7/28/2019 60174797

1/5

BRIEF REPORT

What are we doing about septic arthritis? A survey

of UK-based rheumatologists and orthopedic surgeons

Usman Butt & Maame Amissah-Arthur &

Fazal Khattak& Chris F. Elsworth

Received: 4 October 2010 /Revised: 9 December 2010 /Accepted: 13 December 2010 /Published online: 11 January 2011# Clinical Rheumatology 2011

Abstract This study aims to determine the current practices

and beliefs of United Kingdom (UK)-based rheumatologistsand orthopedic surgeons (OS) in managing septic arthritis

(SA) and to determine awareness levels of national guidance.

Two-hundred OS and 200 rheumatologists were sent a link to

a web-based survey tool via email. Questions posed related to

the management of SA, including the respondents views on

antibiotic therapy, joint drainage, which specialty should

manage these cases, and also the clinicians evidence base.

There were 354 functioning addresses with 182 responses

(51%). One hundred fifty-one (77 OS, 74 rheumatologists)

(43%) responses were complete and included for analysis.

Eighty percent of rheumatologists and 82% of OS recom-

mended 6-weeks total antibiotic therapy. Seventy-three

percent in each group recommended 12 weeks intravenous

therapy initially followed by oral continuation therapy. In

patients at risk of methicillin-resistantStaphylococcus aureus

(MRSA), 25% rheumatologists and 14% OS would ensure

MRSA cover. Seventy-seven percent of rheumatologists and

66% of OS recommended surgical joint drainage; 22% and

27%, respectively, recommended repeated closed needle

aspiration as their chosen method of joint drainage. Sixty-

six percent of rheumatologists and 65% of OS believed OS

should manage SA. Twenty-three percent of rheumatologists

and 22% of OS quoted published guidance as their main

evidence base in the treatment of SA. Only 24% of

rheumatologists and 34% of OS quoted British Society of

Rheumatology (BSR) guidance when asked if they wereaware of any guidelines. Views of rheumatologists and OS

are not that dissimilar in managing SA. Surprisingly,

rheumatologists are more aggressive regarding the recom-

mendation for surgical joint drainage. Within both groups,

significant variation in management principles exists often

discrepant to recommendations laid out by the BSR. There

are poor awareness levels of the BSR guidelines.

Keywords Infective arthritis . Joint infection . Septic

arthritis . Survey

Introduction

Septic arthritis (SA), though relatively uncommon, is a

clinical emergency which should be identified early and

treated promptly, as it can lead to rapid and irreversible

articular cartilage destruction. It is associated with a

significant mortality risk with reported figures as high as

11% for monoarticular sepsis and 50% in polyarticular

cases [1, 2]. Given the varied causes of a hot swollen joint,

obtaining a firm diagnosis can often be difficult even for

experienced clinicians. Early referral for specialist assess-

ment and management is imperative if SA is suspected.

This is often carried out by rheumatologists or orthopedic

surgeons (OS) depending upon local policies.

To facilitate standardized care, guidelines for the

management of hot swollen joints were introduced in

2006 by a multi-disciplinary working party set up by the

British Society for Rheumatology (BSR), which comprised

of the British Orthopaedic Association (BOA), the British

Society for Antimicrobial Chemotherapy, and the Royal

College of General Practitioners [3]. These laid out clear

U. Butt (*) : C. F. Elsworth

Pennine Acute Trust, Royal Oldham Hospital,

Rochdale Road,

Oldham OL1 2JH, UK

e-mail: usmanbutt02@yahoo.co.uk

M. Amissah-Arthur: F. Khattak

Sandwell and West Birmingham Hospitals NHS Trust,

Birmingham, UK

Clin Rheumatol (2011) 30:707710

DOI 10.1007/s10067-010-1672-3

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-

7/28/2019 60174797

2/5

instructions for the assessment and management of SA.

Diagnostic recommendations stated that the affected joint

must be aspirated and synovial fluid sent for analysis

(including crystals) and culture, before commencing anti-

biotics where possible. Gram-stain analysis of synovial

fluid gives quick results and can facilitate early, targeted

antibiotic therapy. Specificity approaches 100% for this

test, however sensitivity is in the region of 5070% makinga negative result particularly unreliable [2, 4]. Where

clinical suspicion is high, it is imperative to treat it as

infection.

