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Best treatments for Septic Arthritis

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Written by Andrew Le, MD.
Medically reviewed by
Clinical Physician Assistant, Summit Health
Last updated June 16, 2024

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Introduction

Septic arthritis is a serious medical condition in which a joint becomes infected with bacteria, viruses, or fungi. This infection can cause severe pain, swelling, and permanent damage to the joint if left untreated. Septic arthritis is considered a medical emergency, as rapid diagnosis and treatment are important to prevent long-term complications. In this article, we will explore what septic arthritis is, its causes and risk factors, symptoms and diagnosis, and the best non-surgical and surgical treatments available.

What is Septic Arthritis?

Septic arthritis, also known as infectious arthritis, is a severe infection of a joint caused by microorganisms such as bacteria, viruses, or fungi. These microorganisms enter the joint, causing inflammation of the synovial membrane (the thin lining of the joint) and a build-up of pus. The most commonly affected joints are the knee, hip, shoulder, elbow, and ankle.12,13

Once the infection begins, it can quickly spread and cause significant damage to the cartilage and bone within the joint. Septic arthritis can cause permanent joint damage, disability, and can become life-threatening if not quickly diagnosed and treated.

The severity of septic arthritis varies depending on factors such as the type of microorganism causing the infection, your overall health, and how quickly treatment is started. In some cases, the infection may be localized to a single joint, while in others, it may spread to multiple joints or even to other parts of the body.

Causes and Risk Factors for Septic Arthritis

Septic arthritis is caused by infectious microorganisms entering a joint. The most common microorganisms are bacteria, particularly Staphylococcus aureus (staph) and Streptococcus species.14,15 These bacteria can enter the joint through various routes, such as:

  • Direct contamination from an injury which breaks skin or surgical procedure
  • Spread from an infection in another part of the body (such as a skin infection or urinary tract infection) through the bloodstream
  • Reactivation of a previously treated joint infection

Less commonly, septic arthritis can also be caused by viruses and fungi. In sexually active young adults, the bacteria Neisseria gonorrhoeae, which causes gonorrhea, is a large cause of septic arthritis.11

Certain factors can increase your risk of developing septic arthritis. These include:

  • Older age (over 80 years old)8,10
  • Weakened immune system due to conditions like diabetes, HIV/AIDS, or cancer, or from taking immunosuppressive medications5,7
  • Pre-existing joint problems such as osteoarthritis, rheumatoid arthritis, or gout3,4
  • Recent joint surgery or having a prosthetic joint1,2
  • Skin infections or open wounds near a joint6
  • Intravenous drug use9
  • Underlying medical conditions like diabetes, sickle cell disease, or liver disease

Symptoms and Diagnosis of Septic Arthritis

The symptoms of septic arthritis usually develop quickly, often within hours to a few days. The most common signs and symptoms include:

  • Severe pain in the affected joint, often beginning suddenly
  • Swelling, redness, and warmth around the joint
  • Limited range of motion or inability to move the joint
  • Fever and chills
  • Fatigue and general feeling of being unwell

If you have these symptoms, especially if you have risk factors for septic arthritis, it is important to seek medical attention right away.

Your healthcare provider will likely use a combination of factors to diagnose septic arthritis. They may start by asking about your symptoms, medical history, and any recent infections or injuries. They will then examine the affected joint for signs of inflammation, such as swelling, redness, and tenderness.

Your healthcare provider may perform a procedure called arthrocentesis to confirm the diagnosis and identify the specific microorganism causing the infection. They will use a needle to draw a sample of synovial fluid (the lubricating fluid within the joint) for analysis. The fluid will be examined for bacteria, white blood cells, and other markers of infection. It may also be sent to a laboratory to figure out which bacteria could be causing the infection.

Imaging tests such as X-rays, ultrasound, or MRI may be used to check for joint damage and rule out other conditions that can look like septic arthritis, such as gout or rheumatoid arthritis.

Blood tests, such as a complete blood count (CBC) and C-reactive protein (CRP) level, can also help diagnose septic arthritis and monitor the body's response to treatment. People with septic arthritis often have high white blood cell counts and CRP levels.

Non-Surgical Treatments for Septic Arthritis

The main goals of treating septic arthritis are to treat the infection, prevent permanent joint damage, and restore joint function. Non-surgical treatments are often used first.

Antibiotics

Intravenous (IV) antibiotics are typically started as soon as the diagnosis is suspected, even before the specific type of bacteria is identified. Delaying antibiotic treatment can allow the infection to worsen and cause more joint damage.

The initial choice of antibiotic is based on the most likely causes, such as Staphylococcus aureus and Streptococcus species. Once the specific bacteria are identified, the antibiotics can be adjusted to target that particular microorganism.

