Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Bacterial arthritis: Treatment and outcome in infants and children

Paul Krogstad, MD
Section Editors
Sheldon L Kaplan, MD
William Phillips, MD
Thomas JA Lehman, 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 treatment and outcome of bacterial arthritis in infants and children will be reviewed here. The epidemiology, pathogenesis, microbiology, clinical features, and diagnosis of bacterial arthritis in infants and children are discussed separately. (See "Bacterial arthritis: Epidemiology, pathogenesis, and microbiology in infants and children" and "Bacterial arthritis: Clinical features and diagnosis in infants and children".)

The treatment of arthritis due to Lyme disease is also discussed separately. (See "Treatment of Lyme disease", section on 'Arthritis'.)


Bacterial arthritis requires prompt recognition and management. Delays in treatment are often associated with long-term sequelae. These sequelae can have major lifelong impact if a major weight-bearing joint is involved, particularly when the hip joint is involved in infants.

The goals of treatment include sterilization and decompression of the joint space and removal of inflammatory debris to relieve pain and prevent deformity or functional sequelae [1,3]. Surgical drainage and antimicrobial therapy are the cornerstones of therapy.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jan 2017. | This topic last updated: Wed Mar 02 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  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. 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.
  4. Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol 2008; 20:457.
  5. Kang SN, Sanghera T, Mangwani J, et al. The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br 2009; 91:1127.
  6. Krogstad P. Septic arthritis. In: Current Pediatric Therapy, 18th ed, Burg FD, Ingelfinger JR, Polin RA, Gershon AA (Eds), Saunders, Philadelphia 2006. p.665.
  7. Baciocco EA, Iles RL. Ampicillin and kanamycin concentrations in joint fluid. Clin Pharmacol Ther 1971; 12:858.
  8. Balboni V, Shapiro IM, Kydd DM. The penetration of penicillin into joint fluid following intramuscular administration. Am J Med Sci 1945; 210:588.
  9. Nelson JD. The bacterial etiology and antibiotic management of septic arthritis in infants and children. Pediatrics 1972; 50:437.
  10. Plott MA, Roth H. Penetration of clindamycin into synovial fluid. Clin Pharmacol Ther 1970; 11:577.
  11. Peltola H, Pääkkönen M, Kallio P, et al. Clindamycin vs. first-generation cephalosporins for acute osteoarticular infections of childhood--a prospective quasi-randomized controlled trial. Clin Microbiol Infect 2012; 18:582.
  12. Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop 2006; 26:703.
  13. 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.
  14. Carrillo-Marquez MA, Hulten KG, Hammerman W, et al. USA300 is the predominant genotype causing Staphylococcus aureus septic arthritis in children. Pediatr Infect Dis J 2009; 28:1076.
  15. 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.
  16. Odio CM, Ramirez T, Arias G, et al. Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children. Pediatr Infect Dis J 2003; 22:883.
  17. Wenger DR. Childhood hip sepsis: improving the yield of good results. Instr Course Lect 1985; 34:457.
  18. Fabry G, Meire E. Septic arthritis of the hip in children: poor results after late and inadequate treatment. J Pediatr Orthop 1983; 3:461.
  19. Riegels-Nielsen P, Frimodt-Møller N, Sørensen M, Jensen JS. Antibiotic treatment insufficient for established septic arthritis. Staphylococcus aureus experiments in rabbits. Acta Orthop Scand 1989; 60:113.
  20. Smith RL, Schurman DJ. Bacterial arthritis. A staphylococcal proteoglycan-releasing factor. Arthritis Rheum 1986; 29:1378.
  21. Nord KD, Dore DD, Deeney VF, et al. Evaluation of treatment modalities for septic arthritis with histological grading and analysis of levels of uronic acid, neutral protease, and interleukin-1. J Bone Joint Surg Am 1995; 77:258.
  22. 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.