Guidelines stipulate that aspiration of the joint should

be followed by antibiotic administration, and complete

drainage of pus by means of arthroscopic washout or

closed needle aspiration is regarded essential. Arthrotomy

was not considered in the guidelines. The working party

acknowledged insufficient evidence in the literature to

suggest any additional benefit of surgical drainage over

closed needle aspiration in the majority of cases and

deemed either as acceptable. However, in cases ofunsatisfactory response to medical management, the

presence of thick, inspissated pus, or hip involvement,

surgical intervention is required [3].

There is a scarcity of evidence to guide antibiotic

choice and duration. There are no randomized controlled

trials in the literature. It is acknowledged that local

policies may be developed, but as a general guide,

flucloxacillin is first choice with or without the addition

gentamicin, as 60% or more of cases of SA are due to

Staphylococcus organisms. Clindamycin or cephalosporins

(2nd or 3 rd generation) are used in cases of penicillin

allergy. Where there is a risk of gram-negative organisms,

cephalosporins are advised. If there is a risk of methicillin-

resistant Staphylococcus aureus (MRSA) (known case,

recent inpatient, nursing home resident, leg ulcers or

catheters, or other risk factors determined locally), then

vancomycin is advised in addition to cephalosporins.

Discussion with a microbiologist is recommended for

complex cases such as those involving intravenous drug

users or intensive care patients [3].

Despite the lack of solid evidence for certain aspects

in the treatment of SA, the BSR guidelines provided a

welcome step toward standardizing care for patients with

SA. Four years on from this publication, we conducted a

survey to determine the current trends and beliefs

surrounding the management of SA among OS and

rheumatologists. We hypothesized that there would not

only be a consistent divide in management, but also

reticence from the surgical community to acknowledge

the option of non-surgical management. In addition, we

sought to ascertain the evidence base for the clinicians

management principles and assess awareness levels of

the BSR guidelines.

Method

Two-hundred consultant OS and 200 rheumatologists were

identified using the BOA and the BSR handbooks,

respectively. A link to an online questionnaire, using a

web-based survey tool [5], was emailed to the doctors with

a covering letter from the first two authors in three phases

(November 2009, December 2009, and February 2010).The doctors were asked to confirm their grade and specialty

and whether they routinely managed cases of SA. A short

clinical scenario was presented of a patient with a strong

working diagnosis of a septic knee joint. Initial questioning

focused on early, commonly encountered, management

decisions in cases of presumed SA. Respondents were

asked about choice of antibiotic therapy including their

views on MRSA cover. Views on the need and methods of

joint drainage were determined, and also whether the

clinicians management would alter on the basis of a

negative rather than positive gram-stain result. The final

section of questioning addressed the evidence base for theclinicians practice, including their knowledge of any

published guidelines. Beliefs relating to the role for surgery

and which hospital specialty should manage SA were also

enquired about.

Results

From 400 emails sent out in phase 1, a total of 46 (23

rheumatology and 23 orthopedic) addresses were non-

functional, leaving a sample of 354. By the end of phase

3, there were 182 responses (51%). Of these, 151 (43%)

completed the survey in its entirety and were included for

analysis77 (51%) were OS and 74 were rheumatologists

(49%).

Antibiotic therapy

The duration of antibiotic cover the respondents would

advise varied, but the majority of doctors recommended

at least 12 weeks of intravenous therapy, or would

consult a microbiologist for advice (Fig. 1). Regarding

total duration of antibiotic treatment (including oral

continuation therapy), most would continue for a mini-

mum of 6 weeks (82% OS and 80% rheumatologists); 6%

OS and 14% rheumatologists advised a total of 4 weeks

antibiotic therapy. A small proportion of each group stated

some other duration (4% OS answered 2 weeks only); 4%

OS would rely on microbiology advice; 4% OS and 7%

rheumatologists would continue until inflammatory

markers had normalized.

None of the OS questioned would routinely cover for

MRSA infection, compared with 4 (6%) rheumatologists

708 Clin Rheumatol (2011) 30:707710

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-

7/28/2019 60174797

3/5

who would. Eleven (14%) OS compared with 19 (25%)

rheumatologists said they would cover if there were risk

factors for MRSA. Microbiology advice must always besought when there is uncertainty or an unusual organism is

being treated.

Additional measures (Joint drainage)

In a presumed case of SA, 50 (65%) OS and 56 (76%)

rheumatologists would recommend an arthroscopic joint

washout as their preferred method of joint drainage, with 21

(27%) OS and 16 (22%) rheumatologists recommending

closed needle aspiration repeated as required. Three OS and

one rheumatologist recommended open joint washout. Three

OS and one rheumatologist would use antibiotics alone.

