We review 170 previously reported cases of sternoclavicular septic arthritis, and report 10 new cases. The mean age of patients was 45 years; 73% were male. Patients presented with chest pain (78%) and shoulder pain (24%) after a median duration of symptoms of 14 days. Only 65% were febrile. Bacteremia was present in 62%. Common risk factors included intravenous drug use (21%), distant site of infection (15%), diabetes mellitus (13%), trauma (12%), and infected central venous line (9%). No risk factor was found in 23%. Serious complications such as osteomyelitis (55%), chest wall abscess or phlegmon (25%), and mediastinitis (13%) were common. Staphylococcus aureus was responsible for 49% of cases, and is now the major cause of sternoclavicular septic arthritis in intravenous drug users. Pseudomonas aeruginosa infection in injection drug users declined dramatically with the end of an epidemic of pentazocine abuse in the 1980s. Sternoclavicular septic arthritis accounts for 1% of septic arthritis in the general population, but 17% in intravenous drug users, for unclear reasons. Bacteria may enter the sternoclavicular joint from the adjacent valves of the subclavian vein after injection of contaminated drugs into the upper extremity, or the joint may become infected after attempted drug injection between the heads of the sternocleidomastoid muscle. Computed tomography or magnetic resonance imaging should be obtained routinely to assess for the presence of chest wall phlegmon, retrosternal abscess, or mediastinitis. If present, en-bloc resection of the sternoclavicular joint is indicated, possibly with ipsilateral pectoralis major muscle flap. Empiric antibiotic therapy may need to cover methicillin-resistant Staphylococcus aureus (MRSA).

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This article reports 13 cases of pneumococcal septic arthritis and reviews another 177 cases reported since 1965. Of 2407 cases of septic arthritis from large series, 156 (6%) were caused by Streptococcus pneumoniae. Mortality was 19% among adults and 0% among children. Pneumococcal bacteremia was the strongest predictor of mortality. At least 1 knee was involved in 56% of adults. Polyarticular disease (36%) and bacteremia (72%) were more common among adults with septic arthritis caused by S. pneumoniae than among adults with other causative organisms. Only 50% of adults with pneumococcal septic arthritis had another focus of pneumococcal infection, such as pneumonia. Functional outcomes were good in 95% of patients. Uncomplicated pneumococcal septic arthritis can be managed with arthrocentesis and 4 weeks of antibiotic therapy; most cases of pneumococcal prosthetic joint infection can be managed without prosthesis removal. A fatal case of septic arthritis caused by a b-lactam-resistant strain of S. pneumoniae is also presented.Pneumococcal septic arthritis is described as "rarely encountered" [1] or "unusual" [2]. However, Streptococcus pneumoniae causes septic arthritis more often than is generally thought. Ispahani et al.[3] last reviewed pneumococcal septic arthritis in this journal, reporting 32 cases and reviewing 58 cases from large series published since 1965. We present 13 previously unreported cases and review 177 cases of pneumococcal septic arthritis reported in the English-language literature since 1965 , emphasizing the frequency of bacteremia and polyarticular disease among adults, the absence of extra-articular infection in many patients, and the emerging problem of pneumococcal antibiotic resistance. We report 2 cases of pneumococcal prosthetic joint infection and a case of pneumococcal arthritis in an adult that was caused by a strain of S.

We report a novel case of septic arthritis of the symphysis pubis due to Streptococcus pneumoniae and review 99 previously reported cases of infection of this joint. Typical features of pubic symphysis infection included fever (74%), pubic pain (68%), painful or waddling gait (59%), pain with hip motion (45%), and groin pain (41%). Risk factors included female incontinence surgery (24%); sports, especially soccer (19%); pelvic malignancy (17%); and intravenous drug use (15%). Septic arthritis of the pubic symphysis is often misdiagnosed as osteitis pubis, a sterile inflammatory condition. Causative organisms differed according to risk factors. Staphylococcus aureus was the major cause among athletes, Pseudomonas aeruginosa among intravenous drug users, and infections among patients with pelvic malignancies were usually polymicrobial, involving fecal flora. Patients with recent urinary incontinence surgery usually had monomicrobial infection, with no predominant pathogen. Since osteomyelitis is present in 97% of patients, we recommend antibiotic courses of 6 weeks' duration. Surgical debridement is required in 55% of patients.

Recommendations for prolonged penicillin treatment of actinomycosis date from the early antibiotic era, when patients often presented with neglected, advanced disease and received interrupted therapy at suboptimal dosages. This report describes cases of esophageal and of cervicofacial actinomycosis treated successfully with short-term antibiotic therapy and reviews the literature. Many patients are cured with <6 months of antibiotic therapy. If short-term antibiotic treatment is attempted, the clinical and radiological response should be closely monitored. Cervicofacial actinomycosis is especially responsive to brief courses of antibiotic treatment.

Long term acid suppressing treatment is common, and a substantial number of patients are taking these drugs long term without a diagnosis having been reached. It is hoped that protocols for investigation and treatment will improve these figures. Patients need to be better informed about their disease and the possible adverse effects of taking non-steroidal anti-inflammatory drugs in acid related upper gastrointestinal disease.

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Septic arthritis has increased in incidence in the United States in the past two decades, and increasingly affects an older population with a greater burden of chronic illness and a higher risk for drug-resistant organisms. Successful management depends on a high diagnostic suspicion, empiric antibiotic treatment, and joint drainage. A bacteriologic diagnosis is more likely with inoculation into blood culture bottles than plating on solid media. As MRSA increases in prevalence in the community, empiric anti-biotic regimens increasingly need to be active against MRSA.