Streptococcal septic arthritis in adults. A study of 55 cases with a literature review

doi:10.1016/S1297-319X(03)00122-2

Joint Bone Spine

Volume 71, Issue 4, July 2004, Pages 303-311

https://doi.org/10.1016/S1297-319X(03)00122-2 Get rights and content

Abstract

Objectives. – To evaluate the rate of occurrence and characteristics of streptococcal septic arthritis.

Methods. – Retrospective single-center study of patients with bacteriologically documented septic arthritis admitted to a rheumatology department over a 20–year period.

Results. – Of 303 cases of septic arthritis, 55 (18%) were due to streptococci and 166 (55%) to Staphylococcus aureus (55%). As compared to patients with S. aureus arthritis, patients with streptococcal arthritis was more likely to be in female (56% vs. 36%, P < 0.006) and older than 60 years of age (71% vs. 58%), less likely to have comorbidities (36% vs. 56%), rheumatoid arthritis (5% vs. 19%, P < 0.01), or diabetes (2% vs. 15%, P < 0.01), and more likely to have cancer (13% vs. 7%). Involved joints and proportions of patients with arthritis in multiple joints were similar in two groups. Mortality was lower in the group with streptococcal infection (3.6% vs. 7.8%). The streptococci were distributed as follows: group A (n = 7), group B (n = 12), group C (n = 4), group D (n = 7), group F (n = 1), group G (n = 2), nongroupable (n = 14), nontypable (n = 1), and Streptococcus pneumoniae (n = 7). Groups A and B and nongroupable strains mainly affected women; group A selectively involved younger patients and group B very elderly patients. Comorbidity, most notably cancer, was common in patients with S. pneumoniae or group D streptococci. The portal of entry was often a skin lesion for groups A and B and a medical procedure for group D. Multiple joint involvement was common with groups A and B and prosthetic joint infection with groups B and C. Group A and S. pneumoniae were associated with severe systemic symptoms and extra articular foci of infection, whereas a smoldering course was more common with groups D and G and with nongroupable strains. Residual joint abnormalities were noted in half the patients, with no differences across groups.

Conclusions. – The features of streptococcal septic arthritis vary according to the group of the causative organism and differ from those of S. aureus arthritis.

Introduction

Staphylococcus aureus is responsible for over 60% of cases of bacteriologically documented nongonococcal septic arthritis [1]. Streptococci come in second position, with about 20% of cases on average and 30% in a recent study in the United Kingdom [2]. Although many streptococci can cause septic arthritis, most reports indicate the proportion of cases due to Streptococcus pneumoniae but provide no details on the other species. The characteristics of streptococcal septic arthritis have not been extensively evaluated. Available data come from small series or from anecdotal case-reports that were often selected because of an unusual presentation. A study of 51 cases seen in Thailand [3] showed that β-hemolytic streptococci were the most common organisms, with equal proportions of groups A, B, and G; however, detailed clinical information was not collected. Schattner and Vosti [4] recently studied 23 cases of septic arthritis due to β-hemolytic streptococci seen over a 12–year period. They found substantial differences among streptococcal groups: group A streptococci caused severe infections, often with septic shock, disseminated intravascular coagulation or necrotizing fasciitis, whereas group B streptococci were typically associated with involvement of multiple joints in patients with cancer or diabetes mellitus and group G streptococci with apparently mild infections.

Over the last 20 years, 55 patients with streptococcal septic arthritis were admitted to our rheumatology department. The objective of the present study was to evaluate the frequency and characteristics of streptococcal arthritis comparatively with arthritis due to S. aureus; to compare proportions of cases and clinical features among streptococcal groups; and to compare our findings to data from the literature.

Section snippets

Patients and methods

We retrospectively reviewed the medical charts of patients admitted for septic arthritis to the rheumatology department of the Clermont-Ferrand Teaching Hospital between 1979 and 1998. Only patients in whom the causative organism was recovered from joint specimens and/or blood cultures were included in the study. Patients with infections confined to the spine or sacroiliac joints were excluded.

