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Bacterial arthritis: Clinical features and diagnosis in infants and children

Paul Krogstad, MD
Section Editors
Morven S Edwards, MD
William Phillips, MD
Robert Sundel, MD
Deputy Editor
Mary M Torchia, MD


Infections of the joints (known as septic arthritis, pyogenic arthritis, suppurative arthritis, purulent arthritis, or pyarthrosis) may be caused by bacteria, fungi, mycobacteria, and viruses. The term "septic arthritis" usually refers to bacterial arthritis or fungal arthritis, but bacterial joint infections are most common [1,2].

The clinical features and diagnosis of bacterial arthritis in infants and children will be reviewed here. The epidemiology, pathogenesis, microbiology, treatment, and outcome of bacterial arthritis in infants and children are discussed separately. (See "Bacterial arthritis: Epidemiology, pathogenesis, and microbiology in infants and children" and "Bacterial arthritis: Treatment and outcome in infants and children".)


Bacterial arthritis classically presents with acute onset (two to five days) of fever and joint pain, swelling (picture 1A-B), and limited range of motion. However, the presentation varies depending upon the age of the child, the site of infection, and the causative organism (table 1).

Site of infection — Bacterial arthritis usually occurs in a single joint, most commonly of the lower extremity [2]. Infections of the knee, hip, and ankle consistently account for at least 80 percent of cases, with the hip and knee most commonly affected [2-7]. Bilateral bacterial arthritis of the hip occurs in a small number of cases [8].

Up to 10 percent of cases involve more than one joint [5,9,10]. Polyarticular infections are more common in neonates and with certain pathogens (eg, Neisseria meningitidis, N. gonorrhoeae, and occasionally Staphylococcus aureus) [9,11,12].

