Joint irrigation and drainage in septic arthritis: A comparison of early versus late intervention and its influence on C-reactive protein normalization

INTRODUCTION

Septic arthritis is a condition where joints become inflamed due to infections caused primarily by bacterial organisms such as staphylococcal and streptococcal species.^[1] Occasionally, viral and fungal organisms can cause septic arthritis as well. The incidence of this condition varies between regions, with the United States and Western Europe reporting an incidence rate ranging from 5.7 to 10/100,000 population.^[2-4] In comparison, Saudi Arabia has a lower incidence rate of 2.13/100,000 population, according to a study conducted at a single center.^[5] The author suggested that the reason they found a lower incidence in Saudi Arabia might be explained, in part, by the use of the Newman Grade A criteria, which are more strict than the criteria used in other studies. The common symptoms of septic arthritis include acute onset pain, redness, warmth, fever, and reduced mobility in the affected joint.^[6] While confirmation of septic arthritis is done by aspiration fluid analysis from the infected joint and identifying the causative organism, diagnosis is mainly based on clinical evaluation using the patient’s medical history, physical examination, and basic laboratory results.^[7]

Numerous risk factors can elevate the likelihood of developing septic arthritis. Among these risk factors is age, particularly those aged 80 and above. Other potential risk factors include rheumatoid arthritis, diabetes mellitus, cancer, immunosuppressive medication use, and having prostheses.^[8] Although the incidence of prosthetic joint infection (PJI) following total hip or knee arthroplasty is relatively low, estimated at 2.3% and 2%, respectively, this number has risen since the early 2000s, possibly due to antibiotic resistance.^[9,10] PJI has three phases: Early infection, which happens within the first three months after joint arthroplasty and is most commonly caused by virulent microorganisms like Staphylococcus aureus; delayed phase, occurring between three months and two years after the arthroplasty; and caused by less virulent microorganisms such as Coagulase-negative Staphylococcus species; and the late phase, where the infection develops after two years and shares the same common pathogen with native septic arthritis.^[11]

Failure to promptly diagnose and treat septic arthritis can lead to unfavorable outcomes.^[12] Older patients, those with prosthetic joints, pre-existing joint disorders, and delayed diagnosis, are more likely to experience complications and poor outcomes. Despite treatment, the joint mechanical function may be negatively impacted in a significant proportion of patients, ranging from 25% to 50%.^[13] Treatment for septic arthritis entails both medication and surgical intervention, with intravenous antibiotics aimed at the causative organism and supportive care forming the basis of medical therapy. Adequate joint irrigation and drainage are essential components of surgical intervention and have proven effective.^[14]

To monitor the recovery of patients with septic arthritis, medical practitioners commonly use laboratory results such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell count. While indicating ongoing inflammation, ESR may not necessarily correspond to clinical recovery.^[15] As a result, it is not an ideal marker to assess recovery in patients with septic arthritis. Conversely, CRP is a more accurate marker to monitor the course of the illness, and research suggests that the normalization of CRP is associated with healing from bacterial infection.^[16,17] While there may be various reasons for the delay in surgical intervention, it is unclear if it has similar outcomes to early intervention. Unfortunately, no studies have yet compared CRP levels in patients who receive early (<24 h) versus late (>24 h) surgical intervention for septic arthritis. Therefore, we proposed comparing CRP levels in septic arthritis patients, who received surgical treatment within 24 h versus those who had it after more than 24 h to determine the impact of timing on recovery.

MATERIALS AND METHODS

RESULTS

From 2015 to 2021, 53 patients underwent irrigation and drainage in Riyadh Center, and they were all enrolled in our study. Most of our patients, 34 (64.2%), were male with a mean age of 64 years and an SD of 20.7 years [Table 1]. Seventeen (32.1%) patients had normal body mass index. However, overweight and obese patients constituted 26.4% and 32.1%, respectively. Most of our patients (92.5%) were non-smokers, and six (11.3%) had recent trauma. Furthermore, only 17 patients (32.1%) were medically free, and the most common concurrent chronic diseases were diabetes mellitus, osteoarthritis, and renal failure, with a prevalence of 25 patients (47.2%), 17 patients (32.1%), and 7 patients (13.2%), respectively.