Until 1989, joint fluid specimens were seeded on Schaedler broth (Institut Pasteur Production), Eugon

Rate of occurrence

Between 1979 and 1998, 303 patients were admitted to our department for bacteriologically documented septic arthritis. A streptococcus was recovered in 55 patients, representing 18% of all patients with septic arthritis and 20% of patients with nontuberculous nongonococcal septic arthritis. During the same time period, 166 patients had septic arthritis due to S. aureus.

The distribution of causative organisms showed little change over time. However, the proportion of streptococcal infections

Discussion

Over the 20–year study period, 55 patients with streptococcal septic arthritis were admitted to our rheumatology department. These patients represented 18% of all cases of bacteriologically documented septic arthritis and 20% of cases of nontuberculous nongonococcal septic arthritis. Similar proportions have been found in other case-series [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31],

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Septic arthritis is a serious condition resulting in rapid joint destruction and irreversible loss of function, with mortality rates of up to 15% [1–3]. While relatively rare in the general population (annual incidence of 2–10 per 100,000), comorbidities including rheumatoid arthritis, HIV, and diabetes mellitus greatly increase risk of developing these infections [2,4,5]. Emergent treatment with formal operative incision and drainage is essential to optimize outcomes, as studies have shown that permanent cartilage damage occurs within hours to days of the onset of infection [5–7].
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Patients with immunosuppressive conditions who received a joint aspiration for a painful joint were retrospectively identified. Laboratory results from their work up were gathered and analyzed.
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Original articleStreptococcal septic arthritis in adults. A study of 55 cases with a literature review

Abstract

Introduction

Section snippets

Patients and methods

Rate of occurrence

Discussion

Orthop Clin North Am

J Infect

Semin Arthritis Rheum

J Infect

Eur J Radiol

Pyogenic arthritis in adults

Joint Bone Spine

Bacterial joint infections in England and Wales: analysis of bacterial isolates over a four year period

Br J Rheumatol

Streptococcal arthritis in Thai adults: case series and review

J Med Assoc Thai

Bacterial arthritis due to beta-hemolytic streptococci of serogroups A, B, C, F and G. Analysis of 23 cases and a review of the literature

Medicine

Changes in nongonococcal septic arthritis: drug abuse and methicillin-resistant Staphylococcus aureus

Arthritis Rheum

Suppurative arthritis. Clinical features of 42 cases

Arch Intern M

Recent observations of acute suppurative arthritis

Clin Orthop

Bacterial arthritis in an English health district a 10 year review

Ann Rheum Dis

Clinical study of culture-proven cases of non-gonococcal arthritis

J Med Assoc Thai

Les arthrites septiques non tuberculeuses (spondylodiscites exclues)

Rhumatologie

Treatment of septic arthritis. Comparison of needle aspiration and surgery as initial modes of joint drainage

Arthritis Rheum

Therapy for septic arthritis

JAMA

Les arthrites septiques à germes banals de l’adulte

Acta Orthop Belg

Incidence and sources of native and prosthetic joint infection: a community based prospective survey

Ann Rheum Dis

Peripheral pyogenic arthritis. A study of one hundred seventy-nine cases

Rev Rhum [Engl Ed]

Twenty-nine cases of bacterial arthritis

Acta Orthop Scand

Septic arthritis in a general hospital 1966–1977

J Rheumatol

Long-term functional results of the non-surgical treatment of common bacterial infections of joints

Scand J Rheumatol

An 18 year clinical review of septic arthritis from tropical Australia

Epidemiol Infect

Review of septic arthritis throughout the antibiotic era

Ann Rheum Dis

Bacterial arthritis in a district hospital

Clin Rheumatol

Acute nongonococcal infectious arthritis. Evaluation of risk factors, therapy and outcome

Arthritis Rheum

Septic arthritis

Ann Rheum Dis

Les arthrites aiguës suppurées métastatiques à germes identifiés

Sem Hôp Paris

Arthrites bactériennes aiguës suppurées après injections intra-articulaires de dérivés cortisoniques

Rev Rhum Mal Ostéoartic

Les arthrites infectieuses des membres à germes banals

Rev Rhum Mal Ostéoartic

Original article
Streptococcal septic arthritis in adults. A study of 55 cases with a literature review