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A Prospective 2-Year Study of 75 Patients with Adult-Onset Septic Arthritis

A Prospective 2-Year Study of 75 Patients with Adult-Onset Septic Arthritis

2001;40:24±30

A prospective 2-year study of 75 patients with adult-onset septic

M. N. Gupta, R. D. Sturrockand M. Field Centre for Rheumatic , University Department of Medicine, Royal In®rmary, 10 Alexandra Parade, Glasgow G31 2ER, UK

Abstract Aims and methods. To assess the clinical features of and characterize therapeutic strategies and outcome in a prospective study of 75 patients selected by positive synovial ¯uid culture. Results. Underlying was present in 46patients, 25 of whom had and 15 . Eleven patients were i.v. drug abusers. Fifty-six per cent of cases involved the , 15% involved two or more , and staphylococci and streptococci were cultured in >90%. Seventy-eight per cent of patients lived in areas of high social deprivation. was present in 64% and the white cell count -WCC) was normal in 38%. The C-reactive protein was elevated in 98%. Leg ulcers were present in 11% of all patients but in 38% of patients who died -P-0.006). Median duration of therapy was 15 days i.v. with subsequent oral treatment for 21 days. Thirty-seven per cent of cases required surgical intervention. Mortality was 11%. A raised WCC at presentation -P-0.02) and the development of abnormal renal function -P-0.015) were predictors of poor prognosis.

KEY WORDS: Septic arthritis, Clinical characteristics, Risk factors, Treatment, Outcome.

Septic arthritis -SA) is a rheumatological emergency that age ->80 yr). To date there is no information regarding can lead to rapid joint destruction and irreversible loss the role of social deprivation and i.v. drug abuse in of function. Patients with SA have previously been SA, and little prospective data on antibiotic use and classi®ed w1x into three categories: -i) those in whom longer-term outcome. can be cultured from infected synovial ¯uid We have therefore undertaken a multicentre prospec- -SF); -ii) those in whom organisms can be isolated from tive study to identify hospital in-patients in Scotland elsewhere; and -iii) patients in whom no organism can be with SA selected by the presence of bacteria cultured identi®ed but clinical examination and investigations from SF. We have speci®cally excluded patients in whom support the diagnosis. Despite improvements in anti- bacteria cannot be identi®ed on SF culture to investigate biotic therapy for SA, mortality and morbidity has not a cohort of patients in whom diagnostic homogeneity improved signi®cantly over the last two decades w2±9x. can be maintained and to enable future comparisons Most recent studies are retrospective, with the inherent with patients ful®lling Newman Grade B and C criteria problems of ascertainment. They have analysed all for SA. Clinical features, serological indices and poten- patients with clinical features of SA irrespective of tial risk factors were evaluated at presentation. We have bacterial culture from synovial ¯uid. Nevertheless, older identi®ed current therapeutic strategies, antibiotic use age at diagnosis, polyarticular involvement and confu- and systemic complications and evaluated outcome in sion have been identi®ed as predictors of poor outcome this highly selected cohort of 75 patients recruited over w4, 9x. Chronic alcohol abuse has also been implicated the past 2 yr. in one study w8x. However, the role of open surgical drainage of the infected joint remains controversial, one study showing this to be detrimental w9x and another Methods bene®cial w5x. In prospective studies, again investigating patients Study design with clinically diagnosed SA w6,10x, irrespective of SF We undertook a prospective investigation of SA over bacterial culture, major risk factors included skin a 24-month period between August 1997 and July 1999. , joint , lower limb joint prosthesis, This was part of an ongoing multicentre study incorpor- rheumatoid arthritis -RA), mellitus and older ating 11 teaching and district general hospitals serving a combined population of 2.3 million people in the Submitted 12 November 1999; revised version accepted 24 July 2000. central belt of Scotland. Adult patients -over 16yr of Correspondence to: M. Field. age) with a clinical diagnosis of SA were identi®ed

