ALG Septic Arthritis
intraarticular infection. Fig. E1 illustrates
BASIC INFORMATION
DEFINITION
Septic arthritis is a highly destructive form of
joint disease most often caused by hematog-
enous spread of organisms from a distant site
of infection. Direct penetration of the joint as
a result of trauma or surgery and spread from
adjacent osteomyelitis may also cause bacterial
arthritis. Any joint in the body may be affected.
SYNONYMS
Infectious arthritis
Bacterial arthritis
Pyogenic arthritis
ICD-10CM CODES
M00.9 Pyogenic arthritis, unspecified
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE (IN U.S.): Unknown.
PREVALENCE (IN U.S.): Unknown.
PREDOMINANT SEX: Gonococcal arthritis in
females.
PREDOMINANT AGE: Gonococcal arthritis in
sexually active adults.
PEAK INCIDENCE:
• Gonococcal arthritis: young adults.
• Other bacterial causes: all ages.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
• Hallmark: acute onset of monoarticular joint
pain, erythema, heat, and immobility.
• Limited range of motion of the joint.
• Effusion, with varying degrees of erythema
and increased warmth around the joint.
• Single joint affected in 80% to 90% of cases
of nongonococcal arthritis.
• Gonococcal dermatitis-arthritis syndrome.
1. Typical pattern is a migratory polyarthritis
or tenosynovitis.
2. Small pustules on the trunk or extremities.
• Febrile patient at presentation.
• Most commonly affected joints in adult: knee
and hip, but any joint may be involved; in
children: hip.
ETIOLOGY
• Bacteria spread from another locus of
infection.
1. Highly vascular synovium is invaded by
hematogenously spread bacteria.
2. WBC enzymes cause necrosis of synovi-
um, cartilage, and bone.
3. Extensive joint destruction is rapid if
infection is not treated with appropriate
IV antibiotics and drainage of necrotic
material.
• Predisposing factors: rheumatoid arthritis,
prosthetic joints, advanced age, immunodefi-
ciency (HIV, DM, immunosuppressive drugs),
gout, sexual activity (gonococcal arthritis),
skin infections, cutaneous ulcers (contigu-
ous spread), recent joint surgery, recent
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1161
When elevated, ESR and CRP may be useful
routes by which bacteria can reach the joint.
• The most common nongonococcal organisms
are staphylococci (40%), streptococci (28%),
and gram-negative bacilli (19%). Less com-
mon are mycobacteria (8%), gram-negative
cocci (3%), anaerobes (1%), and gram-pos-
itive bacilli (1%).
• Staphylococci (S. aureus and coagulase-
negative staphylococcal species) account for
>50% of prosthetic-hip and prosthetic-knee
infections. S. aureus is very common in
patients with rheumatoid arthritis.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Gout.
• Pseudogout.
• Trauma.
• Hemarthrosis.
• Rheumatic fever.
• Adult or juvenile rheumatoid arthritis.
• Spondyloarthropathies such as reactive
arthritis (Reiter’s syndrome).
• Osteomyelitis.
• Viral arthritides.
• Septic bursitis.
• Lyme disease caused by Borrelia burgdorferi.
WORKUP
• Joint aspiration, Gram stain, and culture of the
synovial fluid. Fig. 2 describes an algorithm
for synovial fluid analysis in septic arthritis.
• Immediate arthrocentesis before other stud-
ies are undertaken or antibiotics instituted.
Synovial fluid should be evaluated at bedside
and then sent for lab evaluation.
LABORATORY TESTS
• Joint fluid analysis.
1. Synovial fluid leukocyte count is usually
elevated >50,000 cells/mm3 with > 80%
polymorphonuclear cells.
2. Counts are highly variable, with similar
findings in gout, pseudogout, or rheu-
matoid arthritis. Lower WBC counts can
occur in joint replacement, disseminated
gonococcal disease, and peripheral leu-
kopenia.
3. Synovial fluid glucose or protein is not
helpful because results are not specific
for septic arthritis. The differential diag-
nosis of synovial fluid abnormalities is
described in Section IV.
4. PCR testing: useful for detection of uncom-
mon organisms (e.g., Lyme disease).
5. Crystal analysis: septic arthritis can coex-
ist with crystal arthropathy; therefore, the
presence of crystals does not preclude a
diagnosis of septic arthritis.
• Blood cultures: positive in 25% to 50% of
patients with septic arthritis.
• Culture of possible extraarticular sources of
infection.
• Elevated peripheral WBC count, ESR (nonspe-
cific), C-reactive protein (CRP) (nonspecific).
to monitor therapeutic response.
• If gonococcus is suspected, perform nucleic
S
acid amplification tests (NAATs) on synovial
fluid.
IMAGING STUDIES
• Radiograph of the affected joint (Fig. E3):
useful to rule out osteomyelitis, fractures,
chondrocalcinosis, or inflammatory arthritis.
• MRI: findings that suggest an acute intraar-
ticular infection include the combination of
bony erosions with marrow edema.
and Disorders
Diseases
• CT scan: useful for early diagnosis of infec-
tions of the spine, hips, and sternoclavicular
and sacroiliac joints.
• Ultrasound: can be useful for detecting effu-
sions in joints that are more difficult to exam-
ine (e.g., hip).
I
TREATMENT
NONPHARMACOLOGIC THERAPY
• Affected joints aspirated daily to remove
necrotic material and to follow serial WBC
counts and cultures.
• If no resolution with IV antibiotics and closed
drainage: open debridement and lavage, par-
ticularly in nongonococcal infections.
• Prevention of contractures:
1. After acute stage of inflammation, range-
of-motion exercises of the affected joint.
2. Physical therapy helpful.
ACUTE GENERAL Rx
• IV antibiotics immediately after joint aspira-
tion and Gram stain of the synovial fluid.
Empiric antibiotic therapy (Table E1) is based
on organism found on Gram stain of synovial
fluid:
1. Gram-positive cocci: vancomycin: 15 to
20 mg/kg IV q8 to 12h. Keep trough levels
at 15 to 20 mcg/ml.
2. Gram-negative cocci: ceftriaxone: 1 to 2 g
IV q day in adults (children: 50 to 100 mg/
kg IV q day).
3. G ram-negative rods: ceftriaxone,
cefepime: 1 to 2 g IV q8 to 12 h in adults
(children: 100-150 mg/kg/day divided in
q8h dosing), piperacillin-tazobactam: 4-5
g q6h. Aztreonam or fluoroquinolones can
be used in patients with allergy to penicil-
lin or cephalosporins.
4. Negative Gram stain: vancomycin plus
either cefepime or a carbapenem such
as meropenem: 1 g IV q8h in adults
(children: 60 mg/kg/day divided in q8h
dosing) or ertapenem.
SUGGESTED READINGS
Available at www.expertconsult.com
RELATED CONTENT
Septic Arthritis (Patient Information)
AUTHOR: GLENN G. FORT, M.D., M.P.H.
1162 Septic Arthritis ALG

