DIP Episode 492 - The Clutch Septic Joint Podcast

Welcome. This is episode 492 of the Divine Intervention Podcasts. Into this podcast we're going to be addressing a topic I like to title the Clutch Joint Infections Podcasts. The Clutch Joint Infections Podcasts. So what if they give you a question about a 25 year old male and your daughter for the past two days who has been having a significant right knee pain? And your daughter on physical exam, the knee is red, is exquisitely tender to a palpation, and you're asked what's going to be your next step? Well your next step obviously is to get an arthrosynthesis. This person certainly has a septic joint. Septic joint, septic arthritis, stuff like that. So that's going to be the main topic of this podcast. We're going to go into detail. Again I'm not going to waste time on fluff. I just want to hit on the things that are very important for you to know for your exams. So again whenever you see a person that has a joint, especially when it's a singular joint, that's actually kind of a high-yield detail, a singular joint that's red, hot and tender. The person likely has septic arthritis. Again there are many different names they can use for it on exams. They can call it septic arthritis, they can call it septic joint, they can call it an infectious arthritis. Just many different terms for the same thing. And most times when I did give away that this person probably has septic joint, is that involvement is going to be just one joint.

Most times when people have septic joint, it's one joint that is involved. Most times it is monoarticular. It is very, very, really polyarticular. That's a very high-yield factor to know. If you see a person having polyarticular involvement of their joints, it's just highly unlikely to be septic joint. In fact, the only people I will see should probably worry about for polyarticular arthritis are people that have like a rheumatoid arthritis. Sometimes they can have like a polyarticular joint infection. I may wonder why. The reason there is these people are usually going to be on some kind of immunosuppressive therapy and whatnot. So if you have immunosuppressive, it's like you're a systemically immunosuppress, so that can cause problems. And also don't forget people that have a gonococular arthritis. They can also have a polyarticular involvement. And the thing about joint infection is that they are just a lot of like discrete facts that are important. So we're going to be discussing those discrete facts. But again, I'm going to try to throw in some context for you. And then what if they give you a question about a patient that has septic joint and the ass goal? What is the most likely mechanism of spread? What is the most likely mechanism of spread? You've got to be careful. So again, if they don't give you many clues, if they don't give you many clues in the question, I want you to think of him at all in our spread.

Most times people get septic arthritis because there's an infection elsewhere. And then through the bloodstream, that infection travels to the joint. I may wonder why is it that the joint gets this kind of problem? Well, the thing is the synovium is like the epithelium that we find in a joint. Most epithelial surfaces have a basement membrane. But the synovium does not have a basement membrane. It literally does not. So it doesn't have that protective underlying coating. So because it doesn't have that basement membrane, blood worn bacteria, they can easily just kind of walk into the person's joint. When they get into the person's joint, they can trigger a nasty inflammatory response and that can cause joint damage. But again, if they give you clues, then they may want you to go more specific. So again, if you're going epidemiologically, hematogenous spread is the most common etiology. But people can have direct inoculation of a joint, especially in some very specific situations. So say, for example, you recently had surgery on the joint. Yeah, you can get direct inoculation of infection, especially if the people that did the surgery didn't do a good job with infection control. Or let's say you were in trauma. Or let's say it's like a diabetic foot ulcer. Or let's say you've had athrosynthesis. Believe it or not, you can get infection from getting athrosynthesis. So the thing is, all these things can cause a person to have direct inoculation of the joint.

Even prosthetic, if you've just put a prosthetic joint, especially if it's within the first three months. That's actually very high-youtuna. Within the first three months of your patient prosthetic joint, if people have infection, it's very likely from direct inoculation. Because remember, these prosthetic joints have biofilm. I mean, they provide a good surface for biofilm where just boxing just have a wonderful, wonderful, wonderful time. It's like a great living situation for box. But usually, if a person has a prosthetic joint and is more than three months, after they have the prosthetic joint implanted, they usually that's going to be from hematogenous spread. So again, if they give you more detail, you can make a specific diagnosis as to the method of spread. But most times, please, very high-yout, most times it's going to be from hematogenous spread. And again, there are many ways they can test septic joints. I want to try to give you some kinds of questions, stems that you may see. Let me tell you that, ooh, this is septic joint. If they want to give you a very hard question, right? So let's go in order of difficulty. They want to give you a very hard question. They're going to give you a patient that has another joint problem, right? A person that has like rheumatoid arthritis, right? And then those people can have a joint infection. But again, there are many other things you can see, right?

