Diagnosis Prevention and Management Osteoarthritis Rheumatoid Arthritis Septic

  • Slides: 106
Download presentation
Diagnosis, Prevention and Management: Osteoarthritis Rheumatoid Arthritis Septic Arthritis Rae. Anne Fondriest, RN, BSN

Diagnosis, Prevention and Management: Osteoarthritis Rheumatoid Arthritis Septic Arthritis Rae. Anne Fondriest, RN, BSN Katie Kearney, RN, BSN Michelle Nissen, RN, BSN Angela Robinson, RN, BSN Teresa Siefke, RN, BSN

Objectives • Identify prevalence of arthritic conditions • Discuss the pathophysiology of arthritic conditions

Objectives • Identify prevalence of arthritic conditions • Discuss the pathophysiology of arthritic conditions • Recognize physical assessment attributes of arthritic conditions • Discuss current treatment guidelines for arthritic conditions • Identify preventative strategies of arthritic conditions • Outline needed follow up for the treatment of arthritic conditions

Osteoarthritis

Osteoarthritis

Pathophysiology (Ling et al. , 2009)

Pathophysiology (Ling et al. , 2009)

Causative Agents • Old Age • Obesity • Improper joint alignment • Direct or

Causative Agents • Old Age • Obesity • Improper joint alignment • Direct or repetitive trauma • Genetic abnormalities (Keenan et al. , 2012)

Prevalence • Osteoarthritis affects 13. 9% of the population over the age of 25

Prevalence • Osteoarthritis affects 13. 9% of the population over the age of 25 and 33. 6% over the age 65 • Job related costs from AO average 3. 4 to 13. 2 billion per year • OA of the knee is one of the top 5 leading causes of disability among adults • Hospitalizations: OA accounts for 69. 9% of arthritis related hospitalizations • The rate of total knee replacement and total hip replacement increased by 187% and 86. 2% from 1991 to 2007 • The estimated costs due to hospital expenditures of TKR and THR average 28. 5 billion and 13. 7 billion in 2009 (Centers for Disease Control and Prevention, 2014)

Signs and Symptoms Early stages of disease • Early morning stiffness of less then

Signs and Symptoms Early stages of disease • Early morning stiffness of less then 30 minutes Middle stages of disease • Pain with activity • Improves with rest Later Stage of Disease • Pain with rest and sleep • Limited Range of motion (Ling et al. , 2009)

Physical Assessment • Subtle prominence of the finger joints • Herberden’s Nodes • Bouchard’s

Physical Assessment • Subtle prominence of the finger joints • Herberden’s Nodes • Bouchard’s Nodes Adapted from: American College Of Rheumatology 2014 Osteoarthritis: Heberden’s and Bouchard’s Nodes, Fingers Retrieved from http: //images. rheumatology. org/viewphoto. php? album. Id=77030&image. Id=2897683 201411011813361594496608

Physical Assessment • Effusion of the knee • Bony prominence • Joint laxity or

Physical Assessment • Effusion of the knee • Bony prominence • Joint laxity or unexpected mobility • Mal-alignment of the joint • Varus or valgus deformity (Ling et al. , 2009)

Differential Diagnosis • Rheumatoid arthritis • Crystalline diseases: • Gout, calcium pyrophosphate deposition disease

Differential Diagnosis • Rheumatoid arthritis • Crystalline diseases: • Gout, calcium pyrophosphate deposition disease and hyproxyappetite • Seronegative spondyloarthropathy: • Psoriatic arthritis and Rieter’s • Polymyalgia rheumatica • Bone disease: • Osteomalacia, hypovitaminosis D and Paget’s disease • Malignancy: • Myeloma and metastatic (Ling et al. , 2009)

Differential Diagnosis • Infectious disease: • Infectious arthritis, osteomyelitis and sepsis syndrome • Periarticular

Differential Diagnosis • Infectious disease: • Infectious arthritis, osteomyelitis and sepsis syndrome • Periarticular soft-tissue abnormalities: • Tendonitis and bursitis • Neuromuscular diseases: • Neuropathy • Systemic disease: • Diabetes, autoimmune-lupus vasculitis (Ling et al. , 2009)

Diagnostic Criteria • Conventional Radiology • Optical Coherence Tomography Hand • Ultrasound • MRI

Diagnostic Criteria • Conventional Radiology • Optical Coherence Tomography Hand • Ultrasound • MRI Knee Hip Hand pain, aching or stiffness Knee pain Hip pain and and Hand tissue enlargement of 2 or more joints Radiographic osteophytes 2 or more of the following: Fewer than 3 swollen MCP joints and ESR <10 mm/h and 1 or more of the following: Radiographic femoral or acetabular osteophytes 2 or more DIP joints with hand tissue enlargement Age ≥ 50 Radiographic joint space narrowing or Morning stiffness <30 min Deformity in 2 or more select joints Creptus on motion (Braun & Gold, 2012; Sinusas, 2012)

Treatment (Sinusas, 2012)

Treatment (Sinusas, 2012)

Knee Surgery • Transplantation of autologous chondrocytes: • Used to repair discrete defects in

Knee Surgery • Transplantation of autologous chondrocytes: • Used to repair discrete defects in articulate cartilage • Arthroscopy with debridement: • Allows visualization of the joint and is appropriate for patients with mechanical problems such as locking and giveaway weakness while awaiting more definitive treatment. • Osteotomy: • Transfers the load to the unaffected part of the knee - high tibial osteotomy effective for OA for patients with a single compartment of a varus malaligned knee • Arthroplasty: • Including unicompartment, patellafemoral, total joint in which they replace the damaged cartilage with metal or plastic (Ling et al. , 2009)

Hip Surgery • Arthroscopy: • Used to debride labral tears, loose body removal, osteophyte

Hip Surgery • Arthroscopy: • Used to debride labral tears, loose body removal, osteophyte resection, biopsy, synovectomy , or lengthening or releasing of iliopsoas or IT band • Osteotomy: • Cutting the bone of the femur or pelvis to realign and fix the bone with plates or screws • Resection arthroplasty: • Complete resection of the femoral head without replacement, salvage procedure for severe hip infection resistant to antibiotics or failed total hip arthroplasty with unreconstructable bone defects (Srinivasan, Tolhurst, Vanderhave, & Doherty, 2010)

Hip Surgery • Arthrodesis: • realigns the hip to 5 to 10 degrees of

Hip Surgery • Arthrodesis: • realigns the hip to 5 to 10 degrees of external rotation and 20 to 30 degrees of flexion and neutral adduction, • Total Hip and hemiarthroplasty: • replacement of the femoral head and or acetabulum with manufactured components • Resurfacing arthroplasty: • replacement of an acetabular component in addition to resurfacing the femoral head with resection of the entire femoral head (Srinivasan, Tolhurst, Vanderhave, & Doherty, 2010)