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Literature review current through: Nov 2017. | This topic last updated: Aug 04, 2017.
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  1. Nade S. Septic arthritis. Best Pract Res Clin Rheumatol 2003; 17:183.
  2. Krogstad P. Septic arthritis. In: Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.727.
  3. Heberling JA. A review of two hundred and one cases of suppurative arthritis. J Bone Joint Surg 1941; 23:917.
  4. Morrey BF, Bianco AJ Jr, Rhodes KH. Septic arthritis in children. Orthop Clin North Am 1975; 6:923.
  5. Nelson JD. The bacterial etiology and antibiotic management of septic arthritis in infants and children. Pediatrics 1972; 50:437.
  6. SAMILSON RL, BERSANI FA, WATKINS MB. Acute suppurative arthritis in infants and children; the importance of early diagnosis and surgical drainage. Pediatrics 1958; 21:798.
  7. Wang CL, Wang SM, Yang YJ, et al. Septic arthritis in children: relationship of causative pathogens, complications, and outcome. J Microbiol Immunol Infect 2003; 36:41.
  8. OBLETZ BE. Suppurative arthritis of the hip joint in infants. Clin Orthop 1962; 22:27.
  9. Welkon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children: a review of 95 cases. Pediatr Infect Dis 1986; 5:669.
  10. Fink CW, Nelson JD. Septic arthritis and osteomyelitis in children. Clin Rheum Dis 1986; 12:423.
  11. Dan M. Septic arthritis in young infants: clinical and microbiologic correlations and therapeutic implications. Rev Infect Dis 1984; 6:147.
  12. Gutierrez K. Infectious and inflammatory arthritis. In: Principles and Practice of Pediatric Infectious Diseases, 4th ed, Long SS, Pickering LK, Prober CG (Eds), Elsevier Saunders, Edinburgh 2012. p.477.
  13. Chung SM, Pollis RE. Diagnostic pitfalls in septic arthritis of the hip in infants and children. Clin Pediatr (Phila) 1975; 14:758.
  14. OBLETZ BE. Acute suppurative arthritis of the hip in the neonatal period. J Bone Joint Surg Am 1960; 42-A:23.
  15. Krogstad P. Septic arthritis. In: Current Pediatric Therapy, 18th ed, Burg FD, Ingelfinger JR, Polin RA, Gershon AA (Eds), Saunders, Philadelphia 2006. p.665.
  16. Yagupsky P, Bar-Ziv Y, Howard CB, Dagan R. Epidemiology, etiology, and clinical features of septic arthritis in children younger than 24 months. Arch Pediatr Adolesc Med 1995; 149:537.
  17. Omene JA, Odita JC. Clinical and radiological features of neonatal septic arthritis. Trop Geogr Med 1979; 31:207.
  18. Asnes RS, Arendar GM. Septic arthritis of the hip: a complication of femoral venipuncture. Pediatrics 1966; 38:837.
  19. Chacha PB. Suppurative arthritis of the hip joint in infancy. A persistent diagnostic problem and possible complication of femoral venipuncture. J Bone Joint Surg Am 1971; 53:538.
  20. Freiberg JA, Perlman R. Pelvic abscesses associated with acute purulent infection of the hip joint. J Bone Joint Surg 1936; 18:417.
  21. Gillespie R. Septic arthritis of childhood. Clin Orthop Relat Res 1973; :152.
  22. Fleisher G. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott, Williams & Wilkins, Philadelphia 2006. p.783.
  23. Osman AA, Govender S. Septic sacroiliitis. Clin Orthop Relat Res 1995; :214.
  24. Schaad UB, McCracken GH Jr, Nelson JD. Pyogenic arthritis of the sacroiliac joint in pediatric patients. Pediatrics 1980; 66:375.
  25. Molinos Quintana A, Morillo Gutiérrez B, Camacho Lovillo MS, et al. Pyogenic sacroiliitis in children-a diagnostic challenge. Clin Rheumatol 2011; 30:107.
  26. Stans AA. Osteomyelitis and septic arthritis. In: Lovell and Winter's Pediatric Orthopaedics, 6th ed, Morrissy RT, Weinstein SL (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.440.
  27. Rompalo AM, Hook EW 3rd, Roberts PL, et al. The acute arthritis-dermatitis syndrome. The changing importance of Neisseria gonorrhoeae and Neisseria meningitidis. Arch Intern Med 1987; 147:281.
  28. Bradley JS, Kaplan SL, Tan TQ, et al. Pediatric pneumococcal bone and joint infections. The Pediatric Multicenter Pneumococcal Surveillance Study Group (PMPSSG). Pediatrics 1998; 102:1376.
  29. Holmes KK, Counts GW, Beaty HN. Disseminated gonococcal infection. Ann Intern Med 1971; 74:979.
  30. Olarte L, Romero JR, Barson WJ, et al. Pneumococcal osteoarticular infections in children in the pneumococcal conjugate vaccine era. Abstract and poster presentation, 10th International Symposium on Pneumococci & Pneumococcal Diseases, Glasgow, Scotland, June 2016.
  31. Frank G, Eppes SC. Bone, joint, and soft tissue infections. In: Comprehensive Pediatric Hospital Medicine, Zaoutis LB, Chiang WV (Eds), Mosby, Philadelphia 2007. p.414.
  32. Bennett OM, Namnyak SS. Acute septic arthritis of the hip joint in infancy and childhood. Clin Orthop Relat Res 1992; :123.
