REVIEW

Peripheral Bacterial Septic Arthritis

Review of Diagnosis and Management
Ahmed S. Hassan, MD,* Allison Rao, MD,† Augustine M. Manadan, MD,‡ and Joel A. Block, MD§

joint surgery, intravenous (IV)–drug abuse, skin infections, and

Abstract: Septic arthritis refers to an infection in a joint due to a bacterial, prior intra-articular corticosteroid injection.4
mycobacterial, or fungal cause. Joint infections are a serious cause of mor-
bidity and mortality and constitute a true musculoskeletal emergency. The
estimated incidence of septic arthritis in the general population is between
MICROBIOLOGY
2 and 6 cases per 100,000 people per year. The most common presentation The most common organism identified in septic arthritis in
is an acute monoarthritis. Identification of organisms in the synovial fluid adults is Staphylococcus aureus, responsible for an estimated 37%
is the criterion standard for diagnosis. Synovial fluid aspiration should be to 56% of cases5,6 with methicillin-resistant S. aureus (MRSA) in-
performed prior to initiating antibiotics. While no diagnostic cutoff exists creasingly common. Several risk factors were proposed to identify
for synovial fluid white blood cell count, increasing leukocytosis is associ- patients at a higher risk of MRSA infections such as those with
ated with a higher likelihood of an infectious cause of arthritis, and patients IV-drug use, human immunodeficiency virus infection, or DM.
commonly present with values greater than 50,000/μL. The cornerstones of The most well-documented at-risk group is patients recently admit-
treating septic bacterial arthritis are adequate drainage and antimicrobials. ted to a hospital within 1 year.7 The next most common causative or-
Joint drainage is always recommended in septic arthritis; however, no clear ganisms are groups A and B streptococci, which are especially
guidelines or strong evidence exist to guide the preferred method of drain- prevalent among the elderly and among those with chronic diseases
age. Options for joint drainage include daily needle aspiration, arthroscopy, such as DM or cirrhosis.8 Gram-negative organisms are less com-
or open surgical drainage via arthrotomy. mon. The 2 most frequently observed gram-negative organisms are
Neisseria gonorrhoeae and Neisseria meningitidis.5 Gram-negative
Key Words: arthrocentesis, arthroscopic drainage, bacterial arthritis, enteric organisms are generally limited to patients who are immuno-
joint infections, management of septic arthritis, rheumatologic compromised or who are IV-drug abusers and include Escherichia
emergencies, septic arthritis coli, Proteus mirabilis and Klebsiella.9 In approximately 20% to
(J Clin Rheumatol 2017;00: 00–00) 50% of cases of septic arthritis, no causative organisms are identi-
fied; this is often due to antibiotic treatment prior to arthrocentesis10
(Tables 1 and 2).
S eptic, infectious, pyogenic, suppurative, or purulent arthritis
refers to an infection in a joint due to a bacterial, mycobacterial,
or fungal cause. Joint infections are a serious cause of morbidity MECHANISM
and mortality and constitute a true musculoskeletal emergency The synovium is highly vascularized and lacks a protective
where a substantial difference in outcomes depends on a timely di- basement membrane; thus, the most common route of bacterial
agnosis and early institution of treatment. Several challenges in entry is via hematogenous spread.16–18 Joints with preexisting
the management of bacterial septic arthritis include selection of damage, such as in RA or osteoarthritis, are especially prone to
appropriate antimicrobials and selection of appropriate joint fluid septic arthritis.19 Similarly, there are suggestions of elevated risk
drainage method. In this narrative review, we focus on the epide- in other forms of arthritis, such as gout and pseudogout.20
miology, mechanism, pathogenesis, clinical signs, diagnosis, and Rare means of joint infection include direct inoculation after
treatment of native joint bacterial septic arthritis. trauma or surgery disrupting the integrity of the joint capsule. Sep-
tic arthritis only rarely occurs following intra-articular corticoste-
roid injections or arthrocentesis, with an estimated risk of less
EPIDEMIOLOGY than 1 in 1000.21 Upon introduction to the joint space, microorgan-
The estimated incidence of septic arthritis in the general pop- isms precipitate an acute inflammatory reaction that may progress
ulation is between 2 and 6 cases per 100,000 people per year.1,2 to involve the surrounding bone. Destruction is due to inflammatory
The incidence is higher in populations predisposed to septic arthri- cytokines and proteases.22 Bacterial toxins may also be destructive;
tis, such as among patients with rheumatoid arthritis (RA), where for example, staphylococcal enterotoxins and superantigens produced
the incidence has been estimated to be up to 70 per 100,000 people in staphylococcal toxic shock syndrome have been shown to damage
per year.3 A prior systematic review of 14 studies and 6242 patients cartilage in animal models, and this effect may be ameliorated by
identified several risk factors for septic arthritis; these included dia- prevaccination with recombinant staphylococcal enterotoxin.23 Mi-
betes mellitus (DM), RA, the presence of a prosthetic joint, recent crobial surface components such as adhesins that mediate staphylo-
coccal adherence to intra-articular proteins (e.g., elastin, laminin,
fibronectin), so-called microbial surface components recognizing ad-
From the *Cook County Health & Hospital Systems; †Midwest Orthopedics hesive matrix molecules, have also been shown to influence the abil-
Rush University Medical Center; ‡Division of Rheumatology, Rush Uni- ity of certain S. aureus strains to cause septic arthritis.24
versity Medical Center; §Division of, Rush University, Chicago, IL.
The authors declare no conflict of interest.
Correspondence: Ahmed S. Hassan MD, Cook County Health & Hospital CLINICAL PRESENTATION
Systems, 1900 W Polk, Suite 740 Chicago, IL 60612. The most common presentation of septic arthritis is an acutely
E‐mail: ahassan@cookcountyhhs.org.
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swollen, warm, and painful single joint with a limited range of mo-
ISSN: 1076-1608 tion4,25; fever is present in approximately only 40% to 60% of pa-
DOI: 10.1097/RHU.0000000000000588 tients,26,27 especially among the elderly who usually may not