  23. Morrey BF, Bianco AJ Jr, Rhodes KH. Septic arthritis in children. Orthop Clin North Am 1975; 6:923.
  24. Herndon WA, Knauer S, Sullivan JA, Gross RH. Management of septic arthritis in children. J Pediatr Orthop 1986; 6:576.
  25. Goldenberg DL, Brandt KD, Cohen AS, Cathcart ES. Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage. Arthritis Rheum 1975; 18:83.
  26. Daniel D, Akeson W, Amiel D, et al. Lavage of septic joints in rabbits: effects of chondrolysis. J Bone Joint Surg Am 1976; 58:393.
  27. 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.
  28. OBLETZ BE. Suppurative arthritis of the hip joint in infants. Clin Orthop 1962; 22:27.
  29. Morrey BF, Bianco AJ, Rhodes KH. Suppurative arthritis of the hip in children. J Bone Joint Surg Am 1976; 58:388.
  30. Paterson DC. Acute suppurative arthritis in infancy and childhood. J Bone Joint Surg Br 1970; 52:474.
  31. Kim SJ, Choi NH, Ko SH, et al. Arthroscopic treatment of septic arthritis of the hip. Clin Orthop Relat Res 2003; :211.
  32. Nusem I, Jabur MK, Playford EG. Arthroscopic treatment of septic arthritis of the hip. Arthroscopy 2006; 22:902.e1.
  33. Chung WK, Slater GL, Bates EH. Treatment of septic arthritis of the hip by arthroscopic lavage. J Pediatr Orthop 1993; 13:444.
  34. Pääkkönen M, Kallio MJ, Peltola H, Kallio PE. Pediatric septic hip with or without arthrotomy: retrospective analysis of 62 consecutive nonneonatal culture-positive cases. J Pediatr Orthop B 2010; 19:264.
  35. Givon U, Liberman B, Schindler A, et al. Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations. J Pediatr Orthop 2004; 24:266.
  36. Griffet J, Oborocianu I, Rubio A, et al. Percutaneous aspiration irrigation drainage technique in the management of septic arthritis in children. J Trauma 2011; 70:377.
  37. Wilson NI, Di Paola M. Acute septic arthritis in infancy and childhood. 10 years' experience. J Bone Joint Surg Br 1986; 68:584.
  38. Belthur MV, Palazzi DL, Miller JA, et al. A clinical analysis of shoulder and hip joint infections in children. J Pediatr Orthop 2009; 29:828.
  39. Pioro MH, Mandell BF. Septic arthritis. Rheum Dis Clin North Am 1997; 23:239.
  40. Gordon JE, Wolff A, Luhmann SJ, et al. Primary and delayed closure after open irrigation and debridement of septic arthritis in children. J Pediatr Orthop B 2005; 14:101.
  41. 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.
  42. Betz RR, Cooperman DR, Wopperer JM, et al. Late sequelae of septic arthritis of the hip in infancy and childhood. J Pediatr Orthop 1990; 10:365.
  43. Stanitski CL, Harvell JC, Fu FH. Arthroscopy in acute septic knees. Management in pediatric patients. Clin Orthop Relat Res 1989; :209.
  44. Forward DP, Hunter JB. Arthroscopic washout of the shoulder for septic arthritis in infants. A new technique. J Bone Joint Surg Br 2002; 84:1173.
  45. Broy SB, Schmid FR. A comparison of medical drainage (needle aspiration) and surgical drainage (arthrotomy or arthroscopy) in the initial treatment of infected joints. Clin Rheum Dis 1986; 12:501.
  46. Peltola H, Pääkkönen M, Kallio P, et al. Prospective, randomized trial of 10 days versus 30 days of antimicrobial treatment, including a short-term course of parenteral therapy, for childhood septic arthritis. Clin Infect Dis 2009; 48:1201.
  47. Nade S. Acute septic arthritis in infancy and childhood. J Bone Joint Surg Br 1983; 65:234.
  48. Badgley CE, Yglesias L, Perham WS, Snyder CH. Study of the end results in 113 cases of septic hips. J Bone Joint Surg Br 1936; 18:1047.