24 ß 2001 British Society for Rheumatology Adult-onset septic arthritis 25 weekly by telephone contact with rheumatologists -American Association) criteria for and orthopaedic surgeons in participating hospitals, RA w13x. The median duration of disease was 18 yr and were followed up until death or discharge. At no -IQR 11±27 yr). The sex ratio in patients with RA was point did this analysis alter the practice of the individual 3:1 in favour of females. In those without RA the sex physician or surgeon in patient management. For the ratio was equal. Fifteen patients -20%) had radio- purposes of this study only patients ful®lling the criterion logical evidence of osteoarthritis w14x, three -4%) had for Newman Grade A -bacteria present on synovial ¯uid a previously identi®ed crystal -two had culture) were eligible for inclusion w1x. pseudogout, one had ), two -3%) ful®lled the New York criteria for w15x Patient data and one -1%) had a seronegative arthropathy associated Demographic data, socio-economic status -Carstairs with psoriasis. index w11x), the duration and nature of symptoms before Seven patients -9%) had suffered a previous episode admission, details of comorbid conditions -including of SA, in all patients except one involving the same primary joint disease), drug therapy at diagnosis and joint. However, in two patients, on the second occasion recent surgical procedures were noted. the infection not only affected the index joint but was Body temperature, white cell count -WCC), C-reactive polyarticular. In one of these two patients the initial protein -CRP) and erythrocyte sedimentation rate -ESR) infection was in one knee prosthesis and the second were noted, as were sites of infection and the organisms infection involved the other . that were cultured. Details were recorded of antibiotic therapy, surgical intervention, complications attributable Symptoms, signs and investigations at presentation to acute SA and the need for central venous catheteriza- was the most frequent presenting symptom -85%), tion, arti®cial feeding, dialysis and intensive therapy unit usually being present on movement and at rest. New -ITU) admission. Mortality rates were calculated. joint swelling was present in 58 patients -77%). Fever Synovial ¯uid culture was described in only 33 -44%), and sweats and rigors in only 31 and 16% of patients respectively. The median SF was aspirated with an aseptic technique on the ward time to admission after symptom onset was 7 days except in the case of infected and prosthetic joints, -IQR 4±22 days). Overall, the median temperature was when aspiration was undertaken in operating theatres. 37.58C -IQR 36.1±408C), but 30% of non-RA patients Culture of SF was done on the day of admission using and 57% of RA patients were apyrexial. routine methods as described previously w12x. Blood Table 1 shows the results of the biochemical and culture bottles were not used for this purpose. haematological investigations at presentation. Only one Statistical analysis patient had a normal CRP; the ESR was elevated in all cases. The WCC was normal in 28 patients with SA Data were analysed using the Mann±Whitney U-test 2 -33% of non-RA and 50% of RA patients). There were with 95% con®dence intervals or the x test. P values less no differences in these variables between the RA and than 0.05 were accepted as signi®cant. non-RA patients. Results Coexistent conditions A number of coexistent conditions were identi®ed Patient demography -Table 2). Twenty-one patients -28%) had infected pros- Seventy-®ve patients in whom bacteria were cultured thetic joints and 11 -15%) were regular i.v. drug-abusers from SF -Newman Grade A) were identi®ed. Median -IVDAs). Local causes for infection -including recent age was 63 yr winterquartile range -IQR) 45±74 yrx. joint , and within Forty-six -61%) patients with SA had primary joint 6months) were identi®ed in 10 patients -13%), and disease. Twenty-six patients -33%) ful®lled the ARA distant sites of infection -including leg ulcers, chest

TABLE 1. Acute phase response in 75 patients with septic arthritis

Indicator of All patients with SA RA patients with SA Non-RA patients with SA in¯ammation -n s 75) -n s 25) -n s 50)

CRP -gul) Median -range) 185 -6±440) 184 -16±422) 191 -6±440) IQR 101±256137±233 94±281 ESR -mmuh) Median -range) 80 -10±197) 103 -27±135) 72 -10±197) IQR 43±105 70±117 39±94 WCC -109ul) Median -range) 13.1 -5.5±40.5) 10.2 -5.7±40.5) 14.4 -5.5±32.2) IQR 9.3±18.1 8.0±16.7 10.2±18.5 26 M. N. Gupta et al. , , cholangitis, pharyngitis and IVDA) One patient in the non-RA group was taking in 40 -53%). Interestingly, three patients developed SA prednisolone -5 mg daily) for autoimmune nephritis. within 2 weeks of insertion of a permanent pacemaker. Social deprivation Use of disease-modifying anti-rheumatic drugs and Socio-economic status was assessed using the Carstairs immunosuppressants index, a composite score derived by postcode and In the RA group, ®ve patients -21%) were taking calculated on the basis of social class, male unemploy- prednisolone -2±10 mg daily) and ®ve were prescribed ment, overcrowding and car ownership w11x. Those in methotrexate -5±15 mg weekly) -Table 3). Seven group 1 are the most privileged and group 7 comprises patients -28%) were taking standard disease-modifying the most deprived. Patients with SA resided in the more anti-rheumatic drug -DMARD) therapy -gold salts, socially deprived areas, 39 of the 50 non-RA patients , sulphasalazine or penicillamine). with SA -78%) being in Carstairs categories 5±7 However, nine RA patients -38%) were not on any compared with 44% of the normal population -n s 2.3 DMARD on admission. Of the three patients with million, P-0.0001). Furthermore, 62% were in the most seronegative arthropathy, one was taking methotrexate severely deprived groups -6and 7) compared with only -5 mg weekly) and two were not on DMARD therapy. 27% of the normal population -P-0.0001) -Table 4). Eleven patients were IVDAs and fell into groups 5±7.