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Hassan et al. JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2017

of several rheumatologic conditions such as RA. However, bio-

TABLE 1. Most Common Organisms Known to Cause Septic logic agents have also been associated with a 2-fold increased risk
Arthritis4–8
of septic arthritis, with the highest risk being in the months follow-
ing the initiation of treatment. Notably, some patients who re-
S. aureus Mycobacterium tuberculosis
ceived tumor necrosis factor α inhibitors had septic arthritis
Streptococcus pyogenes E. coli caused by organisms that rarely cause the disease, including Sal-
S. pneumoniae P. mirabilis monella, Listeria, and Pseudomonas aeruginosa.28,32
Haemophilus influenzae P. aeruginosa
N. gonorrhoeae Klebsiella pneumoniae
N. meningitidis Salmonella species DIAGNOSIS
Kingella kingae Multiple species of microorganisms Identification of organisms in the synovial fluid is the crite-
Fungi rion standard for diagnosis. Synovial fluid aspiration should be
performed prior to initiating antibiotics, and the analysis should
present with fever.4 Fever is usually low-grade, but up to 40% of include a white blood cell (WBC) count with differential, Gram
patients can present with high-grade fever.22 There are insufficient stain, culture, and examination for crystals under polarized mi-
data to correlate specific causative pathogens with a higher inci- croscopy.28 A Gram stain can provide immediate information
dence of fever. and is often positive in bacterial arthritis, with a sensitivity be-
In more than 50% of adult cases, the knee is the site of the in- tween 29% and 50%.4,33,34 In addition, synovial fluid WBC count
fection, followed by the shoulders, wrists, hips, and ankles, whereas tends to be highly elevated. Although no definitive cutoff value
the hip is the most commonly affected joint in children.20,28 Less exists, a culture-proven diagnosis of septic arthritis was made in
commonly affected joints such as the sacroiliac (SI) joint and sym- approximately only 5% of patients with a synovial fluid WBC
physis pubis can have unique presentations. Septic arthritis of the count of less than 50,000/μL, 47% of patients with values greater
SI joint can present with buttocks pain, gait changes, and fever.29 than 50,000 but less than 100,000/μL, and 77% of patients with a
Infection of the symphysis pubis can occur with pelvic malignan- synovial fluid WBC count exceeding 100,000/μL.1,6,35,36
cies and in female patients who have undergone urinary inconti- While the results are typically available after the synovial
nence surgeries or in IV-drug abusers and can present with fever, fluid WBC and Gram stain, synovial fluid cultures are extremely
suprapubic pain, and an antalgic gait.30 sensitive in nongonococcal bacterial arthritis and are positive in
Septic arthritis is usually monoarticular, but is oligoarticular in the majority of cases.26 Their sensitivity can be compromised in
approximately 10% to 20% of cases, typically in patients with over- patients who have received antibiotic treatment prior to obtaining
whelming sepsis, multiple systemic comorbid conditions, or RA.31,32 cultures and can also be falsely negative in infections caused by
The increased risk of septic arthritis in patients with RA has less common organisms such as Mycoplasma.36 Studies have
been attributed to several factors including the preexisting joint demonstrated conflicting results when attempting to improve the
damage, as well as immune suppression from medications com- yield of the synovial fluid culture by inoculation of blood culture
monly used to treat RA such as the biological agents.32 Further re- bottles at the bedside compared with the traditionally used agar
search is needed to identify if the hypervascularity seen in the plate cultures, with 1 study showing a third of specimens obtained
synovium of RA patients plays a role in predisposing them to sep- prior to initiating antibiotics yielding positive culture results in
tic arthritis via hematogenous spreading. blood culture bottles while being negative on conventional solid
media.37 Another report challenged this claim, however, in a study
involving 90 patients with acute joint effusions where no statisti-
Biologic Agents and Septic Arthritis Risk cally significant differences were found in the rates of isolating
Biologic drugs targeting tumor necrosis factor and interleukin bacteria with either method.38 Advances in the diagnosis of less
1, among others, are increasingly being used in the management common organisms such as Yersinia and Chlamydia species as

TABLE 2. Differential Diagnoses for Septic Arthritis

Differential Diagnosis Notes

Crystal arthritis11,12
• Can present in a very similar fashion and can coexist with bacterial arthritis
• Diagnosis is made by microscopic visualization of monosodium urate or calcium
pyrophosphate crystals in gout and pseudogout, respectively
• Other clues: tophi and first metatarsophalangeal joint involvement in gouty arthritis and
radiographs showing chondrocalcinosis in pseudogout
• The presence of crystals in the synovial fluid does not definitively exclude
bacterial arthritis
Reactive arthritis13 • May report a recent gastrointestinal or genitourinary tract infection and may report
other symptoms such as skin lesions, enthesitis, dactylitis, or ocular inflammation
Rheumatoid arthritis4,14 • Typically present with chronic symmetrical polyarthritis; however, they can still present
with an acute monoarthritis with elevated synovial fluid WBC counts
• If an RA patient with good disease control acutely presents with an inflamed joint,
then septic arthritis should be considered
Lyme disease15 • Infections with B. burgdorferi causing Lyme disease generally develop many weeks
after a visit to an endemic area and after the acute picture of fever with a characteristic rash
• Measurement of serum Borrelia immunoglobulin G levels and synovial fluid
analysis with PCR can be helpful in distinguishing the 2 conditions

