eMedicine Specialties > Orthopedic Surgery > Pediatrics
Septic Arthritis, Pediatrics: Treatment
Updated: Jan 21, 2009
Treatment
Medical Therapy
Administer parenteral antibiotics as soon as blood and joint aspirates have been cultured. The choice of antibiotic should be based on the Gram stain results. When the Gram stain fails to show bacteria, the choice should be empirically based on the patient's age and circumstance. Treat children older than 4 years with a penicillinase-resistant penicillin alone. For children 4 years of age or younger who have not been vaccinated against H influenzae type b, add coverage for ampicillin-resistant strains of H influenzae. Treat neonates, patients who are immunocompromised, and older patients suspected of abusing parenteral drugs with an aminoglycoside in addition to a penicillinase-resistant penicillin in order to cover against enteric gram-negative bacilli and Pseudomonas species. Appropriately adjust the choice of antibiotic after culture and sensitivity results are known.
For children younger than 3 years, K kingae must be considered. This organism is susceptible to a wide variety of antibiotics, including ampicillin, first- and third-generation cephalosporins, aminoglycosides, and semisynthetic penicillins.
A third-generation cephalosporin should be the initial treatment for gonococcal arthritis.
In regions where community-associated methicillin-resistant Staphylococcus aureus (MRSA) is common or when an infection with MRSA is otherwise a risk (such as an infection acquired in the hospital), empirical therapy should include coverage for MRSA.10,11 Clindamycin and vancomycin are the 2 agents most commonly used for this purpose, but the antibiotic choice should be adjusted depending on the antibiotic susceptibility patterns of local isolates.
Maintain adequate blood levels of a culture-specific antibiotic for at least 3 weeks after the joint has been drained and the patient has responded clinically. ESR and CRP levels are valuable indicators of clinical response. The CRP is generally more sensitive than the ESR, and antibiotics should be continued at least until this measure has normalized. If visiting nurse services are available, responding patients may be discharged to receive home intravenous antibiotic therapy. Switching to oral antibiotics is also acceptable, provided that adequate blood levels of the antibiotic are demonstrated, the patient’s parents are reliable, and the antibiotic does not cause a gastrointestinal disturbance that would interfere with its absorption.
Surgical Therapy
Consider a septic joint to be a closed abscess and do not expect antibiotic treatment alone to resolve the infection. Remember that the risks of complication are time dependent. In addition to administration of medical therapy, the joint must be adequately drained. Patients may be treated with antibiotics and repeated joint aspiration in cases of involvement of an easily accessible peripheral joint; a clinical course shorter than 6 days; and no evidence of an associated osteomyelitis, immune deficiency, or other chronic illness. If the patient's condition fails to improve, open drainage is the next approach. Peripheral joints may be adequately drained with arthroscopy if the technology is available.
Open drainage performed in the operating room is unquestionably more effective than percutaneous aspiration. In such procedures, encountering heavy fibrin deposits that clearly cannot be removed (even through large-bore needles) is not unusual. Open drainage is definitely indicated in the hip and the shoulder and in peripheral joints that do not respond to percutaneous aspiration. Open drainage is indicated in patients who are systemically ill, and it should be given greater consideration when the suspected organism is S aureus or a gram-negative bacterium that produces cartilage-damaging enzymes. Gonococcal arthritis is less likely to rapidly damage a joint, and these infections may be managed with repeated aspirations if the joints involved are peripheral. Open drainage should still be performed in cases of gonococcal arthritis of the hip.
Perform open drainage through an approach that allows adequate visualization of the joint surfaces and thorough irrigation. Anterior approaches are best for the hip and the shoulder. Inspect the joint surfaces for damage, but be aware that early cartilage damage may not be grossly apparent. Leave the capsular incision open, and loosely close the remaining portion of the wound over a drain placed next to the capsule.
Postoperative Details
Postoperatively, place the joint at rest in a position of comfort. If the preoperative clinical course was short and the joint was promptly drained, manage a hip with simple bed rest, place a postoperative shoulder in a sling, and use a plaster splint for a peripheral joint. As the patient recovers and the symptoms and signs subside, allow the patient to regain mobility as his or her comfort dictates.
If treatment was significantly delayed, however, substantial capsular damage may have occurred. This complication is particularly likely with a neglected septic hip or shoulder. If instability is suspected, immobilize the patient for a longer period. A neglected septic hip with radiographic instability requires a spica cast, and an unstable shoulder requires a sling and swathe.
Follow-up
Continue antibiotics until the patient's clinical condition and the erythrocyte sedimentation rate or C-reactive protein normalize. Follow up with the patient for at least a year after surgery. Further follow-up can be discontinued if joint function has returned to normal and if no radiographic evidence suggests loss of joint space, avascular necrosis of the epiphysis, joint instability, or damage to the growth plate.
For excellent patient education resources, visit eMedicine's Arthritis Center and Bacterial and Viral Infections Center. Also, see eMedicine's patient education article Gonorrhea and Knee Pain.
Complications
As indicated earlier, potential complications associated with delay in treatment include irreversible articular damage, growth arrest, and disruption of joint continuity. Complications that can occur in an inadequately treated septic hip are illustrated in Images below and Multimedia Images 2-7.
