Bacterial arthritis: Epidemiology, pathogenesis, and microbiology in infants and children
- Paul Krogstad, MD
Paul Krogstad, MD
- Professor of Pediatrics and Molecular and Medical Pharmacology
- Vice Chair for Academic Affairs, Department of Pediatrics
- David Geffen School of Medicine at UCLA
- Section Editors
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
- William Phillips, MD
William Phillips, MD
- Section Editor — Pediatric Orthopedics
- Professor of Pediatrics and Orthopedics
- Baylor College of Medicine
- Robert Sundel, MD
Robert Sundel, MD
- Section Editor — Pediatric Rheumatology
- Associate Professor of Pediatrics
- Harvard Medical School
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 epidemiology, pathogenesis, and microbiology of bacterial arthritis in infants and children will be reviewed here. The clinical manifestations, evaluation, diagnosis, treatment, and outcome are discussed separately. (See "Bacterial arthritis: Clinical features and diagnosis in infants and children" and "Bacterial arthritis: Treatment and outcome in infants and children".)
Bacterial arthritis occurs more commonly in childhood than during other periods of life, with approximately 50 percent of cases occurring in individuals younger than 20 years [2-4]. The reported incidence of bacterial arthritis in children ranges from 5 to 37 cases per 100,000 [5,6].
Children younger than three years are affected most frequently [5,7,8]. Boys are affected more often than girls (male-to-female ratio of 1.2-2 to 1) [6,8-10]. The hip and knee are the joints most frequently involved.
Risk factors — Risk factors for bacterial arthritis in the neonate (younger than one month) include [11-16]:
- Nade S. Septic arthritis. Best Pract Res Clin Rheumatol 2003; 17:183.
- 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.
- Heberling JA. A review of two hundred and one cases of suppurative arthritis. J Bone Joint Surg 1941; 23:917.
- BAITCH A. Recent observations of acute suppurative arthritis. Clin Orthop 1962; 22:157.
- Riise ØR, Handeland KS, Cvancarova M, et al. Incidence and characteristics of arthritis in Norwegian children: a population-based study. Pediatrics 2008; 121:e299.
- 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.
- 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.
- Barton LL, Dunkle LM, Habib FH. Septic arthritis in childhood. A 13-year review. Am J Dis Child 1987; 141:898.
- Luhmann JD, Luhmann SJ. Etiology of septic arthritis in children: an update for the 1990s. Pediatr Emerg Care 1999; 15:40.
- Morrey BF, Bianco AJ Jr, Rhodes KH. Septic arthritis in children. Orthop Clin North Am 1975; 6:923.
- 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.
- Asnes RS, Arendar GM. Septic arthritis of the hip: a complication of femoral venipuncture. Pediatrics 1966; 38:837.
- Pittard WB 3rd, Thullen JD, Fanaroff AA. Neonatal septic arthritis. J Pediatr 1976; 88:621.
- Omene JA, Odita JC. Clinical and radiological features of neonatal septic arthritis. Trop Geogr Med 1979; 31:207.
- Frederiksen B, Christiansen P, Knudsen FU. Acute osteomyelitis and septic arthritis in the neonate, risk factors and outcome. Eur J Pediatr 1993; 152:577.
- 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.
- Sauer ST, Farrell E, Geller E, Pizzutillo PD. Septic arthritis in a patient with juvenile rheumatoid arthritis. Clin Orthop Relat Res 2004; :219.
- 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.
- Yagupsky P, Dagan R, Howard CB, et al. Clinical features and epidemiology of invasive Kingella kingae infections in southern Israel. Pediatrics 1993; 92:800.
- Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis 2003; 36:319.
- Rush PJ, Shore A, Inman R, et al. Arthritis associated with Haemophilus influenzae meningitis: septic or reactive? J Pediatr 1986; 109:412.
- Karuppaswamy V, Shauq A, Alphonso N. Purulent pericarditis secondary to septic arthritis: a rare life threatening association. Arch Dis Child 2008; 93:277.
- 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.
