Septic Arthritis: Diagnosis and Treatment

 

Am Fam Physician. 2021 Dec ;104(6):589-597.

Author disclosure: No relevant financial affiliations.

Septic arthritis must be considered and promptly diagnosed in any patient presenting with acute atraumatic joint pain, swelling, and fever. Risk factors for septic arthritis include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, hip or knee prosthesis, skin infection, and immunosuppressive medication use. A delay in diagnosis and treatment can result in permanent morbidity and mortality. Physical examination findings and serum markers, including erythrocyte sedimentation rate and C-reactive protein, are helpful in the diagnosis but are nonspecific. Synovial fluid studies are required to confirm the diagnosis. History and Gram stain aid in determining initial antibiotic selection. Staphylococcus aureus is the most common pathogen isolated in septic arthritis; however, other bacteria, viruses, fungi, and mycobacterium can cause the disease. After synovial fluid has been obtained, empiric antibiotic therapy should be initiated if there is clinical concern for septic arthritis. Oral antibiotics can be given in most cases because they are not inferior to intravenous therapy. Total duration of therapy ranges from two to six weeks; however, certain infections require longer courses. Consideration for microorganisms such as Neisseria gonorrhoeae, Borrelia burgdorferi, and fungal infections should be based on history findings and laboratory results.

Septic arthritis should be considered in adults presenting with acute monoarticular arthritis. A delay in diagnosis and treatment of septic arthritis can lead to permanent morbidity and mortality. Subcartilaginous bone loss, cartilage destruction, and permanent joint dysfunction can occur if appropriate antibiotic therapy is not initiated within 24 to 48 hours of onset.1 The reported incidence of septic arthritis is four to 29 cases per 100,000 person-years, and risk increases with age, use of immunosuppressive medications, and lower socioeconomic status.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Before initiating antibiotic therapy in patients with suspected septic arthritis, analysis of synovial fluid obtained through arthrocentesis should be performed, including Gram stain, cultures, white blood cell count with differential, and crystal analysis.4

C

Expert opinion and consensus guideline in the absence of clinical trials

Initial empiric antibiotic therapy for adults with septic arthritis should cover Staphylococcus aureus and Streptococcus species.4

C

Expert opinion and consensus guideline in the absence of clinical trials

Oral antibiotics are not inferior to intravenous antibiotics for treatment of septic arthritis.25

B

Large cohort study evaluating six weeks of therapy that was started within one week of surgery and/or treatment with intravenous antibiotics

Septic arthritis caused by methicillin-resistant S. aureus should be treated with drainage or debridement and 14 days of intravenous antibiotics followed by oral antibiotics, totaling three to four weeks of therapy.7

C

Expert opinion and consensus guideline in the absence of clinical trials

In patients with joint replacements, prophylactic antibiotics are not recommended to prevent joint infection for routine outpatient dental, urologic, or gastrointestinal procedures.4648

C

Expert opinion and consensus guideline; systematic reviews for dental and gastrointestinal procedures


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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JOHN SCOTT EARWOOD, MD, is assistant program director of the Family Medicine Residency Program at Dwight D. Eisenhower Army Medical Center, Fort Gordon, Ga., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

TYLER R. WALKER, MD, is a flight surgeon with the 3rd Military Intelligence Battalion, Camp Humphreys, South Korea. At the time this article was written, he was a resident in the Family Medicine Residency Program at Dwight D. Eisenhower Army Medical Center.

GREGORY J. C. SUE, DO, is a resident in the Family Medicine Residency Program at Dwight D. Eisenhower Army Medical Center.

Address correspondence to John Scott Earwood, MD, Dwight D. Eisenhower Army Medical Center, 300 Hospital Rd., Fort Gordon, GA 30905 (email: john.s.earwood.civ@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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