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The Rational Clinical Examination
David L. Simel, Drummond Rennie
Septic Arthritis
Mary E. Margaretten, Jeffrey Kohlwes, Dan Moore, Stephen Bent
An abnormal peripheral WBC count, ESR, and CRP were found to have limited diagnostic power for...

Topics Discussed: arthritis, infectious, bacterial arthritis, criterion standard comparisons (diagnostic tests), erythrocyte sedimentation rate, leukocyte count, likelihood ratio, neutrophils, sensitivity, signs and symptoms, specificity, summarizing the evidence, synovial fluid, synovial fluid examination

Excerpt: "The PubMed searches identified 251 articles and the EMBASE search identified an additional 399 articles for a total of 650 articles (Figure 65-1). Studies were judged irrelevant if they did not include original data on the accuracy or precision of history, physical examination, and/or routine laboratory test results in diagnosing septic arthritis. Six hundred eighteen articles were excluded based on review of their abstracts, leaving 32 articles for full manuscript review. There were 13 studies that reviewed patients with infected joints but did not provide sufficient data and, therefore, could not be included in our study.5,7,8,10,28-36 Five studies did not evaluate clinical tests of interest.37-41 Thus, the final data shown in Table 65-3 are based on 14 studies that met all the inclusion criteria 3,6,15,42-51 and included 6242 patients, of whom 653 were diagnosed with septic arthritis. The studies took place between 1979 and 2003, and ranged in size from 41 to 4889 patients. However, 1 study42 evaluating risk factors involved the majority of the patients. The other 7 studies43-48 included a total of 1353 patients, ranging from 41 to 362 patients and assessed symptoms, signs, serum laboratory values, and synovial fluid for the diagnosis of septic arthritis. Although we did not exclude studies of gonococcal arthritis, the difficulty of confirming gonococcal arthritis by Gram stain or culture (gold standard) meant that only a few of these patients were included in the retained studies.Two of the studies were prospective studies enrolling patients with acutely swollen, painful joints, and were therefore useful for estimating a pretest probability of septic arthritis. In the prospective study by Shmerling et al,46 8 (8%) of 100 consecutive patients evaluated for 1 or more painful, swollen joints between 1987 and 1988 at Beth Israel Hospital in Boston, Mass, had septic arthritis. In the prospective study by Jeng et al,48 20 (27%) of 75 patients presenting to the emergency department with acute arthritis between 1993 and 1995 in Taiwan were found to have septic arthritis. Thus, the range of reported prevalence from 2 prospective studies of septic arthritis in patients who presented with an acutely painful and swollen joint is 8% to 27%.46,48 We report the prevalence estimate as a range rather than a summary because the risks are significantly different (2 test, P<.001), and the patient populations were from 2 different clinical settings...."
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