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JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2017 Review of Diagnosis and Management

well as N. gonorrhoeae and Borrelia burgdorferi have been made tuberculosis, but may be confounded by colonizing organisms
using synovial polymerase chain reaction (PCR).26 (bacteria or fungi) that are not the true causative organisms.55,56
Other clues to the diagnosis include a low synovial fluid glu- Synovial biopsies with culture are more sensitive and should be
cose level and elevated protein or lactic acid levels; however, those obtained whenever clinical suspicion is high.57
laboratory values are nonspecific and can be found in all forms of
inflammatory arthritis. Elevated inflammatory markers, such eryth- Brucellosis
rocyte sedimentation rate and C-reactive protein, and an elevated Despite its relatively low incidence in North America, bru-
serum WBC count are nonspecific on their own for the diagnosis cellosis is one of the most common zoonotic infections worldwide
of septic arthritis. However, elevated inflammatory markers and leu- and one with significant human and animal morbidity.58 Caused
kocytosis, along with a clinical history suggestive of septic arthritis by Brucella species (Brucella melitensis, Brucella suis, and Bru-
and an elevated synovial WBC count greater than 50,000/μL, can cella abortus), the infection is transmitted by human contact with
increase the overall sensitivity close to 100%.39,40 Measuring bodily fluids from infected animals or food products.59,60 The typ-
C-reactive protein levels in the synovial fluid offers no added sensi- ical presentation of acute brucellosis is a patient with a history of ex-
tivity compared with measuring it in the serum, and the 2 laboratory posure to animal products presenting with fever, night sweats,
values generally strongly correlate.41 weight loss, myalgias, and arthralgias.61 The most common focal
The first imaging modality of an infected joint should be a presentation of brucellosis is osteoarticular involvement, usually af-
radiograph and should be compared with a baseline image if avail- fecting the SI, hip, or knee joints.62–64 The diagnosis is made by
able and later to a follow-up image in cases of nonresponse to positive blood and synovial fluid cultures and/or enzyme-linked im-
treatment. Characteristics of an acutely inflamed joint include munosorbent assay testing for Brucella species.65,66 Synovial fluid
joint space widening, periarticular fat pad displacement, loss of analysis is generally nonspecific for diagnosing brucellosis.67
the white cortical line over extended and continuous segments,
and, occasionally, erosive changes.42 Other imaging modalities are Lyme Disease
more sensitive and specific than plain radiographs for detecting in-
flammation or effusions especially early in the disease process and Infections with B. burgdorferi causing Lyme disease gener-
include ultrasonography, computed tomography, magnetic reso- ally develops many weeks to months after a visit to an endemic
nance imaging, and scintigraphy. Advanced imaging methods can area and after the acute picture of fever with a characteristic rash.
be especially useful for examining the SI and hip joints where in- Lyme arthritis presents with either an intermittent or persistent
flammatory changes may be difficult to identify on a plain radio- monoarthritis of the knee or, less commonly, an asymmetric
graph.43 Ultrasonography is a safe and easily conducted bedside oligoarthritis. Measurement of serum Borrelia immunoglobulin
imaging modality to assist in the identification of joint effusions G levels and synovial fluid analysis with PCR can also be helpful
and can be used to guide arthrocentesis. It is especially helpful in in distinguishing Lyme disease from septic arthritis.14
hip arthrocentesis, a procedure otherwise traditionally performed
under fluoroscopic guidance.44–46 DIFFERENTIAL DIAGNOSIS
The chief differential diagnoses for bacterial arthritis are other
Gonococcal Arthritis and Disseminated causes of acute mono or oligoarthritis and include acute crystal ar-
Gonococcal Infection thropathies (gout and pseudogout), reactive arthritis, RA, and Lyme
The typical presentation of gonococcal arthritis or dissemi- disease (Table 2).
nated gonococcal infection (DGI) is in a young (usually <40 years Crystal arthritis is usually the first diagnosis to consider be-
old), sexually active patient presenting with fever, polyarthralgia, cause it can present in a very similar fashion and can coexist with
tenosynovitis, and painless skin lesions, which can progress to bacterial arthritis. The diagnosis can be made by polarizing micro-
persistent oligoarthritis or monoarthritis. At this stage, it may be scopic visualization of monosodium urate or calcium pyrophos-
difficult to distinguish DGI from typical pyogenic arthritis.47–49 phate crystals in gout and pseudogout, respectively. Other clues
It is important to note that N. gonorrhoeae cannot be reliably cul- include the presence of tophi and first metatarsophalangeal joint
tured from routine culture media. Synovial fluid Gram stains have involvement in gouty arthritis and knee radiographs showing
a very low sensitivity in DGI being positive in less than 10% of chondrocalcinosis in pseudogout.11,12,68 It is critical to remember
cases, and synovial fluid cultures are commonly negative.50 Pa- that neither the presence of crystals in the synovial fluid nor the
tients suspected to have DGI should have pharyngeal, urogenital, absence of a positive synovial fluid Gram stain can definitively ex-
and rectal cultures sent for N. gonorrhoeae because most of pa- clude bacterial arthritis.
tients with DGI will have evidence of infection in those sites even Patients with reactive arthritis may report a recent gastrointes-
without symptoms.50 Synovial fluid cultures on Thayer-Martin tinal or genitourinary tract infection and may report other symptoms
medium or nucleic acid amplification testing of the synovial fluid such as skin lesions, enthesitis, dactylitis, or ocular inflammation.69
to identify N. gonorrhoeae are both diagnostic of DGI, the latter Patients with RA typically present with chronic polyarthritis that is
being the preferred test.51,52 Synovial fluid testing with PCR to de- symmetrical and not associated with fever or leukocytosis; however,
tect gonococcal DNA has also been used with a reported sensitiv- they can still present with an acute monoarthritis with elevated sy-
ity of approximately 78% in patients with DGI.53 novial fluid WBC counts. It should be noted that if an RA patient
with good disease control acutely presents with an inflamed joint,
then septic arthritis should be considered. The 2 conditions can still
Tuberculous Arthritis
overlap, and RA is a risk factor for bacterial arthritis as previously
The presentation of a patient with monoarthritis or oligoarthritis discussed.4,13 Lyme disease is another important differential diag-
refractory to treatment and with repeatedly negative synovial fluid nosis as discussed previously.14
cultures should raise suspicion for tuberculous arthritis, especially
if the patient is from a tuberculosis endemic area. The most com-
monly affected joints are the hips and knee; however, tuberculous MANAGEMENT
arthritis may be found in any joint.54 Synovial fluid analysis is The cornerstones of treatment include adequate drainage
generally nonspecific, and cultures are frequently negative for and antimicrobials (Figure). The initial choice of antibiotics is