Diagnostic arthrocentesis:
(always try to tap the joint dry)
• Note which joint
• Total volume of synovial fluid
• Gross description of fluid,
• bloody or nonbloody

Bloody fluid: Nonbloody fluid:

Consider the following differential Note color, turbidity, and viscosity
diagnosis of hemarthrosis:
• Trauma with or without fracture
• Over anticoagulation
• Hemophilia
• Other bleeding disorders
• Pigmented villonodular synovitis
• or other tumors
• Traumatic tap

Synovial fluid WBC

50,000 WBC/mm3

Positive Negative

Markedly inflammatory fluid: Noninflammatory to

Consider empiric antibiotic
therapy pending culture results
moderately inflammatory fluid:
Consider a broad differential
diagnosis from OA to RA.
However, septic arthritis is
less likely but still possible

Crystals?
Under polarized light

Negative Positive

Inflammatory arthritis Gout or pseudogout

not due to crystals at least

Gram stain and/or Gram stain and/or

culture positive? culture positive?

Negative Positive Positive Negative

Markedly inflammatory Septic arthritis Crystal-induced arthritis

fluid not due to crystals defined by the nature
or infection: of the crystals
Consider the other
possibilities of
pseudoseptic arthritis

FIG. 2  Algorithm for synovial fluid analysis in septic arthritis.  OA, osteoarthritis; RA, rheumatoid arthri-
tis; WBC, white blood cell count. (From Harris ED et al: Kelley’s textbook of rheumatology, ed 7, Philadelphia,
2005, Saunders.)

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Septic Arthritis 1162.e1

1 – The hematogenous route. 1

2 – Dissemination from
osteomyelitis.
2
3 – Spread from an adjacent
soft tissue infection.
4 – Diagnostic or therapeutic
measures.
5 – Penetrating damage by
puncture or trauma.
4

FIG. E1  Routes by which bacteria can reach the joint. (From Hochberg MC et al: Rheumatology, ed 5,
St. Louis, Mosby, 2011.)