The knee was the most commonly affected joint [Table 2], with a prevalence of 47 patients (88.6%). Moreover, 12 patients (22.6%) had joint replacement surgery that led to PJI. Five patients (42.7%) developed PJI early, in the first 90 days. However, three patients (25%) had delayed PJI, more than 90 days and <2 years, whereas four patients (33.3%) developed the infection late, more than two years.

Forty patients (75.4%) underwent surgery >24 h after the first medical encounter, while 13 patients (24.5%) had the surgery done in <24 h [Table 3]. The mean length of hospital stay was 22.5 days (SD 11.8).

Patients who underwent irrigation and drainage in the first 24 h had 18.8 days as a mean length of hospital stay ± 8.1 days [Table 4]. On the other hand, patients who underwent irrigation and drainage after 24 h had a mean length of stay of 23.8 ± 12.7 days, resulting in P = 0.15.

More than half (53.8%) of the patients who underwent irrigation and drainage in the first 24 h had normal CRP levels [Table 5]. On the other hand, 40% of patients, who underwent irrigation and drainage after 24 h experienced normalization of CRP level with P = 0.52.

DISCUSSION

As far as the authors are aware, this study is the initial one to compare CRP levels in septic arthritis patients who underwent early (<24 h) and late (>24 h) surgical intervention. This study compared the CRP level of 53 patients, who had undergone joint irrigation and drainage in <24 h, and those who had undergone it after 24 h from the diagnosis of septic arthritis. The two groups did not show a significant difference in the normalization of CRP levels.

Past research emphasizes that early diagnosis and treatment are crucial in avoiding long-term functional impairments and reducing the likelihood of cartilage damage from joint arthrosis. Vispo Seara et al. demonstrated that the functional outcome of septic arthritis is influenced by several factors, including the patient’s age, joint condition, and the duration between symptom onset and surgical intervention.^[18] In addition, Balabaud et al. determined that the time interval between symptom onset and surgical treatment is the most significant prognostic factor in patients with septic arthritis. They proposed timely and aggressive arthroscopic debridement.^[19]

Another study by Kodumuri et al. also found no significant difference in intensive care unit (ICU) admission and mortality between patients with delayed surgical intervention (>24 h) and those with early intervention (<6 h).^[20] Therefore, it appears that delaying joint irrigation and drainage in septic arthritis patients does not affect ICU admission, mortality, or CRP normalization. Although the difference in the mean length of hospital stay between the two groups was not statistically significant, patients treated >24 h had a longer stay (23.8 ± 12.7 days) compared to those treated <24 h (18.8 ± 8.1 days) [Table 4], this difference may still have clinical significance.

Our study has some limitations worth noting. First, its retrospective design restricts the data collection to what was already recorded in the electronic medical reports of the patients. In addition, the sample size of our study was small, consisting of only 53 patients, which may have hindered the ability to detect statistical significance between the groups. Moreover, randomized controlled trials are generally considered to have a stronger level of evidence than retrospective cohort studies. However, conducting randomized-controlled trials may be ethically challenging, as it is considered unethical not to provide patients with an intervention that is believed to be superior to another intervention, which is why most studies in this area are observational.^[21-24] As a result, further studies with larger sample sizes are necessary to establish the significance of the time delay of surgical intervention on patients’ outcomes.

CONCLUSION

The findings revealed no discrepancy in CRP values between the two groups. While the outcome suggests that postponing surgical intervention did not affect CRP levels, the authors do not recommend delaying the intervention in these patients, as this study looked at CRP normalization and did not look at other factors that may affect the prognosis of these patients. However, this study showed that it could be done safely if it was necessary to delay the intervention for a good reason. Additional investigations are warranted to evaluate the short- and long-term consequences. A more extensive sample size and prospective studies are advised to assess the actual impact.

RECOMMENDATION

Further research with a larger sample size is warranted to ascertain the result of the present study.