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Hassan et al. JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2017

FIGURE. Suggested management algorithm of nongonococcal bacterial peripheral native joint septic arthritis. *Synovial WBC count
elevated (usually >50,000/μL), blood culture positive, Gram stain–positive, and/or synovial culture–positive. **Patient characteristics that
may affect selection of drainage type include joint size/accessibility, comorbidities, and inability to tolerate anesthesia. ***Exact frequency
of serial joint aspiration has not been studied but typically is performed daily until synovial fluid WBC count approaches normal, fluid stops
accumulating, and cultures sterilize. Consideration for more frequent aspiration during the first 24 to 36 hours is reasonable if fluid
reaccumulates quickly.

generally based on epidemiological factors, as well as the age, risk There have been no controlled trials so far to identify the op-
factors, and clinical presentation in addition to Gram stain results. timal duration of antibiotic treatment in septic arthritis. Intrave-
No randomized controlled trials to date have compared different nously administered antibiotics are typically administered for
antibiotic regimens for the treatment of bacterial arthritis, nor is 14 days followed by a similar-duration course of oral antibiotics;
there strong evidence to guide the duration of treatment.6,15 Sim- however, some organisms that are commonly difficult to treat such
ilarly, there is no evidence to recommend joint immobilization, but as P. aeruginosa may need 4 to 6 weeks of parenteral therapy.
weight bearing is generally discouraged until after the resolution of There is insufficient evidence in favor of the use of systemic
the acute inflammation.22 Further research is needed to determine corticosteroids along with antibiotics in septic arthritis in adult pa-
the ideal time to fully restart daily activities or start physical therapy. tients; however, studies in the pediatric population did suggest a
possible benefit. A double-blind, randomized, placebo-controlled trial
Antibiotic Therapy of dexamethasone for 4 days in the management of hematogenous
septic arthritis in 100 children significantly shortened the duration
Vancomycin is generally the initial antibiotic used in the of symptoms in the acute phase, as well as the residual joint dysfunc-
United States. If the patient is immunocompromised or an tion at the end of therapy and at 12 months of follow-up.71 A theoret-
IV-drug abuser, vancomycin plus a third-generation cephalosporin ical benefit can also be conceived as most damage inflicted upon
such as ceftriaxone, cefotaxime, or ceftazidime should be given. infected joints is a result of the host's own inflammatory response
The initial antibiotic regimen should be tailored to Gram stain, as opposed to direct damage caused by the organisms.33
culture, and susceptibility results.44 If the clinical picture is sug-
gestive of disseminated gonococcal or meningococcal infections,
IV ceftriaxone provides adequate coverage.13 If P. aeruginosa is Synovial Fluid Drainage
suspected, then a third-generation cephalosporin plus gentamicin Septic arthritis, like any other form of a closed infection,
should be given.13,70 The use of intra-articular antibiotics is not needs drainage in conjunction with antibiotics. However, as there
advised because it adds no therapeutic benefit and exposes the pa- have not been randomized controlled trials in adults comparing
tient to the potential of an inflammatory response to intra- drainage methods, namely, daily needle aspiration, arthroscopic
articular antibiotics.36 drainage, or open surgical drainage via arthrotomy, the choice has

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JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2017 Review of Diagnosis and Management