Fifty-three (69%) OS reported there would be no change

in their management plan if the gram-stain result was

negative, whereas 24 (31%) OS said that their management

would alter mainly by deferring surgery. Sixteen (22%)

rheumatologists would alter their management in light of a

negative gram-stain result most commonly by deferring

surgery; 58 (78%) rheumatologists would not change their

management plan.

Evidence base

Less than one quarter of either rheumatologists or OS

quoted published guidelines as the main evidence base for

their practice (22% OS and 23% rheumatologists). The

remaining doctors across both specialties answered that

their practice was primarily based on personal experience,

senior recommendation or general reading. When asked if

they were aware of any published guidelines and asked to

say what the source of these were, only 34% of OS and

24% of rheumatologists quoted the BSR guidelines.

Discussion

Regarding empirical antibiotics, rheumatologists were more

likely to provide MRSA cover, though a sizeable propor-

tion of each group, not unsurprisingly, said they would be

guided by microbiology advice. MRSA is increasingly

being recognized as the causative organism in a range of

invasive infections, both community and hospital acquired[6, 7].

A large amount of current literature and commentary on

SA, written mainly by rheumatologists, would suggest no

additional benefit of surgery in uncomplicated cases of a

septic knee [1, 2, 812]. It was therefore interesting to find

the overwhelming majority of rheumatologists (76%)

recommended arthroscopic joint washout as the method of

choice for joint drainage, an even larger proportion than the

OS surveyed (65%). Furthermore, a smaller proportion of

rheumatologists than OS (22% vs 27%) recommended

closed needle aspirations repeated as required. The

expected observation that OS would be more likely torecommend that surgery was not realized. One prospective

observational study of 75 patients found that 83% of

patients undergoing surgical management were orthopedic

patients compared with only 17% patients on non-surgical

wards [11]. This sample did however include prosthetic

joint infections and hip infections, which, as previously

mentioned, are inevitably managed surgically. As such,

any inference regarding management preferences between

different specialists is difficult to make from that

particular study.

To further re-enforce the notion that surgery is not an

inevitability whilst under the care of an OS, and in keeping

with the question regarding joint drainage, a larger

proportion of rheumatologists (50% vs 43%, respectively)

agreed with the position that non-surgical management had

no place in the management of cases of SA such as that

described. Most rheumatologists (66%) also suggested

orthopedics was the most appropriate specialty to manage

such cases. Interestingly, these views were virtually

mirrored by the OS (65%).

As regards antibiotic duration, in line with guidance, the

vast majority of OS and rheumatologists would use

intravenous antibiotics for a minimum of 12 weeks and

continue with oral antibiotics for a minimum of 6 weeks in

total.

Less than one quarter of both OS and rheumatologists

quoted published guidelines as their primary evidence base

in managing SA. The most likely reason for this is the

relatively low levels of awareness of the BSR guidelines in

our sample. Only 34% OS and 24% rheumatologists were

aware of the guidance (43% and 40% respectively were

aware of any published guidance at all). Likewise, in a

survey of trainee doctors conducted by Ravindran et al.,

Fig. 1 Duration of initial intravenous antibiotic therapy

Clin Rheumatol (2011) 30:707710 709

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-

7/28/2019 60174797

4/5

only 42% (13 of 31 surveyed) were aware of the BSR

guidelines [13]. The poor awareness level they reported was

exemplified by a lack of compliance with the guidelines in

their own trust audit, the findings of which were presented

in the same article. Other similar audits have been carried

out which likewise show variable and often poor adherence

to the BSR guidelines with a general lack of awareness of

their existence [1418].Useful recommendations from these audits include the

introduction of a hot joint pack containing a management

algorithm and specimen bottles for patients presenting with

a hot swollen joint [16]. At the very least, this could

improve the diagnosis and early management of infected

joints along with the recognition amongst doctors that

guidance exists for this condition. Ravindran et al.

suggested that clinical audits themselves provide a vehicle

for wider dissemination of the BSR guidance and could

help in optimizing care [13].

Contrary to our initial hypothesis, the views of rheuma-

tologists and OS are not that dissimilar. If anything,rheumatologists were more aggressive regarding the rec-

ommendation for surgical joint drainage. However, it is

apparent that within both groups, significant variation in

management principles exists which is discrepant to the

recommendations laid out in the BSR guidelines. The

guidelines were comprehensive and produced by experts,

but nevertheless a poor evidence base was acknowledged in

the document for certain aspects in the management of SA.