  49. Fink CW, Nelson JD. Septic arthritis and osteomyelitis in children. Clin Rheum Dis 1986; 12:423.
  50. Bowerman SG, Green NE, Mencio GA. Decline of bone and joint infections attributable to haemophilus influenzae type b. Clin Orthop Relat Res 1997; :128.
  51. Luhmann JD, Luhmann SJ. Etiology of septic arthritis in children: an update for the 1990s. Pediatr Emerg Care 1999; 15:40.
  52. Nelson JD. Antibiotic concentrations in septic joint effusions. N Engl J Med 1971; 284:349.
  53. Kaplan SL. Osteomyelitis in children. Infect Dis Clin North Am 2005; 19:787.
  54. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
  55. Yagupsky P. Kingella kingae: from medical rarity to an emerging paediatric pathogen. Lancet Infect Dis 2004; 4:358.
  56. Yagupsky P. Antibiotic susceptibility of Kingella kingae isolates from children with skeletal system infections. Pediatr Infect Dis J 2012; 31:212.
  57. 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.
  58. Brewer GF, Davis JR, Grossman M. Gonococcal arthritis in an adolescent girl. Am J Dis Child 1971; 122:253.
  59. Barton LL, Dunkle LM, Habib FH. Septic arthritis in childhood. A 13-year review. Am J Dis Child 1987; 141:898.
  60. 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.
  61. Wiley JJ, Fraser GA. Septic arthritis in childhood. Can J Surg 1979; 22:326.
  62. Mallet C, Ceroni D, Litzelmann E, et al. Unusually severe cases of Kingella kingae osteoarticular infections in children. Pediatr Infect Dis J 2014; 33:1.
  63. Tetzlaff TR, McCracken GH Jr, Nelson JD. Oral antibiotic therapy for skeletal infections of children. II. Therapy of osteomyelitis and suppurative arthritis. J Pediatr 1978; 92:485.
  64. Bennett OM, Namnyak SS. Acute septic arthritis of the hip joint in infancy and childhood. Clin Orthop Relat Res 1992; :123.
  65. Bradley JS. What is the appropriate treatment course for bacterial arthritis in children? Clin Infect Dis 2009; 48:1211.
  66. Perkins MD, Edwards KM, Heller RM, Green NE. Neonatal group B streptococcal osteomyelitis and suppurative arthritis. Outpatient therapy. Clin Pediatr (Phila) 1989; 28:229.
  67. Schwartz GJ, Hegyi T, Spitzer A. Subtherapeutic dicloxacillin levels in a neonate: possible mechanisms. J Pediatr 1976; 89:310.
  68. Ballock RT, Newton PO, Evans SJ, et al. A comparison of early versus late conversion from intravenous to oral therapy in the treatment of septic arthritis. J Pediatr Orthop 2009; 29:636.
  69. Maraqa NF, Gomez MM, Rathore MH. Outpatient parenteral antimicrobial therapy in osteoarticular infections in children. J Pediatr Orthop 2002; 22:506.
  70. Ruebner R, Keren R, Coffin S, et al. Complications of central venous catheters used for the treatment of acute hematogenous osteomyelitis. Pediatrics 2006; 117:1210.
  71. Newton PO, Ballock RT, Bradley JS. Oral antibiotic therapy of bacterial arthritis. Pediatr Infect Dis J 1999; 18:1102.
  72. Jaberi FM, Shahcheraghi GH, Ahadzadeh M. Short-term intravenous antibiotic treatment of acute hematogenous bone and joint infection in children: a prospective randomized trial. J Pediatr Orthop 2002; 22:317.
  73. Kim HK, Alman B, Cole WG. A shortened course of parenteral antibiotic therapy in the management of acute septic arthritis of the hip. J Pediatr Orthop 2000; 20:44.