TABLE 3. Summary Points

(1) Septic arthritis can be caused by a variety of microorganism including S. aureus, streptococcal species, N. gonorrhoeae, Gram-negative rods,
Brucella fungal organisms (sporotrichosis, blastomycoses), and Mycobacterium tuberculosis.
(2) Methods of joint infection include hematogenous dissemination, contiguous spread (adjacent osteomyelitis, cellulitis), or direct inoculation
(prosthesis, arthrocentesis, penetrating trauma).
(3) Joint drainage in addition to appropriate antibiotics is usually needed for successful treatment of typical pyogenic septic arthritis.
(4) There exists controversy about the preferred method of drainage. Orthopedic surgeons prefer arthroscopic lavage, and rheumatologists
prefer daily needle arthrocenteses.
(5) Inability to completely drain joint (inaccessibility, viscous fluid, or loculations) would favor arthroscopic lavage over daily needle
arthrocentesis.
(6) Neisseria gonorrhoeae septic arthritis may not always require extensive joint drainage.
(7) Patients with features to suggest disseminated N. gonorrhoeae should have multiple cultures (synovial, urethral, cervical, rectal, and
pharyngeal) submitted on Thayer-Martin media or DNA PCR analysis.
(8) Patients with N. gonorrhoeae septic arthritis should be offered screening for other sexually transmitted diseases (syphilis serology,
chlamydia cultures, and human immunodeficiency virus screening).
(9) Crystal arthritis can coexist with septic arthritis.
(10) Crystal arthritis can cause synovial cell counts higher than 50,000–100,000/μL (pseudoseptic arthritis).
(11) Synovial cell counts less than 50,000/μL do not exclude septic arthritis.
(12) Gram stain and preliminary cultures may be negative in septic arthritis. Prior antibiotics may affect microbiologic yield.
(13) Tuberculosis septic arthritis often requires synovial biopsy for diagnosis.
(14) Plain radiographs of involved joint may appear normal on presentation. Ultrasonography is helpful in the diagnosis of effusions and hip
joint arthrocentesis. Effusions and soft tissue extension are better visualized by computed tomography scan.
(15) Septic arthritis can involve axial joints such as sternoclavicular joint and SI joint.
(16) Risk factors for septic arthritis include DM, RA, IVDA, and immunosuppression.
(17) Septic arthritis after therapeutic intra-articular joint injection is extremely rare.
(18) Septic arthritis is a potentially life-threatening infection that can be complicated by fasciitis, osteomyelitis, secondary hematogenous
dissemination, and permanent articular damage.
(19) Brucella is a zoonosis (goats and sheep) often transmitted via unpasteurized milk or cheese or by inhalation. Brucella can infect a variety
of organs including bone and SI joints.
(20) Initial empiric antibiotic regimen in the United States is vancomycin and possibly a third-generation cephalosporin but is then tailored
based on Gram stain, culture, and sensitivity.
(21) Neisseria gonorrhoeae septic arthritis is usually treated with IV ceftriaxone followed by oral cefixime.
IVDA, intravenous drug abuse.

generally been guided by retrospective studies and often depends through synovial WBC counts and cultures. The main disadvan-
on the extent and duration of the infection, site of the effected joint, tages are inability to debride and reach loculated effusions. Also,
and procedural availability. One study found that patients hospital- some joints such as hips are inaccessible. Some clinical clues that
ized in the orthopedic unit were more likely to be treated with sur- suggest success of daily needle arthrocentesis include improvement
gical intervention compared with patients hospitalized in the of joint pain and swelling, resolution of fever and systemic leukocy-
medical unit with no statistically significant difference in treatment tosis, and improvement of synovial fluid WBC count. If daily-need
failure rates between the 2 groups.72 arthrocentesis is utilized, then repeated analyses of the synovial
Studies performed to date were all retrospective and with a fluid WBC count are recommended to document improvement
small sample size, making it difficult to establish evidence-based rec- and, more significantly, synovial fluid sterility.74
ommendations for either strategy. For instance, a retrospective study
over an 8-year period of patients with nongonococcal septic arthritis
seemed to show better outcomes with daily needle aspiration com- Arthroscopic Drainage
pared with surgical treatment (67% vs. 42% achieved good clinical Benefits of surgical drainage include the ability to remove
outcomes defined as complete recovery and no secondary ankylo- nonviable tissue, obtain biopsies after debridement, and evaluate for
sis, osteomyelitis, or flexion deformities).73 However, because this a potential synovectomy. These benefits may be more pronounced
was a retrospective study, it is likely that there were significant dif- in infections of the knees, wrist, and shoulders, where arthroscopy
ferences in the overall health of patients treated surgically compared provides better visualization and easier access to irrigation.75–77
with those treated conservatively. Randomized controlled trials Arthroscopic and open arthrotomy can both be used as treat-
comparing daily needle aspiration, arthroscopy, and arthrotomy in ment options for management of an acute bacterial septic joint.
various joints are needed to outline a standardized approach that Arthroscopic treatment is primarily used in treatment of the knee,
provides the best outcomes. shoulder, or hip joint involvement, given the ease of use and avail-
able equipment.78–81 Arthroscopic treatment may also be used in
Daily Needle Arthrocentesis acutely detected infection; a delayed diagnosis may warrant a
Daily needle arthrocentesis, usually performed with an 18- more extensive open approach for thorough examination.82 With
gauge needle, has many advantages. It can be performed safely either open or arthroscopic treatment, the surgeon's preferred ap-
at the bedside; it can be performed in patients who are poor surgi- proach can be used. After entry into the joint, multiple tissue sam-
cal candidates and allows for daily measure of clinical response ples are sent for microbiologic analysis including aerobic and

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Hassan et al. JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2017