Like you can see a person that has had a prosthetic joint pleased, because they had like, you know, osteoarthritis of some joint. A new joint replacement was done. And then now they have problems, right? You can also see this in joint infection people that use drugs. In fact, you believe it or not, there's a lot of injective drugs into their joints, right? So if you see like sternoclavic joint, septic joint, you really want to think about a person that's like an IV drug user, right? People that have diabetes, diabetes compromises your immune system. People that have diabetes, they tend to get very, very nasty infection. So those are just higher things to keep out the back of your mind, for example. So for a person who comes in with septic joint, what are you supposed to do? Or literally the first thing you're supposed to do is tap that joint. Literally get an athrocentesis, get an athrocentesis, right? And honestly, most times when we give you a septic joint question, they're going to give it in the knee. The knee is probably the most common location of septic joint. The knee is the most common location of septic joint. So you're going to go ahead and just do an athrocentesis, because you're athrocentesis, right? St.esis means you're getting fluid from somewhere, just like thoraccentesis, fluid from the pleural cavity. Paraccentesis, fluid from the peritoneal cavity. Now this is a athrocentesis, right? St.esis from an athro, from a joint, right?

So you're literally getting fluid from a joint, you're getting fluid from a joint. Right? So again, if you're getting fluid from a joint, you're getting fluid from a joint, right? So again, you're going to get that athrocentesis, fluid. But beyond doing that, getting that athrocentesis, fluid, obviously you're going to do a gramsteine on it, you're going to do cultures on it. But many people forget that many times you have to do all their diagnostic studies when you're working up a person for septic joint. Many times you're going to get a blood culture. So the first thing you get is athrocentesis, fluid, you know, sign of your fluid, you know, gramsteine on culture, second, get a blood culture. Remember that thing I said about, you know, torgenous spread, right? I said you know, torgenous spread, right? So it makes sense that you get blood cultures, right? Many times you can actually isolate the bulk from the blood cultures. And then a third thing you want to get is imaging, imaging, imaging, imaging. You know, you can do like an x-ray, right? Or you can do a CTO and an MRI, believe it or not, right? But most times on the USML is thankfully, you don't go all the way to step three, right? But step one and step two for sure, you should know you're going to get athrocentesis. Number two, you're going to get a blood culture, you're going to get a blood culture, right? And here's one thing I want to comment on that many resources almost used to put people in trouble.

Not newly, it's common knowledge, but it's not a helpful knowledge for your exams, right? So most times when people have septic arthritis, especially it's like, if it's like bacteria, the leukocyte counting, the joint fluid is going to be more than 50,000. That's a number, I'm sure most of you have committed to memory. But please do not let the fact that the number of white cells in the joint fluid, don't let the fact that, oh wow, it's less than 50,000, dissuade you from picking septic arthritis as your answer. That's actually very important to know, right? People can have septic arthritis and have values that are much less than 50,000. In fact, when people have like, going to cochlear throides, or people have like arthritis from some kind of septic, from some kind of persthetic joint, the white count may not be 50,000. It may be like 10,000, 20,000, 30,000. Just something you kind of want to keep at the back of your mind for, for example. So you want to keep at the back of your mind, for example. So please, that magic number 50,000 is not always true, right? Yes, usually for a person has like a non-gone, or cochlear throides, from some bacteria, you know, like stuff or else or whatever. Yeah, it's going to usually not all the time. Usually going to be more than 50,000, but it's not always going to be more than 50,000.

In fact, many other causes like if you have like a fungal joint infection, micro bacterial joint infection, conococal joint infection, many times, the white count may be less than 50,000, maybe less than 50,000. And if they would ask you, oh, what is the most common cause of septic arthritis? Honestly, on your exams, you want to go for a star-phoria. You want to go for a star-phoria. You want to go for a star-phoria. The thing is, conococular throides is kind of, it's own special thing, I'm going to talk about it. But if you ask me like, oh, what's the most common cause of non-gone cochlear throides? Number one is star-phoria. Number two should be thinking about strep pneumo. I keep you not. Strep pneumo can go to a person's joints. Strep pneumo can go to a person's joints. Okay? Strep pneumo can go to a person's joints. So non-gone cochlear throides, most common cause, star-phoria. Segment most common cause, it's going to be strep pneumo. It's going to be strep pneumo. Right? So let me be focused on this conococular throides business real quick. So typically, they're going to give you a person that is sexually active and young. They're not going to give you a conocular throides question like some 80 year old man. It's kind of ridiculous. They're going to give you to a young person that is sexually active. Young person that is sexually active and it's going to be an acute presentation. And many times, you're going to see them having polyathrology.

