BSR & BHPR, BOA, RCGP and BSAC guidelines formanagement of the hot swollen joint in adults
G. Coakley1, C. Mathews1, M. Field2, A. Jones3, G. Kingsley4, D. Walker5, M. Phillips6,C. Bradish7, A. McLachlan8, R. Mohammed9 and V. Weston10, on behalf of the BritishSociety for Rheumatology Standards, Guidelines and Audit Working Group
KEY WORDS: Septic arthritis, Guidelines, Management.
The clinical presentation of a hot swollen joint is common and has
(1) The synovial fluid must be aspirated, Gram-stained and
wide differential diagnosis. The most serious is septic arthritis,
cultured prior to starting antibiotics (B). Warfarin does not
with a case fatality of 11%. Delayed or inadequate treatment leads
contraindicate needle aspiration (C).
to joint damage. These guidelines focus on the diagnosis and
(2) A possibly infected prosthetic joint should always be referred
management of septic arthritis. Hot swollen joints commonly have
other underlying diagnoses, including crystal arthritis, reactive
(3) Neither the absence of organisms on Gram stain nor a
arthritis and a monoarticular presentation of polyarthritis.
negative subsequent synovial fluid culture excludes thediagnosis of septic arthritis (B).
(4) Specimens must be sent fresh to the laboratory and obtained
Guidelines for managing the hot swollen joint in adults
The guidelines have been developed for use with adults who
(5) Polarising microscopy should always be carried out (B).
develop a hot swollen native joint acutely (typically with ahistory of two weeks or less) affecting any joint except the axial
skeleton. This is an abridged version, which is available in full assupplementary material on the journal website.
(1) Blood cultures should always be taken (B).
(2) The white cell count, erythrocyte sedimentation rate (ESR) and
Symptoms and signs suggestive of septic arthritis
C-reactive protein (CRP) should be measured (B). Inflammatorymarkers are useful for monitoring response to treatment (B).
(1) Patients with a short history of a hot, swollen and tender
(3) The serum urate level is of no diagnostic value in acute gout
joint (or joints) with restriction of movement should be
regarded as having septic arthritis until proven otherwise (B).
(4) Electrolytes and liver function should be measured to detect
(2) If clinical suspicion is high, then it is imperative to treat as
end organ damage because renal function may influence
septic arthritis even in the absence of fever (B).
1Queen Elizabeth Hospital, Woolwich, London, 2Centre for Rheumatic Diseases, Royal Infirmary, Glasgow, 3City Hospital, Nottingham, 4University HospitalLewisham, London, 5Freeman Hospital, Newcastle, 6King’s College Hospital, London, 7Royal Orthopaedic Hospital, Birmingham (representing the BritishOrthopaedic Association), 8Hetherington Group Practice, London SW4, 9Arthritis Care and 10University Hospital NHS Trust, Nottingham (representing theBritish Society for Antimicrobial Chemotherapy), UK.
Submitted 13 March 2006; revised version accepted 4 April 2006.
Correspondence to: Dr Gerald Coakley, Consultant Rheumatologist, Queen Elizabeth Hospital, Stadium Road, London, SE18 4QH, UK.
The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected]
(5) If the history suggests non-articular infection, then appro-
Note: antibiotic choice will need to be modified in light of results of
priate cultures and swabs should be taken prior to starting
Gram stain and culture. This table is based on expert opinion and should
be reviewed locally by microbiology departments. UTI, urinary tractinfection; MRSA, methicillin-resistant Staphylococcus aureus; ITU,
Plain radiographs of the affected joint are of no benefit in
diagnosing septic arthritis but may show chondrocalcinosis. Theyshould be performed as a baseline investigation (C).
(1) Septic joints should be aspirated to dryness as often as
Magnetic resonance imaging is the most appropriate imaging
where required, since it is sensitive in detecting osteomyelitis that
(2) This can be done either through a closed-needle approach or
may require a surgical approach (B).
arthroscopically according to local preferences (C).
In suspected hip sepsis, diagnostic aspiration will usually
(3) If the response is not satisfactory with a closed-needle
require the use of ultrasound or an image intensifier (C).
approach, arthroscopic aspiration should be used (C).
(4) In suspected hip sepsis, arrange early referral for an
orthopaedic opinion. Urgent open debridement is oftennecessary (C).
There is no evidence on which to advise the optimal duration ofi.v. or oral antibiotics. Conventionally, they are given intrave-
Recommendations specific to primary care and the
nously for up to 2 weeks or until signs improve, then orally for 4weeks. Symptoms, signs and acute phase responses are all helpful
in guiding the decision to stop antibiotics. Expert review may berequired if the expected resolution does not occur (C).
(1) The commonest hot joint to present in primary care is the
great toe metatarsophalangeal joint. This is almost always
Summary of recommendations for initial empirical antibiotic
due to gout and can be diagnosed on clinical grounds (B).
(2) Some general practitioners (GPs) regularly aspirate and
inject joints. If they aspirate unexpected cloudy fluid froma joint, they should send the sample with the patient to the
ED and not inject corticosteroid (C).
(3) GPs and ED doctors should refer patients with suspected
septic arthritis to a specialist within the hospital who has the
expertise to aspirate the joint (C).
(4) Patients should be admitted to hospital if sepsis is suspected
(5) If there is doubt about whether sepsis might be present,
intra-articular steroids should not be used (C).
(6) The skills necessary to aspirate a joint in hospitals will
commonly be held by specialists and trainees in ED,
3rd generation cephalosporin.
Discuss allergic patients withmicrobiology—Gram stainmay influence antibiotic choice
(1) Was the joint aspirated at presentation prior to antibiotics? If
(2) Was there a delay in treatment and, if so, why?
(3) Was ESR and CRP measured at diagnosis and serially?
(5) Was the initial antibiotic choice in keeping with the
(6) Was prosthetic joint sepsis managed by orthopaedic
Patient presents with acute increase in pain ± swelling in one or more joints
Empirical antibiotic treatment (as per local protocol)
Alter if necessary once results available
Management of septic arthritis in secondary care
Admit patient to hospital (rheumatology or
Ensure synovial fluid sample is taken, with blood and any other relevant
culture samples prior to starting antibiotics
If there is lack of resolution despite treatment consider the following:
Alternative foci of infection or systemic sepsis
Further imaging e.g. MRI–osteomyelitis may require surgical intervention
The authors have declared no conflicts of interest.
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