Septic Arthritis in Infancy and

Childhood

Manuel Cassiano Neves, J. L. Campagnolo, M. J. Brito, and

C. F. Gouveia

Contents Keywords
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4469
Aetiology  Antibiotic treatment  Children :
Septic Arthritis  Complications  Diagnosis 
Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4470
Epidemiology  Pathophysiology  Surgical
Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4471 Treatment
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4472
Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4474
Introduction
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4475
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4478 Most bacterial infections in childhood are easily
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4479 diagnosed, readily treated, and have good out-
comes. By contrast suppurative infections of the
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4480
skeletal system still present challenges, since
these illnesses are often difficult to manage med-
ically and surgically. In spite of our best efforts,
a substantial portion of those treated are left with
disabling sequelae [1]. Although physicians are
getting better at diagnosis and treatment, septic
arthritis can still be a challenge in terms of the
diagnosis and management, especially in infants,
due to the lack of clinical symptoms.
According to Nelson [1], in the USA one in
5,000 children under the age of 13 years will have
osteomyelitis, and about twice as many will have
a septic arthritis (Fig. 1). Although pyogenic
M.C. Neves (*) arthritis occurs in all age groups the peak inci-
Orthopaedic Department, Hospital Cuf Descobertas, dence of the disease is in children under 3 years of
Parque das Nacoes, Lisboa, Portugal age [2] and boys are more likely to be affected
e-mail: Cassianoneves.manuel@gmail.com
than girls [3]. The incidence of septic arthritis in
J.L. Campagnolo children has been estimated as 5.5 to 12 cases per
Orthopaedic Department, Hospital Dona Estefania,
Lisbon, Portugal 100,000 individuals [4].
Although most children have no underlying
M.J. Brito  C.F. Gouveia
Infectious Disease Department, Hospital Dona Estefania, disorder, risk factors for pyogenic arthritis
Lisbon, Portugal include immunodeficiency, haemoglobinopathy,

