This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (15)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Infectious Diseases, Other  • Physical Examination  • Rheumatology  • Diagnosis  • The Rational Clinical Examination  • Rheumatoid Arthritis  • Immunology  • Immunologic Disorders  • Alert me on articles by topic  Social Bookmarking   What's this?

Mary E. Margaretten, MD; Jeffrey Kohlwes, MD, MPH; Dan Moore, PhD; Stephen Bent, MD

JAMA. 2007;297:1478-1488.

Context  In patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality.

Objective  To review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis.

Data Sources  Structured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity.

Study Selection  Studies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis.

Data Extraction  Three authors independently abstracted data from the included studies.

Data Synthesis  Fourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts <25 000/µL: LR, 0.32; 95% CI, 0.23-0.43; for counts 25 000/µL: LR, 2.9; 95% CI, 2.5-3.4; for counts >50 000/µL: LR, 7.7; 95% CI, 5.7-11.0; and for counts >100 000/µL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47).

Conclusions  Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.

Author Affiliations: Division of Rheumatology (Dr Margaretten), Prime Program, Department of Medicine, University of California, San Francisco, and Department of Medicine, San Francisco Veterans Administration Medical Center (Drs Kohlwes and Bent), and Department of Epidemiology and Biostatistics, University of California, San Francisco (Dr Moore).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Septic until proven otherwise: Approach to and treatment of the septic joint in adult patients
Visser and Tupper
cfp 2009;55:374-375.
FULL TEXT  

Acute Pediatric Monoarticular Arthritis: Distinguishing Lyme Arthritis From Other Etiologies
Thompson et al.
Pediatrics 2009;123:959-965.
ABSTRACT | FULL TEXT  

The greater trochanter triangle; a pathoanatomic approach to the diagnosis of chronic, proximal, lateral, lower pain in athletes
Falvey et al.
Br. J. Sports. Med. 2009;43:146-152.
ABSTRACT | FULL TEXT  

Acute monoarthritis: What is the cause of my patient's painful swollen joint?
Ma et al.
CMAJ 2009;180:59-65.
FULL TEXT  

BET 4. IS A NORMAL C-REACTIVE PROTEIN SENSITIVE ENOUGH TO RULE OUT SEPTIC ARTHRITIS
Emerg. Med. J. 2008;25:767-768.
FULL TEXT  

EMQ EMQ answers
Emerg. Med. J. 2008;25:245-245.
FULL TEXT  

Rapid PCR-Based Diagnosis of Septic Arthritis by Early Gram-Type Classification and Pathogen Identification
Yang et al.
J. Clin. Microbiol. 2008;46:1386-1390.
ABSTRACT | FULL TEXT  

Sophia
Cattermole and Wyatt
Emerg. Med. J. 2007;24:608-608.
FULL TEXT  

Synovial Lactic Acid and Septic Arthritis
Kopterides
JAMA 2007;298:40-40.
FULL TEXT  

Septic arthritis in patients with pre-existing inflammatory arthritis
Kherani and Shojania
CMAJ 2007;176:1605-1608.
FULL TEXT