Septic Arthritis: A Need to Strengthen the Referral Chain in a Developing Economy

Ikpeme A. Ikpeme, Ngim E. Ngim, Anthonia A. Ikpeme, Afiong O. Oku

Department of Community Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria..
Department of Radiology, University of Calabar Teaching Hospital, Calabar, Nigeria.
Department of Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria.

DOI: 10.4236/ojo.2013.32022                

Abstract

Aim: This retrospective analysis documents the features and factors that potentially affect outcomes in septic arthritis in the Cross River Basin area of south-south Nigeria. Patients and Methods: A retrospective analysis of 43 patients who presented with septic arthritis in 45 joints between September 2007 and August 2010. All patients with pain, fever, joint swelling and non-weight bearing/refusal to move the limb and had a joint aspiration productive of a turbid and/or purulent aspirate were included in the analysis. Patients whose joint aspiration produced frank blood or a clear exudate were excluded. Results: There were 24 males and 19 females (M:F = 1.3:1). Forty patients were children while three were adults. Thirty-three patients were urban dwellers, 8 were semi-urban dwellers and 2 were rural dwellers. Twenty-five children were first seen by a Paediatrician. Only 5 patients were first seen by an Orthopaedic surgeon. Definitive treatment was conservative in 28 children and arthrotomy/washout in 12 children and 3 adults. Staphylococcus aureus was the commonest isolated pathogen in both age groups. Conclusion: Injudicious interventions in musculoskeletal conditions consist not only of traditional bone setting and other unorthodox practices, but also sub-optimal orthodox medical practices. Healthcare outcomes in Africa are a function of the skewed distribution of the healthcare workforce and a weak referral chain. The near absence of follow-up culture underscores the need for education on injudicious antibiotic therapy to be directed at patients and physicians. Judicious interventions in musculoskeletal sepsis at first contact and a strengthening of the referral chain are important.

Keywords

Septic Arthritis; Health Seeking Contact; Definitive Treatment; South-South Nigeria

