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== Background ==
==Background==
*Most important diagnostic consideration in acute joint pain (can destroy joint in days)
*Bacterial infection of a joint space — a '''true orthopedic emergency'''
*Knee most commonly involved in adults; hip most common in peds
*Rapid cartilage destruction occurs within hours if untreated<ref name="mathews">Mathews CJ, et al. Bacterial septic arthritis in adults. ''Lancet''. 2010;375(9717):846-855. PMID 20206778.</ref>
*Most often seen in pts &gt;65yr
*Staphylococcus aureus is the most common pathogen in adults (~50%)
*Gonococcal arthritis is the most common cause in adolescents and young adults
*Neisseria gonorrhoeae is the most common cause in sexually active young adults
*Knee is the most commonly affected joint (~50%)
*Mortality: 5-15% overall; higher in elderly and prosthetic joints


== Clinical Features ==
==Risk Factors==
*Fever
*Pre-existing joint disease (rheumatoid arthritis, osteoarthritis)
*Warm, red, painful, swollen joint  
*Prosthetic joint
*Decreased range of motion to active and passive movement
*Recent joint surgery or injection
*Gonococcal arthritis
*IV drug use
**Urethritis/vaginitis may be absent
*Immunosuppression (diabetes, HIV, steroids)
**may have prodromal phase:
*Skin infection or bacteremia
***Migratory arthritis and tenosynovitis predominate before pain and swelling occurs
*Advanced age
***Macularpapular rash or pustules esp on hands/feet may proceed overt arthritis
*Endocarditis should be considered in the presence of 2 or more affected joints


== Diagnosis  ==
==Clinical Features==
{{Arthrocentesis diagnostic chart}}
*Acute monoarticular joint pain, swelling, warmth, erythema
*Pain with both active and passive range of motion (distinguishes from periarticular pathology)
*Effusion
*Fever (present in ~60%, absence does not exclude)
*In gonococcal arthritis: migratory polyarthralgias, tenosynovitis, dermatitis (pustular skin lesions), may involve multiple joints
*Prosthetic joint infection: may have subtle presentation with chronic pain and loosening


== DDx ==
==Differential Diagnosis==
#Toxic synovitis
*[[Gout]] / [[Pseudogout]] (crystal arthropathy)
#Abscess
*[[Reactive arthritis]]
#Cellulitis
*[[Rheumatoid arthritis]] flare
#Primary rheumatologic disorder (i.e. vasculitis)  
*Hemarthrosis
#Iatrogenic
*[[Lyme disease]] (Lyme arthritis)
#Reactive arthritis (post-infectious)
*Viral arthritis
*[[Osteomyelitis]] with joint extension
*Periarticular abscess or [[Bursitis|bursitis]]


== Work-Up ==
==Evaluation==
#Arthrocentesis with synovial fluid analysis
*'''Arthrocentesis''' — '''must be performed''' in any suspected septic joint<ref name="long">Long B, et al. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. ''West J Emerg Med''. 2019;20(2):331-341. PMID 30881554.</ref>
##Synovial fluid culture only (not 100% sensitive)
**Send for: cell count with differential, Gram stain, culture, crystal analysis
#CBC
**WBC >50,000/mm³ with >90% PMNs strongly suggests infection
#ESR
**WBC >100,000/mm³ is virtually diagnostic
##Sn 94% (with 15mm/h cut-off)<ref>Hariharan, H, et al. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients. J of Emerg Med. 2010; 40(4):428–431. http://dx.doi.org/10.1016/j.jemermed.2010.05.029</ref>
**Lower counts do not exclude — partially treated or early infection may have lower counts
#CRP
**Gram stain positive in ~50% of non-gonococcal cases
##Sn 92% (with 20mg/L cut-off)
*Labs: CBC, ESR, CRP, blood cultures (positive in ~50%), lactate
#Blood Culture
*If gonococcal suspected: GC/CT NAAT (urine, cervix/urethra, pharynx, rectum)
#Gonorrhea culture (urethral/cervical/pharyngeal/rectal)  
*Imaging:
#Imaging
**X-ray: evaluate for effusion, osteomyelitis, fracture
##Helpful for excluding other diagnoses (e.g. trauma, osteo)
**Ultrasound: guide arthrocentesis, confirm effusion
#Immunocompromised
**MRI if concerned for adjacent osteomyelitis
##Consider mycobacterial or fungal arthritis