  74. Kolyvas E, Ahronheim G, Marks MI, et al. Oral antibiotic therapy of skeletal infections in children. Pediatrics 1980; 65:867.
  75. Arnold JC, Cannavino CR, Ross MK, et al. Acute bacterial osteoarticular infections: eight-year analysis of C-reactive protein for oral step-down therapy. Pediatrics 2012; 130:e821.
  76. Chou AC, Mahadev A. The Use of C-reactive Protein as a Guide for Transitioning to Oral Antibiotics in Pediatric Osteoarticular Infections. J Pediatr Orthop 2016; 36:173.
  77. Nelson JD, Bucholz RW, Kusmiesz H, Shelton S. Benefits and risks of sequential parenteral--oral cephalosporin therapy for suppurative bone and joint infections. J Pediatr Orthop 1982; 2:255.
  78. Martínez-Aguilar G, Hammerman WA, Mason EO Jr, Kaplan SL. Clindamycin treatment of invasive infections caused by community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus in children. Pediatr Infect Dis J 2003; 22:593.
  79. Benjamin B, Khan MR. Hip involvement in childhood brucellosis. J Bone Joint Surg Br 1994; 76:544.
  80. Peltola H, Unkila-Kallio L, Kallio MJ. Simplified treatment of acute staphylococcal osteomyelitis of childhood. The Finnish Study Group. Pediatrics 1997; 99:846.
  81. Sakiniene E, Bremell T, Tarkowski A. Addition of corticosteroids to antibiotic treatment ameliorates the course of experimental Staphylococcus aureus arthritis. Arthritis Rheum 1996; 39:1596.
  82. Harel L, Prais D, Bar-On E, et al. Dexamethasone therapy for septic arthritis in children: results of a randomized double-blind placebo-controlled study. J Pediatr Orthop 2011; 31:211.
  83. Fogel I, Amir J, Bar-On E, Harel L. Dexamethasone Therapy for Septic Arthritis in Children. Pediatrics 2015; 136:e776.
  84. Ho G Jr, Su EY. Therapy for septic arthritis. JAMA 1982; 247:797.
  85. WARD J, COHEN AS, BAUER W. The diagnosis and therapy of acute suppurative arthritis. Arthritis Rheum 1960; 3:522.
  86. Goldenberg DL, Brandt KD, Cathcart ES, Cohen AS. Acute arthritis caused by gram-negative bacilli: a clinical characterization. Medicine (Baltimore) 1974; 53:197.
  87. 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.
  88. Jackson MA, Burry VF, Olson LC. Pyogenic arthritis associated with adjacent osteomyelitis: identification of the sequela-prone child. Pediatr Infect Dis J 1992; 11:9.
  89. EYRE-BROOK AL. Septic arthritis of the hip and osteomyelitis of the upper end of the femur in infants. J Bone Joint Surg Br 1960; 42-B:11.
  90. Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care 1985; 1:7.
  91. Bos CF, Mol LJ, Obermann WR, Tjin a Ton ER. Late sequelae of neonatal septic arthritis of the shoulder. J Bone Joint Surg Br 1998; 80:645.
  92. Yuan HC, Wu KG, Chen CJ, et al. Characteristics and outcome of septic arthritis in children. J Microbiol Immunol Infect 2006; 39:342.
  93. SAMILSON RL, WATKINS MB, WINTERS DM. Acute suppurative arthritis. J Bone Joint Surg Am 1956; 38-A:1313.
  94. OBLETZ BE. Acute suppurative arthritis of the hip in the neonatal period. J Bone Joint Surg Am 1960; 42-A:23.
  95. Lunseth PA, Heiple KG. Prognosis in septic arthritis of the hip in children. Clin Orthop Relat Res 1979; :81.
  96. Goldenberg DL, Cohen AS. Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med 1976; 60:369.
  97. Newman JH. Review of septic arthritis throughout the antibiotic era. Ann Rheum Dis 1976; 35:198.