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Ortho Infectious

Orthopedics

QuestionAnswer
Inf arthritis: pathophys Bac enter jt fr bloodstream; surround infected ST / bone; synovium vascular / lacks basement mem, bac access to jt; bac trigger inflame response; cartilage / bone destruction
Inf arthritis incidence 2-5/100,000 (bimodal: kids, >50 yo) (in RA: 28-38/100,000)
Inf arthritis risk factors DM, EtOH, CRF, AIDS, TB; prosthetic joints / recent surg, trauma, older, immunosupp tx, malig, exp to animals; low SES, IVDU
Inf arthritis: characterize Large bones > small bones (usu knee); usu monoarticular (poly <20%)
Inf arthritis Microbiology: gonococcal and nongonococcal
Gono arthritis: incidence 2/3 of infxs arth in pts <40; DGI sequela; F>M (higher risk w/ menses & PG)
Gono arthritis: 2 presentations 1. rash, fever, chills, migratory tenosynovitis of knees, ankles, wrists, feet and hands (30-60%) (some = skin lesions: papulovesicular or hemorrhagic, varying size); 2. monoarticular process: KNEE; hip, ankle, wrist or elbow
Gono arthritis: labs syn fluid, blood cx not too helpful; cx likely infected mucosal surfaces (cervix, anus, oropharynx); WBC usually normal
Gono arthritis: Tx: hospitalize pt; ceftriaxone 1gm (IM or IV) q 24 hours until clinical improvement; po cefixime or cefpodoxime > 1 wk
Non-gono arthritis: agents Usu S. aureus (or strep A/B; SP, coag neg staph)
Non-gono arthritis: common hosts RA, diabetes, immunosuppressive drugs
Non-gono arthritis: affected joints 90% monoarticular; knee>hip>shoulder>wrist>elbow; following bite: small bones / joints of hands / feet; IVDU: spine, SI, sternoclavicular joints
Non-gono arthritis: Clinical presentation: mod - severe pain surrounding joint; effusion, spasm, warmth & erythema; chills & fever common (but may be absent)
Essential for dx / tx of infxs arthritis: synovial fluid (usu pos as are cx) (Blood cx pos in 50%)
Nongono arthritis gram pos Rx: Nafcillin or cefazolin (vanc for MRSA)
Nongono arthritis: gram neg esp Enterobacteriaceae; IVDU; & neutropenic (also pseudomonas) ; ceftazidime or genta; IV 2wks & po 4 wks
Other nongono arthritis agents spirochetal (congenital: long bones; secondary: diffuse); Lyme; Myco TB
TB arthritis: Clin presentation pain & swelling dev in affected joint over mos / yrs; knee & hip > ankle, shoulder, elbow;
TB arthritis: occurs as: part of disseminated primary disease or through reactivation; usu a chronic monoarticular process
TB arthritis: labs Syn fluid cell counts may be lower (than other infxs arth); AFB found in syn fluid in <20%
TB arthritis: Tx same as for pulmonary dz: multiple agents for at least 9 months
Lyme arthritis: incidence 70% of untreated Lyme disease pts develop arthritis
Lyme arthritis: 3 dz patterns 40% intermittent monoarticular / oligoarticular process: involves knee +/- other large joints; 20% pattern of waxing / waning polyarthralgias; 10% inflame synovitis: evolves into erosions & joint destruction
Lyme arthrtitis: dx clinical; serologic (90% Abs to B. burgdorferi)
Lyme arthrtitis: Tx oral doxycycline or amox x 1-2 mo; or IV ceftriaxone for 2-4 wks
Viral arthritis: most common agents Hep B & C, rubella, & parvovirus (parvo can be confused with RA)
Viral arthritis: findings Nondestructive; usually self-limited; No specific tx, except supportive
Fungal arthritis often immunocompromised pts; chronic indolent course
Fungal arthritis: etiologies: endemic dimorphic fungi in gardeners / occupations w/exp to soil
Fungal arthritis: Candida surg procedures, joint injections, critical illness (knee, hip or shoulder); IVDUs: spine, SI joints
Fungal arthritis: other agents: Aspergillus, Cryptococcus, Pseudallescheria, dematiaceous fungi
Fungal arthritis: Labs cx joint fluid may be neg; Complement fixation, antigen assays, synovial bx: all dx important
Fungal arthritis: Tx Ampho B (IV +/- intra-art)
Infxs arthritis: prosthetic joint: early Usu Staph epi
Infxs arthritis: prosthetic joint: late Usu Staph aureus (often indolent presentation)
Infxs arthritis: prosthetic joint: dx Aspiration and growth of organism
Infxs arthritis: prosthetic joint: Tx aggressive debridement (early), removal of prosthesis (late), and prolonged Abx tx
Prosthetic joint infection: on xray usu appears as: increased lucency around prosthesis
Prosthetic joint infection: rates highest among: pts w/ RA, h/o prior joint surgery, immunosuppressive therapy
Prosthetic joint: prophylaxis? not recommended (but consider for pts w/ inflame arthritis, DM, immunosuppression or within 2 yrs of joint replacement)
Bone marrow infection due to blood-borne pathogens = osteomyelitis
Osteo often affects whom? Kids (M > F)
Osteo bugs S aureus (no. 1); GAS (kids); GBS & E coli in neonates
Osteo bugs in IVDU SA, Pseudomonas, Serratia, Candida
Osteo bugs after open fx or ORIF SA, Pseudomonas, coliforms
Osteo bugs in pts with sickle cell dz Salmonella
Imaging for osteo X-rays (ST swelling, demineralization (10 days - 2 wks), dead bone w/surrounding granulation tissue, periosteal new bone growth later); MRI shows changes earlier; CT radiolucent in cancellous bone & periosteal elevation
Osteo labs Elevated WBC and ESR. CRP most sensitive to monitor course
Chronic osteo: fistulous tracts may develop into: epdermoid carcinoma
Chronic osteo: CT is excellent to detect: sequestra (localized mass of bone, denser than surroundings), cortical destruction, ST abscess, sinus tracts
Septic joint/osteo: orgs: bone Bone: GAS, S. aureus
Septic joint/osteo: orgs: joint H. flu, GAS, E. coli, NG
Septic joint/osteo: sx Fever, joint or bone pain, leukocytosis
Osteomyelitis after stepping on nail wearing sandals or tennis shoes Pseudomonas aeruginosa (foam padding in shoes)
Septic Joint & Osteomyelitis: frequently following: URI
Septic Joint & Osteomyelitis: Common Organisms: Bone: GAS, S. aureus
Septic Joint & Osteomyelitis: Common Organisms: Joint: H. flu, GAS, E. coli, N. gono
Septic Joint & Osteomyelitis: Dx: Bone scans localize osteomyelitis; Joint aspiration to ID organism
Septic Joint & Osteomyelitis: Sx: Fever, joint or bone pain, leukocytosis
Septic Joint & Osteomyelitis: Dx: Bone scans localize osteomyelitis; Joint aspiration to ID organism
Septic Joint & Osteomyelitis: Rx: Parenteral Abx, I&D
Infection: prevalence in LBP Only .01% of all causes of LBP
Infection: clin features Fever, leukocytosis; hx of other infections, hematogenous spread
Infection: includes: Osteomyelitis; Septic Discitis; Paraspinous abscess; Shingles
Created by: Abarnard
 

 



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