined with a synovial fluid
WBC count > 25 000/μL, puts the
probability of septic arthritis in the
range of 62%

• The probability of septic arthritis is high

enough and the consequences severe
enough that treatment should be
initiated pending the results of synovial
fluid culture
• Synovial fluid differential WBC count
should also be ordered; if > 90%, this
further supports the probability of septic
arthritis (LR+ 3.4)

• An 81-year-old man with diabetes

mellitus and hypertension presents to
clinic with 2 days of left ankle pain
• He has difficulty walking and notes an
exquisitely tender ankle
• Prior episode clinically diagnosed as
gout

• Febrile to 38.2° C
• Swelling and extreme tenderness of the
dorsal aspect of the midfoot and ankle
• Direct pressure over the ankle confirms
extreme tenderness and swelling

Case 2 Questions ©

• Can gout and septic arthritis occur
together?
• Should an arthrocentesis be performed
and how will it help with making a
diagnosis?

Can You Come Up With an LR? ©
• Yes
• Age > 80 years: LR 3.5 (1.8-7.0)
• Diabetes mellitus: LR 2.7 (1.0-6.9)

Likelihood Ratio ©
Age > 80
years,
LR+ = 3.5

arthritis

Likelihood Ratio ©
Diabetes
mellitus,
LR+ = 2.7

arthritis

• This patient presents with an acute

monoarthritis and fever
• His advanced age (LR+ 3.5) and
underlying diabetes mellitus (LR+ 2.7)
are risk factors for development of
septic arthritis
• Using a pretest probability of 18%, the
probability of septic arthritis is ~40%

• A prior diagnosis of gout (a common

disease) provides an alternative
explanation for symptoms
• Thus, we might choose 8% prior
probability for septic arthritis, which
yield a posttest probability of ~20%
• Arthrocentesis is still warranted to
confirm gout and exclude infection

Likelihood Ratio ©
Diabetes mellitus,
LR+ = 2.7
Age > 80 years,

~19%-23%
LR+ = 3.5 Posttest
probability
8% Pretest probability
of septic arthritis in a
patient with gout

The Bottom Line ©
• In patients with acute arthritis, the

underlying cause is difficult to
determine by clinical history and
examination alone.
• Historical elements, including advanced
age, diabetes mellitus, prior joint
surgery and RA are helpful in increasing
the likelihood of septic arthritis in a
patient with acute onset of joint pain.

The Bottom Line ©
• Arthrocentesis will often be warranted

to evaluate for septic arthritis because
consequences of not treating an
infected joint are severe.
• Synovial fluid WBC count and
percentage of PMNs provide the best
utility in evaluating septic arthritis while
awaiting culture results.

©
This Education Guide slide set

has been created as a part of
The Rational Clinical Examination series
Larry Young, MD
Miami VA Health System
University of Miami Miller School of Medicine
Sheri A. Keitz, MD, PhD

Editor, Education Guides
Septic Arthritis ©
Simel DL. “Septic arthritis—make the diagnosis.” In

Simel DL, Rennie D, Keitz SA, eds. The Rational
Clinical Examination: Evidence-Based Clinical
Diagnosis.
http://www.jamaevidence.com/content/3493542
Margaretten ME, Kohlwes J, Moore D, Bent S. “Does

this adult patient have septic arthritis?” In Simel DL,
Rennie D, Keitz SA, eds. The Rational Clinical
Examination: Evidence-Based Clinical Diagnosis.
http://www.jamaevidence.com/content/3493560

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Does This Adult Patient Have Septic

The Rational Clinical Examination

• Case Scenarios • Hands On!

The Rational Clinical Examination

• A 48-year-old woman with rheumatoid

The Rational Clinical Examination

The Rational Clinical Examination

The Rational Clinical Examination

• What is the likelihood that this patient

The Rational Clinical Examination

• An 81-year-old man with diabetes

The Rational Clinical Examination

The Rational Clinical Examination

• What is the likelihood that this patient

The Rational Clinical Examination

The Rational Clinical Examination

Many less destructive arthritides

Many conditions mimic presentation

The Rational Clinical Examination

Populations to evaluate for septic arthritis

• In patients with an acutely swollen and

The Rational Clinical Examination

• Synovial fluid culture is the generally

• Response to antibiotics sometimes used

The Rational Clinical Examination

The Rational Clinical Examination

• Likelihood Ratio (LR)

• Conceptually related to how much more (LR > 1)

• LR = 1 will not change your assessment of the

The Rational Clinical Examination

Values of Likelihood Ratio: How much do

• LR = 3-10 Disease More Likely

• LR > 10 Disease More Likely

The Rational Clinical Examination

The Rational Clinical Examination

Risk Factors LR (95% CI)

Clinical Finding Sensitivity %

The Rational Clinical Examination

Clinical Finding LR (95% CI)

Synovial Fluid Cell Count LR (95% CI)

PMNs ≥ 90% 3.4 (2.8-4.2)

The Rational Clinical Examination

The Rational Clinical Examination

• Plot patient’s pretest

The Rational Clinical Examination

• A 48-year-old woman with RA is treated

The Rational Clinical Examination

The Rational Clinical Examination

The Rational Clinical Examination

• What is the likelihood that this patient

The Rational Clinical Examination

• History of RA: LR, 2.5 (2.0-3.1)

• Synovial WBC > 25 000/μL: LR, 2.9 (2.5-

• Elevated ESR: LR, 1.3 (1.1-1.6)

The Rational Clinical Examination

18% Pretest ~36% Posttest

The Rational Clinical Examination

The Rational Clinical Examination

The Rational Clinical Examination

• This patient presents with an acute

The Rational Clinical Examination

• The probability of septic arthritis is high

The Rational Clinical Examination