  33. Bosilkovski M, Kirova-Urosevic V, Cekovska Z, et al. Osteoarticular involvement in childhood brucellosis: experience with 133 cases in an endemic region. Pediatr Infect Dis J 2013; 32:815.
  34. Nade S. Acute septic arthritis in infancy and childhood. J Bone Joint Surg Br 1983; 65:234.
  35. Walsh S, Phillips F. Deep vein thrombosis associated with pediatric musculoskeletal sepsis. J Pediatr Orthop 2002; 22:329.
  36. Nelson JD. Skeletal infections in children. Adv Pediatr Infect Dis 1991; 6:59.
  37. Shaw BA, Kasser JR. Acute septic arthritis in infancy and childhood. Clin Orthop Relat Res 1990; :212.
  38. Aprin H, Turen C. Pyogenic sacroiliitis in children. Clin Orthop Relat Res 1993; :98.
  39. Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluid tests. What should be ordered? JAMA 1990; 264:1009.
  40. Saavedra-Lozano J, Falup-Pecurariu O, Faust SN, et al. Bone and Joint Infections. Pediatr Infect Dis J 2017; 36:788.
  41. Barton LL, Dunkle LM, Habib FH. Septic arthritis in childhood. A 13-year review. Am J Dis Child 1987; 141:898.
  42. Wiley JJ, Fraser GA. Septic arthritis in childhood. Can J Surg 1979; 22:326.
  43. Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM. Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests. Ann Emerg Med 1992; 21:1418.
  44. Zawin JK, Hoffer FA, Rand FF, Teele RL. Joint effusion in children with an irritable hip: US diagnosis and aspiration. Radiology 1993; 187:459.
  45. Klein DM, Barbera C, Gray ST, et al. Sensitivity of objective parameters in the diagnosis of pediatric septic hips. Clin Orthop Relat Res 1997; :153.
  46. Levine MJ, McGuire KJ, McGowan KL, Flynn JM. Assessment of the test characteristics of C-reactive protein for septic arthritis in children. J Pediatr Orthop 2003; 23:373.
  47. Deanehan JK, Kimia AA, Tan Tanny SP, et al. Distinguishing Lyme from septic knee monoarthritis in Lyme disease-endemic areas. Pediatrics 2013; 131:e695.
  48. Kallio MJ, Unkila-Kallio L, Aalto K, Peltola H. Serum C-reactive protein, erythrocyte sedimentation rate and white blood cell count in septic arthritis of children. Pediatr Infect Dis J 1997; 16:411.
  49. Singhal R, Perry DC, Khan FN, et al. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br 2011; 93:1556.
  50. Wall EJ. Childhood osteomyelitis and septic arthritis. Curr Opin Pediatr 1998; 10:73.
  51. Nade S, Robertson FW, Taylor TK. Antibiotics in the treatment of acute osteomyelitis and acute septic arthritis in children. Med J Aust 1974; 2:703.
  52. Trapp CM, Tamai J, Schleiss MR. Septic arthritis secondary to fusobacterium necrophorum in a 4-year-old girl: case report and review of the literature. Pediatr Infect Dis J 2005; 24:846.
  53. Section J, Gibbons SD, Barton T, et al. Microbiological culture methods for pediatric musculoskeletal infection: a guideline for optimal use. J Bone Joint Surg Am 2015; 97:441.
  54. Thompson A, Mannix R, Bachur R. Acute pediatric monoarticular arthritis: distinguishing lyme arthritis from other etiologies. Pediatrics 2009; 123:959.
  55. Bachur RG, Adams CM, Monuteaux MC. Evaluating the child with acute hip pain ("irritable hip") in a Lyme endemic region. J Pediatr 2015; 166:407.
  56. Glotzbecker MP, Kocher MS, Sundel RP, et al. Primary lyme arthritis of the pediatric hip. J Pediatr Orthop 2011; 31:787.
  57. Kunnamo I, Pelkonen P. Routine analysis of synovial fluid cells is of value in the differential diagnosis of arthritis in children. J Rheumatol 1986; 13:1076.
  58. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA 2007; 297:1478.
  59. Baldassare AR, Chang F, Zuckner J. Markedly raised synovial fluid leucocyte counts not associated with infectious arthritis in children. Ann Rheum Dis 1978; 37:404.
  60. Coutlakis PJ, Roberts WN, Wise CM. Another look at synovial fluid leukocytosis and infection. J Clin Rheumatol 2002; 8:67.
  61. Ropes MW. Examination of synovial fluid. Bull Rheum Dis 1957; 7 Suppl:S21.
  62. WARD J, COHEN AS, BAUER W. The diagnosis and therapy of acute suppurative arthritis. Arthritis Rheum 1960; 3:522.
  63. Heyworth BE, Shore BJ, Donohue KS, et al. Management of pediatric patients with synovial fluid white blood-cell counts of 25,000 to 75,000 cells/mm³ after aspiration of the hip. J Bone Joint Surg Am 2015; 97:389.
  64. Press J, Peled N, Buskila D, Yagupsky P. Leukocyte count in the synovial fluid of children with culture-proven brucellar arthritis. Clin Rheumatol 2002; 21:191.
  65. Yagupsky P, Press J. Use of the isolator 1.5 microbial tube for culture of synovial fluid from patients with septic arthritis. J Clin Microbiol 1997; 35:2410.
  66. Kiang KM, Ogunmodede F, Juni BA, et al. Outbreak of osteomyelitis/septic arthritis caused by Kingella kingae among child care center attendees. Pediatrics 2005; 116:e206.