G. Bentley (ed.), European Surgical Orthopaedics and Traumatology, 4469

DOI 10.1007/978-3-642-34746-7_169, # EFORT 2014
4470
Fig. 1 Prevalence of septic
arthritis
400
No Patients
300
200
100
<2
diabetes, intravenous drug abuse and rheumatoid
arthritis [57].
The outcome is poor in 27 % of patients with
septic arthritis and in nearly 40 % of those with
involvement of the hip [1]. The clinical picture
has not changed, but more recently we have seen
a change in the incidence and in the type of
bacteria responsible for this particular condition
[8]. The best example is in the virtual elimination
of septic arthritis caused by Haemophilus
influenzae type b in immunised patients after the
introduction of the vaccine [9]. At the same time
diagnostic tools such as ultrasound or the use of
polymerase chain reaction for the detection of
bacterial pathogens have been improving the
accuracy in the diagnosis [10, 11]. These have
led to an increase in the diagnosis of
osteoarticular infections caused by Kingella
kingae in toddlers [12, 13]. The modern Orthope-
dic paediatric surgeon should be alerted to these
new trends in order to improve his ability to
diagnose and to better treat this condition.
Pathophysiology
Septic arthritis is considered to be a secondary
infection from a primary focus, or due to
a transient bacteraemia from an event like
brushing the teeth [14]. Infection may reach
the joint through several routes with
haematogeneous dissemination being the most
M.C. Neves et al.
2 to 5 6 to 10 11 to 16
Age in years
common. Penetrating injuries, especially in the
knee joint and foot, can be responsible for septic
arthritis. Metaphyseal osteomyelitis may result in
involvement of the adjacent joint. In infants and
until 18 months of age, small vessels cross the
proximal growth-plates, particularly in the non-
ossified epiphysis, leading to an extension of the
metaphyseal abscess into the joint [15, 16]
(Fig. 2). This is more evident in the proximal
femur and may cause devastating consequences
in the young child if not promptly treated. After
this age the vascular channels disappear and the
growth-plate starts to act as a barrier to the ter-
minal vessels of the metaphysis. In certain joints
like the hip, knee, shoulder and elbow, the cap-
sular attachments are at the level of the
metaphysis [17]. There is then a high possibility
of direct spread of the metaphyseal abscess into
the joint after perforation of the thin cortex by the
abscess. Perlman et al. [18] found a 33 % inci-
dence of concomitant septic arthritis in their
patients who had osteomyelitis, one third of
them located at the knee joint (Fig. 2).
In the absence of early treatment, destruction
of the articular cartilage takes place secondary to
the release of proteolytic enzymes from the syno-
vial cells. Interleukin-1 triggers the release of
proteases from chondrocytes and synoviocytes
in response to polymorphonuclear leucocytes
and bacteria. Degradation results in loss of pro-
teoglycans after 5 days and of collagen by 9 days.
Impairment of the intracapsular vascular supply
Septic Arthritis in Infancy and Childhood
Fig. 2 Mechanism of
spread of a metaphyseal
abscess into the joint
also plays a role in the articular destruction,
with elevation of the intracapsular pressure,
thrombosis, and progressive displacement of the
femoral head from the acetabulum [1921].
Aetiology
Age is the most important predictor of aetiology
of pyogenic arthritis. Staphylococcus aureus,
enteric gram-negative organisms and a group
B Streptococcus (GBS) are the most frequent
causes of pyogenic arthritis among neonates.
Staphylococcus aureus, Kingella kingae, Strepto-
coccus pyogenes and Streptococcus pneumonia
cause pyogenic arthritis in children younger than
5 years of age. Staphylococcus aureus and
S. pyogenes are the most common causes of pyo-
genic arthritis in children older than 5 years
[13, 22]. Staphylococcus aureus is the most com-
mon agent causing septic arthritis in all ages.
In recent years methicillin-resistant S. aureus
