Skip to main content
SpringerLink
Log in

Leukocyte esterase analysis in the diagnosis of joint infection: Can we make a diagnosis using a simple urine dipstick?

  • Scientific Article
  • Published:
Skeletal Radiology Aims and scope Submit manuscript

Abstract

Purpose

Analysis of joint fluid remains a key factor in the diagnosis of periprosthetic infection. Recent reports have shown that neutrophils in infected joint fluid release esterase, an enzyme that is a reliable marker for infection. Testing for leukocyte esterase is routinely done in the analysis of urine for the presence of urinary tract infection, by a simple “dipstick” method. We report our experience with this technique in the evaluation of patients suspected of having septic arthritis or periprosthetic joint infection (PJI) by comparing results of leukocyte esterase positivity with confirmed joint infection as defined by the American Academy of Orthopaedic Surgeons (AAOS).

Materials and methods

We retrospectively reviewed leukocyte esterase test results performed on synovial fluid aspirated from 57 patients with prosthetic (52) and native (5) joints. Patients either presented with unexplained painful arthroplasties, routine testing of PROSTALAC (PROSthesis with Antibiotic-Loaded Acrylic Cement) orthopedic implants, or clinical suspicion of periprosthetic infection or septic arthritis. Synovial fluid was percutaneously aspirated using a standard technique. The patient age range was 31–91 years with a mean age of 69.1 years, consisting of 30 women (52.6 %) and 27 men (47.4 %). The “gold standard” for the presence or absence of infection at our institution and in the study group was based on the most recent recommendations of the AAOS. Positive culture remained the “gold standard” for native joint infection.

Results

Of the total 57 joints aspirated and included in the study, 20 (35.1 %) were read as positive (2+) on the leukocyte test strip and 37 (64.9 %) were read as negative (negative, trace, or 1+). PJI was diagnosed in 19 patients and native joint septic arthritis was identified in one patient. Sensitivities were excellent at 100 % with no false negatives in the entire cohort. There was one false positive in the periprosthetic group yielding a specificity, positive predictive value and negative predictive value of 97, 95, and 100 %, respectively. The results for the native joints showed markedly less specificity and positive predictive value at 50 and 33 %; however, its negative predictive value remained at 100 %.

Conclusions

Our test results confirm that the leukocyte esterase test can accurately detect PJI and that it can be used as a part of the traditional PJI workup. In the assessment of native joints, its high negative predictive value suggests that it is a valuable tool in excluding native joint septic arthritis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Jeng GW, Wang CR, Liu ST, Su CC, Tsai RT, Yeh TS, et al. Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis. Am J Emerg Med. 1997;15(7):626–9.

    Article  CAS  PubMed  Google Scholar 

  2. Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluid tests. What should be ordered? JAMA. 1990;264(8):1009–14.

    Article  CAS  PubMed  Google Scholar 

  3. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford). 2001;40(1):24–30.

    Article  CAS  Google Scholar 

  4. Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res. 2010;468(1):52–6.

    Article  PubMed Central  PubMed  Google Scholar 

  5. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1):128–33.

    Article  PubMed  Google Scholar 

  6. Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. Periprosthetic joint infection increases the risk of 1-year mortality. J Bone Joint Surg Am. 2013;95(24):2177–84.

    Article  PubMed  Google Scholar 

  7. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5.

    Article  PubMed  Google Scholar 

  8. Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis of periprosthetic infection. J Bone Joint Surg Am. 2006;88(4):869–82.

    Article  PubMed  Google Scholar 

  9. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645–54.

    Article  CAS  PubMed  Google Scholar 

  10. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478–88.

    Article  CAS  PubMed  Google Scholar 

  11. Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992–4.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Deirmengian CA, Patel R. Clinical and laboratory evaluation. In: Cierny G, McLaren AC, Wongworawat MD, eds. Musculoskeletal infection. Rosemont: American Academy of Orthopaedic Surgeons; 2009:57–65

  13. Deville WL, Yzermans JC, van Duijn NP, Bezemer PD, van der Windt DA, Bouter LM. The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC Urol. 2004;4:4.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Smalley DL, Dittmann AN. Use of leukocyte esterase-nitrate activity as predictive assays of significant bacteriuria. J Clin Microbiol. 1983;18(5):1256–7.

    PubMed Central  CAS  PubMed  Google Scholar 

  15. Azoulay E, Fartoukh M, Galliot R, Baud F, Simonneau G, Le Gall JR, et al. Rapid diagnosis of infectious pleural effusions by use of reagent strips. Clin Infect Dis. 2000;31(4):914–9.

    Article  CAS  PubMed  Google Scholar 

  16. Gal-Oz A, Kassis I, Shprecher H, Beck R, Bentur L. Correlation between rapid strip test and the quality of sputum. Chest. 2004;126(5):1667–71.

    Article  PubMed  Google Scholar 

  17. Keski-Nisula L, Katila ML, Kirkinen P, Ollikainen M, Saarikoski S. Amniotic fluid leukocytes and leukocyte esterase activity in parturients delivered by caesarean section. Scand J Infect Dis. 1997;29(3):291–6.