anaerobic culture. If using an arthroscopic technique, a motorized 4. Margaretten ME, Kohlwes J, Moore D, et al. Does this adult patient have
shaver is used to debride fibrinous or inflamed synovial tissue. A septic arthritis? JAMA. 2007;297:1478.
minimum of 6 L, with up to 20 L for arthroscopic treatment, is 5. Sharp JT, Lidsky MD, Duffy J, et al. Infectious arthritis. Arch Intern Med.
used for irrigation.83 The wound is often closed over a closed suc- 1979;139:1125–1130.
tion drain. All aspects of the involved joint must be visualized and 6. Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic
explored to ensure complete debridement and irrigation. Range of algorithm. Curr Opin Rheumatol. 2008;20:457.
motion and weight bearing are sometimes held for a brief period
postoperatively to support wound healing. 7. Furuno JP, McGregor JC, Harris AD, et al. Identifying groups at high risk
for carriage of antibiotic-resistant bacteria. Arch Intern Med. 2006;166:
Delayed treatment can have devastating local consequences
580–585.
including bone and cartilage destruction, osteonecrosis, second-
ary arthritis, and potentially ankylosis. In addition, multiple surgi- 8. Goldenberg DL. Septic arthritis. Lancet. 1998;351:197–202.
cal debridements may be necessary, with evidence showing that 9. Goldenberg DL, Brandt KD, Cathcart ES, et al. Acute arthritis caused by
only 62% of septic joints may be effectively managed with a sin- gram-negative bacilli: a clinical characterization. Medicine (Baltimore).
gle surgical debridement.81,84 Risk factors for a failed single sur- 1974;53:197–208.
gical treatment include RA, diabetes, a synovial fluid of more 10. Nade S. Septic arthritis. Best Pract Res Clin Rheumatol. 2003;17:183–200.
than 85,000/μL, involvement of a large joint, delayed diagnosis,
11. Wallace SL, Robinson H, Masi AT, et al. Preliminary criteria for the
and an infection with S. aureus.81
classification of the acute arthritis of primary gout. Arthritis Rheum. 1977;
20:895.
Outcomes
12. Epstein JH, Zimmermann B 3rd, Ho G Jr. Polyarticular septic arthritis.
Poor joint outcomes in bacterial arthritis range from mild de-
J Rheumatol. 1986;13:1105–1107.
terioration of joint function to the need for arthrodesis, prosthetic
surgery, or amputation. Outcomes seem to vary widely, depending 13. Allison DC, Holtom PD, Patzakis MJ, et al. Microbiology of bone and joint
on several factors pertaining to the causative organism, as well as the infections in injecting drug abusers. Clin Orthop Relat Res. 2010;468:
host. Factors that predicted poor outcomes identified in retrospective 2107–2112.
studies include older patient age, DM, renal and liver diseases, 14. Guidelines for laboratory evaluation in the diagnosis of Lyme disease.
preexisting joint disease, and infection with MRSA.73,85 Studies American College of Physicians. Ann Intern Med. 1997;127:1106–1108.
reporting outcomes in infections caused by S. aureus in adult patients 15. Mathews CJ, Kingsley G, Field M, et al. Management of septic arthritis:
showed poor joint outcomes in up to 50% of cases compared with a systematic review. Ann Rheum Dis. 2007;66:440–445.
only 5% in infections caused by Streptococcus pneumoniae.2,16,36
16. Ross JJ, Saltzman CL, Carling P, et al. Pneumococcal septic arthritis:
review of 190 cases. Clin Infect Dis. 2003;36:319–327.
SUMMARY 17. Cooper C, Cawley MI. Bacterial arthritis in an English health district: a
Septic arthritis is a musculoskeletal emergency and a cause 10 year review. Ann Rheum Dis. 1986;45:458–463.
of significant morbidity and mortality. Staphylococcus aureus is 18. McCarthy DJ. Joint sepsis: a chance for cure. JAMA. 1982;247:835.
the most common infectious organism and is typically transmitted
19. Kaandorp CJ, Krijnen P, Moens HJ, et al. The outcome of bacterial arthritis:
hematogenously. Patients typically present with a monoarthritis,
a prospective community-based study. Arthritis Rheum. 1997;40:884.
sometimes with systemic symptoms such as low-grade fever.
The knee is the most commonly affected joint and is involved in 20. Goldenberg DL. Septic arthritis and other infections of rheumatologic
approximately 50% of the cases. A definitive diagnosis is made significance. Rheum Dis Clin North Am. 1991;17:149.
by a positive synovial fluid culture in the face of a consistent clin- 21. von Essen R, Savolainen HA. Bacterial infection following intra-articular
ical presentation. Although no diagnostic cutoff exists for synovial injection. A brief review. Scand J Rheumatol. 1989;18:7–1.
fluid WBC, increasing leukocytosis is associated with a higher 22. Smith JW, Chalupa P, Shabaz HM. Infectious arthritis: clinical features,
likelihood of an infectious cause of arthritis, and patients com- laboratory findings and treatment. Clin Microbiol Infect. 2006;12:309–314.
monly present with values greater than 50,000/μL. Synovial fluid
23. Frank G, Mahoney HM, Eppes SC. Musculoskeletal infections in children.
Gram stains, although helpful, are not always positive in septic ar-
Pediatr Clin North Am. 2005;52:1083–1106. ix.
thritis, and a negative Gram stain should not be used to exclude a
septic arthritis. The cornerstones of treating septic bacterial arthritis 24. Nilsson IM, Verdrengh M, Ulrich RG, et al. Protection against
are adequate drainage and antimicrobials. Joint drainage is always Staphylococcus aureus sepsis by vaccination with recombinant
recommended in septic arthritis; however, no clear guidelines or staphylococcal enterotoxin A devoid of superantigenicity. J Infect Dis.
1999;180:1370.
strong evidence exists to guide the preferred method of drainage.
Options for joint drainage include daily needle aspiration, arthros- 25. Nilsson IM, Lee JC, Bremell T, et al. The role of staphylococcal
copy, or open surgical drainage via arthrotomy. Outcomes depend polysaccharide microcapsule expression in septicemia and septic arthritis.
on the causative organism, patient age and risk factors, and timely Infect Immun. 1997;65:4216–4221.
management (Table 3). 26. Pioro MH, Mandell BF. Septic arthritis. Rheum Dis Clin North Am. 1997;
23:239–258.
REFERENCES 27. Goldenberg DL, Cohen AS. Acute infectious arthritis: a review of patients
with nongonococcal joint infections (with emphasis on therapy and
1. Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults.
prognosis). Am J Med. 1976;60:369–377.
Lancet. 2010;375:846–855.
28. Tarkowski A. Infection and musculoskeletal conditions: infectious arthritis.
2. Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome
Best Pract Res Clin Rheumatol. 2006;20:1029–1044.
of septic arthritis in a single UK Health District 1982–1991. Ann Rheum
Dis. 1999;58:214–219. 29. Mancarella L, De Santis M, Magarelli N, et al. Septic sacroiliitis: an
3. Favero M, Schiavon F, Riato L, et al. Rheumatoid arthritis is the major uncommon septic arthritis. Clin Exp Rheumatol. 2009;27:1004–1008.
risk factor for septic arthritis in rheumatological settings. Autoimmun Rev. 30. Ross JJ, Hu LT. Septic arthritis of the pubic symphysis: review of 100 cases.
2008;8:59–61. Medicine (Baltimore). 2003;82:340.