(MRSA) has emerged in the community,
frequently associated with the production of
Panton-Valentine leukocidin (PVL). Osteoarticular
4471
infections caused by these S. aureus strains are
now much more frequent, mostly in the United
States, and are thought to be associated with
worse clinical outcomes [2325]. Risk
factors for acquisition of MRSA have been
described, such as young age or lower socio-
economic status, however their clinical relevance
is questionable [26]. MRSA infections are
more aggressive than Methicillin susceptible
infections involving multiple bones and joints
and sometimes are associated with thrombosis
and pulmonary disease [24, 27, 28].
Streptococci (especially group A beta-
haemolytic organisms and pneumococi) have
been responsible for the majority of other gram-
positive infections. Haemophilus influenzae type
b used to be important in children under 2 years of
age but due to widespread immunization is rarely
seen nowadays.
Other organisms reported to cause pyogenic
arthritis in children include Neisseria
meningitidis and Kingela kingae [29, 30].
In recent years, Kingella kingae has emerged
as an important cause of septic arthritis
[12, 13] mostly due to the improvement in
4472
laboratory methods [11]. Moumile et al., using
a combination of blood-culture vials and
a DNA-amplification method for synovial fluid
specimens, found that Kingella kingae was the
most common cause of skeletal infections in
France, in children below 3 years [13]. Overall,
K. kingae seems to be responsible for musculoskel-
etal infections below the age of 5 years, with over
60 % of the episodes below the age of two [22].
Children with invasive K. kingae infections often
have a recent history of stomatitis or symptoms of
an infection of the upper respiratory tract [31].
In newborns and sexually active adolescents
who have a septic arthritis, Neisseria gonorrhea
should be considered [32]. Septic arthritis caused
by gram-negative bacteria is rare in children.
However Salmonella should be considered,
especially in children with sickle-cell disease
[33], or Pseudomonas aeruginosa when associ-
ated with an infected puncture wound [34].
Brucella and Mycobacterium tuberculosis may
cause chronic monoarticular arthritis with a gran-
ulomatous reaction especially in endemic regions
in southern Europe [35].
Diagnosis
The diagnosis of septic arthritis is based on clin-
ical findings, their correlation with laboratory
results and the findings on imaging. Almost all
patients have fever and constitutional symptoms
within the first few days of infection.
The typical constitutional symptoms are the
acute onset, anorexia and irritability. There is
severe pain in the involved segment, aggravated
by any attempt to move the limb passively. Usu-
ally the child refuses to use the limb and if the leg
I 18s involved will limp or refuse to bear weight.
The affected joint is swollen, tense and is locally
hot. It usually lies in flexion to release the
intracapsular pressure from the accumulation of
pus. This is particularly evident in the hip with
the child holding the joint in a position of flexion,
abduction and external rotation [36, 37, 69].
However, due to the deficiency of their
immune system, neonates may display only
anorexia, irritability and lethargy and may not
M.C. Neves et al.
Fig. 3 Radiograph showing capsular distention and wid-
ening of the joint space on the left
move the affected limb (pseudoparalysis)
[16, 38, 39]. All joints can be affected but 80 %
of infections occur in the lower limb with the hip
and the knee being the most implicated.
Imaging can be very helpful in establishing
a correct diagnosis. In a study by Jung et al. [40]
all the children who presented with septic arthri-
tis showed a displacement or blurring of the peri-
articular fat pads. Plain radiographs can reveal
subtle signs such as capsular distention and wid-
ening of the joint space early in the disease pro-
cess (Fig. 3). With continued swelling of the
capsule of the hip joint, the femoral head is
displaced laterally and upward [41]. Ultrasound