- Joffe MD, Loiselle JM. Orthopedic emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott, Williams & Wilkins, Philadelphia 2006. p.1689.
- Perlman MH, Patzakis MJ, Kumar PJ, Holtom P. The incidence of joint involvement with adjacent osteomyelitis in pediatric patients. J Pediatr Orthop 2000; 20:40.
- Pääkkönen M, Kallio MJ, Kallio PE, Peltola H. Shortened hospital stay for childhood bone and joint infections: analysis of 265 prospectively collected culture-positive cases in 1983-2005. Scand J Infect Dis 2012; 44:683.
- Branson J, Vallejo JG, Flores AR, et al. The Contemporary Microbiology and Rates of Concomitant Osteomyelitis in Acute Septic Arthritis. Pediatr Infect Dis J 2017; 36:267.
- Ogden JA. Pediatric osteomyelitis and septic arthritis: the pathology of neonatal disease. Yale J Biol Med 1979; 52:423.
- Trueta J. The three types of acute hematogenous osteomyelitis. J Bone Joint Surg 1959; 41:671.
- 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.
- Smith RL, Schurman DJ, Kajiyama G, et al. The effect of antibiotics on the destruction of cartilage in experimental infectious arthritis. J Bone Joint Surg Am 1987; 69:1063.
- Nicholson J. Pyogenic arthritis with pathologic dislocation of the hip in infants. JAMA 1949; 141:826.
- Nelson JD. The bacterial etiology and antibiotic management of septic arthritis in infants and children. Pediatrics 1972; 50:437.
- Wiley JJ, Fraser GA. Septic arthritis in childhood. Can J Surg 1979; 22:326.
- Moumile K, Merckx J, Glorion C, et al. Bacterial aetiology of acute osteoarticular infections in children. Acta Paediatr 2005; 94:419.
- Lundy DW, Kehl DK. Increasing prevalence of Kingella kingae in osteoarticular infections in young children. J Pediatr Orthop 1998; 18:262.
- Goergens ED, McEvoy A, Watson M, Barrett IR. Acute osteomyelitis and septic arthritis in children. J Paediatr Child Health 2005; 41:59.
- Kao HC, Huang YC, Chiu CH, et al. Acute hematogenous osteomyelitis and septic arthritis in children. J Microbiol Immunol Infect 2003; 36:260.
- 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.
- Fink CW, Nelson JD. Septic arthritis and osteomyelitis in children. Clin Rheum Dis 1986; 12:423.
- Smith SP, Thyoka M, Lavy CB, Pitani A. Septic arthritis of the shoulder in children in Malawi. A randomised, prospective study of aspiration versus arthrotomy and washout. J Bone Joint Surg Br 2002; 84:1167.
- Nduati RW, Wamola IA. Bacteriology of acute septic arthritis. J Trop Pediatr 1991; 37:172.
- Molyneux E, French G. Salmonella joint infection in Malawian children. J Infect 1982; 4:131.
- Martínez-Aguilar G, Avalos-Mishaan A, Hulten K, et al. Community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children. Pediatr Infect Dis J 2004; 23:701.
- Gonzalez BE, Martinez-Aguilar G, Hulten KG, et al. Severe Staphylococcal sepsis in adolescents in the era of community-acquired methicillin-resistant Staphylococcus aureus. Pediatrics 2005; 115:642.
- Gonzalez BE, Teruya J, Mahoney DH Jr, et al. Venous thrombosis associated with staphylococcal osteomyelitis in children. Pediatrics 2006; 117:1673.
- 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.
- 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.
- 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.
- Moylett EH, Rossmann SN, Epps HR, Demmler GJ. Importance of Kingella kingae as a pediatric pathogen in the United States. Pediatr Infect Dis J 2000; 19:263.
- 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.
- Dubnov-Raz G, Ephros M, Garty BZ, et al. Invasive pediatric Kingella kingae Infections: a nationwide collaborative study. Pediatr Infect Dis J 2010; 29:639.
- El Houmami N, Minodier P, Dubourg G, et al. Patterns of Kingella kingae Disease Outbreaks. Pediatr Infect Dis J 2016; 35:340.
