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曾紀洲主任醫(yī)師 北京潞河醫(yī)院 骨關(guān)節(jié)外科 成人和兒童化膿性關(guān)節(jié)炎的診斷和治療指南(執(zhí)行摘要)_GEIO(SEIMC)、SEIP和SECOT制定(2024)Executivesummary:Guidelinesforthediagnosisandtreatmentofsepticarthritisinadultsandchildren,developedbytheGEIO(SEIMC),SEIPandSECOT?BenitoN,Martinez-PastorJC,Lora-TamayoJ,ArizaJ,BaezaJ,Belzunegui-OtanoJ,CoboJ,Del-ToroMD,FontechaCG,Font-VizcarraL,HorcajadaJP,MorataL,MurilloO,NollaJM,Nunez-CuadrosE,PigrauC,PortilloME,Rodriguez-PardoD,Sobrino-DiazB,Saavedra-LozanoJ.Executivesummary:Guidelinesforthediagnosisandtreatmentofsepticarthritis?inadultsandchildren,developedbytheGEIO(SEIMC),SEIPandSECOT[J].EnfermInfeccMicrobiolClin(EnglEd),2024,42(4):208-214.?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/37919201/轉(zhuǎn)載文章的原鏈接2：https://www.sciencedirect.com/science/article/pii/S2529993X23002551?via%3Dihub?AbstractInfectionofanativejoint,commonlyreferredtoassepticarthritis,isamedicalemergencybecauseoftheriskofjointdestructionandsubsequentsequelae.Itsdiagnosisrequiresahighlevelofsuspicion.Theseguidelinesforthediagnosisandtreatmentofsepticarthritisinchildrenandadultsareintendedforusebyanyphysiciancaringforpatientswithsuspectedorconfirmedsepticarthritis.TheyhavebeendevelopedbyamultidisciplinarypanelwithrepresentativesfromtheBoneandJointInfectionsStudyGroup(GEIO)belongingtotheSpanishSocietyofInfectiousDiseasesandClinicalMicrobiology(SEIMC),theSpanishSocietyofPaediatricInfections(SEIP)andtheSpanishSocietyofOrthopaedicSurgeryandTraumatology(SECOT),andtworheumatologists.Therecommendationsarebasedonevidencederivedfromasystematicliteraturereviewand,failingthat,ontheopinionoftheexpertswhopreparedtheseguidelines.Adetaileddescriptionofthebackground,methods,summaryofevidence,therationalesupportingeachrecommendation,andgapsinknowledgecanbefoundonlineinthecompletedocument關(guān)于背景、方法、證據(jù)摘要、支持每項建議的基本原理以及知識差距的詳細描述可以在完整的在線文件中找到。?ResumenLainfeccióndeunaarticulaciónnativa,generalmentedenominadaartritisséptica,constituyeunaurgenciamédicaporelriesgodedestrucciónarticularylasconsecuentessecuelas.Sudiagnósticorequiereunaltoniveldesospecha.Estaguíadediagnósticoytratamientodelaartritissépticaenni?osyadultosestádestinadaacualquiermédicoqueatiendapacientesconsospechadeartritissépticaoartritissépticaconfirmada.LaguíahasidoelaboradaporunpanelmultidisciplinarenelqueestánrepresentadoselGrupodeEstudiodeInfeccionesOsteoarticulares(GEIO)delaSociedadEspa?oladeEnfermedadesInfecciosasyMicrobiologíaClínica(SEIMC),laSociedadEspa?oladeInfectologíaPediátrica(SEIP)ylaSociedadEspa?oladeCirugíaOrtopédicayTraumatología(SECOT);ademáshanparticipadodosreumatólogos.Lasrecomendacionessebasanenlaevidenciaproporcionadaporunarevisiónsistemáticadelaliteraturay,ensudefecto,enlaopinióndelosexpertosquehanelaboradolapresenteguía.Eneltextocompletoonlinesehaceunadescripcióndetalladadelosantecedentes,métodos,resumendelaevidencia,fundamentosqueapoyancadarecomendaciónylaslagunasdeconocimientoexistentes.?KeywordsSepticarthritis?Infectiousarthritis?Bacterial?arthritisNativejointinfection?RecommendationsfordiagnosisI.Whenshouldthediagnosisofsepticarthritis(SA)inchildrenandadultsbeconsidered?1.Allacutearthritisshouldbeconsideredinfectiousuntilprovenotherwise.AhighindexofsuspicionforinfectiousarthritisisrequiredbecauseSAisamedicalemergencyandshouldbediagnosedasearlyaspossible(A-II).2.SuspectadiagnosisofSAinanypatientwithsigns/symptomsofarthritis:jointpain,swelling,effusion,warmth,erythema,and/orrestrictionofmovementinoneormorejoints,?withorwithoutsystemicsigns/symptoms(fever,chills,shivering),and?withorwithoutriskfactorsforSA(previousjointdisorder,immunosuppressiveconditions,recentjointprocedures,bacteraemia)(A-II).3.IncreaseclinicalsuspicionofSAinpatientswithacutemonoarticulararthritisespeciallyoflargeperipheraljoints(kneeandhipinparticular)(A-II).4.AdiagnosisofSAshouldbeconsideredespeciallyinadultswithacutemonoarticularorpolyarticulararthritis(usuallyinvolvingtwoorthreejoints)with:?inflammatoryjointdiseases(mainlyrheumatoidarthritis),?persistentbacteraemia,and/or?immunosuppression(A-II).5.MaintainahighindexofsuspicionforthediagnosisofSAofaxialjoints(sternoclavicular,acromioclavicular,costochondral,symphysispubis,sacroiliacandfacetjoints)becauseoftheirlowerincidenceandoftennon-specificclinicalfeatures(localpainandtenderness)(A-II).6.Inpatientswithsubacuteorchronicjointpainandswelling,consideradiagnosisofinfectiousarthritiscausedbyotherinfrequentorganisms,suchasmycobacteria結(jié)核分枝桿菌orfungi,orinfrequentbacteria(Borreliaburgdorferi,Brucellaspp.布魯氏菌,Coxiellaburnetii,Bartonellaspp.,Legionellaspp.軍團桿菌,mollicutes[Ureaplasma/Mycoplasma],Nocardiaspp.,orTropherymawhipplei)(A-II).II.WhatotherpossiblediseasesmaybeimportanttoconsiderinpatientswithsuspectedSA?1.?????InpatientswithsuspectedSA,wesuggestconsideringalternativediagnoses,mainlythefollowing:????Non-infectiousarthritis,suchascrystal-inducedarthritis,post-traumaticarthritis,rheumatoidarthritis,andspondyloarthritis(includingreactivearthritis,axialspondyloarthritis,psoriaticarthritis,andarthritisassociatedwithinflammatoryboweldisease).Inchildrenoradolescents,considerjuvenileidiopathicarthritis.????Infectionsofstructuresadjacenttothejoint,suchasbursitis,mainlyinadults,andosteomyelitisorpyomyositis(typicallyaroundthepelvisandhip),mainlyinchildren.????Variousviralinfectionsthatcanpresentwitharthralgiasand/orarthritismimickingsepticarthritis.????TransientsynovitisandPerthesdiseaseinchildrenwithhipinvolvement(A-II).2.?????InadultswithsuspectedSA,itisrecommendedtoruleoutcrystalarthritis(gout,pseudogout)(A-III).Comment:Itispossibletohaveconcomitantinfectiousandcrystalarthritis.III.WhatistheappropriatediagnosticevaluationandinitialmanagementofpatientswithsuspectedSA?1.AcompletehistoryandphysicalexaminationarerecommendedinallcasesofsuspectedSA(A-III).ThiscanhelptodifferentiatebetweenSAandotherdisordersandtoidentifypathogen-specificriskfactors.2.Adiagnosticalgorithm(Fig.1)showinglaboratoryandimagingtests(B-III)isprovided.Thesearedescribedinfurtherdetailinthefollowingthreesections.??Fig.1.Diagnosticalgorithmofsepticarthritis(SA).??IV.WhatsamplesshouldbecollectedandwhatmicrobiologicaltestsshouldbeperformedifSAissuspected?1.BloodculturesarerecommendedinallpatientswithsuspectedSAandshouldbeobtainedpriortoantibioticadministrationwheneverpossible(A-II).Forbloodculturespositivefororganismsthatcommonlycauseendocarditis(suchasStaphylococcusaureus,viridansgroupstreptococci,orenterococci),wesuggestevaluationforendocarditis(B-III).2.Synovialfluid(SF)samplesshouldbetakenassoonaspossibleinallpatientswithsuspectedSA,preferablybeforeinitiatingantimicrobialtherapy(A-II).3.ItisrecommendedtosendtheSFinasterilecontainerforGramstaining,cultureand,whenindicated,molecularstudies(A-II).Ifthereisenoughfluid(e.g.,morethan2mL)forstaining,culture,possiblemolecularstudiesandleucocytecount,wesuggestbedsideinoculationofbloodculturebottleswithSF(B-II).4.InpatientswithsuspectedSAandnegativeSFcultures,wesuggestobtaininganewsampleofSFformicrobiologicalstainingandculture(includingmycobacteriaandfungi),moleculartesting(seebelow)andhistopathologicalanalysis,especiallyif:?theydonotrespondtoempiricaltherapyagainsttypicalSApathogensand/or?mycobacteriaorfungiaresuspected(B-II).5.Molecularmethods(broad-range,multiplexorspecificpolymerasechainreaction[PCR])forSFanalysisortissuebiopsy:?ThesearenotroutinelyrecommendedforallSFsamplesfrompatientswithsuspectedSA(D-III).?Theiruseshouldbepreviouslydiscussedwithamicrobiologist(A-III)andconsideredwhenSAissuspectedin:-Allchildrenaged6monthsto5years:Kingellakingae-specificPCR(A-II).-PatientswithnegativeSFculturereceivingantibioticsbeforeoratarthrocentesis:broad-rangeormultiplexPCR(A-II).-PatientswithnegativeSFculturewhodonotimprovewithempiricalantibioticsand/orwithclinicaland/orepidemiologicalsuspicionofinfectionwithNeisseriagonorrhoeaeorfastidious/difficult-to-culturemicroorganisms,includingBrucellaspp.,B.burgdorferi,Bartonellaspp.,C.burnetii,Legionellaspp.,Ureaplasmaspp.,Mycoplasmaspp.,andT.whipplei:targetedPCR(B-II).??6.SerologicaltestingforBrucellaspp.B.burgdorferi,Bartonellaspp.,C.burnetii,and/orMycoplasmaspp.issuggestedinpatientswithnegativeSFculture,especiallyinthepresenceofriskfactorsand/orepidemiological,clinicalorradiologicalevidence(B-III).7.Inpatientswithsuspectedmycobacterialorfungaljointinfection,asmuchSFaspossibleshouldbesentinasterilecontainerforculture;synovialbiopsyisalsorecommendedbecauseofitshigheryieldfortheseorganisms(A-III).8.Inpatientswithsuspectedgonococcalarthritis,inadditiontobloodandjointcultures,wesuggestN.gonorrhoeacultureandnucleicacidamplificationtestingofgenitourinaryspecimensand/orfreshlyvoidedurine,and,ifclinicallyindicated,rectalandoropharyngealswabs(A-II).V.Whatadditionalsynovialfluidandblood/serumtestsshouldbeperformedinpatientswithsuspectedSA?1.RecommendedtestsonSF:grossexamination,leucocytecountandpolymorphonuclearpercentage(A-II).IftheamountofSFislow,priorityshouldbegiventomicrobiologicaltests(A-III).Comment:ThereisnothresholdtoaccuratelydiagnoseSAortodifferentiateSAfromotheracutearthritis,althoughthelikelihoodofSAriseswithincreasingleucocytecountandPMNpercentage.SFleucocytecount>100,000/mm3or50,000–100,000/mm3with>90%PMNaresuggestiveofinfection.2.Additionalmarkers:determinationofSFglucose,lactatedehydrogenase(LDH),serumprocalcitonin(PCT)and/orlactate(ifavailable)aresuggested,especiallyifpreviousinitialdata(includingGramstain)areinconclusive(C-III).Comment:LowglucoselevelsandelevatedLDH,lactateandPCTlevelsarecommoninSA.TheseSFabnormalitiesarenotreliablydiagnosticofSAbutmaybeusefulincombinationwithotherdata.3.UseofleucocyteesteraseandglucosereagentstriptestsinSFmaybeofvalueasarapidscreeningtool(B-II).4.SFshouldbeexaminedforcrystalstoexcludemicrocrystallinearthritisinadults(A-II).5.Recommendedblood/serumtestsatinitialassessment:C-reactiveprotein(CRP),erythrocytesedimentationrate,whitebloodcell(WBC)countandPMNpercentage(A-III).Comment:Thesetestsarenon-specificandcannotdiagnoseSAordifferentiateitfromotherformsofarthritis,buttheirperformancecanbeimprovedinconjunctionwithclinicaldataandotherSFanalyses.Theycanalsobeusedasabaselineforserialmonitoringoftreatmentresponse,particularlyCRP.6.Inadults,considerthedeterminationofserumprocalcitoninlevels,ifavailable.Comment:Althoughserumprocalcitoninlevelsshowlowsensitivity