6 www.jclinrheum.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2017 Review of Diagnosis and Management

31. Dubost JJ, Fis I, Denis P, et al. Polyarticular septic arthritis. Medicine 55. Kim SJ, Postigo R, Koo S, et al. Total hip replacement for patients with
(Baltimore). 1993;72:296–310. active tuberculosis of the hip: a systematic review and pooled analysis.
32. Galloway JB, Hyrich KL, Mercer LK, et al. Risk of septic arthritis in Bone Joint J. 2013;95-B:578.
patients with rheumatoid arthritis and the effect of anti-TNF therapy: results 56. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American
from the British Society for Rheumatology Biologics Register. Ann Rheum Thoracic Society/Infectious Diseases Society of America/Centers for
Dis. 2011;70:1810–1814. Disease Control and Prevention clinical practice guidelines: diagnosis of
33. Klinger HM, Baums MH, Freche S, et al. Septic arthritis of the shoulder tuberculosis in adults and children. Clin Infect Dis. 2017;64:e1–e33.
joint: an analysis of management and outcome. Acta Orthop Belg. 2010;76: 57. Allali F, Mahfoud-Filali S, Hajjaj-Hassouni N. Lymphocytic joint fluid
598–603. in tuberculous arthritis. A review of 30 cases. Joint Bone Spine. 2005;
34. Faraj AA, Omonbude OD, Godwin P. Gram staining in the diagnosis of 72:319.
acute septic arthritis. Acta Orthop Belg. 2002;68:388–391. 58. Merino P, Candel FJ, Gestoso I, et al. Microbiological diagnosis of spinal
35. Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med. 1985;312:764. tuberculosis. Int Orthop. 2012;36:233–238.
36. Maneiro JR, Souto A, Cervantes EC, et al. Predictors of treatment failure 59. Colmenero JD, Reguera JM, Martos F, et al. Complications associated
and mortality in native septic arthritis. Clin Rheumatol. 2015;34: with Brucella melitensis infection: a study of 530 cases. Medicine
1961–1967. (Baltimore). 1996;75:195–211.
37. von Essen R, Holtta A. Improved method of isolating bacteria from joint 60. Mantur BG, Amarnath SK, Shinde RS. Review of clinical and
fluids by the use of blood culture bottles. Ann Rheum Dis. 1986;45: laboratory features of human brucellosis. Indian J Med Microbiol.
454–457. 2007;25:188–202.
38. Kortekangas P, Aro HT, Lehtonen OP. Synovial fluid culture and blood 61. Young EJ. An overview of human brucellosis. Clin Infect Dis. 1995;21:
culture in acute arthritis. A multi-case report of 90 patients. Scand J 283–289.
Rheumatol. 1995;24:44–47.
62. Pappas G, Akritidis N, Bosilkovski M, et al. Brucellosis. N Engl J Med.
39. Li SF, Cassidy C, Chang C, et al. Diagnostic utility of laboratory tests in 2005;352:2325.
septic arthritis. Emerg Med J. 2007;24:75–77.
63. Bosilkovski M, Krteva L, Caparoska S, et al. Osteoarticular involvement
40. Hariharan P, Kabrhel C. Sensitivity of erythrocyte sedimentation rate and
in brucellosis: study of 196 cases in the Republic of Macedonia.
C-reactive protein for the exclusion of septic arthritis in emergency
Croat Med J. 2004;45:727–733.
department patients. J Emerg Med. 2011;40:428.
64. Geyik MF, Gür A, Nas K, et al. Musculoskeletal involvement of
41. Tetreault MW, Wetters NG, Moric M, et al. Is synovial C-reactive protein a
brucellosis in different age groups: a study of 195 cases. Swiss
useful marker for periprosthetic joint infection? Clin Orthop Relat Res.
Med Wkly. 2002;132:98–105.
2014;472:3997.
42. Brower AC. Septic arthritis. Radiol Clin North Am. 1996;34:293–309. 65. Hashemi SH, Keramat F, Ranjbar M, et al. Osteoarticular complications
of brucellosis in Hamedan, an endemic area in the west of Iran. Int
43. Zimmermann B 3rd, Mikolich DJ, Lally EV. Septic sacroiliitis. Semin J Infect Dis. 2007;11:496.
Arthritis Rheum. 1996;26:592.
66. Mantecón Mde L, Gutiérrez MP, Zarzosa Mdel P, et al. Influence of
44. Shmerling RH. Synovial fluid analysis: a critical reappraisal. Rheum Dis
brucellosis history on serological diagnosis and evolution of patients
Clin North Am. 1994;20:503–512.
with acute brucellosis. J Infect. 2008;57:397.
45. Laine JC, Denning JR, Riccio AI, et al. The use of ultrasound in the
67. Al Dahouk S, Tomaso H, Nöckler K, et al. Laboratory-based diagnosis of
management of septic arthritis of the hip. J Pediatr Orthop B. 2015;24:
brucellosis—a review of the literature. Part II: serological tests for
95–98.
brucellosis. Clin Lab. 2003;49:577–589.
46. Freeman K, Dewitz A, Baker WE. Ultrasound-guided hip arthrocentesis in
68. Chen LX, Schumacher HR. Current trends in crystal identification.
the ED. Am J Emerg Med. 2007;25:80–86.
Curr Opin Rheumatol. 2006;18:171.
47. Coutlakis PJ, Roberts WN, Wise CM. Another look at synovial fluid
leukocytosis and infection. J Clin Rheumatol. 2002;8:67–71. 69. Sieper J, Rudwaleit M, Braun J, et al. Diagnosing reactive arthritis:
role of clinical setting in the value of serologic and microbiologic assays.
48. Rompalo AM, Hook EW 3rd, Roberts PL, et al. The acute Arthritis Rheum. 2002;46:319–327.
arthritis-dermatitis syndrome. The changing importance of Neisseria
gonorrhoeae and Neisseria meningitidis. Arch Intern Med. 1987;147: 70. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the
281–283. Infectious Diseases Society of America for the treatment of
methicillin-resistant Staphylococcus aureus infections in adults and
49. O'Brien JP, Goldenberg DL, Rice PA. Disseminated gonococcal infection: a
children. Clin Infect Dis. 2011;52:e18.
prospective analysis of 49 patients and a review of pathophysiology and
immune mechanisms. Medicine (Baltimore). 1983;62:395. 71. Odio CM, Ramirez T, Arias G, et al. Double blind, randomized,
placebo-controlled study of dexamethasone therapy for hematogenous
50. McCutchan HJ, Fisher RC. Synovial leukocytosis in infectious arthritis.
septic arthritis in children. Pediatr Infect Dis J. 2003;22:883–888.
Clin Orthop Relat Res. 1990;257:226–230.
51. Rice PA. Gonococcal arthritis (disseminated gonococcal infection). Infect 72. Lim SY, Pannikath D, Nugent K. A retrospective study of septic arthritis
Dis Clin North Am. 2005;19:853–861. in a tertiary hospital in West Texas with high rates of methicillin-resistant
Staphylococcus aureus infection. Rheumatol Int. 2015;35:1251–1256.
52. Centers for Disease Control and Prevention. Recommendations for the
laboratory-based detection of Chlamydia trachomatis and Neisseria 73. Goldenberg D, Brandt KD, Cohen AS, et al. Treatment of septic arthritis:
gonorrhoeae—2014. MMWR Recomm Rep. 2014;63:1–19. comparison of needle aspiration and surgery as initial modes of joint
drainage. Arthritis Rheum. 1975;18:83–90.
53. Liebling MR, Arkfeld DG, Michelini GA, et al. Identification of Neisseria
gonorrhoeae in synovial fluid using the polymerase chain reaction. 74. Nusem I, Jabur MK, Playford EG. Arthroscopic treatment of septic
Arthritis Rheum. 1994;37:702. arthritis of the hip. Arthroscopy. 2006;22:902. e1.
54. Hodgson SP, Ormerod LP. Ten-year experience of bone and joint 75. Manadan AM, Block JA. Daily needle aspiration versus surgical lavage
tuberculosis in Blackburn 1978–1987. J R Coll Surg Edinb. 1990;35: for the treatment of bacterial septic arthritis in adults. Am J Ther. 2004;
259–262. 11:412–415.