- Yagupsky P. Kingella kingae: from medical rarity to an emerging paediatric pathogen. Lancet Infect Dis 2004; 4:358.
- Kleiman MB, Lamb GA. Gonococcal arthritis in a newborn infant. Pediatrics 1973; 52:285.
- Kohen DP. Neonatal gonococcal arthritis: three cases and review of the literature. Pediatrics 1974; 53:436.
- Krogstad P. Septic arthritis. In: Current Pediatric Therapy, 18th ed, Burg FD, Ingelfinger JR, Polin RA, Gershon AA (Eds), Saunders, Philadelphia 2006. p.665.
- Calin A, Fries JF. An "experimental" epidemic of Reiter's syndrome revisited. Follow-up evidence on genetic and environmental factors. Ann Intern Med 1976; 84:564.
- Garcia-Kutzbach A, Masi AT. Acute infectious agent arthritis (IAA): a detailed comparison of proved gonococcal and other blood-borne bacterial arthritis. J Rheumatol 1974; 1:93.
- 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.
- Harwood MI, Womack J, Kapur R. Primary meningococcal arthritis. J Am Board Fam Med 2008; 21:66.
- Bilavsky E, Yarden-Bilavsky H, Zevit N, Amir J. Primary meningococcal arthritis in a child: case report and literature review. Scand J Infect Dis 2006; 38:396.
- Wells M, Gibbons RB. Primary meningococcal arthritis: case report and review of the literature. Mil Med 1997; 162:769.
- Bowerman SG, Green NE, Mencio GA. Decline of bone and joint infections attributable to haemophilus influenzae type b. Clin Orthop Relat Res 1997; :128.
- Granoff DM, Sargent E, Jolivette D. Haemophilus influenzae type b osteomyelitis. Am J Dis Child 1978; 132:488.
- Schwartz RH, Reing CM. Acute hematogenous osteomyelitis secondary to Hemophilus influenzae. J Pediatr Orthop 1981; 1:385.
- Castagnini LA, Laham FR, Demmler GJ. Haemophilus influenzae type B disease: have we forgotten? Clin Pediatr (Phila) 2008; 47:507.
- Pavlik DF, Johnston JJ, Eldredge JD, Dehority W. Non-Type b Haemophilus influenzae Septic Arthritis in Children. J Pediatric Infect Dis Soc 2016.
- Goldenberg DL, Brandt KD, Cathcart ES, Cohen AS. Acute arthritis caused by gram-negative bacilli: a clinical characterization. Medicine (Baltimore) 1974; 53:197.
- Ament ME, Gaal SA. Bacteroides arthritis. Am J Dis Child 1967; 114:427.
- Chmel H, Armstrong D. Acute arthritis caused by Aeromonas hydrophola: clinical and therapeutic aspects. Arthritis Rheum 1976; 19:169.
- Martin CM, Merrill RH, Barrett O Jr. Arthritis due to Serratia. J Bone Joint Surg Am 1970; 52:1450.
- Norenberg DD, Bigley DV, Virata RL, Liang GC. Corynebacterium pyogenes septic arthritis with plasma cell synovial infiltrate and monoclonal gammopathy. Arch Intern Med 1978; 138:810.
- Tindel JR, Crowder JG. Septic arthritis due to Pseudomonas aeruginosa. JAMA 1971; 218:559.
- Ritter MS, Mroch H, Burns MJ. Soaring suppurative sea shells from the sea shore: Pseudomonas aeruginosa and Klebsiella pneumoniae septic arthritis after a marine sea shell injury. Pediatr Emerg Care 1993; 9:289.
- Gifford DB, Patzakis M, Ivler D, Swezey RL. Septic arthritis due to pseudomonas in heroin addicts. J Bone Joint Surg Am 1975; 57:631.
- 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.
- Benjamin B, Khan MR. Hip involvement in childhood brucellosis. J Bone Joint Surg Br 1994; 76:544.
- 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.
- Brook I. Microbiology and management of joint and bone infections due to anaerobic bacteria. J Orthop Sci 2008; 13:160.