,theirhighspecificitymayhelpdifferentiatebetweenSAandotherformsofarthritis(B-II).7.Wesuggestacompletebloodcountandassessmentofliverandkidneyfunctionaspartoftheevaluationofpatientseverityatpresentation,astheycouldinfluencethechoiceanddoseofantibiotics(B-III).VI.WhatistheroleofimaginginpatientswithsuspectedSA?1.Plainradiographsoftheaffectedjointatbaselinearesuggestedinallpatients(B-II).Comment:AlthoughnotusuallyhelpfulforaSAdiagnosis,theycanshowpre-existingjointorbonedisease,ruleoutotherdiagnoses,andcanbeusedasareferenceimagetoassessfuturejointdamage.Additionalimagingisnotusuallynecessary(D-III).2.Ultrasoundisrecommendedtodetecteffusionswhenthephysicalexaminationisunclear,andtoguidejointaspirationinjointsthataredifficulttoexamine,suchasthehiporsacroiliacjoint(A-II).Inchildrenwithhipinvolvementandsuspectedtransientsynovitis,ultrasoundofbothjointsissuggested,asbilateralhipeffusionisatypicalfindingoftransientsynovitisofthehipthatmaysupportthisdiagnosis(B-II).3.Magneticresonanceimaging(MRI)isrecommendedforasuspecteddiagnosisofSAofaxialjoints(A-III),andwhenfurtherimagingisneededforsuspectedspreadofinfectionfromthejointtoadjacentsofttissues,and/orosteomyelitis(morecommoninchildren'sjoints)(A-II).Inchildren,MRImaybeindicatedtodifferentiatetransientsynovitisofthehipfromSAifthediagnosisremainsindoubtaftertheinitialevaluationandinvestigation(A-III).4.Computedtomography(CT)maybeanalternativetoMRIwhenthelatterisnotreadilyavailable(A-II),althoughCTshouldgenerallybeavoidedinchildrenduetoitshighradiationindex.CTmaybeanalternativetoultrasoundtoguidejointaspiration(B-III).5.NuclearmedicineexaminationsarenotrecommendedforthediagnosisofSA(D-III).?RecommendationsfortreatmentVII.GeneralprinciplesofmanagementofSA1.Asageneralrule,patientswithsuspectedordocumentedSAshouldbeadmittedtohospital(A-II).Somestudiesinchildrentreatedexclusivelywithoraloutpatientantibioticsshowedafavourableoutcomewhenspecificcriteriaweremet(BII).2.Jointdrainageisrecommendedforperipheralbacterialarthritis(exceptforgonococcalandearlymycobacterialinfections,whichdonotusuallyrequirejointdrainage)andforfungalarthritis(A-II).3.Werecommendjointdrainageoflargeperipheraljointswithpyogenicarthritisassoonaspossible(A-II).4.Whilemostpatientswithearlydiagnosisofaxialjointinfectiondonotrequiresurgery(B-III),drainageofadjacentabscessesandvarioustypesofsurgeryforconcomitantosteomyelitismaybenecessary,especiallyifdiagnosisisdelayed(A-II).MRIisrecommendedtoassessthepresenceofthesecomplications(A-III).5.Inhaemodynamicallystablepatientswithoutsepsisorsepticshockandwithclinicalandlaboratoryfindingsofperipheralpyogenicarthritis,werecommendstartingempiricalantimicrobialtherapyafterobtainingbloodculturesandSFaspirate,aswellasintraoperativespecimensifthepatientisundergoingurgentsurgery(A-II).6.Inpatientswithhaemodynamicinstability,sepsisorsepticshock,wesuggestobtainingbloodandSFforculturebeforestartingantimicrobialtherapy,ifthisdoesnotsignificantlydelayinitiationofantimicrobialtherapy(<45min)(B-III).7.Werecommendthatthedefinitiveantibioticregimenbebasedontheidentifiedpathogenanditsantimicrobialsusceptibilityor,ifnopathogenisidentified,onthemostlikelycausativeorganism(s),tobediscussedwithaninfectiousdiseasespecialistorclinicalmicrobiologistwheneverpossible(A-II).8.Wesuggeststartingantimicrobialtherapyintravenously(B-III).9.Itisrecommendedtoswitchtooralantibioticsafterafewdays(e.g.,2–7days)ofintravenousantibioticsinadultswithoutendocarditis,withnegativebloodculturesandwithclinicalandlaboratoryimprovement(providedthatappropriateoralantimicrobialscanbeadministered)(A-II).Inchildrenwithafavourableclinicalandanalyticalevolutionafter2–4daysofintravenousantibiotics,switchingtotheoralrouteisstronglyrecommended(A-I).10.Totaldurationofantimicrobialtreatmentinadultswithoutendocarditis:?Forlargeperipheraljointsafterdrainage,wesuggest3–4weeksforS.aureus(SA)andgram-negativebacilli(GNB),2–3weeksforstreptococcalarthritisand1–2weeksforgonococcalarthritis(B-III).?AlongerdurationisrecommendedforSAofaxialjoints(6weeks)andSAwithadjacentosteomyelitis(A-III)andisalsosuggestedforpatientswithimmunosuppressionoraslow/inadequateresponsetoinitialtreatment(B-III).?TwoweeksarerecommendedforSAofthewristorhandjointsaftersurgicaldrainage(thisrecommendationmaynotapplytoSAcausedbymethicillin-resistantS.aureus[MRSA])(A-I).11.Totaldurationofantimicrobialtreatmentinchildren:?Werecommend2–3weeksforalluncomplicatedSAinchildren,and3–4weeksforSAwithosteomyelitis(A-I).?Longertherapy(4–6weeks)mayberequiredin:°InfectionscausedbyMRSA(B-II),Salmonella,EnterobacteralesorPseudomonasaeruginosa(B-III)°SAofaxialjoints(A-III)°Newbornsandyounginfants(<3months)(B-III)°Immunocompromisedchildren(B-III)?EmpiricalantimicrobialtherapyVIII.WhatistherecommendedinitialempiricalantimicrobialtherapyforSA?1.EmpiricaltherapyactiveagainstS.aureusisalwaysrecommendedinanypatient(adultsandchildren)withsuspectedSAandnegativeSFGramstain(A-II).Additionalempiricalantimicrobialcoveragemaybenecessaryforotherpathogens(A-III).2.InadultswithnegativeSFGramstainandnospecificriskfactorsforspecialpathogensorresistantbacteria,wesuggestcoverageofS.aureus,streptococciandthemorecommonGNBwith:?Cloxacillinplusceftriaxoneormonotherapywithamoxicillin–clavulanate(B-III).?Aglycopeptideordaptomycincombinedwithaztreonamorafluoroquinoloneincaseofbeta-lactamallergy(B-III).Otheroptionsshouldbeconsideredinthepresenceofcertainriskfactorsorclinicalcontexts(B-III).3.InchildrenwithoutspecificriskfactorsforspecialpathogensorresistantbacteriaandwithanegativeSFGramstain,werecommendtreatmentasfollows(A-II):?<3months:cloxacillinorcefazolin+cefotaximeorgentamicin(avoiding2cephalosporinstogether).?3monthsto2years:cefuroxime;alternatively,cloxacillin+cefotaximeoramoxicillin–clavulanate.?2–4years:cefazolin;alternatively,cefuroximeforcoverageofHaemophilusinfluenzaeandStreptococcuspneumoniaeinunder-vaccinatedchildren.??>4years:cefazolinorcloxacillin.?TargetedantimicrobialtherapyIX.WhatisthedefinitiveantimicrobialtherapyforS.aureusSA?a)Inadults1.Formethicillin-susceptibleS.aureus,intravenouscloxacillinorcefazolinisrecommended(A-II).Initialadditionofdaptomycinmaybeconsidered(C-III).Patientsallergictobeta-lactamscanbetreatedwithvancomycinordaptomycin(A-II).2.PatientswithMRSASAcanbetreatedwithvancomycinordaptomycin(A-II)(initialcombinationofdaptomycinplusabeta-lactammaybeconsidered,C-III).3.Sequentialoraltreatmentwithbeta-lactams,levofloxacin,clindamycinorlinezolidarepossibleoptions,dependingonisolatesusceptibilityandbeta-lactamallergy(B-III).4.TheuseofrifampinforpureSAisnotsupportedbypathogenesisorevidence.Itcouldbeconsideredincomplicatedcaseswithconcomitantosteomyelitis(A-III).b)Inchildren1.Formethicillin-susceptibleS.aureus,initialintravenouscefazolinorcloxacillinisrecommended(A-II).Sequentialoraltreatmentwithabeta-lactam(i.e.,cefadroxil)isrecommended(A-II).Clindamycin(A-I),linezolid,levofloxacin(children