eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Arthritis, Septic: Treatment & Medication
Updated: Apr 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Splint the affected joint in a functional position for the first few days after diagnosis. Encourage early passive range of motion to stretch tendons and prevent contractures in patients with septic arthritis (SA).
Surgical Care
- For uncomplicated septic arthritis involving joints other than the hip or shoulder, serial needle aspirations are indicated. This 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 indicated 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.
Consultations
- Orthopedic surgeon: Septic arthritis of the hip requires emergent irrigation and drainage to minimize risk of aseptic necrosis of the femoral head.
- Infectious diseases specialist: This consultation is particularly indicated if the diagnosis is uncertain or if the microbiology is unusual.
Activity
- After 2-3 days of immobilization, encourage early passive range of motion.
Medication
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 all 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 both vancomycin and a third-generation cephalosporin, such as ceftriaxone, is a reasonable choice for initial coverage.
S aureus is the most common cause of septic arthritis 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 community-acquired methicillin-resistant S aureus (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.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Oxacillin
A semisynthetic penicillin that is effective against staphylococci.
Adult
500 mg to 2 g IV q6h
Pediatric
Neonates <7 days:
<2000 g: 25 mg/kg/dose IV q12h
>2000 g: 25 mg/kg/dose IV q8h
Neonates >7 days:
<2000 g: 25 mg/kg/dose IV q8h
>2000 g: 25 mg/kg/dose IV q6h
Infants and children: 40 mg/kg/dose IV q6h
Decreases effects of contraceptives and tetracycline; disulfiram and probenecid, may increase oxacillin levels; effect of anticoagulants increase when large IV doses of oxacillin given
Documented hypersensitivity to oxacillin or other penicillins
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with caution in patients with severe renal impairment or with a history of hypersensitivity to cephalosporins
Gentamicin
An aminoglycoside with good gram-negative activity. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution.
Adult
1.5-1.8 mg/kg/dose IV
Dosing intervals based on CrCl:
>60 mL/min: Administer q8h
40-60 mL/min: Administer q12h
20-40 mL/min: Administer q24h
10-20 mL/min: Administerq48h
<10 mL/min: Administer q72h
Pediatric
2.5 mg/kg/dose IV q8h
Potentiates the effects of neuromuscular blockers; amphotericin B, cyclosporine, cephalosporins, and furosemide may increase the risk of renal toxicity; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Nephrotoxicity and ototoxicity may be associated with prolonged elevated trough concentrations; monitor levels to minimize the risk of toxicity and to optimize therapy
Ceftriaxone (Rocephin)
A third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
1-2 g IV/IM q24h
Pediatric
Neonates <7 days: 50 mg/kg/d IV/IM q24h
Neonates >7 days:
<2000 g: 50 mg/kg/d IV/IM q24h
>2000 g: 75 mg/kg/d IV/IM q24h
Infants and children: 50-75 mg/kg/d IV/IM q24h
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity; hyperbilirubinemic neonates
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in those allergic to penicillin antibiotics; more common adverse drug reactions include skin rashes, diarrhea, and pain at the site of injection; caution with history of gallbladder, biliary tract, or hepatic disease
Penicillin G potassium (Pfizerpen)
Active against most gram-positive organisms except S aureus as well as some anaerobes. Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
1-2 million U IV q4-6h
Pediatric
Neonate:
Postnatal age <7 days: 100,000 U/kg/dose IV q8h
Postnatal age >7 days: 100,000 U/kg/dose IV q6h
Infants and children: 25,000-60,000 U/kg/dose IV q6h (not to exceed 4.8 million U/24 h)
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Cross sensitivity to cephalosporin antibiotics; caution with renal impairment, impaired cardiac function, or seizure disorders
Clindamycin (Cleocin)
Active against most gram-positive organisms and anaerobes. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult
600-1200 mg/d IV divided q6-8h
Pediatric
Neonates <7 days:
<2000 g: 5 mg/kg/dose IV q12h
>2000 g: 5 mg/kg/dose IV q8h
Neonates >7 days:
<2000 g: 5 mg/kg/dose IV q8h
>2000 g: 7.5 mg/kg/dose IV q8h
Infants and children: 10 mg/kg/dose IV q8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis, ulcerative colitis, antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Pseudomembranous colitis has been associated with the use of clindamycin; dose adjustment may be necessary in patients with severe hepatic dysfunction; conversely, no adjustment is necessary in patients diagnosed with renal insufficiency; administer capsule with a full glass of water
Vancomycin (Vancocin, Vancoled)
For treatment of infections due to suspected or documented MRSA or serious or life-threatening infections due to S aureus.
Adult
2 g/d IV divided q12h
Pediatric
Neonates:
Postnatal age <7 days: 10 mg/kg/dose IV q12h
7-30 days: 10 mg/kg/dose IV q8h
Infants >30 days with CNS infection: 15 mg/kg/dose IV q6h
Erythema, histaminelike flushing and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity; previous severe hearing loss
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome (ie, erythema-multiforme like reaction with rash involving face, neck, and upper trunk, pruritus, urticaria, and hypotension) is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
More on Arthritis, Septic |
| Overview: Arthritis, Septic |
| Differential Diagnoses & Workup: Arthritis, Septic |
 Treatment & Medication: Arthritis, Septic |
| Follow-up: Arthritis, Septic |
| Multimedia: Arthritis, Septic |
| References |
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References
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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].
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].
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Thompson A, Mannix R, Bachur R. Acute pediatric monoarticular arthritis: distinguishing lyme arthritis from other etiologies. Pediatrics. Mar 2009;123(3):959-65. [Medline].
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].
Fordham L, Gunderman R, Blatt ER, et al. Limping child--ages 0-5 years. American College of Radiology (ACR). 2007;5.
Dagan R. Management of acute hematogenous osteomyelitis and septic arthritis in the pediatric patient. Pediatr Infect Dis J. Jan 1993;12(1):88-92. [Medline].
Frank G, Mahoney HM, Eppes SC. Musculoskeletal infections in children. Pediatr Clin North Am. Aug 2005;52(4):1083-106, ix. [Medline].
Kratz A, Greenberg D, Barki Y, et al. Pantoea agglomerans as a cause of septic arthritis after palm tree thorn injury; case report and literature review. Arch Dis Child. Jun 2003;88(6):542-4. [Medline].
Shetty AK, Gedalia A. Septic arthritis in children. Rheum Dis Clin North Am. May 1998;24(2):287-304. [Medline].
Further Reading
Keywords
septic arthritis, SA, bacterial arthritis, infectious arthritis, pyogenic arthritis, suppurative arthritis, purulent synovitis, pyarthrosis, suppurative synovitis, osteomyelitis, pressure necrosis, avascular necrosis, Haemophilus influenzae type B, community-acquired methicillin-resistant Staphylococcus aureus, MRSA-CA, hemophilia, hemarthrosis, sickle cell anemia, human immunodeficiency virus, HIV, chronic arthritis, joint pain, polyarticular disease, pseudoparalysis, arthralgia, transient synovitus, reactive arthritis, Escherichia coli, varicella-zoster virus, Salmonella, diagnosis, treatment
