Approach to managing native joint septic arthritis

Suspected native joint septic arthritis usually requires urgent hospital referral. In children, septic arthritis of the hip is an emergency, and urgent operative drainage is required to prevent necrosis of the femoral head.

Note: Urgent hospital referral is usually required for suspected native joint septic arthritis. In particular, septic arthritis of the hip in a child is an emergency.

Early surgical intervention is essential for source control of septic arthritis. Drainage of pus with joint irrigation and synovectomy reduces pathogen load, facilitates antibiotic diffusion into the joint, and protects the articular surface. Drainage and irrigation may need to be repeated several times to control the infection.

Urgent empirical therapy is indicated for patients with septic arthritis complicated by sepsis or septic shock, while awaiting the results of Gram stain. For regimens, see Sepsis or septic shock associated with a bone or joint source.

For patients without sepsis or septic shock, empirical therapy is directed by the Gram stain of a joint aspirate, when available. When Gram stain is not available, therapy targeting the most common pathogen, or tailored to the location of infection, is used.

In adults and children, when the results of Gram stain are available, treat as for:

suspected staphylococcal septic arthritis if gram-positive cocci in clusters are identified
suspected streptococcal septic arthritis if gram-positive cocci in chains are identified
gram-negative septic arthritis if a gram-negative organism is identified
the most common pathogen in the patient group if Gram stain does not demonstrate an organism or morphology (clusters or chains) is not reported. Alternatively, treat as for the site of infection – see below.

When the results of Gram stain are not available, empirical therapy may be guided by the location of infectionCabet, 2021.

For septic arthritis of the hand joints, including the wrist, treat as per Bone and joint infections of the hand.
For septic arthritis contiguous with ulceration, particularly in patients with infection of joints of the lower limbs and vascular insufficiency or diabetes, treat as for Infections of diabetes-related foot ulcers.
For postprocedural infection of the shoulder joint, treat as per Postprocedural infections of the shoulder.
For adults with septic arthritis of the facet joints, treat as for Vertebral osteomyelitis in adults.

Empirical regimens for neonates with septic arthritis are not included in these guidelines – seek expert advice.

Modify therapy according to the results of culture and susceptibility testing. For suggested regimens, see:

For advice on duration of therapy including the minimum duration of intravenous therapy, see Intravenous to oral switch and duration of therapy for native joint septic arthritis.