Septic arthritis in adults
- Don L Goldenberg, MD
Don L Goldenberg, MD
- Section Editor — Pain Disorders in Rheumatology
- Professor of Medicine
- Tufts University School of Medicine
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Septic arthritis refers to infection in a joint; it is usually caused by bacteria but can be caused by fungi or mycobacteria. Septic arthritis due to bacterial infection is often a destructive form of acute arthritis. The predisposing factors, pathogenesis, clinical manifestations, diagnosis, and treatment of nongonococcal bacterial arthritis are reviewed here. Prosthetic joint infections, gonococcal arthritis, and fungal and mycobacterial arthritis are discussed separately. (See "Clinical manifestations and diagnosis of prosthetic joint infections" and "Treatment of prosthetic joint infections" and "Disseminated gonococcal infection" and "Skeletal tuberculosis".)
Prevalence — The prevalence of bacterial arthritis as the diagnosis among adults presenting with one or more acutely painful joints has been estimated to range from 8 to 27 percent; the lower figure is based on a series of 100 patients presenting to an urban hospital emergency department; the latter figure is based on a study of 75 patients presenting emergently in Taiwan [1,2]. These series included some patients with prosthetic joints and a small minority in whom the final diagnosis was gonococcal septic arthritis.
Predisposing factors — Predisposing factors for septic arthritis were identified in a systematic review that included more than 6200 patients with acutely painful joints; 10 percent had septic arthritis . The predisposing factors are summarized as follows [3,4]:
●Age >80 years
- Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluid tests. What should be ordered? JAMA 1990; 264:1009.
- Jeng GW, Wang CR, Liu ST, et al. Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis. Am J Emerg Med 1997; 15:626.
- Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA 2007; 297:1478.
- Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol 2008; 20:457.
- Kaandorp CJ, Krijnen P, Moens HJ, et al. The outcome of bacterial arthritis: a prospective community-based study. Arthritis Rheum 1997; 40:884.
- Goldenberg DL. Septic arthritis and other infections of rheumatologic significance. Rheum Dis Clin North Am 1991; 17:149.
- Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med 1985; 312:764.
- Mor A, Mitnick HJ, Greene JB, et al. Relapsing oligoarticular septic arthritis during etanercept treatment of rheumatoid arthritis. J Clin Rheumatol 2006; 12:87.
- Nadarajah K, Pritchard C. Listeria monocytogenes septic arthritis in a patient treated with etanercept for rheumatoid arthritis. J Clin Rheumatol 2005; 11:120.
- Schett G, Herak P, Graninger W, et al. Listeria-associated arthritis in a patient undergoing etanercept therapy: case report and review of the literature. J Clin Microbiol 2005; 43:2537.
- Katsarolis I, Tsiodras S, Panagopoulos P, et al. Septic arthritis due to Salmonella enteritidis associated with infliximab use. Scand J Infect Dis 2005; 37:304.
- Morgan DS, Fisher D, Merianos A, Currie BJ. An 18 year clinical review of septic arthritis from tropical Australia. Epidemiol Infect 1996; 117:423.
- Gavet F, Tournadre A, Soubrier M, et al. Septic arthritis in patients aged 80 and older: a comparison with younger adults. J Am Geriatr Soc 2005; 53:1210.
- Sapico FL, Liquete JA, Sarma RJ. Bone and joint infections in patients with infective endocarditis: review of a 4-year experience. Clin Infect Dis 1996; 22:783.
- Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis 2003; 36:319.
- Weisfelt M, van de Beek D, Spanjaard L, de Gans J. Arthritis in adults with community-acquired bacterial meningitis: a prospective cohort study. BMC Infect Dis 2006; 6:64.
- Aglas F, Gretler J, Rainer F, Krejs GJ. Sternoclavicular septic arthritis: a rare but serious complication of subclavian venous catheterization. Clin Rheumatol 1994; 13:507.
- Fromm SE, Toohey JS. Septic arthritis of the hip in an adult following repeated femoral venipuncture. Orthopedics 1996; 19:1047.
- Messieh M, Turner R, Bunch F, Camer S. Hip sepsis from retroperitoneal rupture of diverticular disease. Orthop Rev 1993; 22:597.
- Deng GM, Tarkowski A. The features of arthritis induced by CpG motifs in bacterial DNA. Arthritis Rheum 2000; 43:356.