So, many times, many joints are going to be hurting. They're going to have tenocino virus. It's almost like pain. Basically, like with a tendon in search, you have tendon in there. Many times, they're going to have those things in their small joints, like their fingers, in their toes. That's a very, very classic presentation. And typically, you also see them have skin findings, right? Like postures, papules, achymosis and stuff like that. That's actually very high, you know, that's a classic way. That is a very, very classic way that's going to coccoceptic arthritis present on an exam. So, and again, again, because many people fall for this. Many times, when you do a throats disease in these people, and you do like a blood, and you do a culture of the atrocent disease fluid, you're not going to find jack, you're not going to find anything, right? That's why, again, you'll need to do blood cultures in these people, right? And sometimes, you may not even be a blood culture, if you know they are sexually active, you can maybe get like a urethral culture, you can get like a vaginal culture. You can get a specimen from the likely initial source of that infection, the likely initial source of that infection.

And one of the weird things to me, seeing your exams that they can throw is they can say, oh, you know, a person, you know, presents, they'll give it like the classic presentation of conococlo-thritis, they'll tell you that what they did, you know, atrocenteses, they saw gram-negative coxay, yara yara yara yara yara. And then, they see the person, you know, therapy started with septraxone and is enthromalisone, whatever, we'll talk about that in a bit. And then you'll see what is the next step in management. And your next step may be to test the person for other ST Is. Be careful about that, right? That can be a very nice backhand way. They can test you, checking for their ST Is like HIV. HIV is probably going to be the big one on the exams, right? We also want to screen this book for stuff like HSV, for example, right? Like HSV, for example. So again, kind of focused on conococlo-thritis and then prosthetic joint infections. Again, remember, I've said a few higher-old factoids about them already. Number one, I said, if you get a prosthetic joint infection within the first three months after you get the joint replaced, it's very likely going to be directing the circulation. That's how you're getting the infection. But if it's more than three months after, if it's more than three months after, I want you to think about hematogenose spread.

And if you ask you, like, what's the most likely cause of a prosthetic joint infection, staff epidermis, that's what you're going for, staff epidermis. Staff epidermis, most of them, it's glorious biofilm, and that can cause problems for the patient. So those are kind of like the big things with a prosthetic joint. And I guess I also want to say that, you know, most times, you know, I get an joint replaced. To me, think that, oh, man, because of this high-risk biofilm and all this stuff, we're going to put them on prophylactic antibiotics. We really don't do that. We really don't do that. Okay, so now let's go to management. How do you manage these problems? How do you manage these problems? Again, we're going to be wrapping up here soon. So we're going to manage this, right? Again, after you've done your diagnostic, whatever. The first thing you're going to do is you're going to try to do, again, surgical drainage of the joint, right? You're going to be studying antibiotics, but you want to do surgical drainage of the joint. Many times you're going to do like a needle aspiration, but if you cannot do a needle aspiration, or some things you may have to take them to your breeding room, and just drain it after a scopically, we are going to try to drain that joint of that fluid. You want to remove that infected fluid from the joint. Because, honestly, if inflammation keeps happening in the joint, all these cytokines, all these produces, remember those produces from the lungs?

That cause issues in our phone, in people that smoke and what not, and cause them physema and what not. Yeah, those produces can also exist in the joint. They can choke your joint, and they can cause accelerated joint disease. You certainly do not want that. So you want to make sure that you surgically drain the joint from the last defluid, right? We're going to talk about antibiotic therapy, but again, surgically drain the joint. Many times on the exams, they will test more of the antibiotics, but you just want to get this other stuff out of the way. So, surgically drain the joint, and not just surgically drain the joint. If, for example, it's a prosthetic joint infection, it's actually pretty high-youtes, you know, that you need to remove the hardware. The stuff you put in there, joint, you've got to get rid of it. If it gets infected, you absolutely have to get rid of it. So, how do you treat septic joint? The way you treat septic joint is guided by gram-steen results. In fact, they're going to give you a few different permutations on your exams, so you know exactly what to do. So, let's start off with permutation number one. Permutation number one is, you get the atrocentesis fluid, and you don't see anything on grams, then you're like, man, I have absolutely no idea what's going on. What are you going to use for empiric therapy? You're going to give vank, think of my scene as going to cover gram positives, and then you're going to try to also cover gram negatives.

You want to be as broad as possible. So, what are you going to use for gram-negative coverage? You're going to use septriaxone, or septazidein, or septotaxine. These are all third-generation septal osporins. So, septriaxone, septazidein, or septotaxine. If you don't know what you're dealing with, they don't give you any grams in resulting in your q-stem. Vancomycin, and a third-gen septal osporin, like septriaxone, septazidein, or septotaxine. Now, what if you do your atrocentesis, and you see gram positives? You see gram positives. If you see gram positives, what are you, if you see gram positive coxite, then you're going to go ahead and give vancomycin, right? Because the person very likely has staff orders. But we want to use vanque because we're kind of worried about mercy. Mercy is pretty common these days. Okay, now, what if you do our atrocentesis, and you see gram-negative coxite? You're running negative coxite. You want to go ahead and give septriaxone. We're worried about going to cocculinfection at that point, right? Give septriaxone, and many times, especially if you've no road out clammedia infection, you're going to go ahead and add in doxycycline oizithro-mycin, doxycycline oizithro-mycin, right? To empirically cover clammedia as well. Okay, now, what if you see gram-negative raunts? They tell you that, ooh, you see gram-negative raunts, or gram-negative bacillite? Then what are you going to be doing there?