IV antibiotics are usually given for at least 2 weeks, sometimes longer depending on the severity of the infection and response to treatment. After the initial IV course, oral antibiotics may be prescribed for several more weeks to make sure the infection is completely gone.

Joint drainage

In addition to antibiotics, draining the infected synovial fluid helps to relieve pressure within the joint, reduce inflammation, and remove bacteria and debris.

Using a needle to drain the fluid from the joint (arthrocentesis) may need to be done daily or every few days until the infection improves.

In infections of larger joints, like the hip or shoulder, a small drainage tube may be left in place to allow the infected fluid to keep draining.

Immobilization and rest

To reduce further damage to the infected joint and promote healing, your healthcare provider may recommend temporarily stabilizing the joint with a splint or brace. This helps to lower pain and inflammation by preventing movement of the joint.

Rest is also important during the onset and initial treatment of septic arthritis. You may be advised to avoid putting weight on the joint and to limit your overall activity level until the infection gets better.

Pain and fever management

Septic arthritis can cause pain and discomfort, as well as fever and chills. Over-the-counter pain relievers like acetaminophen or ibuprofen can help you manage these symptoms. Your healthcare provider may also prescribe stronger pain medications if needed.

Staying well-hydrated and using cold compresses on the affected joint can also provide some relief from pain and inflammation.

Monitoring and follow-up

Close monitoring is important to make sure the infection is responding to treatment. This may involve regular blood tests to check inflammatory markers, as well as further synovial fluid analyses to confirm that the bacteria are decreasing.

Once the acute infection has been treated, your doctor may recommend a gradual return to normal activities, as well as physical therapy to help improve joint function and strength. Long-term follow-up is important to monitor for any signs of the infection coming back or joint damage.

While non-surgical treatments are effective for many cases of septic arthritis, some people may need surgical intervention to fully get rid of the infection and repair joint damage.

Surgical Treatments for Septic Arthritis

Surgical intervention may be needed in some cases to thoroughly clean out the infected joint and remove any damaged tissue. The decision to get surgery depends on the severity of the infection, the specific joint involved, and your overall health.

Arthroscopic drainage and lavage

Arthroscopy is a minimally invasive surgical procedure in which a small camera (arthroscope) and specialized instruments are inserted into the joint through small incisions. This allows the surgeon to see the inside of the joint and perform various procedures.

In the context of septic arthritis, arthroscopy is used to completely drain the infected synovial fluid and clean out the joint with sterile saline solution. This process, known as lavage, helps to flush out bacteria, pus, and debris from the joint space.

Arthroscopic treatment is often used for infections of the knee, ankle, wrist, and elbow.16 It has several advantages over traditional open surgery, including smaller incisions, less pain, and faster recovery times.

Open arthrotomy

In some cases, a more extensive open surgical procedure called arthrotomy may be needed. This involves making a larger incision to fully expose the infected joint and allow for more thorough debridement (removal of infected or damaged tissue).

During an open arthrotomy, the surgeon will carefully inspect the joint, remove any infected or necrotic tissue, and clean out the joint with antibiotic solution. In some cases, temporary drains may be placed to allow any remaining infection to drain.

Open arthrotomy is typically used for infections of larger joints like the hip and shoulder, or when the infection has caused significant damage to the joint tissues.16 It may also be used if arthroscopic treatment was ineffective.

Prosthetic joint infections

Septic arthritis can be particularly difficult to treat when it involves a prosthetic joint, such as an artificial hip or knee. Because there is a foreign body (the prosthetic joint), it is easier for bacteria to attach and form biofilms, which can be difficult to treat with antibiotics alone.

In many cases of prosthetic joint infection, a two-stage surgical approach is practiced. The first stage involves removing the infected prosthesis and thoroughly cleaning the joint tissues. A temporary spacer with antibiotics may be placed to hold the joint space and deliver high localized concentrations of antibiotics.

After several weeks of IV antibiotic therapy, there is a second surgery to remove the spacer and implant a new prosthetic joint. This staged approach makes sure the infection is completely gone before introducing a new prosthesis.

Post-operative care and rehabilitation

Regardless of the specific surgical approach used, post-operative care and rehabilitation are important to successfully recover from septic arthritis. This typically involves:

  • Continued IV antibiotic therapy for several weeks after surgery
  • Pain management with medications as well as ice and elevation
  • Wound care to prevent secondary infections
  • Gradual movement of the affected joint to prevent stiffness
  • Physical therapy to restore strength, range of motion, and function

The timeline of antibiotic treatment and rehabilitation will vary depending on the severity of the infection and your response to treatment. Close follow-up with the surgical and medical teams is important to monitor progress and address any complications.

While surgical treatment of septic arthritis can be complex and long, it is often needed to prevent permanent joint damage and disability.

