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

Abstract

Objectives Prompt diagnosis of septic arthritis (SA) in acute native hot joints is essential to reduce unnecessary antibiotics and hospital admissions. We evaluated the utility of SF and serum tests in differentiating causes of acute hot joints. Methods We performed a systematic literature review of diagnostic testing for in 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 curve (AUC). Results 8443 articles were identified, 49 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, leukocyte 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 +/- stratification score is required to optimise rapid assessment of the hot joint.

Diagnosing Septic Arthritis in Acute Hot Joint

“…In a systematic review and meta-analysis, researchers report on the potential of multiple individual tests in synovial fluid and serum, which may be able to facilitate prompt exclusion of joint sepsis arthritis in the acute setting. (See Dey et al, 2022. )…”