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Septic Arthritis 1162.e2

A B C
FIG. E3  Septic arthritis (x-ray and magnetic resonance imaging [MRI]).  A, X-ray in anteroposterior
view of sacroiliac joints shows destruction of the right sacroiliac joint as part of septic arthritis (arrows). B, In
another patient, short tau inversion recovery (STIR) coronal MRI through sacroiliac joints shows erosive changes
in the right sacroiliac joint with extensive bone marrow edema. C and D, Tuberculous spondylitis. C, X-ray of the
lumbar spine in lateral view shows disk space narrowing at the L3-L4 level with destructive changes involving
the superior end plate of the L4 vertebral body (arrow). D, Coronal STIR MRI of the lumbar spine of the same
patient confirms focal destruction of the L4 vertebral body (arrow). Enlargement of both psoas muscles (P)
with increased signal is noted, owing to paraspinal extension of the infection. (From Firestein GS et al: Kelly’s
textbook of rheumatology, ed 9, Philadelphia, 2013, Saunders.)

TABLE E1  Recommended Empiric Therapy for Adult Native Joint Bacterial Arthritis
Gram Stain
Gram-positive cocci
Gram-negative coccid
Gram-negative rodsf
Gram stain negativef
Preferred Antibiotica Alternative Antibiotic
Vancomycin, 15-20mg/kg (ABW) daily every 8-12hrb Daptomycin, 6-8mg/kg dailyc or linezolid, 600mg IV or PO every 12hrc
Ceftriaxone, 1g every 24hr Cefotaxime, 1g every 8hre
Ceftazidime, 2g every 8hr or Aztreonam, 2g every 8hr or
cefepime, 2g every 8hr or fluoroquinolone or
piperacillin-tazobactam, 4.5g every 6hr carbapenemh,i
Vancomycin Daptomycinc or linezolidc
plus plus
ceftazidime or piperacillin-tazobactam or
cefepime aztreonam or
fluoroquinoloneg or
carbapenemh,i

ABW, Actual body weight; IgE, immunoglobulin E; IV, intravenous; PO, by mouth.
aUnless noted otherwise, dosages are IV for persons with normal renal function.
bTherapeutic monitoring should target a serum trough of 15-20mg/L.
cFor patients allergic to, or intolerant of, vancomycin.
dEquivocal gram-negative morphology should be considered as gram-negative rods.
eGram-negative cocci with epidemiology or history suggestive of gonococcal infection should be initially treated per Centers for Disease Control and Prevention Sexually Transmitted Disease Guidelines.

Alternative therapies have not been suggested for patients with a history of a Stevens-Johnson syndrome or severe IgE-mediated allergy to β-lactam antibiotics. Possible empiric options for
penicillin-allergic patients, pending culture sensitivities, include azithromycin, ciprofloxacin, tobramycin, gentamicin, and spectinomycin (not available in U.S.).
fFor patients with risk factors for resistant gram-negative pathogens (significant health care exposure, immunosuppression, or history of extended-spectrum β-lactamase gram-negative infection or

colonization), drug selection should consider regional or local antibiograms.

gCiprofloxacin, 400mg IV q8h or 750mg PO q12h or levofloxacin, 750mg IV or PO q24h.
hDoripenem, 500mg q8h; imipenem, 500mg q6h; or meropenem, 1g q8h.
iUsually reserved for patients with risk factors for resistant gram-negative pathogens (significant health care exposure, immunosuppression, or history of extended-spectrum β-lactamase gram-

negative infection or colonization).

Bennett JE et al: Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, ed 8, Philadelphia, 2015, WB Saunders.

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Septic Arthritis 1162.e3

SUGGESTED READINGS
Arnold JC, Bradley JS: Osteoarticular infections in children, Infect Dis Clin North
Am 29:557–574, 2015.
Horowitz DL, et  al.: Approach to septic arthritis, Am Fam Physician 84(6):653–
660, 2011.
Lim SY, et al.: Septic arthritis in gout patients: a population-based cohort study,
Rheumatology (Oxford) 54:2095–2099, 2015.

Descargado para DARIELA REY GARCIA (dreyg@unbosque.edu.co) en Fundacion Cardio Infantil de ClinicalKey.es por Elsevier en julio 11, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.