TABLE 2. Potential risk factors for septic arthritis After removal of these patients from the calculations, there were still more SA patients in groups 5±7 -64% vs No. of patients No. of patients 44% of the control population P-0.001). Similarly, with RA without RA when compared with a cohort of 374 RA patients w16x -n s 25) -n s 50) attending the Centre for Rheumatic Diseases, Glasgow, Distant sites of infection 64% of the RA patients with SA fell into categories IVDA 0 11d 5±7 vs 49% of these RA patients without SA. Leg ulceration 7 1 Chest infection 4 5 Bacteriological investigations Pharyngitis 2 0 Pacemaker insertiona 12Fig. 1 shows the sites of infection after SF culture, Cellulitis 1 1 undertaken as described previously w12x. The knee -56%) Cholangitis 0 2 was the commonest site, followed by the -16%). Othersb 12In 11 cases -15%), two or more joints were involved. Local factors in infection Infection occurred in a prosthetic joint in 28% of cases. Prosthetic joint 8 13 Median time from joint replacement to the development Blunt trauma 1 2 Primary peri-articular 0 3 of SA was 6months -IQR 3 months to 2 yr). Blood Recent joint surgeryc 42culture was undertaken in 56patients, and this was Previous septic arthritis 3 4 determined by the practice of the individual unit. In 26 Recent intra-articular injectiona 20 a -46%) of the patients tested, bacteria were cultured from Recent arthroscopy 02both blood and SF. Systemic diseases Staphylococci and streptococci were implicated in Diabetes mellitus 0 4 Alcoholic liver disease 0 4 91% of cases, staphylococci -71%) being the commonest -Table 5). epidermidis was aWithin the preceding 2 weeks. more common in prosthetic than native joint infections b One patient each with , chest wall abscess or -19 vs 6%), but this difference was not statistically signi- bronchiectasis. cWithin the preceding 6months. ®cant. Gram-negative bacteria were present in seven dOne further patient was an ex-IVDA for 4 yr. Two patients were cases -9%). Multiply resistant hepatitis C-positive. None was HIV-positive. -MRSA) was implicated in 9% of Staphylococcus aureus infections -5% of all infections). In three patients -4%), TABLE 3. DMARDs in 25 RA patients with acute SA two organisms were isolated from the infected joint, and in one case three organisms were identi®ed. The DMARD RA -n s 25) organisms were cultured in all cases despite 11 patients None 9 -36%) -15%) having received in the preceding week. Methotrexate 5 -21%) In this adult study there were no infections with Prednisolonea 5 -21%) Haemophilus in¯uenzae, mycobacteria or gonococci. D-Penicillamine 3 -13%) Gold saltsb 2 -8%) Antibiotic therapy Hydroxychloroquine 1 -4%) Sulphasalazine 1 -4%) The median duration of i.v. antibiotic therapy was 15 days -IQR 10±42 days) and oral antibiotics 21 days aTwo patients taking prednisolone were also taking either metho- -IQR 10±42 days). There were no differences in trexate or hydroxychloroquine. Another patient had received i.v. cyclophosphamide 3 months earlier. prescription at presentation for RA and non-RA patient each on myocrisin -sodium aurothiomalate) and patients; formal characterization of the bacteria present aurano®n. de®ned later antibiotic use. Five patients received oral Adult-onset septic arthritis 27

TABLE 4. Social deprivation in 75 patients with septic arthritis as assessed by the Carstairs index

No. -%) of No. -%) of West of Scotland No. -%) of No. -%) of Carstairs non-RA patients controls RA patients RA controlsa index -n s 50) -n s 2.36106)-n s 25) -n s 374)

1 1 -2%) 1.86105 -8%) 3 -12%) 21 -6%) 2 1 -2%) 2.36105 -10%) 2 -8%) 23 -6%) 3 4 -8%) 4.16105 -18%) 1 -4%) 41 -11%) 4 5 -10%) 4.66105 -20%) 3 -12%) 74 -20%) 5 8 -16%) 3.96105 -17%) 7 -28%) 39 -10%) 614 -28%) 3.9 6105 -17%) 6-24%) 82 -22%) 7 17 -34%) 2.36105 -10%) 3 -12%) 61 -16%)

aMissing values in 9% of RA population w15x.