    Article  CAS  PubMed  Google Scholar 

  18. Matsuda M, Noda Y, Takemori Y. Novel diagnostic method of testing for Helicobacter pylori infection using the rapid leukocyte strip test, Leukostix. J Gastroenterol Hepatol. 2003;18(10):1196–201.

    Article  PubMed  Google Scholar 

  19. Nguyen-Khac E, Cadranel JF, Thevenot T, Nousbaum JB. Review article: the utility of reagent strips in the diagnosis of infected ascites in cirrhotic patients. Aliment Pharmacol Ther. 2008;28(3):282–8.

    Article  CAS  PubMed  Google Scholar 

  20. Parvizi J, Jacovides C, Antoci V, Ghanem E. Diagnosis of periprosthetic joint infection: the utility of a simple yet unappreciated enzyme. J Bone Joint Surg Am. 2011;93(24):2242–8.

    Article  PubMed  Google Scholar 

  21. Wetters NG, Berend KR, Lombardi AV, Morris MJ, Tucker TL, Della Valle CJ. Leukocyte esterase reagent strips for the rapid diagnosis of periprosthetic joint infection. J Arthroplasty. 2012;27(8 Suppl):8–11.

    Article  PubMed  Google Scholar 

  22. Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol. 2008;20(4):457–62.

    Article  CAS  PubMed  Google Scholar 

  23. Parvizi J, Jacovides C, Zmistowski B, Jung KA. Definition of periprosthetic joint infection: is there a consensus? Clin Orthop Relat Res. 2011;469(11):3022–30.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Della Valle C, Parvizi J, Bauer TW, Dicesare PE, Evans RP, Segreti J, et al. Diagnosis of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg. 2010;18(12):760–70.

    PubMed  Google Scholar 

  25. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90(9):1869–75.

    Article  PubMed  Google Scholar 

  26. Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81(5):672–83.

    CAS  PubMed  Google Scholar 

  27. Ghanem E, Parvizi J, Burnett RS, Sharkey PF, Keshavarzi N, Aggarwal A, et al. Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am. 2008;90(8):1637–43.

    Article  PubMed  Google Scholar 

  28. Deirmengian C, Kardos K, Kilmartin P, Cameron A, Schiller K, Booth RE, Jr., et al. The alpha-defensin test for periprosthetic joint infection outperforms the leukocyte esterase test strip. Clin Orthop Relat Res. 2014 Jun 19

  29. Dalbeth N, Haskard DO. Mechanisms of inflammation in gout. Rheumatology (Oxford). 2005;44(9):1090–6.

    Article  CAS  Google Scholar 

  30. Wright HL, Moots RJ, Bucknall RC, Edwards SW. Neutrophil function in inflammation and inflammatory diseases. Rheumatology (Oxford). 2010;49(9):1618–31.

    Article  CAS  Google Scholar 

  31. Schwartz AJ, Wetters N, Moric M, Berend KR, Lombardi AV, Gehrke T, et al. Diagnosis of periprosthetic joint infection after unicompartmental knee arthroplasty. J Arthroplast. 2012;27(8 Suppl):46–50.

    Google Scholar 

  32. Della Valle CJ, Sporer SM, Jacobs JJ, Berger RA, Rosenberg AG, Paprosky WG. Preoperative testing for sepsis before revision total knee arthroplasty. J Arthroplast. 2007;22(6 Suppl 2):90–3.

    Article  Google Scholar 

  33. Furnes O, Espehaug B, Lie SA, Vollset SE, Engesaeter LB, Havelin LI. Failure mechanisms after unicompartmental and tricompartmental primary knee replacement with cement. J Bone Joint Surg Am. 2007;89(3):519–25.

    Article  CAS  PubMed  Google Scholar 

  34. Wongworawat MD. Editor’s Spotlight/Take 5: Diagnosing periprosthetic joint infection: has the era of the biomarker arrived? Clin Orthop Relat Res. 2014;472(11):3250–3.

    Article  PubMed  Google Scholar 

  35. Sheehan E. CORR Insights: The alpha-defensin test for periprosthetic joint infection outperforms the leukocyte esterase test strip. Clin Orthop Relat Res. 2014 July 16

Download references

Conflict of interest

No conflict of interest.

Author information

Authors and Affiliations

  1. Department of Radiology, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA

    Otis C. Colvin, Mark J. Kransdorf, Catherine C. Roberts, F. Spencer Chivers & Roxanne Lorans

  2. Department of Orthopedic Surgery, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ, 85054, USA

    Christopher P. Beauchamp & Adam J. Schwartz

Authors
  1. Otis C. Colvin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mark J. Kransdorf
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Catherine C. Roberts
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. F. Spencer Chivers
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Roxanne Lorans
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Christopher P. Beauchamp
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Adam J. Schwartz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mark J. Kransdorf.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Colvin, O.C., Kransdorf, M.J., Roberts, C.C. et al. Leukocyte esterase analysis in the diagnosis of joint infection: Can we make a diagnosis using a simple urine dipstick?. Skeletal Radiol 44, 673–677 (2015). https://doi.org/10.1007/s00256-015-2097-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00256-015-2097-5

Keywords

Search

Navigation