Post Op Care • Pain management with multimodal strategies including • Epidural or spinal

Post Op Care • Pain management with multimodal strategies including • Epidural or spinal analgesia • Femoral nerve block • Periarticular injections • Patient controlled analgesia • Oral analgesics (Maheshwari, Blum, Shekhar, Ranawat, & Ranawat, 2009)

Post Op Care • Deep Vein Prophylaxis • Assess for history of bleeding disorders

Post Op Care • Deep Vein Prophylaxis • Assess for history of bleeding disorders or liver disease • Discontinue all antiplatelet agents prior to surgery • Use of pharmacological and nonpharmacological devices with high risk patients • Mechanical compressive devices with low risk patients and bleeding disorders • Practice early mobilization following surgery • Use epidural, intrathecal and spinal anesthesia to limit blood loss (Jacobs et al. , 2011)

Post Op Care • Infection prevention: Antibiotics within one hour of surgical incision •

Post Op Care • Infection prevention: Antibiotics within one hour of surgical incision • A first or second generation Cephalosporin – cefazolin or cefuroxime with isoxazolyl penicillin for a substitute • Clindamycin or Vancomycin should be used in patients with penicillin allergies • Vancomycin should be used in patients who are carriers for MRSA • Patients with previous joint infections should be treated with the same antibiotics effective for that infection • Patients should not receive antibiotics for more than 24 hours post surgery (Hansen et al. , 2014)

Health Promotion • Weight Loss • Regular Exercise • Diet • Proper use of

Health Promotion • Weight Loss • Regular Exercise • Diet • Proper use of pain medication • Smoking cessation • Immunization status (Stein, 2011)

Prevention • Prevention of the need for surgery in osteoarthritis • Weight loss: Every

Prevention • Prevention of the need for surgery in osteoarthritis • Weight loss: Every one pound of weight loss results in a fourfold reduction in the load exerted on the knee per step (Ling et al. , 2009) • Prevention of joint injury: Improve mechanical efficiency for occupations with repetitive motion, and reduce joint injury in recreational sports with proper technique and education • Estrogen deficiency: Replacement may reduce the risk of OA • C-reactive protein : higher levels increase risk (Centers for Disease Control and Prevention, 2014)

Outcomes (Cushner, Agnelli, Fitzgerald, & Warwick, 2010)

Outcomes (Cushner, Agnelli, Fitzgerald, & Warwick, 2010)

Outcomes • Statistics for total knee and hip arthroplasty • 85 -90% of patients

Outcomes • Statistics for total knee and hip arthroplasty • 85 -90% of patients report a good outcome with absence of pain • Periprosthetic joint infection rate 1. 6 -2. 3% • Pulmonary Embolism rate 0. 5 to 0. 9% • Wound infection rates 0. 3 to 1. 0% • Bleeding and hematoma 0. 94 to 1. 7% • 90 day death rate 0. 7 to 2. 7% (Agency For Health Care Research And Quality, 2014)

Follow Up • Depends on the patient progression and amount of external support the

Follow Up • Depends on the patient progression and amount of external support the patient receives in the way of physical therapy, home nurse visits, home caregivers, and the home environment • First follow up visit in 10 to 14 days for suture removal • Total hip replacement follow up is at two weeks, six weeks and 12 weeks • Follow up yearly for all joint replacement for first five years (Skinner & Mc. Mahon, 2014)

Rheumatoid Arthritis

Rheumatoid Arthritis

Prevalence of RA • Affects approximately 1% of the world population • Women 1.

Prevalence of RA • Affects approximately 1% of the world population • Women 1. 06% vs men 0. 61% • Peak incidence in women 55 -64 years of age • Peak incidence in men 75 -84 years of age • Associated genetic link to RA • Highest prevalence: • American Indian • Alaskan Indian tribes (Carmona et al. , 2002; U. S. Department of Health and Human Services, 2012)

Prevalence Globally of RA (Shah & Clair, 2012)

Prevalence Globally of RA (Shah & Clair, 2012)

Prevalence of Rheumatoid Arthritis (Google Images, 2014)

Prevalence of Rheumatoid Arthritis (Google Images, 2014)

Pathophysiology • Systemic chronic autoimmune disease causing inflammation of the connective tissue that affects

Pathophysiology • Systemic chronic autoimmune disease causing inflammation of the connective tissue that affects synovial tissue, cartilage and bones. • Early disease • Synovium becomes markedly hyperplastic and edematous. • Progression of RA • Activation and recruitment of T cells into the joint result in a complex cascade of inflammatory responses. • Accumulation of inflammatory cells, panus formation, localized osteoporosis, bony erosions, and destruction of periarticular structures. (Young, 2009)

Pathophysiology • Rheumatoid synovitis is accompanied by the accumulation of inflammatory joint fluid with

Pathophysiology • Rheumatoid synovitis is accompanied by the accumulation of inflammatory joint fluid with elevated white cell count • Proteins that have been implicated in the inflammatory process: • Proinflammatory cytokines interleukins • Tumor necrosis factor • Metalloproteinases transforming growth factor-β • Granulocyte colony-stimulating factor • Activated complement components (Young, 2009)

Pathophysiology (Google Images, 2014)

Pathophysiology (Google Images, 2014)

2010 Joint Classification Criteria (Aletaha et al. , 2010)

2010 Joint Classification Criteria (Aletaha et al. , 2010)

2010 Joint Classification Criteria • At least 1 joint with definite clinical synovitis (swelling)

2010 Joint Classification Criteria • At least 1 joint with definite clinical synovitis (swelling) • Synovitis not better explained by another disease • A score of 6/10 is needed for RA classification (Aletaha et al. , 2010; Google Images, 2014)

Early Disease Presentation • Common symptoms: • Morning stiffness > 60 minutes • ROM

Early Disease Presentation • Common symptoms: • Morning stiffness > 60 minutes • ROM improves with activity • Fatigue • Low-grade fevers • Symmetric arthritis • Rheumatoid nodules • Radiographic changes • Mild weight loss • Most frequently involved joints: • Wrist • Metacarpophalangeal (MCP) • Proximal interphalangeal (PIP) (Shah & St. Clair, 2012; Google Images, 2014)

Physical Assessment • Progressive deformity and decrease in ROM • Joint swelling and/or tenderness

Physical Assessment • Progressive deformity and decrease in ROM • Joint swelling and/or tenderness • Early manifestations usually start in the small bones: • Hands • Feet • Flexor tendon tenosynovitis • Reduced grip strength and ROM • “Trigger Finger” (Shah & St. Clair, 2012; Google Images, 2014)

