Evidence-based Diagnostics: Adult Septic Arthritis
Evidence-based Diagnostics: Adult Septic Arthritis
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DOI：
10.1111/j.1553-2712.2011.01121.x
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发表时间：
2011-08-01
影响因子：
4.4
通讯作者：
Pines, Jesse M.
中科院分区：
文献类型：
--
作者：
Carpenter, Christopher R.;Schuur, Jeremiah D.;Pines, Jesse M.
背景：关节急性肿胀或疼痛是急诊室 (ED) 的常见主诉。成人化脓性关节炎是一个具有挑战性的诊断，但及时区分细菌病因对于最大限度地降低发病率和死亡率至关重要。 目的：目的是进行系统评价，描述非淋菌性化脓性关节炎的病史、体格检查和床边实验室检查的诊断特征。次要目标是使用敏感性和特异性的估计值以及最佳证据诊断和治疗风险以及适当治疗的预期益处来量化测试和治疗阈值。方法：使用两个电子搜索引擎（PUBMED 和 EMBASE）以及选定的参考书目和科学摘要手工搜索。纳入标准包括对出现单关节主诉的患者进行的成人试验，如果他们报告了足够的细节，可以使用可接受的标准标准重建部分或完整的 2 x 2 列联表，以获取实验诊断测试特征。两名研究人员使用诊断准确性研究质量评估工具 (QUADAS) 对证据进行评级。当诊断测试存在多个类似设计的试验时，使用随机效应模型进行荟萃分析。在可能的情况下计算区间似然比 (LR)。为了说明一种量化疾病概率理论点的方法，临床医生可以完全停止测试并停止治疗（测试阈值）或开始确定性治疗代替进一步诊断（治疗阈值），设计了一个交互式电子表格，并根据诊断准确性、诊断风险和治疗风险/益处的研究估计提供了样本计算。结果：单关节急性疼痛的 ED 患者中非淋菌性化脓性关节炎的患病率约为 27%（95% 置信区间 [CI]） = 17% 至 38%）。除关节手术（阳性似然比 [+LR] = 6.9）或假体关节上的皮肤感染（+LR = 15.0）外，病史、体格检查和血清检测不会显着改变检测后概率。血清炎症标志物，如白细胞 (WBC) 计数、红细胞沉降率 (ESR) 和 C 反应蛋白 (CRP) 并不能立即发挥作用。滑膜白细胞(sWBC)计数0×10(9)-25×10(9)/L的LR区间为0.33； 25×10(9)-50×10(9)/L，1.06； 50×10(9)-100×10(9)/L，3.59；且超过 100 x 10(9)/L，无穷大。滑液乳酸可用于排除或排除化脓性关节炎的诊断，+LR 范围为 2.4 至无穷大，阴性似然比 (-LR) 范围为 0 至 0.46。滑液的快速聚合酶链反应 (PCR) 可在 3 小时内识别出致病微生物。基于 56% 的敏感性和 90% 的 sWBC 计数 > 50 x 10(9)/L 的特异性，结合诊断相关风险和治疗相关风险/效益的最佳证据估计，关节穿刺术测试阈值为 5%，治疗阈值为 39%。结论：近期关节手术或覆盖假体髋关节或膝关节的蜂窝织炎是病史或体格检查中唯一能显着改变概率的发现非淋菌性化脓性关节炎。 sWBC 的极值 (>50 x 10(9)/L) 会增加（但不会减少）化脓性关节炎的可能性。未来需要基于 ED 的诊断试验来评估临床格式塔的作用以及乳酸等非传统滑膜标志物的功效。学术急诊医学2011； 18:782-796 (C) 2011 由学术急诊医学学会
Background: Acutely swollen or painful joints are common complaints in the emergency department (ED). Septic arthritis in adults is a challenging diagnosis, but prompt differentiation of a bacterial etiology is crucial to minimize morbidity and mortality.Objectives: The objective was to perform a systematic review describing the diagnostic characteristics of history, physical examination, and bedside laboratory tests for nongonococcal septic arthritis. A secondary objective was to quantify test and treatment thresholds using derived estimates of sensitivity and specificity, as well as best-evidence diagnostic and treatment risks and anticipated benefits from appropriate therapy.Methods: Two electronic search engines (PUBMED and EMBASE) were used in conjunction with a selected bibliography and scientific abstract hand search. Inclusion criteria included adult trials of patients presenting with monoarticular complaints if they reported sufficient detail to reconstruct partial or complete 2 x 2 contingency tables for experimental diagnostic test characteristics using an acceptable criterion standard. Evidence was rated by two investigators using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS). When more than one similarly designed trial existed for a diagnostic test, meta-analysis was conducted using a random effects model. Interval likelihood ratios (LRs) were computed when possible. To illustrate one method to quantify theoretical points in the probability of disease whereby clinicians might cease testing altogether and either withhold treatment (test threshold) or initiate definitive therapy in lieu of further diagnostics (treatment threshold), an interactive spreadsheet was designed and sample calculations were provided based on research estimates of diagnostic accuracy, diagnostic risk, and therapeutic risk/benefits.Results: The prevalence of nongonococcal septic arthritis in ED patients with a single acutely painful joint is approximately 27% (95% confidence interval [CI] = 17% to 38%). With the exception of joint surgery (positive likelihood ratio [+LR] = 6.9) or skin infection overlying a prosthetic joint (+LR = 15.0), history, physical examination, and serum tests do not significantly alter posttest probability. Serum inflammatory markers such as white blood cell (WBC) counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are not useful acutely. The interval LR for synovial white blood cell (sWBC) counts of 0 x 10(9)-25 x 10(9)/L was 0.33; for 25 x 10(9)-50 x 10(9)/L, 1.06; for 50 x 10(9)-100 x 10(9)/L, 3.59; and exceeding 100 x 10(9)/L, infinity. Synovial lactate may be useful to rule in or rule out the diagnosis of septic arthritis with a +LR ranging from 2.4 to infinity, and negative likelihood ratio (-LR) ranging from 0 to 0.46. Rapid polymerase chain reaction (PCR) of synovial fluid may identify the causative organism within 3 hours. Based on 56% sensitivity and 90% specificity for sWBC counts of >50 x 10(9)/L in conjunction with best-evidence estimates for diagnosis-related risk and treatment-related risk/benefit, the arthrocentesis test threshold is 5%, with a treatment threshold of 39%.Conclusions: Recent joint surgery or cellulitis overlying a prosthetic hip or knee were the only findings on history or physical examination that significantly alter the probability of nongonococcal septic arthritis. Extreme values of sWBC (>50 x 10(9)/L) can increase, but not decrease, the probability of septic arthritis. Future ED-based diagnostic trials are needed to evaluate the role of clinical gestalt and the efficacy of nontraditional synovial markers such as lactate. ACADEMIC EMERGENCY MEDICINE 2011; 18:782-796 (C) 2011 by the Society for Academic Emergency Medicine