Pediatric Septic Arthritis Treatment & Management

  • Author: Richard J Scarfone, MD; Chief Editor: Robert W Tolan Jr, MD   more...
 
Updated: Jul 29, 2011
 

Approach Considerations

Hospitalize all children presumed to have septic arthritis (SA) for empiric intravenous antibiotic therapy. After 2-3 days of immobilization, encourage early passive range of motion.

The optimal duration of antibiotic therapy is not defined, and recommendations vary from 1-6 weeks. Thus, institutional practices will prevail. In general, 3-4 weeks of antibiotic therapy is used to treat S aureus,H influenzae type B ,or S pneumoniae infections, while gonococcal infections are treated for 7-10 days.

Consultations

Consultation may be indicated with an orthopedic surgeon. Septic arthritis of the hip requires emergent irrigation and drainage to minimize risk of aseptic necrosis of the femoral head. Consultation with an infectious diseases specialist is particularly indicated if the diagnosis is uncertain or if the microbiology is unusual.

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Splinting and Antibiotics

Splint the affected joint in a functional position for the first few days after a diagnosis of septic arthritis (SA). Encourage early passive range of motion to stretch tendons and prevent contractures.

Once an organism is identified, an appropriate antibiotic is selected, and the child is demonstrating a good clinical response, continue outpatient therapy with either high-dose oral antibiotics or parenteral antibiotics. Antibiotics readily enter the joint fluid in high concentrations after oral administration. Frequent revisits to the physician to ensure compliance and good clinical response are essential.

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Aspiration, Arthrotomy, and Drainage

No studies have compared outcomes for children with SA undergoing arthrotomy versus aspiration alone. Traditionally, for uncomplicated septic arthritis involving joints other than the hip or shoulder, serial needle aspirations are performed. These may be discontinued once fluid no longer reaccumulates. Failure to reach this goal is an indication for arthrotomy and open drainage.

Urgent arthrotomy and open drainage is usually performed in septic arthritis of the hip or shoulder, septic arthritis of other joints if no improvement occurs within 3 days of starting antimicrobial therapy, or if a large amount of pus or debris is aspirated during diagnostic arthrocentesis. However, in one recent study of 62 children with septic arthritis of the hip, 50 were treated successfully with aspiration and antibiotics alone.[8]

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Contributor Information and Disclosures
Author

Richard J Scarfone, MD  Associate Professor, Department of Pediatrics, University of Pennsylvania School of Medicine; 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 and American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

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 Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, 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 Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

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, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

References
  1. Welkon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children: a review of 95 cases. Pediatr Infect Dis. Nov-Dec 1986;5(6):669-76. [Medline].

  2. Thompson A, Mannix R, Bachur R. Acute pediatric monoarticular arthritis: distinguishing lyme arthritis from other etiologies. Pediatrics. Mar 2009;123(3):959-65. [Medline].

  3. 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].

  4. Caird MS, Flynn JM, Leung YL, et al. 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].

  5. Kaplan SL. Challenges in the evaluation and management of bone and joint infections and the role of new antibiotics for gram positive infections. Adv Exp Med Biol. 2009;634:111-20. [Medline].

  6. Taekema HC, Landham PR, Maconochie I. Towards evidence based medicine for paediatricians. Distinguishing between transient synovitis and septic arthritis in the limping child: how useful are clinical prediction tools?. Arch Dis Child. Feb 2009;94(2):167-8. [Medline].

  7. [Guideline] Fordham L, Gunderman R, Blatt ER, et al. Limping child--ages 0-5 years. American College of Radiology (ACR). 2007;5. [Full Text].

  8. Pääkkönen M, Kallio MJ, Peltola H, Kallio PE. Pediatric septic hip with or without arthrotomy: retrospective analysis of 62 consecutive nonneonatal culture-positive cases. J Pediatr Orthop B. May 2010;19(3):264-9. [Medline].

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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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