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	J. D. Ogunlusi, O. O. Ogunlusi, L. M. Oginni and J. A. Olowookere, “Septic Arthritis in a Nigerian Tertiary Hospital,” Iowa Orthopaedic Journal, Vol. 26, 2006, pp. 45-47.
[2]	I. A. Ikpeme, A. M. Udosen and I. Okereke-Okpa, “Patients’ Perception of Traditional Bone Setting in Calabar,” Port Harcourt Medical Journal, Vol. 1, No. 2, 2007, pp. 104-108.
[3]	M. Segbefia and A. Howard, “Acute Septic Arthritis and Osteomyelitis in Children—An African Perspective,” 2013. http://ptolemy.library.utoronto.ca/sites/default/files/review/2010/February-Acuteseptic Arthritis and Osteomyelitis.pdf
[4]	G. O. Eyichukwu, “Outcome of Management of NonGonococcal Septic Arthritis at National Orthopaedic Hospital, Enugu, Nigeria,” Nigerian Medical Journal, Vol. 19, No. 1, 2010, pp. 69-76.
[5]	A. L. Akinyoola, P. O. Obiajunwa, L. M. Oginni, “Septic Arthritis in Children,” West African Journal of Medicine, Vol. 25, No. 2, 2006, pp. 119-123.
[6]	G. O. Onyemelukwe and R. D. Sturrock, “Septic Arthritis in Northern Nigeria,” Rheumatology, Vol. 18, No. 1, 1979, pp. 13-17.
[7]	M. Mijiyawa, O. Oniankitan, K. Attoh-Mensah, A. Tékou, E. K. Lawson, G. B. Priuli and J. K. Assimadi, “Musculoskeletal Conditions in Children Attending Two Togolese Hospitals,” Rheumatology, Vol. 38 No. 10, 1999, pp. 1010-1013. doi:10.1093/rheumatology/38.10.1010
[8]	N. Eke, “Late Presentation Begs for a Solution,” Port Harcourt Medical Journal, Vol. 1, No. 2, 2007, p. 75.
[9]	M. E. Shirtlift and J. T. Mader, “Acute Septic Arthritis,” Clinical Microbiology Reviews, Vol. 15, No. 4, 2002, pp. 527-544.
[10]	D. S. Morgan, D. Fisher, A. Merianos and B. J. Currie, “An 18-Year Clinical Review of Septic Arthritis from Tropical Australia,” Epidemiology & Infection, Vol. 117, No. 3, 1996, pp. 423-428. doi:10.1017/S0950268800059070
[11]	L. Le Dantec, F. Maury, R. M. Flipo, S. Laskri, B. Corlet, B. Duquesnoy and B. Delcambre, “Peripheral Septic Arthritis. A Study of One Hundred and Seventy-Nine Cases,” Revue du rhumatisme (English Edition), Vol. 63, No. 2, 1996, pp. 103-110.
[12]	I. M. Nilsson, J. M. Patti, T. Bremell, M. Hook and A. Tarwoski, “Vaccination with a Recombinant Fragment of Collagen Adhesin Provides Protection against Staphylococcus Aureus Mediated Septic Death,” Journal of Clinical Investigation, Vol. 101, No. 12, 1998, pp. 2640-2649. doi:10.1172/JCI1823
[13]	A. H. Patel, P. Nowlan, E. D. Weavers and T. Foster, “Virulence of Protein A-Deficient and alpha-Toxin-Deficient Mutants of Staphylococcus aureus Iso-lated by Allele Replacement,” Infection and Immunity, Vol. 5, No. 12, 1987, pp. 3103-3110.
[14]	S. J. Peacock, N. P. Day, M. G. Thomas, A. R. Berendt and T. J. Foster, “Clinical Isolates of Staphylococcus aureus Exhibit Diversity in Fnb Genes and Adhesion to Human Fibronectin,” Journal of Infection, Vol. 41, No. 1, 2000, pp. 23-31. doi:10.1053/jinf.2000.0657
[15]	L. M. Switalski, J. M. Patti, W. Butcher, A. G. Gristina, P. Speziale and M. Hook, “A Collagen Receptor on Staphylococcus aureus Strains Isolated from Patients with Septic Arthritis Mediates Adhesion to Cartilage,” Molecular Microbiology, Vol. 7, No. 1, 1993. pp. 99-107. doi:10.1111/j.1365-2958.1993.tb01101.x
[16]	M. G. Thomas, S. Peacock, S. Daenke and A. R. Berendt, “Adhesion of Staphylococcus aureus to Collagen Is Not a Major Virulence Determinant for Septic Arthritis, Osteomyelitis or Endocarditis,” The Journal of Infectious Diseases, Vol. 179, No. 1, 1999, pp. 291-293. doi:10.1086/314576
[17]	J. K. Ellington, S. S. Reilly, W. K. Ramp, M. S. Smeltzer, J. F. Kellam and M. C. Hudson, “Mechanisms of Staphylococcus aureus Invasion of Cultured Osteoblasts,” Microbial Pathogenesis, Vol. 26, No. 6, 1999, pp. 317-323. doi:10.1006/mpat.1999.0272
[18]	A. Lammers, P. J. Nuyten and H. E. Smith, “The Fibronectin Binding Properties of Staphy-lococcus aureus Are Required for Adhesion to and Invasion of Bovine Mammary Gland Cells,” FEMS Microbiology Letters, Vol. 180, No. 1, 1999, pp. 103-109. doi:10.1111/j.1574-6968.1999.tb08783.x