In that case on your exams, you're going to use a third gen cephalosporin, a third gen cephalosporin, right? So something like septriaxone, septazidine, or septotoxin. Although, if you're kind of worried about pseudomonas, if you're worried about pseudomonas, then you want to make sure that you use a third gen cephalosporin that has antisoedomonal activity, right? So something like septazidine. Septazidine is honestly the only third gen cephalosporin that for the most part covers pseudomonas. And many times for those people, you're even going to add in an amino glycoside as well, like gen tamaysa. So again, let's go over these permutations so that it's locked in your mind. Permutation number one, I don't know what I'm dealing with. I didn't see anything on gram-stein. Vanque and a third gen cephalosporin, like septriaxone, septazidine mocephotoxin. Oh, I saw gram-positive coxide, well, you're worried about staphoreus, give them chomaysa. Oh, I saw gram-negative coxide. We're worried about chomacoccus. Give a third gen cephalosporin, like septriaxone, septriaxone, septriaxone, septriaxone, septriaxone, septriaxone, septazidine. Right? Oh, I see gram-negative roots. Oh, we're worried about pseudomonas. Right? So usually in that case, you're going to give a third gen cephalosporin that covers pseudomonas, like septazidine. Right? And many times you're going to add an amino glycoside legend tamaysa for example. And these people should be on IV antibiotic therapy. Okay?

They should be on IV antibiotic therapy. So I think I'm going to go ahead and stop here. Again, alpha one on one, two, three, and four. The USMEL exams, step one, two, step three. Preclinical med school exams, 30-ish-elf exams. I have review courses. I have a 25-hour step one course. And then I have 20-hour step two, step three course. And a 100-hour step two, step three course. And then I have classes for step one on the way to step three. Like the 2.5-hour in BME test, the Kinsradigis course. The 4-hour bio-stats course. And the 5-hour social sciences class. You know, that I address these things like quality improvement, ethics, health care systems, communication, professionalism, and quality improvement on all these things. So if you're interested in any of these things, just shoot me an email. Or listen to the podcasts I've made on those. You can see those on the website. And then I have these podcasts on Apple, Google, and Spotify. I have a You Tube channel, Divine Intervention, USMEL, Podcasts, and videos. That's where you can find the videos that I make. And then finally, I have another website called, Divine Intervention Lifelessence.com. Divine Intervention Lifelessence.com. I have many of you know my question. So from a biblical perspective every week, I put up two podcasts. For the most part, that is the Bible to address a life lesson. We need to have a say, they love my life lesson. So I use a biblical perspective in that website to address life lessons every week.

And I put to usually on Friday and Sunday. And there's actually an Apple podcast associated with that. Go to Divine Intervention Life Lessons podcast. So thank you for listening to me today. I will see you next time. I'll see you in a piece of 4.93. Have a wonderful first of a week. God bless you. Bye for now. Thank you.

The knee.

Rheumatoid arthritis or another systemic cause; it makes septic joint highly unlikely.

Direct inoculation.

1) Arthrocentesis/Joint fluid analysis; 2) Blood cultures.

A third-generation cephalosporin with anti-pseudomonal activity (e.g., ceftazidime) plus an aminoglycoside (e.g., gentamicin).

The infected hardware/prosthesis must be removed.

The synovium lacks a basement membrane, offering no protective underlying coating.

Hematogenous spread.

Arthrocentesis fluid (for Gram stain/culture), Blood cultures, and sometimes imaging (X-ray/CT).

Vancomycin (to cover MRSA) plus a third-generation cephalosporin (e.g., ceftriaxone).

Young/sexually active patient, polyarthritis (tenosynovitis), and skin findings (pustules/papules).

Urethral or vaginal cultures (specimens from the likely initial source of infection).

The synovium lacks a basement membrane, offering no protective underlying coating.

Hematogenous spread.

Arthrocentesis fluid (for Gram stain/culture), Blood cultures, and sometimes imaging (X-ray/CT).

Vancomycin (to cover MRSA) plus a third-generation cephalosporin (e.g., ceftriaxone).

Young/sexually active patient, polyarthritis (tenosynovitis), and skin findings (pustules/papules).

Urethral or vaginal cultures (specimens from the likely initial source of infection).