== Treatment ==
==Management==
#Joint drainage
*'''Empiric IV antibiotics''' after arthrocentesis (do NOT delay if aspiration will be delayed):
#Abx
**Vancomycin 15-20 mg/kg IV (covers MRSA) PLUS
##Gram stain can be used to guide treatment
**Ceftriaxone 2 g IV (covers gram-negatives and gonococcus)
###[[Gram+]]: [[vancomycin]] IV
**If prosthetic joint: add Vancomycin + Cefepime or Meropenem
###[[Gram-]] OR [[gonococcus]] suspected: [[Ceftriaxone]] IV 2gm daily
*Orthopedic consultation for:
#Consult ortho for joint irrigation in OR if joint aspirate is indicative of infection
**Joint washout/irrigation (arthroscopic or open)
**Prosthetic joint infections require urgent surgical intervention
*Gonococcal arthritis: Ceftriaxone 1 g IV/IM daily + treat for chlamydia
*Pain management: IV analgesics, joint immobilization, ice


== Disposition ==
==Disposition==
*Admit all to ortho
*Admit all confirmed or suspected septic arthritis
*Orthopedic surgery consultation for joint washout
*Gonococcal arthritis: may be managed with close outpatient follow-up after initial IV antibiotics in select cases


==External Links==
==See Also==
*[http://www.mdcalc.com/kocher-criteria-septic-arthritis/ MDCalc - Kocher Criteria for Septic Arthritis]
*[[Gout]]
*[[Pseudogout]]
*[[Osteomyelitis]]
*[[Prosthetic joint infection]]
*[[Arthrocentesis]]


== See Also ==
==References==
*[[Arthrocentesis]]
<references/>
*[[Monoarticular Arthritis]]
*[[Septic Arthritis (Hip)]]
*[[Septic Arthritis (Peds)]]
*[[Knee Diagnoses]]


== Source ==
[[Category:Orthopedics]]
*Tintinalli
[[Category:Infectious Disease]]
 
[[Category:ID]] [[Category:Ortho]]

Revisión actual - 09:31 22 mar 2026

Background

  • Bacterial infection of a joint space — a true orthopedic emergency
  • Rapid cartilage destruction occurs within hours if untreated[1]
  • Staphylococcus aureus is the most common pathogen in adults (~50%)
  • Neisseria gonorrhoeae is the most common cause in sexually active young adults
  • Knee is the most commonly affected joint (~50%)
  • Mortality: 5-15% overall; higher in elderly and prosthetic joints

Risk Factors

  • Pre-existing joint disease (rheumatoid arthritis, osteoarthritis)
  • Prosthetic joint
  • Recent joint surgery or injection
  • IV drug use
  • Immunosuppression (diabetes, HIV, steroids)
  • Skin infection or bacteremia
  • Advanced age

Clinical Features

  • Acute monoarticular joint pain, swelling, warmth, erythema
  • Pain with both active and passive range of motion (distinguishes from periarticular pathology)
  • Effusion
  • Fever (present in ~60%, absence does not exclude)
  • In gonococcal arthritis: migratory polyarthralgias, tenosynovitis, dermatitis (pustular skin lesions), may involve multiple joints
  • Prosthetic joint infection: may have subtle presentation with chronic pain and loosening

Differential Diagnosis

Evaluation

  • Arthrocentesis — must be performed in any suspected septic joint[2]
    • Send for: cell count with differential, Gram stain, culture, crystal analysis
    • WBC >50,000/mm³ with >90% PMNs strongly suggests infection
    • WBC >100,000/mm³ is virtually diagnostic
    • Lower counts do not exclude — partially treated or early infection may have lower counts
    • Gram stain positive in ~50% of non-gonococcal cases
  • Labs: CBC, ESR, CRP, blood cultures (positive in ~50%), lactate
  • If gonococcal suspected: GC/CT NAAT (urine, cervix/urethra, pharynx, rectum)
  • Imaging:
    • X-ray: evaluate for effusion, osteomyelitis, fracture
    • Ultrasound: guide arthrocentesis, confirm effusion
    • MRI if concerned for adjacent osteomyelitis

Management

  • Empiric IV antibiotics after arthrocentesis (do NOT delay if aspiration will be delayed):
    • Vancomycin 15-20 mg/kg IV (covers MRSA) PLUS
    • Ceftriaxone 2 g IV (covers gram-negatives and gonococcus)
    • If prosthetic joint: add Vancomycin + Cefepime or Meropenem
  • Orthopedic consultation for:
    • Joint washout/irrigation (arthroscopic or open)
    • Prosthetic joint infections require urgent surgical intervention
  • Gonococcal arthritis: Ceftriaxone 1 g IV/IM daily + treat for chlamydia
  • Pain management: IV analgesics, joint immobilization, ice

Disposition

  • Admit all confirmed or suspected septic arthritis
  • Orthopedic surgery consultation for joint washout
  • Gonococcal arthritis: may be managed with close outpatient follow-up after initial IV antibiotics in select cases

See Also

References

  1. ↑ Mathews CJ, et al. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846-855. PMID 20206778.
  2. ↑ Long B, et al. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. West J Emerg Med. 2019;20(2):331-341. PMID 30881554.
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