evaluation has proved to be very useful in the
assessment of septic arthritis, especially in deep
joints such as the hip, where physical examina-
tion is difficult. It is quick and can be performed
by any Orthopaedic surgeon with minimal train-
ing in the technique. It is painless and child
friendly and imparts no ionising radiation.
McCarthy et al. [19] found a 100 % capability
of ultrasound to demonstrate a joint effusion
within a capsule-to-bone distance of > 2 mm
compared with the contralateral side (Fig. 4).
However, Gordon et al. [42] noted the possibility
of false-negative ultrasound scans especially
when performed in the first 24 h after the onset
of symptoms. Ultrasound can also be helpful in
guiding aspiration and needle placement.
Technetium bone scans may show decreased
uptake (cold) early in the disease process and
Septic Arthritis in Infancy and Childhood
a sedimentation rate higher than 50 mm/h. The
b osteomyelitis [45]. According to Levine et al.
Fig. 4 Ultrasound of the hip joint showing (a) joint effu-
sion with a capsule-to-bone distance of > 2 mm compared
with (b) the normal side
increased uptake later (hot) as a result of
hyperaemic response.
Gallium and indium-labelled-leucocyte
scans may be helpful in atypical cases but take
up to 78 h to complete, making them an imprac-
tical tool.
CT scans and MRI can be of use in difficult
cases as in the diagnosis of an infection of the
sacro-iliac joint or in the differential diagnosis of
infections around the joints.
Laboratory evaluation of suspected septic
arthritis generally includes peripheral blood
count and differential, erythrocyte sedimentation
rate, C-reactive protein, blood culture and joint
fluid analysis.
The peripheral blood leucocyte count
usually demonstrates a white blood cell count >
12,000/mm3 with 4060 % polymorphonuclear
leucocytes. Most patients display an erythrocyte
4473
measurement of C-reactive protein (CRP) is an
indication of the inflammation but will also mon-
itor the progression of the disease. It is elevated
(mean 8.5 mg/dl) [43] in more than 90 % of
children with musculoskeletal infection at the
time of admission. It peaks 2 days after admission
and returns to normal after treatment [19, 44].
Measurements of the CRP level may also be
helpful in the identification of septic arthritis in
children with underlying acute haematogenous
[46] it is a better negative than a positive predic-
tor of the disease with an 87 % probability of
ruling out septic arthritis if less than 1.0 mg/dl.
This view was confirmed by Brown [47].
In some cases the blood tests may be only
slightly elevated even in a proven infection,
which can then make the suspicion of septic
arthritis difficult to confirm. Blood for culture
should always be taken when there is suspicion
of septic arthritis because blood cultures may
yield the pathogen when cultures of the joint
fluid do not.
Analysis of joint aspiration is essential for
diagnosis and helpful in differentiating bacterial
and others causes of arthritis.
The fluid must be collected in a heparinised
syringe so that the large clot which usually forms
in fluid from patients with septic arthritis or juve-
nile rheumatoid arthritis does not preclude enu-
meration of leucocytes. Once aspirated joint
samples are obtained, it is crucial that they be
quickly transported to the laboratory and not be
allowed to stand for a long time without
processing. A cell and differential count should
be performed and the aspirate Gram-stained.
A white-blood cell count > 50,000 mm with
90 % polymorphonuclear leukocytes is indicative
of septic arthritis, but 34 % of the patients have
a white blood cell count of < 25,000 mm3
A Gram-stained smear of aspirated joint fluid
must be assessed because joint fluid exerts
a bacteriostatic effect on micro-organisms
which can be seen, but may not grow in culture.
Gram stains of the aspirate are positive in
3050 % of cases [19, 48]. Approximately 35 %
of joint aspirates are sterile in patients with other
4474 M.C. Neves et al.

clinical and laboratory findings of a septic joint, Table 1 Differentiation of septic arthritis from transient
including positive blood cultures [49]. synovitis of the hip
Synovial protein levels that are 40 mg/dl Number of
(400 mg/L) and are less than the serum protein predictors present
(+): predictive
levels are consistent with septic arthritis. Lactate probability of
levels are typically elevated in the joint fluid in Study Predictors analyseda septic arthritis
patients with septic arthritis, except for those with Kocher History of fever 4 + :99.8 %
a gonococcal infection/ and the glucose level in et al. Non-weight bearing 3 + :93 % to 95.2 %
[35] ESR > 40 mm/h
the aspirate is lower than in the serum. 2 + :33.8 % to
In children with hyperuricaemia it is also 62.2 %
recommended that the fluid be examined for the WBC > 12,000/mm3 1 + :2.1 % to 5.3 %
0 + :0.1 %
presence of uric acid crystals in order to rule out
Jung Body temperature 5 + :99.1 %
crystalline joint disease. et al. > 37  C
Fluid aspirated from the joint must be cul- [25] ESR > 20 mm/h 4 + :84.8 % to
tured both aerobically and under anaerobic con- 97.3 %
ditions. The use of blood culture vials enhance CRP > 1 mg/dl 3 + :24.3 % to
the recovery of Kingella kingae and other organ- 77.2 %
isms [11, 13]. WBC > 11,000/mm3 2 + :4.3 % to
22.7 %
Actually, attempts to isolate this organism on
Increased hip joint 1 + :0.3 % to 9.9 %
routine solid media have failed, whereas inocula- space > 2 mm 0 + :0.1 %
tion into aerobic blood vials recovered the organ- a
ESR erythrocyte sedimentation rate; WBC white blood
ism. It has been postulated that the dilution of cell, CRP c-reactive protein
exudates in a large bottle volume decreases the
concentration of destructive factors improving constitutes the first differential diagnosis of septic
recovery of the organism [22]. The use of DNA- arthritis [50]. In both cases the children can pre-
amplification methods for synovial fluid speci- sent with severe limitation of movement, with the
mens, although still investigational, is likely to hip lying in flexion, abduction and external rota-
become a valuable add-on the diagnosis of cul- tion. The pain is severe and the child will cry on
ture negative disease, mostly for K. kingae any attempt to move the limb. The differential
infections. diagnosis between these two conditions is
extremely important since treatment varies dra-
matically, with simple observation and nonsteroi-
Differential Diagnosis dal anti-inflammatory drugs for transient
synovitis to open arthrotomy and prolonged anti-
In the presence of a typical clinical picture of biotic therapy for septic arthritis.
fever associated with inflammatory signs of the In recent years Kocher, Zurakowski and Kasse
joint and a positive culture of the joint fluid, it is [51] and Jung et al. [40] have published algo-
easy to make a diagnosis of septic arthritis. How- rithms to help differentiate septic arthritis from
ever, this is not the situation in almost 50 % of the transient synovitis of the hip (Table 1). In these
cases seen in our clinics. In these children, Ortho- studies when all the four or five criteria were met
paedic surgeons must be aware of other potential respectively, there was a 99 % chance of the
diagnoses that can resemble septic arthritis. Most child having a septic arthritis. More recent data
of the children will be afebrile and have a normal [50, 52, 53] called attention to the difficulty in
erythrocyte sedimentation rate. evaluating these specific findings. Nevertheless
The most common problems are around the the Orthopaedic surgeon must be aware that clin-
hip, because of the difficulty in observing a joint ical judgment is still necessary in the further
covered by large muscles. Transient synovitis of management of these patients. However patients
the hip is very common in children, and with minimal probability (0 predictive score)
Septic Arthritis in Infancy and Childhood
Table 2 Synovila fluid analysis in differential diagnsis
Diagnosis WBC/mm3 (typical)
Normal <150
Bacterial arthritis >50,000
Tuberculous arthritis 10,00020,000
Candidal arthritis
Viral arthritis 15,000
Rheumatoid arthritis
should be managed by observation only in an
appropriate clinical setting, whereas patients
with high probability (4 or 5) are candidates for
aspiration in the operating room since they may
require surgical drainage.
Peripelvic infections mimicking septic arthri-
tis of the hip in children can be very challenging
in diagnosis and treatment. These conditions
often present a similar clinical picture to septic
arthritis with fever and limitation of the range
of movement of the involved hip [44].
A psoas abscess, although a rare entity, has a
predisposition for children [42, 54, 55] and usu-
ally presents with a positive psoas sign, with the
pain aggravated by extension of the hip and
relieved by flexion, leading to the mis-diagnosis
of hip arthritis. Imaging can be very helpful since
in most of these cases the ultrasound does not
show an intra-articular abscess but may indicate
a psoas abscess, better identifiable either by a CT
scan or MRI [54].
Pyomyositis although a rare condition, has been
rising in temperate countries, associated with the
recent emergency of MRSA, PVL positive strains