Conclusion

Septic arthritis is a serious and potentially life-threatening condition that needs fast diagnosis and treatment. If left untreated, the infection can quickly destroy joint tissues, leading to permanent damage and disability. By understanding the causes, risk factors, and symptoms of septic arthritis, you can seek medical attention and improve your treatment results.

Treatment of septic arthritis typically involves a combination of antibiotic therapy and joint drainage, either through non-surgical means like arthrocentesis or surgical procedures like arthroscopy or open arthrotomy.

If you think that you or a loved one may have septic arthritis, seek medical attention right away. With prompt and appropriate treatment, it is possible to treat this condition and restore joint health and function.

Citations:

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<2>Zimmerli, W., Trampuz, A., & Ochsner, P. E. (2004). Prosthetic-joint infections. New England Journal of Medicine, 351(16), 1645-1654.</2>

<3>Eriksson, H. K., & Lazarinis, S. (2022). Patient-related factors associated with superficial surgical site infection and progression to a periprosthetic joint infection after elective primary total joint arthroplasty: a single-centre, retrospective study in Sweden. BMJ Open, 12(9), e060754.</3>

<4>Futterman, O., Lieber, S. B., Nasrullah, K., Fowler, M. L., Shmerling, R. H., & Paz, Z. (2022). Clinical characteristics of patients with polymicrobial septic arthritis. Rheumatology, 61(9), 3605-3612.</4>

<5>Oguni, K., Fukushima, S., Otsuka, Y., Soejima, Y., Kawaguchi, M., Sazumi, Y., ... & Otsuka, F. (2023). Disseminated septic arthritis caused by Ureaplasma urealyticum in an immunocompromised patient with hypogammaglobulinemia after rituximab therapy. Journal of Infection and Chemotherapy, 29(5), 677-681.</5>

<6>McKenna, D. P., Miller, P., McAleese, T., & Cleary, M. (2022). Arthroscopy or arthrotomy for native knee septic arthritis: A systematic review. The Knee, 36, 1-8.</6>

<7>Wang, D. A., & Tambyah, P. A. (2015). Septic arthritis in immunocompetent and immunosuppressed hosts. Best Practice & Research Clinical Rheumatology, 29(2), 275-289.</7>

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<9>Morgan, D. S., Fisher, D., Merianos, A., & Currie, B. J. (1996). An 18 year clinical review of septic arthritis from tropical Australia. Epidemiology and Infection, 117(3), 423-428.</9>

<10>Chouk, M., Verhoeven, F., Sondag, M., Guillot, X., Prati, C., & Wendling, D. (2019). Value of serum procalcitonin for the diagnosis of bacterial septic arthritis in daily practice in rheumatology. Clinical Rheumatology, 38(8), 2265-2273.</10>

<11>WebMD. (2022). Septic Arthritis: Symptoms, Diagnosis, and Treatment. Retrieved from https://www.webmd.com/arthritis/septic-arthritis-symptoms-diagnosis-and-treatment</11>

<12>Kim S.-J., Choi N.-H., Ko S.-H., Linton J. A., Park H.-W. Arthroscopic treatment of septic arthritis of the hip. Clinical Orthopaedics and Related Research. 2003;(407):211–214. [PubMed] [Google Scholar]</12>

<13>Yamamoto Y., Ide T., Hachisuka N., Maekawa S., Akamatsu N. Arthroscopic surgery for septic arthritis of the hip joint in 4 adults. Arthroscopy. 2001;17(3):290–297. doi: 10.1053/jars.2001.20664.</13>

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<15>Manning L., Metcalf S., Clark B., Roberts J.A., Pavlos R., Tan H.L., et al. Clinical Characteristics, Etiology, and Initial Management Strategy of Newly Diagnosed Periprosthetic Joint Infection: A Multicenter, Prospective Observational Cohort Study of 783 Patients. The Journal of Arthroplasty. 2022;37(6):1102–1109.e1. doi: 10.1016/j.arth.2022.01.058.</15>

<16>Ramamurti P, Agarwal AR, Gu A, Probasco WV, Thakkar SC, Chodos MD. Surgical Treatment for Septic Ankle Arthritis: A Comparison of Arthrotomy and Arthroscopy. Foot Ankle Orthop. 2022 Jan. 7 (1):2473011421S00408. [QxMD MEDLINE Link]. [Full Text].</16>

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Clinical Physician Assistant, Summit Health
Jeff brings to Buoy 20 years of clinical experience as a physician assistant in urgent care and internal medicine. He also has extensive experience in healthcare administration, most recently as developer and director of an urgent care center. While completing his doctorate in Health Sciences at A.T. Still University, Jeff studied population health, healthcare systems, and evidence-based medicine....
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