Progression of Physical Assessment • Late manifestations progress to larger bone involvement and increased

Progression of Physical Assessment • Late manifestations progress to larger bone involvement and increased debility • Temporal mandibular joint • Atlantoaxial cerval spine • Compressive myelopathy and neurological dysfunction • Compression of C 1 on C 2 • These complications have decreased significantly due to treatment (Shah & St. Clair, 2012)

Extraarticular Manifestations • Arise in active, untreated or inadequately treated disease • Affects multiple

Extraarticular Manifestations • Arise in active, untreated or inadequately treated disease • Affects multiple organ systems • Can occur prior to arthritic symptoms • Occurs more in smokers • Early onset disability • Will test positive for serum rheumatoid factor (Shah & St. Clair, 2012)

Extraarticular Manifestations (Shah & St. Clair, 2012)

Extraarticular Manifestations (Shah & St. Clair, 2012)

Extraarticular Manifestations • • • Skin: nodules - extensor surfaces, pressure points Bone: osteoporosis

Extraarticular Manifestations • • • Skin: nodules - extensor surfaces, pressure points Bone: osteoporosis Blood: anemia, Felty’s syndrome, lymphoma, leukemia Eyes: scleritis, episcleritis, keratoconjunctivitis sicca – secondary Sjögren syndrome Heart: CAD, atherosclerosis, MI, pericarditis, myocarditis, cardiomyopathy, mitral regurgitation Peripheral neuropathy Rheumatoid vasculitis Neuro: cervical myelopathy Endocrine: hypoandrogenism (Shah & St. Clair, 2012)

Extra-articular Manifestations Lungs: • Interstitial lung disease • Bilateral infiltrates • Honeycomb pattern •

Extra-articular Manifestations Lungs: • Interstitial lung disease • Bilateral infiltrates • Honeycomb pattern • • PFTs – Restrictive pattern Fibrosis Bronchiectasis/Bronchiolitis Rheumatoid nodules • Solitary • Multiple • Often in conjunction with cutaneous nodules • Exudative pleural effusions (Shah & St. Clair, 2012; Google Images, 2014)

Differential Diagnosis • • • Infectious arthritis Parvovirus B 19 (Fifth disease) Hepatitis B

Differential Diagnosis • • • Infectious arthritis Parvovirus B 19 (Fifth disease) Hepatitis B or C Infective endocarditis Mycobacterium tuberculosis Septic arthritis Lyme disease Reactive arthritis Multicentric reticulocytosis (Shah & St. Clair, 2012)

Differential Diagnosis • • • Osteoarthritis Gout/Pseudogout Psoriatic arthritis Ankylosing spondylitis Inflammatory bowel disease

Differential Diagnosis • • • Osteoarthritis Gout/Pseudogout Psoriatic arthritis Ankylosing spondylitis Inflammatory bowel disease Fibromyalgia Lupus Hypothyroidism Polymyalgia rheumatica Sarcoidosis (Shah & St. Clair, 2012)

Diagnostic Laboratory Studies • Anti-cyclic citrullinated peptide antibody (ACPA or anti-CCP) • Helps confirm

Diagnostic Laboratory Studies • Anti-cyclic citrullinated peptide antibody (ACPA or anti-CCP) • Helps confirm diagnosis and prognosis, high sensitivity, positive earlier than RF • Rheumatoid factor (RF) • Useful in differentiating RA from other chronic inflammatory arthritides • C-reactive protein and erythrocyte sedimentation rate • Assess disease activity • Synovial aspirate • Inflammatory changes and white blood cells (Nicoll, 2012)

Treatment and Monitoring • NSAIDS and High Dose Salicylates • Pain and mild inflammation,

Treatment and Monitoring • NSAIDS and High Dose Salicylates • Pain and mild inflammation, do not alter disease course • Monitor: • Bleeding • Renal toxicity • GI distress • Avoid in pregnancy (The Medical Letter, 2012)

Treatment and Monitoring • Disease Modifying Antirhematic Drugs (DMAD) • Corticosteroids • Methotrexate (Trexall),

Treatment and Monitoring • Disease Modifying Antirhematic Drugs (DMAD) • Corticosteroids • Methotrexate (Trexall), leflunomide (Arava) sulfasalazine (Azulfidine) • Hydroxychloroquine (Plaquenil) - Antimalarial • Monitor: • GI Distress • Increased risk for infection • Heptotoxicity • Aplastic anemia • Agranulocytosis • Steven’s Johnson’s Syndrome (The Medical Letter, 2012)

Treatment and Monitoring • Biologic Response Modifiers (TNF - inhibitors) • Newer class that

Treatment and Monitoring • Biologic Response Modifiers (TNF - inhibitors) • Newer class that target pathways responsible for progression and symptoms of RA • Etanercept (Enbrel), Inflixmab (Remicade), Adalimumab (Humira) • Montior: • TB • Hep B • Infection • Avoid in heart failure • Avoid in demyelinating disease • Avoid in pregnancy (The Medical Letter, 2012)

Health Promotion and Prevention • Immune system suppression awareness • Must check for TB

Health Promotion and Prevention • Immune system suppression awareness • Must check for TB prior to drug initiation • Routine assessment for infection, hypertension, hepatic dysfunction and pulmonary abnormalities • Vision screening • Pregnancy screening prior to treatment • Plaquenil only DMAD approved in pregnancy • Vaccination • Must immunize against influenza, pneumonia, hepatitis B and herpes zoster • Live vaccines should be given one month prior to treatment (The Medical Letter, 2012)

Health Promotion and Prevention • Routine assessment: • Cardiac • 40% of RA patients

Health Promotion and Prevention • Routine assessment: • Cardiac • 40% of RA patients die from cardiovascular disease • Increased risk for MI and stroke due endothelial dysfunction • Pulmonary • Skin • Osteoporosis • Smoking cessation • Weight management (Dhawan & Quyyumi, 2008)

Outcomes and Follow Up • Routine monitor of LFTs, CBC and Creatinine • Monitor

Outcomes and Follow Up • Routine monitor of LFTs, CBC and Creatinine • Monitor once a month for first 6 months, then every 6 to 8 weeks • Monitor general health concerns, comorbidities and quality of life • Assess medication doses and monitor for side effects (Dhawan & Quyyumi, 2008)

Septic Arthritis

Septic Arthritis

Pathophysiology • Bacterial deposits cause an inflammatory reaction of the synovial membrane • Synovium

Pathophysiology • Bacterial deposits cause an inflammatory reaction of the synovial membrane • Synovium does not have a basement membrane • Becomes hyperemic and infiltrated with rapidly progressing inflammatory cells • Inflammation develops from acute to chronic within a few weeks (Mascioli & Park, 2013)