>6months),daptomycin(children>1year)orvancomycinarealternativesforbeta-lactamallergy(B-III).2.ForMRSA,initialintravenousclindamycinisrecommendediftheisolateissusceptible(A-I).Otherwise,themostappropriateantibioticsarelinezolidordaptomycin;aglycopeptidewouldbeavalidbutlesssuitableoption(B-III).Forsequentialoraltreatment,clindamycin(children>6–8years)(AI),cotrimoxazole(B-II),levofloxacin(>6months),orlinezolid(B-III)aresuggested,dependingonisolatesusceptibility.X.WhatisthedefinitiveantimicrobialtherapyforstreptococcalSA?a)Inadults1.ForSAcausedbysusceptiblestreptococci,penicillinisthedrugofchoice.Third-generationcephalosporins(ceftriaxone,cefotaxime)orampicillinaregoodalternatives(A-II).Incasesofallergyorreducedsusceptibility,vancomycin,clindamycin,afluoroquinolone,orlinezolidmaybeused(B-III).2.Fortheoraltreatmentphase,amoxicillin,cefuroxime,levofloxacin,ormoxifloxacinareallgoodoptions(A-III).b)Inchildren1.ForgroupAandgroupBstreptococci,andpenicillin-susceptibleS.pneumoniae,initialintravenouspenicillinorampicillinaretherecommendeddrugsofchoice(A-III).2.Sequentialoraltreatmentwithamoxicillinisrecommended(A-III).3.Third-generationcephalosporins(ceftriaxone,cefotaxime),levofloxacin(children>6months),clindamycin,linezolidorvancomycinarealternativesdependingonisolatesusceptibilityandbeta-lactamallergies(C-III).XI.WhatisthedefinitiveantimicrobialtherapyforSAcausedbygram-negativebacilli?a)Inadults1.ForSAcausedbysusceptibleGNB,initialtreatmentwithanintravenoussecond-orthird-generationcephalosporinisrecommended(A-III).ForGNBisolatesresistanttothird-generationcephalosporins,consultationwithaninfectiousdiseasespecialistisrecommended(A-III).Initialtreatmentwithaztreonamorafluoroquinoloneissuggestedforbeta-lactamallergies(B-III).2.Sequentialoraltreatmentwithciprofloxacinisrecommendedwheneverpossible(A-III).Oralbeta-lactamsorcotrimoxazolearesuggestedalternativetreatments,dependingonthesusceptibilityoftheGNBidentified(B-III).b)Inchildren1.K.kingaeSAcanbetreatedwithpenicillinorampicillin.First-andsecond-generationcephalosporinsoramoxicillin–clavulanatearegoodalternatives(A-II).2.ForSAcausedbyotherGNB,antimicrobialselectionshouldbebasedonsusceptibility(A-III).XII.WhatisthedirectedtherapyforSAcausedbyotherlesscommonmicroorganisms??Candidaspp.septicarthritis1.Insurgicallytreatedcases,wesuggest6–8-weeksoftherapywithanazole,echinocandinorliposomalamphotericinB(A-III).2.InneonateswithcandidaSA,anextent-of-diseasestudyissuggested,includinglumbarpunctureandretinalexamination(B-II).?Mycobacteriumtuberculosisarthritis1.Inpatientswithearlydiagnosistuberculousarthritis(withoutlargeabscessesorbonesequestration),tuberculostatictreatmentsimilartothatfortuberculosisatothersitesisrecommended.Someexpertsrecommendlongertreatment(9–12months)(B-III).2.Itissuggestedthattreatmentbesupervisedbyanexpert(B-III).?Gonococcalarthritis1.Inadults,werecommendceftriaxone1gevery24h(firstchoice)orcefotaxime1gintravenouslyevery8h(alternative)(A-III).Afterclinicalimprovement,wesuggestswitchingtoanoralagentguidedbyantimicrobialsusceptibilitytesting:ciprofloxacin500mg/12horcefixime400mg/12h(B-III).Patientswithgonococcalarthritisshouldbescreenedforothersexuallytransmittedinfections(A-II).2.Inchildren,wesuggest7daysofcefotaxime(neonates)orceftriaxone(B-III).XIII.Whatisthetreatmentforculture-negativesepticarthritis?1.Wesuggestthatculture-negativeSAbetreatedwithantimicrobialtherapysimilartoempiricaltherapyinpatientswithGramstain-negativeSF(B-III).2.Inpatientswhoarereceivingorhaverecentlyreceivedantibiotics,weadviseconsideringantibioticcoveragetotailorantimicrobialtherapy(B-III).3.Anaccurateepidemiologicalassessmentisrequiredtoruleoutuncommonorfastidiousmicroorganisms(B-II).?AdjuvanttreatmentXIV.IsanyadjuvanttreatmentrecommendedforSA?1.Inchildren,nonsteroidalanti-inflammatorydrugsmaybebeneficialduringtheacutephasewhilethesignsofinflammationarepresent(A-III).2.InchildrenwithconfirmedSA,earlyadministrationofashortcourseofintravenouscorticosteroidsmayaccelerateclinicalrecoveryandreducehospitalstay(B-I).Comment:Thepotentialimpactofdiagnosticdelayonnon-infectiousarthritisandthelong-termeffectsinSAareunclear.3.Inadults,corticosteroiduseisnotrecommendedforSAduetothelackofclinicalevidenceonitseffects(D-III).?JointdrainageXV.WhatjointdrainageproceduresarerecommendedinpatientswithSA?1.JointdrainagetotreatSAcanbeperformedbyclosed-needleaspiration(repeatedasnecessary),arthroscopyorarthrotomy(opensurgery)(A-III).Werecommendtailoringtheoptimaldrainageproceduretoage,affectedjoint,extentofinvolvement,timecourseandotherclinicaldata(A-III).2.Inadults,arthroscopicjointdrainagewithsynovectomyisthesuggestedfirst-lineprocedureforSAoftheknee(B-II).Needleaspirationisanothertreatmentoption(B-II).Fortheankle,elboworwrist,initialjointdrainagemaybebyneedleaspirationorarthroscopy(B-III).Forthehipandshoulder,arthroscopyorarthrotomyisthesuggestedinitialprocedure(B-II).Opensurgeryissuggestedforcaseswithunfavourableevolutionafterrepeatedaspirationorarthroscopicdrainage(B-III).3.Inchildren,thesuggestedinitialtreatmentprocedureforuncomplicatedSAofjointsotherthanthehipisneedleaspiration(B-I).ForSAofthehip,knee,ankle,shoulder,elboworwrist,arthroscopyispreferabletoopensurgery(B-II).WesuggestjointdrainagebyarthrotomyasthefirstoptionforhipandshoulderSAinyoungchildren,andaftermoreconservativeprocedures(needleaspirationorarthroscopy)havefailed(C-III).?AdditionalmeasuresXVI.WhatadditionalmeasuresmaybeusefultoimprovethefunctionaloutcomeofapatientwithSA??Suggestionsinclude:1.Initiatingphysiotherapyaftersurgicaljointdrainage(B-III).2.Earlymobilisationoftheaffectedjoint,initiallywithpassivemovement(B-III).Inchildrenwithhiparthritis,immobilisationinanabductionspicacastisreservedforcasesofsevereinfectionatriskofjointdislocation(B-II).3.Earlyweightbearing–includingpartialweightbearing–isdiscouragedwhenthehipjointisaffected(D-III).4.EarlypartialweightbearingissuggestedforpatientswithkneeSA,oncethepainiscontrolled(B-III).?Recommendationsforclinicalfollow-upXVII.Howshouldpatientsbefollowedupandforhowlong?1.Outpatientfollow-upwithoralantimicrobialtherapy(oroutpatientparenteralantimicrobialtherapyiforaltreatmentisnotpossible)issuggestedonceafavourableclinicalandanalyticalevolutionisestablished(B-III).2.Clinical(jointpain,inflammationandfunction)andanalytical(bloodcount,CRPanderythrocytesedimentationrate)monitoringissuggested(B-III).Whilepatientsarereceivingantibiotics,wesuggestmonitoringforpossibleassociatedadverseeffects(B-III).3.Outpatientfollow-upbyorthopaedicandinfectiousdiseasespecialistsissuggestedat1–2weeks,4–6weeksand3monthsafterdischarge(C-III).Wesuggestafollow-upperiodofatleast1yearinadultsatriskoflong-termadverseoutcomesandsequelae(suchasthosewithimpairedjointfunctionand/orconcomitantosteomyelitis)andinchildren(preferablybyanexperiencedorthopaedicsurgeon)(B-III).Ininfantswithhip/physealinvolvement,longerfollow-upmaybenecessary(B-III).2024年08月04日
