Dear Editor

Septic arthritis (SA) of the hip is a severe infection less common in adults, predominantly with a bacterial etiology, and originated by hematogenous route or local inoculation of the agents.1-5 The main etiological germs of SA are Staphylococcus aureus and Streptococcus pneumoniae; but, besides other bacteria, more rare infections may be by Mycobacterium tuberculosis or fungi.¹-⁵ Delgadillo-Cañón ED and colleagues reported a 67-year-old male who had a hip SA associated with cystostomy procedures because of prostatic hyperplasia, evolving with iliopsoas abscess.¹ He underwent piperacillin-tazobactam and clindamycin and hip arthrotomy; the fluid culture revealed S. aureus sensitive to the antibiotic schedule utilized with success during 3 weeks.¹ With unremarkable evolution, the patient was listed as a candidate for the hip replacement.¹

Some additional recent literature descriptions can emphasize the current first reference. Cools J and colleagues reviewed data from 41 patients who had surgery for SA during 16 years, and 25 had previous computed tomography (CT) or magnetic resonance imaging (MRI) data.² There was no abscess in 36% of them, 32% had an abscess in one anatomical area, and 32% had abscesses in multiple anatomical regions; gluteal abscesses were more frequent in cases of SA due to contiguity, and those of iliopsoas region in cases of SA by hematogenous seeding.² Significant prognostic factors were not found; the authors recommended advanced imaging studies to search for hip SA, as extra-articular abscesses were detected in 64 % of these cases.² Li M and colleagues reviewed data from 43.5 follow-up months of 10 patients with osteonecrosis of the femoral head (ONFH) and hip SA who had two-stage arthroplasty with success; only one patient had a risk factor (nephrotic syndrome), and seven had positive microbiological culture.³ Patients with ONFH and worsened hip joint pain besides unexplained elevated C-Reactive protein and/or erythrocyte sedimentation rate, have a high suspicion index of a hip SA development.³ Sharoff L and colleagues reviewed joint infections and stressed: surgery for septic arthritis and prosthetic joint infections; joint aspiration only for diagnosis; and antibiotics for treatment.⁴ They also cited the incidence of SA (2 to 6/100 000 population, the post-arthroscopy infections rate (0.5 to 2%), the post-injection infections rate ranging between 0.005 and 0.0002%; and the prevalence of prosthetic joint infections after the primary hip replacement from 0.5% to 3%. ⁴ Major points were multidisciplinary assistance to improve the outcomes; and risk factors including age, joint inflammation, intravenous drugs, immunosuppression, alcohol or drug abuse, diabetes, joint injection or prostheses, avascular necrosis, skin infections, or catheters.⁴ Zhang J and colleagues reviewed findings from Gram stains in 408 joint aspirates from 2015 to 2021 in a trauma service in England, UK, and detected 30.4% sensitivity and 97.6% specificity.⁵ Positive cultures were associated with prosthetic joints, antecedent joint infections, arthritis, arterial hypertension, and diabetes mellitus; false negatives were related to antibiotic therapy; the authors highlighted the limited initial sensitivity and caution to interpret negative results.⁵

Diagnostic suspicion increases with case reports.

References

Keywords: Diagnosis; Hip; Management; Septic arthritis.

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