Pathophysiology • Inflammatory and infectious cascade that can begin depleting the matrix within 2

Pathophysiology • Inflammatory and infectious cascade that can begin depleting the matrix within 2 days after inoculation • Hyperplasia develops in 5 -7 days • Degradation of the matrix appears within 4 -6 days resulting in destruction of articular cartilage • The articular cartilage can have complete destruction in approximately 4 weeks (Abelson, 2009; Mascioli & Park, 2013; Matteson & Osmon, 2012)

Etiology • Hematogenous spread: carried by the bloodstream (e. g. indwelling catheters) • Inoculation

Etiology • Hematogenous spread: carried by the bloodstream (e. g. indwelling catheters) • Inoculation or direct invasion: trauma, accidents, bites, surgery or adjacent infection invading the joint (e. g. osteomyelitis) • Rarely inoculation from arthroscopy or arthrocentesis (Abelson, 2009; Matteson & Osmon, 2012)

Etiology (Kherani & Shojania, 2007, p. 1606)

Etiology (Kherani & Shojania, 2007, p. 1606)

Causative Organisms • Staphylococcus aureus • Most common cause of infection • Contain collagen

Causative Organisms • Staphylococcus aureus • Most common cause of infection • Contain collagen receptors, which are thought to contribute to the infection of the joints • Expression of adhesions, microbial surface proteins, help form biofilms that coat prostheses and make effective treatment more difficult • Increase expression of protein A, which interferes with the host immune opsonization and phagocytosis • Group A streptococcus • Enterobacter (Mascioli & Park, 2013; Raukar & Zink, 2014)

Causative Organisms • Neisseria gonorrhoeae • Cause of about 75% in healthy, sexually active

Causative Organisms • Neisseria gonorrhoeae • Cause of about 75% in healthy, sexually active young adults • Although septic arthritis develops in only 3% of those infected with N. gonorrhoeae • Presents differently • often polyarticular and may have papular rash • joint cultures are usually negative, however cultures from pharynx or urethra may be positive • Polymerase chain reaction (PCR) may be helpful (Mascioli & Park, 2013)

Causative Organisms • Haemophilus influenza was a common cause for children, but has declined

Causative Organisms • Haemophilus influenza was a common cause for children, but has declined drastically since the use of H. influenza b vaccine • Decreased by 70 -80% • Other: • Mycobacteria and fungi • Gram-negative bacilli often in neonates, elderly, & immunocompromised patients (Abelson, 2009)

Causative Organisms • Kingella kingae may be more common than originally thought • Difficult

Causative Organisms • Kingella kingae may be more common than originally thought • Difficult to recover on solid media by joint culture • Salmonella • Increased likelihood in Systemic lupus erythematosus • Pseudomonas • In those with history of IVDU (Mascioli & Park, 2013)

Causative Organisms (Raukar & Zink, 2014, p. 1834)

Causative Organisms (Raukar & Zink, 2014, p. 1834)

Prevalence • General population: 2 -10 per 100, 000 (Abelson, 2009) • 20, 000

Prevalence • General population: 2 -10 per 100, 000 (Abelson, 2009) • 20, 000 cases per year in the United States (Cho, Burke, & Lee, 2014) • 8%-27% present as bacterial acute monoarthritis (Cho, Burke, & Lee, 2014) • Rheumatoid arthritis population: 30 -70 per 100, 000 (Abelson, 2009) • 50% of cases involve the knee joint (Abelson, 2009)

Risk Factors • • Diabetes Alcoholism Cirrhosis Uremia Cutaneous ulcers Skin infections IV drug

Risk Factors • • Diabetes Alcoholism Cirrhosis Uremia Cutaneous ulcers Skin infections IV drug use Indwelling IV catheters • RA • OA • Low socioeconomic status • Advanced age • Cancer • Immunosuppressive therapies • Prosthetic joints • Corticosteroid injections

Charcot Foot http: //trufitusa. com/files/Patient_Education_PICS/patient_ed/Charcot. Foot 1. png http: //contentwithpictures. com/wp-content/uploads/2013/04/charcot-foot. png

Charcot Foot http: //trufitusa. com/files/Patient_Education_PICS/patient_ed/Charcot. Foot 1. png http: //contentwithpictures. com/wp-content/uploads/2013/04/charcot-foot. png

Corticosteroid Injections (Murdoch & Mc. Donald, 2007, p. 2)

Corticosteroid Injections (Murdoch & Mc. Donald, 2007, p. 2)

Signs & Symptoms • Usually monoarticular but as many as 22% can be polyarticular

Signs & Symptoms • Usually monoarticular but as many as 22% can be polyarticular • Hot, swollen, tender joint with decreased range of motion • Fever is an unreliable sign • Chills are uncommon • Symptoms are diminished in the elderly, immunocompromised, and IV drug abusers • Symptoms typically less than 2 weeks although can be delayed by low virulence organisms (Cho, Burke, & Lee, 2014; Mathews, et al. , 2008)

Signs & Symptoms • More common in large joints • 60% affecting the hip

Signs & Symptoms • More common in large joints • 60% affecting the hip or knee • About 50% cases involve the knee • Multiple joints occur in 15% of cases http: //www. onmedica. com/getresource. aspx? resourceid=0 f 058 d 22 -e 44 f -42 cb-8907 -b 32 acf 83 a 1 af (Mathews, et al. , 2008)

Other Joints Infected • Nondiarthrodial joints, are usually associated with IV drug abuse or

Other Joints Infected • Nondiarthrodial joints, are usually associated with IV drug abuse or IV catheters for medical treatments • Symphysis pubis is associated with prior UTI, pelvic malignancy, IV drug use, or vigorous weight bearing physical activity such as longdistance running in females (Matteson & Osmon, 2012; Google Images, 2014)

Physical Assessment • The joint is held in the position that allow for maximal

Physical Assessment • The joint is held in the position that allow for maximal joint space • Accommodate for increased fluid • Increased pain with movement • regardless of passive or active ROM (Cho, Burke, & Lee, 2014)

Diagnostic Tests Per Guidelines • Aspirate synovial fluid: • gram stain and culture prior

Diagnostic Tests Per Guidelines • Aspirate synovial fluid: • gram stain and culture prior to initiation of antibiotics (anticoagulation therapy is not a contra-indication) • Prosthetic joint: always refer to orthopedic surgeon • Polarizing microscopy to evaluate crystals in all synovial fluid (Mathews, et al. , 2008)

Diagnostic Tests • “Neither the absence of organisms on Gram stain, nor a negative

Diagnostic Tests • “Neither the absence of organisms on Gram stain, nor a negative subsequent synovial fluid culture, excludes the diagnosis of septic arthritis” (Mathews, et al. , 2008, p. 2) • Key point: if high clinical suspicion of septic arthritis based on clinical presentation, treat as septic arthritis until proven otherwise! (Mathews, et al. , 2008; Weston & Coakley, 2006)