[19]	B. E. Menzies and I. Kourteva, “Internalization of Staphylococcus aureus by Endothial Cells Induces Apoptosis,” Infection and Immunity, Vol. 66, No. 12, 1998, pp. 5994-1998.
[20]	C. A. Wesson, J. Deringer, L. E. Liou, K. W. Bayles, G. A. Bohach and W. R. Trumble, “Apoptosis Induced by Staphylococcus aureus in Epithelial Cells Utilizes a Mechanism Involving Caspases 8 and 3,” Infection and Immunity, Vol. 68, No. 5, 2000, pp. 2998-3001. doi:10.1128/IAI.68.5.2998-3001.2000
[21]	S. S. Reilly, M. C. Hudson, J. F. Kellam and W. K. Ramp, “In Vivo Internalization of Staphylococcus aureus by Embryonic Chick Osteoblasts,” Bone, Vol. 26, No. 1, 2000, pp. 63-70. doi:10.1016/S8756-3282(99)00239-2
[22]	H. D. Gresham, J. H. Lowrance, T. E. Caver, B. S. Wilson, A. L. Cleung and F. P. Lindberg, “Survival of Staphylococcus aureus inside Neutrophils Contributes to Infection,” The Journal of Immunology, Vol. 164, No. 7, 2000, pp. 3713-3722.
[23]	M. S. Kocher, D. Zurakowski and J. R. KAsser, “Differentiating between Septic Arthritis and Transient Synovitis of the Hip in Children; an Evidence-Based Clinical Prediction Algorithm,” The Journal of Bone & Joint Surgery, Vol. 81, No. 12, 1999, pp. 1662-1670.
[24]	M. S. Kocher, R. Mandiga, D. Zurakowski, C. Barnwoh and J. R. Kasser, “Validation of a Clinical Prediction Rule for the Differentation between Septic Arthritis and Transient Synovitis of the Hip in Children,” The Journal of Bone & Joint Surgery, Vol. 86, No. 8, 2004, pp. 16291635.
[25]	A. Howard and M. Wilson, “Easily Missed? Septic Arthritis in Children,” BMJ, Vol. 341, 2010, Article ID: c4407. doi:10.1136/bmj.c4407
[26]	S. J. Luhmann, A. Jones, M. Schootman, J. E. Gordon, P. L. Schoeneker and J. D. Luhmann, “Differentiation between Septic Arthritis and Transient Synovitis of the Hip in Children with Clinical Prediction Algorithms,” The Journal of Bone & Joint Surgery, Vol. 86, No. 5, 2004, pp. 956-962.
[27]	M. S. Caird, J. M. Flynn, Y. L. Leung, J. E. Millman, J. G. D’Italia and J. P. Dormans, “Factors Distinguishing Septic Arthritis from Transient Synovitis of the Hip in Children. A Prospective Study,” The Journal of Bone & Joint Surgery, Vol. 88, No. 6, 2006, pp. 1251-1257. doi:10.2106/JBJS.E.00216
[28]	T. R. Nunn, W. Y. Cheung and P. D. Rollinson, “A ProSpective Study of Pyogenic Sepsis of the Hip in Childhood,” The Journal of Bone & Joint Surgery, Vol. 89, No. 1, 2007, pp. 100-106. doi:10.1302/0301-620X.89B1.17940
[29]	J. Black, T. L. Hunt, P. J. Godley and E. Mathew, “Oral Antimicrobial Therapy for Adults with Osteomyelitis or Septic Arthritis,” The Journal of Infectious Diseases, Vol. 155, No. 5, 1987, pp. 968-972. doi:10.1093/infdis/155.5.968
[30]	M. Razak and J. Nasiruddin, “An Epidemiological Study of Septic Arthritis in Kuala Lumpur Hospital,” Medical Journal of Malaysia, Vol. 53, Suppl. A, 1998, pp. 86-94.
[31]	A. K. Shetty and A. Gedalia, “Management of Septic Arthritis,” Indian Journal of Pediatrics, Vol. 71, No. 9, 2004, pp. 819-824. doi:10.1007/BF02730722
[32]	P. Riegels-Nielsen, N. Frimodt-Moller, M. Sorensen and J. S. Jensen, “Antibiotic Treatment Insufficient for Established Septic Arthritis. Staphylococcus aureus Experiments in Rabbits,” Acta Orthopaedica Scandinavica, Vol. 60, No. 1, 1989, pp. 113-115. doi:10.3109/17453678909150107
[33]	S. Roy and J. Bhawan, “Ultrastructure of Articular Cartilage in Pyogenic Arthritis,” Archives of Pathology, Vol. 99, No. 1, 1975, pp. 44-47.
[34]	A. L. Akinyola, P. O. Obiajunwa, L. M. Oginni and S. I. I. Adeoye, “Septic Arthritis of the Hip in Nigerian Children,” African Journal of Paediatric Surgery, Vol. 1, No. 2, 2005, pp. 56-61.
[35]	I. A. Ikpeme, A. M. Udosen, A. A. Ikpeme, G. U. Inah and Q. N. Kalu, “Early Outcome of Treatment of Chronic Osteomyelitis Using the Improvised Irrigation and Drainage System for the Lautenbach Procedure,” International Journal of Tropical Surgery, Vol. 3, No. 3, 2009, pp. 110115.