[56]. It can lead to misdiagnosis, particularly when
it involves the muscles around the hip [57]. Once
again the physical signs complemented by thor-
ough imaging studies will allow for the differential
diagnosis. Most of these conditions will be treated
by antibiotics and needle aspiration guided either
by ultrasound or CT scan. Juvenile idiopathic
arthritis (JRA) may be acute in onset. In particular
cases, besides the inflammatory local signs, the
child can present with fever mimicking septic
arthritis, when the knee is involved this is particu-
larly evident, making the differential diagnosis
difficult. The child is usually less sick and the
pain is moderate although the joint adopts the
4475
WBC/mm3 (range) % PMNs (typical)
<25
2,000300,000 >90
4036,000 >50 (1099)
75,000150,000 >90
3,00050,000 >90
2,00050,000 >70
defensive flexion contracture. Analysis of the
fluid aspirated from the joint will help differentiate
the diagnosis (Table 2).
Reactive arthritis refers to a sterile joint effu-
sion associated with an extra-articular infection,
noted particularly following episodes of diar-
rhoea caused by Shigella, Salmonella,
Campylobacteria or Yersinia species [58].
All hip diseases related to development such
as Perthes disease or slipped capital femoral
epiphysis should be considered in the differential
diagnosis of septic arthritis although the clinical
course will run without fever.
Septic suppurative bursitis, though a rare
event in children, can be difficult to distinguish
from septic arthritis. It is mostly associated with
trauma and can present with a similar clinical
picture. Ultrasound can be helpful in differentiat-
ing the diagnosis.
Treatment
Septic arthritis is a true emergency that can lead to
devastating effects if not properly treated, with
serious compromise of the musculoskeletal system
(Fig. 5). The cornerstone when dealing with septic
arthritis is fast identification of the condition,
emergency drainage of the joint and appropriate
antibiotics [46]. The outcome is mostly related to
the time spent between the beginning of the symp-
toms and the initiation of therapy. The presence of
osteomyelitis associated with septic arthritis can
be an aggravating factor, and when it is suspected
aspiration of the bone should be considered at the
same time as drainage of the joint [19].
Identification of the responsible organism is
fundamental for correct antibiotic treatment.
4476
a ultrasound-guided aspirations [59] or arthro-
b arthrotomy is indicated if the symptoms do not
Fig. 5 Radiographs showing (a) serious compromise of
the left hip joint secondary to late diagnosis of septic
arthritis complicated by osteomyelitis of the proximal
femur and (b) a newborn with septic arthritis at a follow-
up of 2.5 years with complete necrosis of the femoral head
Drainage by arthrotomy is still the treatment of
choice for a joint effusion with emphasis on
removing a capsular window in order to allow
continued drainage. A drain should be left in
place until the volume of the drainage decreases
(Fig. 6ad).
There have been several recent reports in
the literature supporting either repeated
M.C. Neves et al.
scopic treatment [60, 61]. Treatment of septic
arthritis of the hip joint by repeated ultrasound-
guided aspirations done under sedation was
described by Givon et al. [59]. This treatment
was successful in 24 of 28 patients. In four
cases the patients did not improve and an
arthrotomy was necessary with resolution of the
symptoms. The mean number of aspirations was
3.6 (35) and 75 % of the patients resumed walk-
ing after 24 h. With a mean follow-up of 7.4 years
they report no complications. This method must
be undertaken with care with close follow-up. An
resolve. It is best used when symptoms have been
present for less than 24 h and when the joint fluid
is rich in fibrin. This should allow a proper wash-
out. The advantages of this method are to avoid
the complications of surgery and general
anaesthesia.
Since the advent of arthroscopy, there have
been several reports on surgical drainage by
arthroscopy in adults. Only recently has arthros-
copy been advocated for septic arthritis in children
[60, 61]. Although it has a learning curve, arthros-
copy allows for decompression of the joint, reduc-
tion of the bacterial load and debridement under
direct vision. It also makes it easier to wash out the
joint and allows placing a drain with a minimal
scar. However, particularly at the hip joint, it is
not an entirely benign procedure and should only
be performed by surgeons experienced in this
particular technique [60].
Independent of the type of surgical approach,
children should be followed with care. If surgery
is not followed by a rapid reversal of the clinical
symptoms and normalisation of the vital signs
and the CRP, re-exploration should be consid-
ered, bearing in mind the possibility of associated
osteomyelitis.
Draining the joint fluid is only one part of the
treatment.
Antimicrobial agents play a major role in
the management of septic arthritis and every
department should have an algorithm for the
treatment of this condition. The antibiotic regi-
men should be started immediately after
Septic Arthritis in Infancy and Childhood 4477