Additional Tests • Blood cultures should always be drawn at the same time as

Additional Tests • Blood cultures should always be drawn at the same time as joint aspiration • White cell count (WCC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) • Again, the absence of elevated WCC, ESR, or CRP does NOT exclude the diagnosis • Urea, electrolytes, liver function measurements for detection of end organ damage (a poor prognostic indicator) and renal function tests that may influence antibiotic treatment • Other tests as indicated by H&P: genitourinary, respiratory tract, cervical, urethral, or other infection (Mathews, et al. , 2008)

Imaging • Plain radiographs • no benefit in diagnosis, however does provide baseline for

Imaging • Plain radiographs • no benefit in diagnosis, however does provide baseline for future joint damage • Scintigraphy and magnetic resonance imaging (MRI): distinguish sepsis from OA but cannot differentiate sepsis and inflammation • not recommended for a hot swollen joint • MRI is preferred for advanced imaging to detect osteomyelitis that may require surgical treatment • Ultrasound or CT may be needed to aspirate septic joints such as the hip (Mathews, et al. , 2008)

(Abelson, 2009, p. 1159)

(Abelson, 2009, p. 1159)

Recommend joint aspiration to dryness as often as required (Abelson, 2009, p. 1159; Mathews,

Recommend joint aspiration to dryness as often as required (Abelson, 2009, p. 1159; Mathews, et al. , 2008)

http: //www. dealwitharthritis. com/wp-content/uploads/2013/10/septic-arthritis-treatment. jpeg

http: //www. dealwitharthritis. com/wp-content/uploads/2013/10/septic-arthritis-treatment. jpeg

Synovial Fluid (Kherani & Shojania, 2007, p. 1607 (Cho, Burke, & Lee, 2014, p.

Synovial Fluid (Kherani & Shojania, 2007, p. 1607 (Cho, Burke, & Lee, 2014, p. 497)

Differential Diagnoses • Crystal-induced arthritis (gout, calcium oxalate, pseudogout, hydroxyapatite crystals) • Calcium Pyrophosphate

Differential Diagnoses • Crystal-induced arthritis (gout, calcium oxalate, pseudogout, hydroxyapatite crystals) • Calcium Pyrophosphate Deposition Disease • Infectious arthritis (bacterial, fungal, mycobacterial, spirochetes, virus) • Rheumatic fever • Inflammatory arthritis (Behcet syndrome, rheumatic arthritis, sarciod, systemic lupus, erythematosus, still disease, seronegative spondyloarthropathy, ankylosing spondylitis, psoriatic arthritis, reactive arthritis, inflammatory bowel disease-related to arthritis, systemic vasculitis) (Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011)

Differential Diagnoses • • Osteoarthritis Avascular necrosis Fracture Hemarthrosis Hyperlipoproteinemia Meniscal tear Systemic infection

Differential Diagnoses • • Osteoarthritis Avascular necrosis Fracture Hemarthrosis Hyperlipoproteinemia Meniscal tear Systemic infection (bacterial endocarditis, HIV) • Tumor (metastasis, pigmented villonodular synovitis) (Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011)

Nongonococcal Arthritis Treatment • • Nongonococcal arthritis Gram-positive Cocci 80% of patients, primarily older

Nongonococcal Arthritis Treatment • • Nongonococcal arthritis Gram-positive Cocci 80% of patients, primarily older adults Acute in nature Synovial fluid are 90% positive Blood cultures are only positive 50% Staphylococcus aureus 40% and streptococcus 28% most identified GPO • Typically associated with IVDU, cellulitis, abscesses, endocarditis, and chronic osteomyelitis (Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011)

Nongonococcal Arthritis Treatment • MRSA • CA-MRSA is emerging, ranges between 525% of bacterial

Nongonococcal Arthritis Treatment • MRSA • CA-MRSA is emerging, ranges between 525% of bacterial infections • Tend to affect older people, primarily shoulder joints • Gram-negative bacilli • Causative organisms pseudomonas aeruginosa and E. coli • 14% to 19% of septic arthritis patients • Mostly related to invasive urinary tract infections, IVDU, older population, immunocompromised patients, and skin conditions (Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011; Mathews et al. , 2008)

Nongonococcal Arthritis Treatment • Recommended IV antibiotic therapy for Grampositive and negative cocci: •

Nongonococcal Arthritis Treatment • Recommended IV antibiotic therapy for Grampositive and negative cocci: • Vancomycin 15 mg/kg IV every 12 hours and ceftriaxone 1 gm IV every 24 hours are good initial treatment • If pseudomonas is suspected, Cefepime 2 gm is given in place of ceftriaxone • Treatment for Nongonococcal infections, IV antibiotic therapy for at least two weeks, followed by one to two weeks of oral antibiotics, tailored to the patent response (Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011; Mathews et al. , 2008)

 Gonococcal Arthritis Treatment • Disseminated neisseria gonorrhoeae • Young, healthy, sexually active adults

Gonococcal Arthritis Treatment • Disseminated neisseria gonorrhoeae • Young, healthy, sexually active adults • Various clinical musculoskeletal clinical presentation, with or without associated skin conditions • 25 -70% of blood cultures positive, when compared Nongonococcal infections • If Gonococcal infections are suspected, cultures should be taken from infected source (urethra, rectum, cervix, pharynx) • PCR test has a high specificity 96%, this may be beneficial in culture negative patients, but present with a septic arthritis picture (Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011; Mathews et al. , 2008)

Gonococcal Arthritis Treatment • Treatment of Gonococcal arthritis • IV antibiotics for one to

Gonococcal Arthritis Treatment • Treatment of Gonococcal arthritis • IV antibiotics for one to three days, thirdgeneration cephalosporin (usually ceftriaxone 1 -2 gm daily) • If the patient responds well, IV therapy can be switched to oral antimicrobial therapy for seven to 14 days • Cefixime 400 mg po BID or amoxicillin 500 to 850 mg po BID • Doxycycline and or azithromycin can be considered if the patient is positive for chlamydia (Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011; Mathews et al. , 2008)

Other Types of Exposure to Septic Arthritis http: //www. aafp. org/afp/2011/0915/p 653. pdf

Other Types of Exposure to Septic Arthritis http: //www. aafp. org/afp/2011/0915/p 653. pdf

Pathogen Specific History and Organisms (https: //www. med. unc. edu/tarc/events/event-files/septic%20 arthritis%20 management. pdf)

Pathogen Specific History and Organisms (https: //www. med. unc. edu/tarc/events/event-files/septic%20 arthritis%20 management. pdf)

Other Types of Treatment • Treatment of fungal arthritis includes an azole or parental