- Nilsson IM, Verdrengh M, Ulrich RG, et al. Protection against Staphylococcus aureus sepsis by vaccination with recombinant staphylococcal enterotoxin A devoid of superantigenicity. J Infect Dis 1999; 180:1370.
- Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev 2002; 15:527.
- Jonsson IM, Pietrocola G, Speziale P, et al. Role of fibrinogen-binding adhesin expression in septic arthritis and septicemia caused by Streptococcus agalactiae. J Infect Dis 2005; 192:1456.
- Kehl-Fie TE, Porsch EA, Yagupsky P, et al. Examination of type IV pilus expression and pilus-associated phenotypes in Kingella kingae clinical isolates. Infect Immun 2010; 78:1692.
- Frazee BW, Fee C, Lambert L. How common is MRSA in adult septic arthritis? Ann Emerg Med 2009; 54:695.
- Mikhail IS, Alarcón GS. Nongonococcal bacterial arthritis. Rheum Dis Clin North Am 1993; 19:311.
- Ross JJ, Hu LT. Septic arthritis of the pubic symphysis: review of 100 cases. Medicine (Baltimore) 2003; 82:340.
- Dubost JJ, Fis I, Denis P, et al. Polyarticular septic arthritis. Medicine (Baltimore) 1993; 72:296.
- Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore) 2004; 83:139.
- Hariharan P, Kabrhel C. Sensitivity of erythrocyte sedimentation rate and C-reactive protein for the exclusion of septic arthritis in emergency department patients. J Emerg Med 2011; 40:428.
- Tetreault MW, Wetters NG, Moric M, et al. Is synovial C-reactive protein a useful marker for periprosthetic joint infection? Clin Orthop Relat Res 2014; 472:3997.
- Zimmermann B 3rd, Mikolich DJ, Lally EV. Septic sacroiliitis. Semin Arthritis Rheum 1996; 26:592.
- Baker DG, Schumacher HR Jr. Acute monoarthritis. N Engl J Med 1993; 329:1013.
- Mathur T, Manadan AM, Hota B, Block JA. Pseudo-septic hip arthritis as the presenting symptom of ankylosing spondylitis: a case series and review of the literature. Clin Exp Rheumatol 2010; 28:416.
- Singleton JD, West SG, Nordstrom DM. "Pseudoseptic" arthritis complicating rheumatoid arthritis: a report of six cases. J Rheumatol 1991; 18:1319.
- Yang SC, Shao PL, Hsueh PR, et al. Successful treatment of Candida tropicalis arthritis, osteomyelitis and costochondritis with caspofungin and fluconazole in a recipient of bone marrow transplantation. Acta Paediatr 2006; 95:629.
- Dalton PA, Munckhof WJ, Walters DW. Scedosporium prolificans: an uncommon cause of septic arthritis. ANZ J Surg 2006; 76:661.
- Sharff KA, Richards EP, Townes JM. Clinical management of septic arthritis. Curr Rheumatol Rep 2013; 15:332.
- 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.
- Allison DC, Holtom PD, Patzakis MJ, Zalavras CG. Microbiology of bone and joint infections in injecting drug abusers. Clin Orthop Relat Res 2010; 468:2107.
- Ho G Jr. How best to drain an infected joint. Will we ever know for certain? J Rheumatol 1993; 20:2001.
- Thiery JA. Arthroscopic drainage in septic arthritides of the knee: a multicenter study. Arthroscopy 1989; 5:65.
- Stutz G, Kuster MS, Kleinstück F, Gächter A. Arthroscopic management of septic arthritis: stages of infection and results. Knee Surg Sports Traumatol Arthrosc 2000; 8:270.
- Sammer DM, Shin AY. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. J Bone Joint Surg Am 2009; 91:1387.
- Nusem I, Jabur MK, Playford EG. Arthroscopic treatment of septic arthritis of the hip. Arthroscopy 2006; 22:902.e1.
- Goldenberg DL. Septic arthritis. Lancet 1998; 351:197.
- Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991. Ann Rheum Dis 1999; 58:214.
- Predisposing factors
- MECHANISM OF INFECTION
- CLINICAL MANIFESTATIONS
- DIFFERENTIAL DIAGNOSIS
- Crystal-induced arthritis
- Reactive arthritis
- Rheumatoid arthritis
- Lyme disease
- Antibiotic therapy
- Duration of therapy
- Joint drainage
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS