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Septic arthritis

Key sources
The following summarized guidelines for the evaluation and management of septic arthritis are prepared by our editorial team based on guidelines from the European Bone and Joint Infection Society (EBJIS 2023), the European Society of Cardiology (ESC 2023), the Infectious Diseases Society of America (IDSA/PIDS 2023), the American College of Radiology (ACR 2022), and the Infectious Diseases Society of America (IDSA 2016; 2011).
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Guidelines

1.Screening and diagnosis

Diagnosis: suspect septic arthritis of a native joint in patients with a painful and/or inflamed joint (redness, hot, swelling, synovial effusion, and/or purulent drainage) with or without a fever. Do not exclude or confirm septic arthritis of a native joint based on no clinical parameters.
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2.Diagnostic investigations

History and physical examination
Elicit a thorough medical history and perform a physical examination in patients with suspected septic arthritis in a native joint.
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Obtain clinical assessment to identify concomitant sepsis or septic shock requiring immediate attention and rapid surgical and medical treatment.
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  • Laboratory tests

  • Joint imaging

  • Cardiac imaging

3.Diagnostic procedures

Synovial fluid analysis, aspiration: perform aspiration of synovial fluid as quickly as possible when septic arthritis of a native joint is suspected.
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  • Synovial fluid analysis (differential cell count and microscopy)

  • Synovial fluid analysis (culture)

4.Medical management

Antibiotic therapy: consider initiating antibiotic treatment in patients with suspected septic arthritis of a native joint after aspiration of synovial fluid for laboratory analysis and obtaining blood cultures.
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5.Surgical interventions

Indications for surgery: offer invasive treatment (open surgery, arthroscopy, or arthrocentesis) to wash out toxins and reduce both the bacterial load and intra-articular pressure:
perform surgical debridement for septic arthritis of a native joint, especially in larger joints
consider performing arthroscopic debridement as initial surgical management in patients with Gächter stage I, II, and probably also III septic arthritis (if logistically and surgically possible)
consider performing open debridement in patients with Gächter stage III and definitely in stage IV
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6.Specific circumstances

Pediatric patients, diagnostic imaging: obtain plain X-ray of the affected joint and adjacent bones in pediatric patients with suspected acute bacterial arthritis.
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  • Pediatric patients (laboratory tests)

  • Pediatric patients (synovial fluid analysis)

  • Pediatric patients (antibiotic therapy, indications)

  • Pediatric patients (antibiotic therapy, route)

  • Pediatric patients (antibiotic therapy, choice of agent)

  • Pediatric patients (antibiotic therapy, duration)

  • Pediatric patients (corticosteroids)

  • Pediatric patients (indications for surgery)

  • Pediatric patients (management of resistant disease)

  • Pediatric patients (follow-up)

  • Patients after ACL reconstruction

  • Patients with MRSA septic arthritis

  • Patients with tuberculosis arthritis (evaluation)

  • Patients with tuberculosis arthritis (management)

  • Patients with Candida arthritis

  • Patients with Aspergillus arthritis

7.Follow-up and surveillance

Assessment of treatment response: assess for the following signs and laboratory markers as indicators of treatment failure:
Situation
Guidance
Clinical signs and symptoms
Persistent pain, local signs of inflammation (including the presence of purulent discharge), systemic signs of infection, and/or deteriorating joint function
Inflammatory biomarkers
CRP and WBC count not decreasing or instead increasing
Synovial fluid at re-aspiration in case of poor clinical progression
Elevated or not decreasing WBC count and percentage polymorphonuclear leucocytes, persistently positive microbial cultures
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More topics in this section

  • Early mobilization