Other Types of Treatment • Treatment of fungal arthritis includes an azole or parental amphotericin B six to 12 weeks (Brusch, 2014) • Lyme arthritis responds well to ceftriaxone IV or oral doxycycline • Repeat of joint aspiration is successful during the first five days of treatment to monitor WBC count, polymorphonuclear cell count, Gram stain, and cultures • Arthroscopic drainage increases outcomes and reduces morbidity • Consult Rheumatologist or Orthopedic surgeon (Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011; Mathews et al. , 2008)

Treatment Algorithm https: //www. med. unc. edu/tarc/events/event-files/septic%20 arthritis%20 management. pdf

Treatment Algorithm https: //www. med. unc. edu/tarc/events/event-files/septic%20 arthritis%20 management. pdf

Health Promotion/ Prevention • Inform your doctor and dentist about a prosthetic joint prior

Health Promotion/ Prevention • Inform your doctor and dentist about a prosthetic joint prior to any type of procedure • Educate the patient of signs of infections • HIV or immunocompromised patients require a therapeutic relationship with their PCP to discuss antibiotics prior to a procedure, regular visits to monitor for joint or skin infections, and any slow healing cuts or sores. • Up to date vaccinations • Traveling out of the country or to another state; you may be exposed to different insects or require vaccinations (CDC, 2014)

Health Promotion/Prevention • IVDU- this is the most common way to introduce a foreign

Health Promotion/Prevention • IVDU- this is the most common way to introduce a foreign bacteria into your body, which can lead to infective arthritis. IVDU are at higher risk for developing recurrent joint infections. Bacteremia can increase the risk for infective arthritis • Weight management and balanced diet • Practice safe sex, use protection • Ensure patients have access and availability to evidenced-based arthritis interventions addressing basic information, weight management, injury prevention, and physical activity tips (CDC, 2014)

Outcomes for Septic Arthritis • Mortality rates ranges 10 -20%, depending upon comorbidities •

Outcomes for Septic Arthritis • Mortality rates ranges 10 -20%, depending upon comorbidities • Greater than 65 years or older and infection in shoulder, elbow, or multiple sites are factors associated with increased mortality • Pneumococcal septic arthritis patients mortality rates ~ 20%, but regain almost full function of their joint • S. aureus causative agents only regain 4650% of their baseline joint function upon completion of antimicrobial therapy (Shirtliff & Mader, 2002; Horowitz, Katzap, Horowitz, & Barilla-La. Barca, 2011)

Outcomes for Septic Arthritis • The high rate has not changed significantly over the

Outcomes for Septic Arthritis • The high rate has not changed significantly over the past 40 years due to the difficultness of the diagnosis • Treatment initiated after seven days or more demonstrate a worse outcome • Prompt diagnosis and initiation of empiric antimicrobial therapy is utmost importance to improve quality of life and outcomes • Early involvement in therapy and aggressive movement of the joint increases optimal outcomes • An extended time > 6 days required to sterilize the joint is another indicator of poor prognosis (Shirtliff & Mader, 2002)

Follow-up • Follow-up appointments are pertinent to maintain to monitor for improved or worsening

Follow-up • Follow-up appointments are pertinent to maintain to monitor for improved or worsening of the joint • Laboratory data will be monitored weekly for adverse reactions secondary to IV antibiotics (CBC, BMP, LFT’s, CRP, ESR) • Most Patients will have an indwelling PICC line, which increases an individuals risk for bacteremia, close monitoring of site and presence of cord • Discuss any questions or concerns with your ACNP to ensure understanding of the disease

Question #1 All of the following regarding OA are true EXCEPT: A: Evidence of

Question #1 All of the following regarding OA are true EXCEPT: A: Evidence of bilateral swelling and warmth affecting only the wrists B: Joint space narrowing and osteophytes at the proximal and distal interphalangeal joints on xray C: Pain that becomes worse when preparing meals D: Stiffness that is worse after brief periods of rest with occasional locking of the more affected joints

Question #1 Answer A: Evidence of bilateral swelling and warmth affecting only the wrists

Question #1 Answer A: Evidence of bilateral swelling and warmth affecting only the wrists • Joints of the hands are most commonly affected, but the wrist is uncommon • OA can also occur in the hips, knees, cervical and lumbosacral spine • Pain occurs with joint use and relieves with rest • Joint stiffness usually occurs after periods of rest

Question #2 47 y. o. female presents complaining of pain in her hands in

Question #2 47 y. o. female presents complaining of pain in her hands in the mornings. She drops things and feels she has difficulty maintaining her grip. X-ray reveals bilateral soft tissue swelling of her metacarpals. The ACNP knows additional testing findings will include: A: Rheumatoid Factor (RF) + B: Heberden’s nodes + C: Anti-CCP Antibodies + D: Antinuclear antibody (ANA +)

Question #2 Answer C: Anti-CCP Antibodies • Anti-CCP has a higher sensitivity than RF,

Question #2 Answer C: Anti-CCP Antibodies • Anti-CCP has a higher sensitivity than RF, and is more likely to be positive early in disease. • Heberden’s nodes are present in osteoarthritis. • ANA is not positive in RA.

Question #3 Which of the follow statements is NOT true regarding RA? A: RA

Question #3 Which of the follow statements is NOT true regarding RA? A: RA results in joint degeneration, which causes deterioration of bone formation at the joint surfaces. B: Patients with RA have on average an onset of cardiovascular disease 10 years earlier than those without RA C: Morning stiffness and joint pain are characteristic symptoms D: RA is a chronic inflammatory disease of the synovial joint and tendon sheath

Question #3 Answer A: RA results in joint degeneration, which causes deterioration of bone

Question #3 Answer A: RA results in joint degeneration, which causes deterioration of bone formation at the joint surfaces. • Joint degeneration is consistent with osteoarthritis, not RA.

Question #4 66 y. o. with a history of RA and pseudogout presents with

Question #4 66 y. o. with a history of RA and pseudogout presents with night sweats and a 2 -day history of left knee pain. Temp is 101. 5. WBC is 16, 000. Tap of knee shows 168, 000 WBCs, 99% neutrophils and crystals. Gram stain shows gram + cocci. Management for this patient includes all of the following EXCECPT: A: Blood cultures B: Glucocorticoids C: Needle aspiration of joint fluid D: Orthopedic surgery consult E: Vancomycin

Question #4 Answer B: Glucocorticoids • Crystals are suggestive of active pseudogout • Septic

Question #4 Answer B: Glucocorticoids • Crystals are suggestive of active pseudogout • Septic arthritis (SA) is the patient’s major problem with a joint leukocyte count >100, 000 and a positive gram stain. • SA should be treated aggressively with antibiotics, a surgical consult should be completed for possible joint drainage and cultures should be sent to assess for bacteremia.