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付朝杰副主任醫(yī)師 棗莊市婦幼保健院 新生兒科 對于除了有疼痛、功能障礙（尤其是不能負重）表現(xiàn)，孩子還有狀態(tài)不佳，有發(fā)熱大于38.5攝氏度，或者關(guān)節(jié)有紅腫（這個可能不明顯）等表現(xiàn)時，需要考慮到化膿性關(guān)節(jié)炎。對于這些孩子，要進行血常規(guī)、CRP和血沉（ESR）檢查，如果白細胞計數(shù)>12X10^9/L，紅細胞沉降率≥40mm/h，C反應(yīng)蛋白>20mg/L，提示化膿性關(guān)節(jié)炎可能性大，需要進行雙側(cè)髖關(guān)節(jié)超聲+穿刺抽液檢查。單純通過超聲檢查，不能明確關(guān)節(jié)內(nèi)積液是否為炎癥性或者化膿性的。但是如果孩子僅一側(cè)疼痛，但是雙側(cè)都有積液，提示一過性滑膜炎可能性更大，而化膿性的，多是只有一側(cè)有積液。癥狀之前的感染史，對鑒別化膿性還是一過性滑膜炎沒有意義，研究發(fā)現(xiàn)，先前上呼吸道感染的患病率在一過性滑膜炎和化膿性關(guān)節(jié)炎之間無顯著差異。2022年06月25日142
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胡潤桐主治醫(yī)師 河北省兒童醫(yī)院 創(chuàng)傷外科（急診外科) 在兒童中，有一種疾病的病因尚未明確，由多方面因素均可引起改疾病的出現(xiàn)。 這種病即化膿性關(guān)節(jié)炎，好發(fā)于髖、膝關(guān)節(jié)，也有見于患兒的手指、足趾等地方，表現(xiàn)有發(fā)熱、疼痛、髖膝關(guān)節(jié)不敢活動，患兒哭鬧。 患兒來就診時，在門診查血象及CRP較高，提示有感染癥狀，結(jié)合查血沉，關(guān)節(jié)部位的穿刺若穿刺出的物質(zhì)可見大量膿性滲液，經(jīng)過把穿刺的標(biāo)本送細菌培養(yǎng)+藥敏試驗，膿液培養(yǎng)+藥敏試驗進行進一步明確性質(zhì)的診斷。 一般檢查還包括雙側(cè)髖膝關(guān)節(jié)彩超，看關(guān)節(jié)腔積液量的多少，進一步判斷。 若患兒病情較急，有高熱癥狀，結(jié)合血象判斷，有化膿性關(guān)節(jié)炎征象，需要立即禁食水，然后等待急診手術(shù)治療。2021年10月29日427
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胡曉波副主任醫(yī)師 濟南市中心醫(yī)院 重癥醫(yī)學(xué)科 什么是化膿性關(guān)節(jié)炎？ 化膿性關(guān)節(jié)炎是由關(guān)節(jié)感染所致，可導(dǎo)致關(guān)節(jié)疼痛、腫脹和積液。感染常為細菌性，但也可能由其他病原體引起。細菌進入關(guān)節(jié)的方式多種多樣，大多是通過血液從其他部位轉(zhuǎn)移而至。 化膿性關(guān)節(jié)炎有時會導(dǎo)致關(guān)節(jié)損傷和長期關(guān)節(jié)問題。 有何癥狀？ 其癥狀通常突然發(fā)作，包括： ●關(guān)節(jié)疼痛 ●關(guān)節(jié)腫脹 ●關(guān)節(jié)周圍皮溫升高 ●關(guān)節(jié)活動問題 ●發(fā)熱 化膿性關(guān)節(jié)炎通常僅累及1個關(guān)節(jié)，但有時也可累及多個關(guān)節(jié)。膝、腕、踝和髖關(guān)節(jié)最常受累。 有針對性檢查嗎？ 有。檢查包括： ●關(guān)節(jié)液實驗室檢查–醫(yī)生通常會使用針和注射器采集液體樣本，但有時必須手術(shù)取樣，然后送檢實驗室。 ●血培養(yǎng)，以查明血液內(nèi)的細菌情況 ●關(guān)節(jié)X線檢查 如何治療？ 治療包括以下兩部分： ●抗菌藥物可以殺死導(dǎo)致感染的病菌，給藥一般是通過插入靜脈的細管，即“靜脈給藥”。 ●醫(yī)生可采用各種方法引流關(guān)節(jié)內(nèi)液體，具體取決于受累的關(guān)節(jié)。許多情況下是使用針和注射器來抽吸液體，但有時需要手術(shù)引流。若關(guān)節(jié)仍不斷有積液，可能需要多次引流。 醫(yī)生可能還會要求就診理療科，從而學(xué)會一些鍛煉方法，以預(yù)防關(guān)節(jié)問題和避免關(guān)節(jié)過于僵硬。2021年04月24日1050
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俞志濤主任醫(yī)師 北京積水潭醫(yī)院 小兒骨科 孩子一直高熱不退，同時某個肢體不愿活動，這時家長需要注意化膿性關(guān)節(jié)炎的可能性！化膿性關(guān)節(jié)炎，是一種由化膿性細菌直接感染，并引起關(guān)節(jié)破壞及功能喪失的關(guān)節(jié)炎，又稱細菌性關(guān)節(jié)炎或敗血癥性關(guān)節(jié)炎。任何年齡均可發(fā)病，但因為兒童免疫力低下，多發(fā)生于兒童，甚至嬰幼兒，應(yīng)引起廣大家長高度重視。對于兒童來說，血源性感染較多，如麻疹、猩紅熱、肺炎等，均有可能引起化膿性關(guān)節(jié)炎。這往往導(dǎo)致化膿性關(guān)節(jié)炎很難被早期發(fā)現(xiàn)。為了能早期發(fā)現(xiàn)并治療化膿性關(guān)節(jié)炎，我們需要首先了解其臨床表現(xiàn)與癥狀：其主要癥狀為中毒表現(xiàn)，患兒寒戰(zhàn)高熱，全身癥狀嚴重，小兒可因高熱引起抽搐。發(fā)生化膿性關(guān)節(jié)炎的關(guān)節(jié)，局部可能有紅腫疼痛及明顯壓痛等急性炎癥表現(xiàn)，同時伴有活動減少甚至不愿活動。因此高熱不退的患兒，需檢查各個大關(guān)節(jié)，如髖關(guān)節(jié)、肩關(guān)節(jié)、膝關(guān)節(jié)、踝關(guān)節(jié)，以確定有無化膿性關(guān)節(jié)炎。如患兒有化膿性關(guān)節(jié)炎癥狀，首先應(yīng)立即于醫(yī)院就診，同時行各項相關(guān)檢查以確診。血液學(xué)檢查初步可行血常規(guī)、C-反應(yīng)蛋白檢查，如血象升高，C-反應(yīng)蛋白升高，則考慮患兒存在感染；關(guān)節(jié)超聲可確定關(guān)節(jié)內(nèi)是否有膿液，如關(guān)節(jié)超聲提示關(guān)節(jié)腔積液，透聲差，結(jié)合血象升高，則應(yīng)高度懷疑化膿性關(guān)節(jié)炎，立即住院行進一步檢查。如關(guān)節(jié)穿刺抽出膿液，則可確診化膿性關(guān)節(jié)炎，需立即急診手術(shù)治療?；撔躁P(guān)節(jié)炎可能引起多種不良后果，需早發(fā)現(xiàn)，早治療。關(guān)節(jié)內(nèi)膿液可導(dǎo)致患兒長期高熱不退，細菌入血會導(dǎo)致敗血癥，貧血，低蛋白，危及患兒生命；同時化膿性關(guān)節(jié)炎有極大可能引起骨髓炎，股骨頭壞死等難以治愈、具有不良后果的并發(fā)癥，導(dǎo)致患兒關(guān)節(jié)發(fā)育不良，四肢畸形，抱憾終身！望廣大患兒家長高度警惕這一疾病，不要避諱手術(shù)治療，如發(fā)現(xiàn)相關(guān)癥狀及時就醫(yī)。2019年09月23日1763
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