  67. Verdier I, Gayet-Ageron A, Ploton C, et al. Contribution of a broad range polymerase chain reaction to the diagnosis of osteoarticular infections caused by Kingella kingae: description of twenty-four recent pediatric diagnoses. Pediatr Infect Dis J 2005; 24:692.
  68. Chometon S, Benito Y, Chaker M, et al. Specific real-time polymerase chain reaction places Kingella kingae as the most common cause of osteoarticular infections in young children. Pediatr Infect Dis J 2007; 26:377.
  69. Rosey AL, Abachin E, Quesnes G, et al. Development of a broad-range 16S rDNA real-time PCR for the diagnosis of septic arthritis in children. J Microbiol Methods 2007; 68:88.
  70. Carter K, Doern C, Jo CH, Copley LA. The Clinical Usefulness of Polymerase Chain Reaction as a Supplemental Diagnostic Tool in the Evaluation and the Treatment of Children With Septic Arthritis. J Pediatr Orthop 2016; 36:167.
  71. Bayer AS, Guze LB. Fungal arthritis. II. Coccidioidal synovitis: clinical, diagnostic, therapeutic, and prognostic considerations. Semin Arthritis Rheum 1979; 8:200.
  72. Miralles M, Gonzalez G, Pulpeiro JR, et al. Sonography of the painful hip in children: 500 consecutive cases. AJR Am J Roentgenol 1989; 152:579.
  73. Robben SG, Lequin MH, Diepstraten AF, et al. Anterior joint capsule of the normal hip and in children with transient synovitis: US study with anatomic and histologic correlation. Radiology 1999; 210:499.
  74. Buchmann RF, Jaramillo D. Imaging of articular disorders in children. Radiol Clin North Am 2004; 42:151.
  75. Volberg FM, Sumner TE, Abramson JS, Winchester PH. Unreliability of radiographic diagnosis of septic hip in children. Pediatrics 1984; 74:118.
  76. Mitchell M, Howard B, Haller J, et al. Septic arthritis. Radiol Clin North Am 1988; 26:1295.
  77. WHITE H. Roentgen findings of acute infectious disease of the hip in infants and children. Clin Orthop 1962; 22:34.
  78. Hefke HW, Turner VC. The obturator sign as the earliest roentgenographic sign in the diagnosis of septic arthritis and tuberculosis of the hip. J Bone Joint Surg 1942; 24:857.
  79. Chont L. Roentgen sign of early suppurative arthritis of the hip in infancy. Radiology 1942; 38:708.
  80. Jaramillo D, Treves ST, Kasser JR, et al. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol 1995; 165:399.
  81. Gordon JE, Huang M, Dobbs M, et al. Causes of false-negative ultrasound scans in the diagnosis of septic arthritis of the hip in children. J Pediatr Orthop 2002; 22:312.
  82. Strouse PJ, DiPietro MA, Adler RS. Pediatric hip effusions: evaluation with power Doppler sonography. Radiology 1998; 206:731.
  83. Kocher MS, Mandiga R, Murphy JM, et al. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am 2003; 85-A:994.
  84. Paisley JW. Septic bursitis in childhood. J Pediatr Orthop 1982; 2:57.
  85. Yang WJ, Im SA, Lim GY, et al. MR imaging of transient synovitis: differentiation from septic arthritis. Pediatr Radiol 2006; 36:1154.
  86. Pääkkönen M, Kallio MJ, Kallio PE, Peltola H. Sensitivity of erythrocyte sedimentation rate and C-reactive protein in childhood bone and joint infections. Clin Orthop Relat Res 2010; 468:861.
  87. Roine I, Faingezicht I, Arguedas A, et al. Serial serum C-reactive protein to monitor recovery from acute hematogenous osteomyelitis in children. Pediatr Infect Dis J 1995; 14:40.
  88. Rosenfeld S, Bernstein DT, Daram S, et al. Predicting the Presence of Adjacent Infections in Septic Arthritis in Children. J Pediatr Orthop 2016; 36:70.
  89. Connolly LP, Connolly SA. Skeletal scintigraphy in the multimodality assessment of young children with acute skeletal symptoms. Clin Nucl Med 2003; 28:746.
  90. Wilson DJ. Soft tissue and joint infection. Eur Radiol 2004; 14 Suppl 3:E64.
  91. Lyon RM, Evanich JD. Culture-negative septic arthritis in children. J Pediatr Orthop 1999; 19:655.
  92. Greenwood BM, Whittle HC, Bryceson AD. Allergic complications of meningococcal disease. II. Immunological investigations. Br Med J 1973; 2:737.
  93. Rush PJ, Shore A, Inman R, et al. Arthritis associated with Haemophilus influenzae meningitis: septic or reactive? J Pediatr 1986; 109:412.
  94. Ahmed S, Ayoub EM. Poststreptococcal reactive arthritis. Pediatr Infect Dis J 2001; 20:1081.
  95. Viani RM, Bromberg K, Bradley JS. Obturator internus muscle abscess in children: report of seven cases and review. Clin Infect Dis 1999; 28:117.
  96. Song J, Letts M, Monson R. Differentiation of psoas muscle abscess from septic arthritis of the hip in children. Clin Orthop Relat Res 2001; :258.
  97. Harwell JI, Fisher D. Pediatric septic bursitis: case report of retrocalcaneal infection and review of the literature. Clin Infect Dis 2001; 32:E102.