SLR - June 2021 - M. Jared Davis

Epidemiology, Management, and Outcomes of Large and Small Native Joint Septic Arthritis in Adults

Reference: McBride S, Mowbray J, Caughey W, Wong E, Luey C, Siddiqui A, Alexander Z, Playle V, Askelund T, Hopkins C, Quek N, Ross K, Orec R, Mistry D, Coomarasamy C, Holland D. Epidemiology, Management, and Outcomes of Large and Small Native Joint Septic Arthritis in Adults. Clin Infect Dis. 2020 Jan 2;70(2):271-279.

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: M. Jared Davis, DPM
Residency Program: Southern Arizona Veterans Affairs Health Care System – Tucson, AZ

Podiatric Relevance: Septic Arthritis (SA) is semi-frequently seen and treated by Podiatric Physicians, however literature on Small Native Joint Septic Arthritis (SNJSA) are underrepresented, as most focuses on Large Native Joint Septic Arthritis (LNJSA). The purpose of this study is to describe the epidemiology, management, and outcomes of SNJSA and LNJSA.

Methods: This was a retrospective review of electronic documentation for patients admitted between 2009 and 2014 meeting criteria of >16 years of age and admitted to the hospital for greater than 24 hours. This study focused on native joints and excludes prosthetic joint patients. The following anatomical joints were defined as “small joints”: interphalangeal, metacarpophalangeal, metatarsophalangeal, acromioclavicular, and sternoclavicular joints, all other joints were defined as “large joints”. Incidence was calculated using MMH-catchment resident episodes and population data from the New Zealand census information from 2006-2013.

Treatment failure was defined as death within 90 days of admission, relapse, reinfection, amputations, excisions or arthrodesis and readmission for same joint septic arthritis. Statistical analysis was conducted to investigate associations between outcomes and various factors.

Results: Included in the study were 543 episodes of NJSA (302 LNJSA and 250 SNJSA). Of these, only 40 percent had a positive synovial fluid culture. There was a higher incidence in the LNJSA group than the SNJSA group (13 versus 8 in 100,000 per year). LNJSA also occurs in older and more comorbid patient with greater rates of treatment failure and mortality. (23 percent versus 12 percent). Incidence was found to rise with age in the LNJSA group only and in both groups in socioeconomic depravation. It was noted that males and tobacco smokers are overrepresented. The most commonly involved joints were the knee (21 percent) and the hand IPJ (20 percent). Staphylococcus aureus was the most common pathogen seen in 53 percent of cases. The mean antibiotic duration was 25 days for the SNJSA group and 40 days for the LNJSA group. Treatment failure was independently associated with the LNJSA group as well as age, intra-articular non-arthroplasty prosthesis and total number of surgical procedures.

Conclusions: This study is the largest contemporary study of adult NJSA. The study notes that SNJSA has better outcomes than the LNJSA and may be able to be safely treated with a shorter duration of antibiotics. Incidence is high with significant variation. Microbiological NJSA often underestimates the case numbers as it often excludes SNJSA. 

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