Zusammenfassung
Hintergrund
Die septische Arthritis des nativen Gelenkes ist ein typischer orthopädischer Notfall. Eine frühzeitige Diagnosestellung mit konsekutiver Einleitung einer adäquaten Therapie ist für die Prognose entscheidend.
Fragestellung
Ziel der vorliegenden Arbeit ist es, einen Überblick über die aktuellen Empfehlungen zu Epidemiologie, Diagnostik und Therapie der septischen Arthritis des nativen Gelenkes zu geben.
Ergebnisse
Die septische Arthritis entsteht hämatogen durch septische Streuung oder aber durch eine meist iatrogen verursachte direkte Inokulation von Bakterien in das Gelenk. Neben Patienten, die sich einem orthopädischen Gelenkeingriff unterziehen, sind solche mit degenerativen und entzündlichen Gelenkerkrankungen, Kleinkinder, ältere Menschen, Immunsupprimierte und i. v. Drogenkonsumenten besonders gefährdet, an einer septischen Arthritis zu erkranken. Staphylococcus aureus ist der am häufigsten isolierte Erreger, gefolgt von Streptokokken. Die Diagnose stützt sich neben anamnestischen, klinischen, laborchemischen und bildgebenden Befunden wesentlich auf die mikroskopische und mikrobiologische Untersuchung des Gelenkpunktats, wobei die differenzialdiagnostische Abgrenzung gegen nichtinfektiöse Arthritiden im Einzelfall schwierig sein kann. Die Therapie wird bei hinreichendem klinischem Verdacht auch vor Keimnachweis begonnen und besteht in einer zunächst kalkulierten, dann erregerspezifischen antibiotischen Therapie sowie einer Drainage des Gelenkergusses. In Deutschland ist die operative, in der Regel arthroskopische Gelenkspülung die Therapie der Wahl, wenngleich eine Überlegenheit gegenüber repetitiven Gelenkaspirationen nicht gezeigt werden konnte.
Nicht abschließend geklärt sind weiterhin das optimale antibiotische Regime hinsichtlich Art, Applikationsweg und Dauer der antibiotischen Therapie und die Bedeutung einer additiven Kortikoidtherapie zur Modulation der überschießenden Immunantwort.
Abstract
Background
Septic arthritis is a common orthopedic emergency. Immediate establishment of the diagnosis and administration of an adequate therapy is paramount in minimizing morbidity and mortality in this severe condition.
Objective
The aim of the present review was to evaluate the existing evidence in order to give an overview on current best practice in diagnostics and treatment of septic arthritis in adults and children.
Results
Joint infections result from either hematogenous spread or direct inoculation of bacteria into the joint, mostly iatrogenically. Predisposing risk factors include recent orthopedic joint surgery, i. v. drug abuse, pre-existing inflammatory and degenerative joint diseases and old age. Although pathogens differ in different populations and age groups Staphylococcus aureus is the single most frequently isolated causative organism, followed by streptococci. Although diagnosis is based on an integration of medical patient history, clinical and laboratory findings and imaging studies, joint fluid analysis remains the mainstay in establishing a valid diagnosis. The range of differential diagnostics is broad and includes non-infectious inflammatory joint diseases, such as gout or reactive arthritis. Once a diagnosis has been established treatment should be started immediately. Treatment is based on adequate antibiotic therapy and joint drainage until dryness. There is a paucity of studies on the optimal antibiotic regimen, route of application and duration of therapy. Moreover, no high-quality studies exist on the optimal mode of joint drainage. While superiority has yet to be shown, operative treatment in terms of arthroscopic lavage must be considered the standard of care in Germany. Finally, despite promising results in children, the role of corticosteroids as an adjunct to antibiotic treatment in adults has yet to be clarified.
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O. Hauschild und N. P. Südkamp geben an, dass kein Interessenkonflikt besteht.
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Hauschild, O., Südkamp, N.P. Infektion des nichtprothetisch versorgten Gelenkes. Chirurg 87, 847–856 (2016). https://doi.org/10.1007/s00104-016-0278-y
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DOI: https://doi.org/10.1007/s00104-016-0278-y