Assessment and diagnosis of the acute hot joint: a systematic review and meta-analysis

Author:

Dey Mrinalini12ORCID,Al-Attar Mariam3,Peruffo Leticia4,Coope Ashley5,Zhao Sizheng Steven6,Duffield Stephen1,Goodson Nicola7

Affiliation:

1. Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK

2. Department of Rheumatology, Queen Elizabeth Hospital , London, UK

3. Salford Royal NHS Foundation Trust , Salford, UK

4. School of Medicine, Federal University of Parana , Curitiba, Brazil

5. Liverpool University Hospitals NHS Foundation Trust , Liverpool, UK

6. Versus Arthritis Centre for Epidemiology, Centre for Musculoskeletal Research, The University of Manchester , Manchester, UK

7. Department of Rheumatology, Liverpool University Hospitals NHS Foundation Trust , Liverpool, UK

Abstract

Abstract Objectives Prompt diagnosis of septic arthritis (SA) in acute native hot joints is essential for avoiding unnecessary antibiotics and hospital admissions. We evaluated the utility of synovial fluid (SF) and serum tests in differentiating causes of acute hot joints. Methods We performed a systematic literature review of diagnostic testing for acute hot joints. Articles were included if studying ≥1 serum or SF test(s) for an acute hot joint, compared with clinical assessment and SF microscopy and culture. English-language articles only were included, without date restriction. The following were recorded for each test, threshold and diagnosis: sensitivity, specificity, positive/negative predictive values and likelihood ratios. For directly comparable tests (i.e. identical fluid, test and threshold), bivariate random-effects meta-analysis was used to pool sensitivity, specificity, and areas under the curves. Results A total of 8443 articles were identified, and 49 were ultimately included. Information on 28 distinct markers in SF and serum, differentiating septic from non-septic joints, was extracted. Most had been tested at multiple diagnostic thresholds, yielding a total of 27 serum markers and 156 SF markers. Due to heterogeneity of study design, outcomes and thresholds, meta-analysis was possible for only eight SF tests, all differentiating septic from non-septic joints. Of these, leucocyte esterase had the highest pooled sensitivity [0.94 (0.70, 0.99)] with good pooled specificity [0.74 (0.67, 0.81)]. Conclusion Our review demonstrates many single tests, individually with diagnostic utility but suboptimal accuracy for exclusion of native joint infection. A combination of several tests with or without a stratification score is required for optimizing rapid assessment of the hot joint.

Funder

British Society for Rheumatology

Wellcome Trust

Publisher

Oxford University Press (OUP)

Subject

Pharmacology (medical),Rheumatology

Reference78 articles.

1. SAT0459 diagnosis and management of acute hot joints at a tertiary rheumatology centre over a 7-month period;Dey;Ann Rheum Dis,2019

2. Does this adult patient have septic arthritis?;Margaretten;JAMA,2007

3. EULAR/EFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee;Landewé;Ann Rheum Dis,2010

4. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults;Coakley;Rheumatology (Oxford),2006

5. Septic arthritis in gout patients: a population-based cohort study;Lim;Rheumatology,2015

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