This is the first radiograph in a series of 6 (see Images below) that document the natural history and complications of an inadequately treated septic arthritis of the left hip. The child is aged 22 months and had been symptomatic for a week before this radiograph was obtained. No bone changes are seen, but the left hip is laterally subluxated.
Second radiograph in the series of a septic left hip. Three days after presentation and 10 days after the onset of symptoms, there is still no change in the bone's appearance, but the hip joint is further subluxated.
Third radiograph in the series of a septic left hip. Three weeks after presentation, the left hip is dislocated, and new periosteal bone formation is noted. This last finding is characteristic of an associated osteomyelitis of the left femur.
Fourth radiograph in the series of a septic left hip. Seven weeks after onset, increased opacity is noted in the central portion of the proximal femoral metaphysis and in the proximal femoral epiphysis. The findings are consistent with avascular necrosis of these structures.
Fifth radiograph in the series of a septic left hip. Five months after onset, the femoral head has been completely resorbed, and the femoral shaft has regenerated.
Sixth radiograph in the series of a septic left hip. At age 11, or 9 years after onset of the infection, the hip joint and the proximal femoral growth plate are destroyed. A profound limb-length discrepancy is noted, in addition to severely impaired hip function.
More on Septic Arthritis, Pediatrics |
| Overview: Septic Arthritis, Pediatrics |
| Workup: Septic Arthritis, Pediatrics |
 Treatment: Septic Arthritis, Pediatrics |
| Follow-up: Septic Arthritis, Pediatrics |
| Multimedia: Septic Arthritis, Pediatrics |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Rice PA. Gonococcal arthritis (disseminated gonococcal infection). Infect Dis Clin North Am. Dec 2005;19(4):853-61. [Medline].
Frank G, Mahoney HM, Eppes SC. Musculoskeletal infections in children. Pediatr Clin North Am. Aug 2005;52(4):1083-106, ix. [Medline].
Peltola H, Kallio MJ, Unkila-Kallio L. Reduced incidence of septic arthritis in children by Haemophilus influenzae type-b vaccination. Implications for treatment. J Bone Joint Surg Br. May 1998;80(3):471-3. [Medline].
Moylett EH, Rossmann SN, Epps HR, Demmler GJ. Importance of Kingella kingae as a pediatric pathogen in the United States. Pediatr Infect Dis J. Mar 2000;19(3):263-5. [Medline].
Kehl-Fie TE, Miller SE, St Geme JW 3rd. Kingella kingae expresses type IV pili that mediate adherence to respiratory epithelial and synovial cells. J Bacteriol. Aug 29 2008;[Medline].
Yagupsky P, Bar-Ziv Y, Howard CB, Dagan R. Epidemiology, etiology, and clinical features of septic arthritis in children younger than 24 months. Arch Pediatr Adolesc Med. May 1995;149(5):537-40. [Medline].
Mataika R, Carapetis JR, Kado J, Steer AC. Acute rheumatic fever: an important differential diagnosis of septic arthritis. J Trop Pediatr. Jun 2008;54(3):205-7. [Medline].
Willis AA, Widmann RF, Flynn JM, Green DW, Onel KB. Lyme arthritis presenting as acute septic arthritis in children. J Pediatr Orthop. Jan-Feb 2003;23(1):114-8. [Medline].
Song J, Letts M, Monson R. Differentiation of psoas muscle abscess from septic arthritis of the hip in children. Clin Orthop Relat Res. Oct 2001;(391):258-65. [Medline].
Korakaki E, Aligizakis A, Manoura A, Hatzidaki E, Saitakis E, Anatoliotaki M, et al. Methicillin-resistant Staphylococcus aureus osteomyelitis and septic arthritis in neonates: diagnosis and management. Jpn J Infect Dis. May 2007;60(2-3):129-31. [Medline].
Arnold SR, Elias D, Buckingham SC, Thomas ED, Novais E, Arkader A, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. Nov-Dec 2006;26(6):703-8. [Medline].
Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. Dec 1999;81(12):1662-70. [Medline].
Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. Jun 2006;88(6):1251-7. [Medline].
Arnold SR, Elias D, Buckingham SC, Thomas ED, Novais E, Arkader A, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. Nov-Dec 2006;26(6):703-8. [Medline].
Further Reading
Related eMedicine topics:
Septic Arthritis (Infectious Disease)
Aspiration Techniques and Indications for Surgery, Septic Arthritis
Septic Arthritis (Orthopedic Surgery)
Septic Arthritis (Radiology)
Guidelines:
Procedure guideline for 99m Tc-Exametazime (HMPAO)-labeled leukocyte scintigraphy for suspected infection/inflammation. Society of Nuclear Medicine, Inc. 1999 Feb (revised 2004 Jun 2). 6 pages. NGC:004260
Clinical trials:
Surgical Lavage Vs Serial Needle Aspiration for Infected Joints
Procalcitonin level and Kinetics in Children With Bacterial Infections
Keywords
septic arthritis, pediatric septic arthritis, septic arthritis and infectious diseases, septic arthritis--radiology, septic arthritis--surgery, joint infections, septic joint, suppurative arthritis, bacterial arthritis, acute septic arthritis, juvenile rheumatoid arthritis, pyogenic arthritis, gonococcal arthritis, Haemophilus influenzae, Haemophilus influenzae type b, H influenzae type b, Staphylococcus aureus, S aureus