Question #5 • 24 y. o. admitted with fever, swollen and painful right knee.

Question #5 • 24 y. o. admitted with fever, swollen and painful right knee. • 3 weeks earlier she had systemic symptoms: fever, chills and migratory joint pains. Rash over her chest and hands. • She has no significant history. Clean arthrocentesis. A: Bacterial cultures of the cervix B: Bacterial cultures of the synovial fluid C: Blood cultures D: Rheumatoid factor

Question #5 Answer A: Bacterial cultures of the cervix • The patient’s history is

Question #5 Answer A: Bacterial cultures of the cervix • The patient’s history is consistent with septic arthritis due to a gonococcal infection. • Diagnostic procedure is to culture the infected mucosal site, including the cervix, urethra or pharynx. • Neisseria gonorrhoeae is responsible for about 70% of acute arthritis infections in patients younger than 40. • Patients usually present with fever, chills, migratory arthralgias and a rash 3 weeks prior to monoarticular septic arthritis.

References • • • Abelson, A. (2009). Septic arthritis. In Cleveland Clinic: Current Clinical

References • • • Abelson, A. (2009). Septic arthritis. In Cleveland Clinic: Current Clinical Medicine (pp. 1158 -1162). Saunders, an imprint of Elsevier. Aletaha, D. , Neogi, T. , Silman, A. , Funovits, J. , Felson, D. , … Hawker, G. (2010). 2010 Rheumatoid Arthritis Classification Criteria. American College of Rheumatology, 62 (9), pp 2569– 2581. DOI 10. 1002/art. 27584 Agency for Health Care Research and Quality (2014, January 10). Total hip arthroplasty (THA) and/or total knee arthroplasty (TKA): hospital-level risk-standardized complication rate following elective primary THA and/or TKA. Retrieved from http: //www. qualitymeasures. ahrq. gov/content. aspx? id=46503 201411051359431262241960 American College of Rheumatology (2014). Osteoarthritis: Heberden’s and Bouchard’s Nodes, Fingers. Retrieved from http: //images. rheumatology. org/viewphoto. php? album. Id=77030&image. Id=2897683 201411011813361594496608 Braun, H. J. , & Gold, G. E. (2012). Diagnosis of Arthritis: Imaging. Bone, 51(2), 278 -288. 201411020932051648936987 Brusch, J. (2014). Septic arthritis. . Retrieved from http: //emedicine. medscape. com/article/236299 overview Carmona, L. , Villaverde, V. , Hernandez-Garcia, C. , Ballina, J. , Gabriel, R. , Laffon, A. (2002). The prevalence of rheumatoid arthritis in the general population of Spain. Rheumatology, 41 (1): 88 -95 doi 10. 1093/rheumatology/41. 1. 88 Centers for Disease Control and Prevention (2014, May). Osteoarthritis. Retrieved from http: //www. cdc. gov/arthritis/basics/osteoarthritis. htm 2014110117300499083423 Centers for Disease Control and Prevention. (2014). Retrieved from http: //www. cdc. gov/arthritis/osteoarthritis. htm Cho, H. J. , Burke, L. A. , & Lee, M. (2014). Septic arthritis. Hospital Medicine Clinics, 3(4), 494 -503. doi: 10. 1016/j. ehmc. 2014. 06. 009

References • • • Dhawan, S. & Quyyumi, A. (2008). Rheumatoid arthritis and cardiovascular

References • • • Dhawan, S. & Quyyumi, A. (2008). Rheumatoid arthritis and cardiovascular disease. Curr Atheroscler Rep, 10 (2): 128 -33. Farlex, Inc. (2014). Ground substance. Retrieved from The Free Dictionary by Farlex: http: //medicaldictionary. thefreedictionary. com/ground+substance Fleisher, L. A. , Fleischmann, K. E. , Auerbach, A. D. , Barnason, S. A. , Beckman, J. A. , Bozkurt, B. , . . . Wijeysundera, D. N. (2014). 2014 ACC/AHA Guideline on Perioperative Cardiovascular evaluation and management of patients undergoing noncardiac surgery. Journal of the American College of Cardiology, , . doi: 10. 1016/j. jacc. 2014. 07. 944 20141105111316472902417 Garcia-Arias, M. , Balsa, A. , & Mola, E. M. (2011). Septic arthritis. Best Practice & Research Clinical Rheumatology, 25, 407 -421. doi: 10. 1016/j. berh. 2011. 02. 001 Genes, N. , & Adams, B. D. (2014). Arthritis. In J. A. Marx, R. S. Hockberger, & R. M. Walls, Rosen's emergency medicine (eighth edition) (pp. 1501 -1517. e 2). Saunders, an Imprint of Elsevier. Grasso, A. W. , & Jaber, W. A. (2014). Cardiac risk stratification for noncardiac surgery. Retrieved from http: //www. clevelandclinicmeded. com/medicalpubs/diseasemanagement/cardiology/cardiac-riskstratification-for-noncardiac-surgery/ 20141105105705630673170 Hansen, E. , Belden, K. , Silibovsky, R. , Vogt, M. , Arnold, W. , Bicanic, G. , . . . Yamada, K. (2014). Perioperative Antibiotics. Journal of Orthopaedic Research, 32, S 31 -S 59. 20141105125803801560640 Hochberg, M. C. , Altman, R. D. , April, K. T. , Benkhalti, M. , Guyatt, G. , Mc. Gowan, J. , . . . Tugwell, P. (2012). American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies for osteoarthritis of the hand, hip and knee. Arthritis Care and Research, 64(4), 465 -474. 201411030808501877582431 Horowitz, D. , Katzap, E. , Horowitz, S. , & Barilla-La. Barca, M. (2011). Approach to septic arthritis. American Family Physician, 84 (6), 654 -659.

References • • • Jacobs, J. J. , Mont, M. A. , Bozic, K.

References • • • Jacobs, J. J. , Mont, M. A. , Bozic, K. J. , Della Valle, C. J. , Goodman, S. B. , Lewis, C. G. , . . . Boggio, L. N. (n. d. ). Preventing venous thromboembolism disease in patients undergoing elective hip and knee arthroplasty. Evidence Based Guideline and Evidence Report, , . 20141105123533984377265 John's Hopkins Arthritis Center (2012). ACR Diagnostic Guidelines. Retrieved from http: //www. hopkinsarthritis. org/physician-corner/education/arthritis-education-diagnosticguidelines/#class_knee 201411021135561752556801 Keenan, R. T. , Krasnokutsky, S. , Pillinger, M. H. , Mc. Kean, S. C. , Ross, J. J. , Dressler, D. D. , . . . Ginsberg, J. S. (2012). Principles and Practice of Hospital Medicine. New York, NY: Mc. Graw-Hill. 20141101170413715891480 Kherani, R. B. , & Shojania, K. (2007). Septic arthritis in patients with pre-existing inflammatory arthritis. Canadian Medical Association, 176(11), 1605 -1608. doi: 10. 1503/cmaj. 050258 Ling, S. M. , Halter, J. B. , Ouslander, J. G. , Tinetti, M. E. , Studenski, S. , High, K. P. , & Asthana, S. (2009). Hazzard's geriatric medicine and gerontology (6 ed. ). New York, NY: Mcgraw-Hill. 20141101164824211898088 Maheshwari, A. V. , Blum, Y. C. , Shekhar, L. , Ranawat, A. S. , & Ranawat, C. S. (2009). Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clinical Orthopaedics and Related Research, 467, 1418 -1423. 20141105121800249406814 Mascioli, A. A. , & Park, A. L. (2013). Infectious arthritis. In S. T. Canale, & J. H. Beaty, Campbell's Operative Orthopaedics (twelfth edition) (pp. 749 -772. e 2). Mosby, an imprint of Elsevier. Mathews, C. , & Coakley, G. (2008). Septic arthritis: current diagnostic and therapeutic algorithm. Mathews, C. , Kingley, G. , Feild, M. , Jones, A. , Phillips, M. , Walker, D. , & Coakley, G. (2008). Management of septic arthritis: a systematic review. Postgrad Med, 84, 265 -270. http: //dx. doi. org/10. 113/ard. 2006. 058909

References • • Matteson, E. L. , & Osmon, D. R. (2012). Infections of

References • • Matteson, E. L. , & Osmon, D. R. (2012). Infections of bursae, joints, and bones. In L. Goldman, & A. L. Schafer, Goldman's cecil medicine, twenty-fourth edition (pp. 1731 -1736). Elsevier Inc. Murdoch, D. M. , & Mc. Donald, J. R. (2007). Mycobacterium avium-intracellulare cellulitis occuring with septic arthritis after joint injection: a case report. Bio. Med Central, 7(9), 1 -4. doi: 10. 1186/1471 -2334 -7 -9 • Nicoll, D. , Lu, C. , Pignone, M. , Mc. Phee, S. J. (2012). Lab Tests. In Nicoll D, Lu C, Pignone M, Mc. Phee S. J. (Eds), Pocket Guide to Diagnostic Tests, 6 e. Retrieved November 02, 2014 from http: //accessmedicine. mhmedical. com/content. aspx? bookid=503&Sectionid=43474716. Radiological Society of North America. (2014). Glossary of terms: scintigraphy. Retrieved from Radiology. Info. org: http: //www. radiologyinfo. org/en/glossary 1. cfm? gid=228 National Center for Complimentary and Alternative Medicine (2014, February). Osteoarthritis and Complementary Health Approaches. Retrieved from http: //nccam. nih. gov/sites/nccam. nih. gov/files/Get_The_Facts_Osteoarthritis_03 -07 -2014. pdf 201411021228101252759338 Richmond, J. , Hunter, D. , Irrgang, J. , Jones, M. , Snyder-Mackler, L. , Van Durme, D. , . . . Levy, B. A. (2013, May 18). Treatment of osteoarthritis of the knee Evidence based guideline 2 ed. 201411030720021959785104 Raukar, N. P. , & Zink, B. J. (2014). Bone and joint infections. In J. A. Marx, R. S. Hockberger, & R. M. Walls, Rosen's emergency medicine (eighth edition) (pp. 1831 -1850. e 2). Saunders, an Imprint of Elsevier. Shah, A. & St. Clair, E. (2012). Chapter 321. Rheumatoid Arthritis. In Longo, D. L. , Fauci, A. S. , Kasper, D. L. , Hauser, S. L. , Jameson, J. , Loscalzo, J. (Eds), Harrison's Principles of Internal Medicine, 18 e. Retrieved November 02, 2014 from http: //accessmedicine. mhmedical. com/content. aspx? bookid=331&Sectionid=40727122.

References • • • Sinusas, K. (2012). Osteoarthirtis: Diagnosis and Treatment. American Family Physician,

References • • • Sinusas, K. (2012). Osteoarthirtis: Diagnosis and Treatment. American Family Physician, 85(1), 49 -56. 201411021124181828236700 Shirtliff, M. , & Mader, J. (2002). Acute septic arthritis. Clinical Microbiology Reviews, 15 (4), 527 -544. http: //dx. doi. org/10. 1128/CMR. 15. 4. 527 -544. 2002 Skinner, H. B. , & Mc. Mahon, P. J. (2014). Current diagnosis and treatment in orthopedics. New York, NY: Mcgraw-Hill. 20141102184141623459101 Smith, R. M. , Schaefer, M. K. , Kainer, M. A. , Wise, M. , Finks, J. , Duwve, J. , . . . Park, B. J. (2013). Fungal infections associated with contaminated methylprednisolone injections. The New England Journal of Medicine, 369(17), 1598 -1609. doi: 10. 1056/NEJMoa 1213978 Srinivasan, R. C. , Tolhurst, S. , Vanderhave, K. L. , & Doherty, G. M. (2010). Current diagnosis and treatment: Surgery (13 ed. ). New York, NY: Mc. Graw-Hill. 20141103075510303864956 Stein, J. (2011). Smoking May Increase Postarthroplasty Complications. Retrieved from http: //www. medscape. com/viewarticle/737679 201411051442471860300541 The Medical Letter (2012). Drugs for rheumatoid arthritis. The Medical Letter, 10 (117), 36 – 44. U. S. Department of Health and Human Services, Centers for Disease Control and Prevention. (2012). Rheumatoid Arthritis. Retrieved from http: //www. cdc. gov/arthritis/basics/rheumatoid. htm. Weston, V. , & Coakley, G. (2006). Guideline for the management of the hot swollen joint in adults with a particular focus on septic arthritis. Journal of Antimicrobial Chemotherapy, 58, 492 -493. doi: 10. 1093/jac/dk 1295 Yagupsky, P. (2014). Outbreaks of Kingella kingae infections in daycare facilities. Emerging Infectious Diseases, 20(5), 746 -453. doi: 10. 3201/eid 2005. 131633 Yung, R. (2009). Chapter 120. Rheumatoid Arthritis and Other Autoimmune Diseases. In Halter J. B. , Ouslander J. G. , Tinetti M. E. , Studenski S, High K. P. , Asthana S (Eds), Hazzard's Geriatric Medicine and Gerontology, 6 e. Retrieved November 02, 2014 from http: //accessmedicine. mhmedical. com/content. aspx? bookid=371&Sectionid=41587742.