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Hassan et al. JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2017

76. Thiery JA. Arthroscopic drainage in septic arthritides of the knee: a 81. Jeon IH, Choi CH, Seo JS, et al. Arthroscopic management of septic
multicenter study. Arthroscopy. 1989;5:65–69. arthritis of the shoulder joint. J Bone Joint Surg Am. 2006;88:1802–1806.
77. Stutz G, Kuster MS, Kleinstück F, et al. Arthroscopic management of septic 82. Chen C, Lin H, Hung S, et al. Surgical treatment for septic arthritis of the
arthritis: stages of infection and results. Knee Surg Sports Traumatol knee joint in elderly patients: a 10-year retrospective clinical study.
Arthrosc. 2000;8:270–274. Orthopedics. 2013;36:e434–e443.
78. Bosilkovski M, Dimzova M, Grozdanovski K. Natural history of 83. Balabaud L, Gaudias J, Boeri C, et al. Results of treatment of septic knee
brucellosis in an endemic region in different time periods. Acta Clin Croat. arthritis: a retrospective series of 40 cases. Knee Surg Sports Traumatol
2009;48:41–46. Arthrosc. 2007;15:387–392.
79. Darren de SA, Cargnelli S, Catapano M, et al. Efficacy of hip arthroscopy 84. Hunter JG, Gross JM, Dahl JD, et al. Risk factors for failure of a single
for the management of septic arthritis: a systematic review. Arthroscopy. surgical debridement in adults with acute septic arthritis. J Bone Joint
2015;31:1358–1370. Surg Am. 2015;97:558–564.
80. Wirtz D, Marth M, Miltner O, et al. Septic arthritis of the knee in adults: 85. Deng GM, Tarkowski A. The features of arthritis induced by CpG motifs
treatment by arthroscopy or arthrotomy. Int Orthop. 2001;25:239–241. in bacterial DNA. Arthritis Rheum. 2000;43:356.

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