TABLE 5. Pathogens in 75 patients with acute SA

Prosthetic joints Native joints Pathogena -n s 21) -n s 54)

Staphylococcus aureusb 10 -48%) 35 -65%) Staphylococcus epidermidis 4 -19%) 3 -6%) species 6-29%) 15 -28%) Gram-negative bacilli 3 -14%) 4 -7%)

aFour patients had mixed infection. Three patients had mixed staphylococcal and streptococcal infection; was also isolated from one of these patients. One patient had mixed streptococcal species -groups D and G). bFour patients -5%) of the study population had MRSA.

MRSA has not previously been a common FIG. 1. Site of infection in 75 patients with acute SA. in SA, but our four cases re¯ect the general increase in j Prosthetic, I native. MRSA infections. Three cases were in RA patients -one knee replacement, one hip prosthesis). In two patients, antibiotics inde®nitely because of physical frailty and MRSA infection had been identi®ed previously from the presence of multiple prosthetic joints. other sites and appropriate antibiotics prescribed. In the All 21 patients presenting with prosthetic joint remaining two, antibiotic therapy was amended to infection were initially treated with i.v. antibiotics. Nine either or teicoplanin after con®rmation of -43%) were commenced on single antibiotics: four on sensitivity. vancomycin, three on ¯ucloxacillin and one each on Three of the 11 IVDA patients presented dif®culties cefuroxime and amoxycillin. The remaining 12 patients with venous access. In one, ¯ucloxacillin and rifampicin received combination antibiotic therapy. The com- were administered orally with i.m. gentamicin. Oral monest antibiotics used at presentation, before the treatment alone was prescribed for two others, one of availability of bacterial sensitivities, were ¯ucloxacillin whom, taking oral ¯ucloxacillin and amoxycillin, dis- -11 patients), gentamicin -seven patients), vancomycin charged himself from the accident and emergency -six patients) and fusidic acid -four patients). The department. In one further in-patient, oral cephalexin commonest combinations included ¯ucloxacillin with and were given, but vancomycin therapy gentamicin or fusidic acid -six patients) and vancomycin was subsequently necessary because of failure to respond with gentamicin or fusidic acid -three patients). to treatment. Of the 54 patients receiving antibiotics for native joint infection, most were commenced on i.v. treatment. Twelve -22%) were prescribed single antibiotics with Surgical treatment ¯ucloxacillin -®ve patients), -three patients), Twenty-eight patients -37%) underwent surgical inter- amoxycillin or vancomycin -two patients each). Thirty- vention. Arthroscopic washout was performed in seven one patients -59%) received two antibiotics in combina- cases and open synovial lavage in 13 patients. There tion and 10 -19%) were given triple therapy. One patient were no obvious differences in patients treated after received a combination of four antibiotics. Of the 34 lavage compared with recurrent aspiration during the patients receiving combination therapy with ¯ucloxa- course of admission. One patient who had had partial cillin, 17 -50%) were also prescribed gentamicin. None treatment for SA of the knee whilst on holiday abroad of the antibiotic combinations included vancomycin. and another with a persistent despite 28 M. N. Gupta et al. conventional therapy underwent surgical features of SA in which each case has been con®rmed in on the advice of the orthopaedic surgeons, with a good this way. functional result. Seven of 21 infected prosthetic joints This study shows an annual incidence of culture- were removed, anticipating replacement at a later date proven SA of 1 in 62 500. Because one hospital had no in ®ve patients. One infected knee joint was fused and rheumatologist and some patients would have come a Girdlestone hip was performed in the through the accident and emergency departments to remaining patient. In one patient with a native hip other units, it is likely that we did not have access to infection, a Girdlestone arthroplasty was fashioned every case, thus making the overall incidence higher. because of extensive joint destruction. Patients with Telephone contact with microbiologists in participating prosthetic joints or those on orthopaedic surgical wards hospitals suggested that we had collected nearly 80% of were more likely to undergo surgery. Overall, 48% of the potential number of cases, based on our inclusion patients were on orthopaedic wards and 52% on rheum- criteria. Nevertheless, we show a frequency of SA similar atology or medical wards, but 83% of those having to that reported in England w9, 18x and Australia w5x. surgical treatment were orthopaedic patients, compared Taking into account the deliberate exclusion of patients with only 17% on non-surgical wards -P-0.001). with suspected SA -Newman grades B and C), which our preliminary results showed to be just as prevalent as Outcome culture-proven SA w17x, the annual incidence in the West Median