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Pediatric Septic Arthritis Medication

  • Author: Richard J Scarfone, MD; Chief Editor: Russell W Steele, MD  more...
Updated: Jun 09, 2016

Medication Summary

Typically, a clinician chooses an antibiotic before synovial fluid culture results are known. Thus, the child's age and risk factors, as well as Gram stain results, should influence initial antibiotic coverage. Neonates are at risk for infection with gram-positive organisms, such as S aureus or group B streptococci, and gram-negative organisms, such as E coli.

For neonates without meningitis, a semisynthetic penicillin (eg, oxacillin) plus an aminoglycoside (eg, gentamicin) may be used. Neonates with concomitant meningitis and septic arthritis (SA) present a therapeutic challenge. Oxacillin does not penetrate the blood-brain barrier well, and ampicillin, although it offers better cerebrospinal fluid levels, does not provide adequate coverage against S aureus. In this case, a combination of vancomycin and a third-generation cephalosporin, such as ceftriaxone, is a reasonable choice for initial coverage.

S aureus is the most common cause of SA among nonneonates. Oxacillin alone should provide adequate coverage in older children who are immunocompetent, assuming that they are immunized for H influenzae type B. However, in communities in which MRSA-CA is prevalent, clindamycin is a better initial choice. A third-generation cephalosporin is the initial therapy for an adolescent possibly infected with gonococcus.

Once culture results and sensitivities are known, antibiotic selection can be more specific. For example, a child with group A beta hemolytic streptococcus (GABHS) infection could be treated with penicillin, whereas one growing anaerobes requires clindamycin.



Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Oxacillin (Bactocill in dextrose)


Oxacillin is a semisynthetic penicillin that is effective against staphylococci.



Gentamicin is an aminoglycoside with good gram-negative activity. Dosing regimens are numerous; adjust the dose based on CrCl and changes in the volume of distribution.

Ceftriaxone (Rocephin)


Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity. It has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Penicillin G potassium (Pfizerpen)


This agent is active against most gram-positive organisms except S aureus, as well as some anaerobes. It interferes with the synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Clindamycin (Cleocin)


Clindamycin is active against most gram-positive organisms and anaerobes. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (t-RNA) from ribosomes, in that way causing RNA-dependent protein synthesis to arrest.

Vancomycin (Vancocin, Vancoled)


Vancomycin is used for the treatment of infections due to suspected or documented MRSA and for the treatment of serious or life-threatening infections due to S aureus.

Contributor Information and Disclosures

Richard J Scarfone, MD Associate Professor, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Attending Physician, Division of Emergency Medicine and Medical Director of Emergency Preparedness, The Children's Hospital of Philadelphia

Richard J Scarfone, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

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Emergency room photograph of an infant with septic arthritis of the left hip. The child holds his hip rigidly in the classic position of flexion, abduction, and external rotation, a position that maximizes capsular volume. The patient is relatively comfortable as long as the hip joint remains immobile in this position.
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