This coupled with poor awareness levels offers some

explanation for variable adherence to the guidance. A

stronger body of evidence in the form of a large-scale

randomized controlled trial with cost-analysis would ulti-

mately help to reduce variation in treatment strategy that

continues to be based largely on personal preferences. It is

recognized that these trials are logistically difficult to carry

out and so in the absence of such, wider dissemination of

current guidance is an essential measure to ensure

standardization and appropriate care. Publication of

guidance in journals accessed by the many specialties

involved in caring for those with SA, particularly

including microbiologists, rheumatologists, OS, emergency

and general physicians, is paramount. Regular multi-

disciplinary audits and presentations at both local and

national levels would ensure that this important condition

receives appropriate attention and consideration by both

policy makers and those involved at the frontline of

patient care across all levels of seniority.

Disclosures None.

References

1. Gupta MN, Sturrock RD, Field M (2001) A prospective 2-yearstudy of 75 patients with adult-onset septic arthritis. Rheumatol

(Oxf) 40:2430

2. Mathews JM, Weston VC, Jones A, Field M, Coakley G (2010)

Bacterial septic arthritis in adults. Lancet 375:846855

3. Coakley G, Mathews C, Field M et al (2006) BSR & BHPR,

BOA, RCGP and BSAC guidelines for management of the hot

swollen joint in adults. Rheumatol (Oxf) 45:10391041

4. Brannan SR, Jerrard DA (2006) Synovial fluid analysis. J Emerg

Med 30:331339

5. Ryan Finley. http://www.SurveyMonkey.com , Portland, OR, USA

6. Frazee BW, Fee C, Lambert L (2009) How common is MRSA in

adult septic arthritis. Ann Emerg Med 54:695700

7. Ross JJ, Davidson L (2005) Methicillin-resistant Staphylococcus

aureus septic arthritis: an emerging clinical syndrome. Rheumatol

(Oxf) 44:119711988. Ravindran V, Logan I, Bourke BE (2009) Medical vs surgical

management for the native joint in septic arthritis: a 6-year,

single UK academic centre experience. Rheumatol (Oxf)

48:13201322

9. Goldenberg DL, Brandt KD, Cohen AS, Cathcart ES (1975)

Treatment of septic arthritis: comparison of needle aspiration and

surgery as initial modes of joint drainage. Arthritis Rheum 18:83

90

10. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M

(1999) Clinical features and outcome of septic arthritis in a single

UK Health District 19821991. Ann Rheum Dis 58:214219

11. Cooper C, Cawley MI (1986) Bacterial Arthritis in an English

health district: a 10 year review. Ann Rheum Dis 45:458463

12. Sammer DM, Shin AY (2009) Comparison of arthroscopic and

open treatment of septic arthritis of the wrist. J Bone Joint SurgAm 91:13871393

13. Ravindran V, Logan I, Bourke BE (2008) Septic arthritis: clinical

audits would help optimise the management. Clin Rheumatol

27:15651567

14. Al-Mossawi M (2010) Clinical audit of the management of

suspected septic arthritis in the emergency department. Rheumatol

(Oxf) 49(Suppl 1):i67

15. Lim CSE, Low ST, Joshi N, Walton T (2010) Acute monoarthritis:

a clinical audit in a district general hospital. Rheumatol (Oxf) 49

(Suppl 1):i73

16. Menezes BF, Cooke RP, Estrach C et al (2010) A hot joint pack

improves the management of the acute hot joint. Rheumatol (Oxf)

48(Suppl 1):i113

17. Shahbaz-Samavi M (2009) An audit of adults with hot swollen

joints presenting to Salford Royal Accident and EmergencyDepartment. Rheumatol (Oxf) 48(Suppl 1):i150

18. Wong Y, Morgan G, Young L (2009) Management of septic

arthritis at a UK district general hospital. Rheumatol (Oxf) 48

(Suppl 1):i153

710 Clin Rheumatol (2011) 30:707710

http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://www.surveymonkey.com/http://www.surveymonkey.com/http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-

7/28/2019 60174797

5/5

Copyright of Clinical Rheumatology is the property of Springer Science & Business Media B.V. and its content

may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express

written permission. However, users may print, download, or email articles for individual use.