in-patient stay was 25 days -IQR 17±46days). of Scotland may be higher than estimated in this study. Three patients required admission to the ITU with We have found that a high number -61%) of SA septicaemic shock. One patient with knee infection with patients had underlying joint disease -RA, 33%; developed a cerebral abscess osteoarthritis, 26%), as in the other prospective hospi- and another with polyarticular Staphylococcus aureus tal-based study w6x. Retrospective analyses w5, 8, 9, 18x infection developed cervical spine requir- may not have the opportunity to evaluate all symptoms ing stabilization. Twenty-one patients suffered acute and investigations, and may therefore underestimate tubular necrosis, and two of them required dialysis. pre-existing joint damage. Ten patients had a probable Eight -11%) patients, three of whom were male, died local portal for entry of infection, including intra- as a result of acute SA. The median interval from articular treatment and joint replacement. The presence admission to death was 39 days -range 8±140 days). of prosthetic joints in 21 patients supports the hypo- Four patients had RA and one had pseudogout. Two of thesis that abnormal bone structure and synovial damage the RA patients were receiving prednisolone -10 and 5 mg are factors which encourage bacterial seeding and daily, respectively) in combination with either metho- growth w19, 20x. The polyarticular infection rate of trexate -7.5 mg weekly) or recent i.v. cyclophosphamide 15% may be an underestimate because joints other than for a vasculitic leg ulcer. the index joint may be less severely affected, and there- Two patients had infected prosthetic joints and fore aspiration may not be attempted. However, this one had polyarticular infection. Three patients had limitation is a feature of all analyses. Staphylococcus aureus infection -including one patient This study highlights the previously identi®ed prob- with MRSA), three had streptococcal infection, and lem of IVDA w21x in the development of SA in the urban Gram-negative bacteria were detected in two cases; two community, although this was not supported by recent of these eight patients had positive blood cultures as well European studies w6,9x. In our investigation, 11 patients as bacteria growing in SF. All eight patients had a high were abusers of i.v. drugs, and of the seven patients with WCC at presentation -range 13±386106ul), higher than previously documented SA, three had failed to modify the cohort as a whole -P-0.02), and each had comorbid their risk behaviour before the second episode. A conditions. In particular, three patients -38%) also had Spanish study during the 1980s w22x demonstrated that infected leg ulcers, signi®cantly more than in the SA over 50% of proven SA patients fell into this category. population who survived -P-0.0006). Impaired renal The prevalence of i.v. drug abuse fell during the 1990s, function was detected in seven of the eight patients which perhaps explains the lower frequency in our -88%), compared with only 21% of the survivors analysis. Nonetheless, 7000 people in the Glasgow area -P-0.015). Two patients also developed liver are estimated to be regular abusers of i.v. drugs w23x. This abnormalities before death. Four patients required implies an annual incidence of 0.1%, which approaches central venous access, three needed arti®cial feeding the 0.3% incidence of SA reported in RA patients w6x. and two required admission to the ITU. More importantly, if the drug abuse problem persists, these patients will continue to be at risk of SA with a Discussion concomitant strain on resources. Poverty increases the risk of infection, and we have This prospective 2-yr study of adult patients with SA shown that social deprivation is relevant in SA. This was speci®cally included only those who ful®lled Newman implied in a recent study in which Aborigines were Grade A criteria -in which a diagnosis of SA is made shown to have a three-fold higher rate of SA than based on positive SF culture). Nevertheless, we identi- non-indigenous Australians w5x. Our SA patients from ®ed 75 proven cases of SA. As such, this study is the ®rst both populations showed skewing towards the higher UK prospective study to examine and characterize the deprivation scores, but this did not reach statistical Adult-onset septic arthritis 29 signi®cance in the RA patients, possibly because our improvement in prognosis despite optimal therapy. uninfected RA patients were already more deprived w16x. However, it is no different from the mortality from Nevertheless, our data unequivocally show that, even other community-acquired infections, such as pneumo- after excluding i.v. drug-abusers, SA patients are more nia w31x. At presentation, all eight patients who died disadvantaged than the local population. It remains to during the acute infective episode had a leuko- be shown whether these individuals are at risk of SA cytosis -range 13±386106ul), which could be useful in because of signi®cant comorbidity. identifying those at greatest risk. Leg ulceration was Of the 25 RA patients in our study, 10 were taking seen in three patients and was notable as a possible prednisolone or methotrexate -either alone or in com- predictor of poor prognosis. The aetiology of leg ulcers bination). Therapy with immunosuppressive drugs has in RA is recognized to be multifactorial, but in one been implicated as a possible cause of impaired immune case the patient had received treatment for vasculitis. It system function in SA w6,9x. However, because this was remains to be seen whether the extra-articular features a multicentre study, we cannot clarify whether these of RA, including vasculitis, are of major importance in drugs were used more frequently in SA patients than the development of SA or in the subsequent outcome. in uninfected RA patients in the West of Scotland. As in other severe infections, renal function became Nevertheless, nine RA patients and two with sero- impaired before death in seven of the eight patients who negative were taking no DMARD died, and in two of these patients liver abnormalities at the time of diagnosis, which supports the theory that also developed. autoimmune disease may be suf®cient to predispose to In conclusion, our experience indicates that all SA in its own right. Furthermore, two of the four RA patients with suspected SA should have both SF and patients who died were not taking any DMARD. analysis, irrespective of body temperature RA is a risk factor for joint , but this study has and in¯ammatory indices. Although other local prac- shown that RA patients are likely to have a normal body tices may vary, the combination of ¯ucloxacillin -or temperature and WCC at presentation, indicating that a macrolide if the patient is allergic to penicillin) plus a high degree of clinical suspicion of SA is necessary gentamicin offers broad-spectrum cover for most in this group. The fact that blood cultures were positive in organisms isolated in SA, but if MRSA or Staphylo- nearly 50% of cases con®rms that this investigation is epidermidis are suspected, vancomycin should be warranted even in apyrexial patients with a normal WCC. used. If bone involvement is thought likely, the addition The infecting pathogen, the needs of the patient and of fusidic acid or rifampicin would be appropriate. the preferences of the physician and microbiologist In most cases, parenteral treatment for at least 2 weeks will all in¯uence the choice and duration of antibiotic followed by oral therapy for a minimum of 3 weeks is treatment, but therapy should be immediate w24±29x. desirable. There are no guidelines for antibiotic treatment in SA, SA is clearly a signi®cant problem in the West of but most authors agree that i.v. antibiotics should be Scotland. Socio-economic factors are important, and given for at least 1 week and subsequent oral antibiotics IVDA is a potential predisposing factor to SA in urban for at least 2 weeks. This practice was adhered to in most communities. In addition, we have shown in a prospect- cases, with a median duration of i.v. antibiotics of ive study of SA patients in whom bacteria had been 15 days and subsequent oral therapy for 21 days in the identi®ed on SF culture that the use of antibiotics is present study. Although 42 patients -57%) were pre- appropriate. This analysis of patients ful®lling Newman scribed two antibiotics, in eleven -15%) patients three or Grade A criteria will facilitate comparisons with patients more antibiotics were given. The combination included in the other two Newman groups in whom bacteria ¯ucloxacillin, gentamicin or vancomycin in 85% of cannot be identi®ed on SF culture but in whom the cases. As staphylococci and streptococci are implicated diagnosis is suspected clinically. in over 90% of cases of SA, and in keeping with published suggestions for therapy w30x, this practice Acknowledgements would seem appropriate. The common use of rifampicin and fusidic acid is an indication of their more effective We are grateful to the Mary Miller Bequest for funding bone penetration. Gentamicin is a favoured combination MNG. We would like to thank Dr G. Gupta and antibiotic in many units in the West of Scotland, until Dr I. McInnes for helpful discussion, Sister R. Hampson sensitivities have been fully established, because it offers for her assistance and all participating physicians and broad-spectrum Gram-positive and Gram-negative surgeons who helped recruit the patients. cover. In the present study, the use of vancomycin as a ®rst-choice antibiotic re¯ected evidence of previous infection with Staphylococcus epidermidis or MRSA in References some cases. In other patients there was a high suspicion 1. Newman JH. Review of septic arthritis throughout the of these infections -after or surgery), but antibiotic era. Ann Rheum Dis 1976;35:198±205. in two cases it was used because of the presence of SA 2. 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