a b Lateral femoral cutancous nerve

Sartorius
muscle

Tensor
fasciae
muscle

Incise
and
enter
here

c d
Reflected head of rectus femoris is devided
Reflected head of rectus for improved access to hip capsule
Rectus femoris
femoris muscle
muscle
straight head Kerrison
rongeur

Tensor Tensor
fasciae fasciae
muscle

Fat over
Anterior
joint capsule
hip
capsula
Sartorius Sartorius
Rectus
muscle
femoris

Fig. 6 (a) Skin incision for drainage of the hip. over hip capsule. (d) Division of reflected head of rectus
(b) Exposure of hip between tensor fascia lata and femoris to expose hip capsule adequately prior to
sartorius. (c) Muscle retraction exposing fatty tissue arthrotomy

aspiration of joint fluid. It should be based on
the most common pathogens and rely on local
antimicrobial susceptibilities. Subsequently
should be adapted, according to the results of
the culture.
There are several therapeutic antibiotic pro-
tocols published in the literature [11, 18, 19, 62].
In healthy neonates, group-B Streptococcus is the
most common organism with S. aureus in more
prominent high-risk neonates. Gram-negative
4478
bacilli should also be considered in this age
group. Recommended antibiotic treatment
includes oxacillin plus cefotaxime or gentamicin
for a high-risk neonate (Table 3).
S. aureus is the most common organism in
infants and children no matter what age, and oxa-
cillin should still be considered the treatment of
choice in areas where MRSA is not a concern. In
severe infections gentamicin can be added based
on the synergic effect. Although clindamycin is
a suitable antibiotic to treat osteoarticular infec-
tions (when local clindamycin resistant is below
15 %) we must discourage its use in patients with
methicilin-susceptible or PVL negative S. aureus
infections as a beta-lactam antibiotic is a more
appropriate option [63]. In regions where MRSA
prevalence approaches 1015 %, vancomycin,
or clindamycin should be included for empiric
treatment [64]. A double disk diffusion test
(D-test) can be used to determine if clindamycin-
susceptible CA-MRSA strains harbour inducible
resistance [63].
Infants younger than 3 months of age should be
treated with antibiotics active agains S. aureus,
gram-negative enteric organisms and GBS.
Children 3 months to 5 years of age should
receive empiric therapy for S. aureus, K. kingae,
S. pneumoniae and S. pyogenes. Children older
than 5 years are most likely to be infected with
S. aureus or streptococci. In children younger
than 2 years unimmunized against H. influenza
type b, second or third-generation cephalosporins
should be added to the antistaphylococcal
agent. Also when Kingella kingae is a possibility
the recommended antibiotics should include
cephalosporins or penicillin [31].
For Streptococcus spp. septic arthritis penicil-
lin G or ampicillin is the treatment option. For
penicillin-resistant S. pneumoniae ceftriaxone or
cefotatime can be an alternative but most resistent
S. pneumoniae isolates are susceptible to vanco-
mycin and clindamycin or meropenem. Ceftriax-
one and cefotaxime are appropriated for the
treatment of gonococal infections [65] (Table 3).
The usual course of therapy is 2 weeks for
arthritis due to H. influenzae or Streptococcus
spp. and 3 weeks for arthritis due to S. aureus or
gram-negative bacilli [65].
M.C. Neves et al.
Table 3 Antibiotic doses for children with septic arthritis
Newborn Oxacillin: varies with age
Cefotaxime:50 mg/Kg/dosis/ 812 h
Gentamicin:4 mg/Kg/day in 1 dosis
28 days to 2 Oxacillin: 200 mg/Kg/day in 4 divided
years dosis
Cefuroxime: 150 mg/Kg/day in 3
divided dosis
>2 years Oxacillin: 200 mg/Kg/day in 4 divided
dosis
MRSA Vancomycin 4060 mg/Kg/day in 4
divided dosisa
Clindamycin 40 mg/Kg/day in 3
divided dosis
Neisseria Cefotaxime:100200 mg/Kg/day
gonorrheae divided in 3 to 4 dosis
Ceftriaxone:100 mg/Kg/day 1 dosis
a
Doses should be adapted to vancomycin serum
concentration
Prognosis
In septic arthritis several factors put the child at
risk of a poor result. They include age (prematu-
rity is associated with poor results), delay in
treatment of more than 4 days, concurrent
osteomyelitis (especially around the hip) and
when associated with dislocation of the hip.
The sequelae of septic arthritis are common and
around the hip such complications occur in as
many as 40 % of the children [19]. Most of the
problems are related to loss of movement related
to partial or total destruction of the epiphysis,
osteonecrosis, growth problems with mal-
alignment and progressive limb-length discrep-
ancy, unstable joints or ankylosis.
Long-term follow-up is essential to identify
these potential outcomes. It is a challenge to the
Orthopaedic surgeon to deal with this problem.
He must consider not only the insult to the joint
but also future growth disturbances. This is par-
ticularly true when the hip is involved and espe-
cially in neonates because of the devastating
complications such as complete necrosis of the
epiphysis. Choi et al. [66, 67] developed
a classification to help plan reconstructive sur-
gery in these particular and difficult cases,
Septic Arthritis in Infancy and Childhood 4479

a b

Fig. 7 Radiographs showing (a) non-union of the femoral neck secondary to septic arthritis complicated by osteomy-
elitis of the proximal femur, (b) and (c) treatment by fixation and valgus osteotomy and (d) follow-up at 6 years

utilizing greater trochanteric arthroplasty or pel-

vic support osteotomy (Fig. 7ad).
Appropriately timed epiphysiodesis of the con-
tralateral limb is easy to perform and more suitable
than lengthening the affected limb with all the
risks of increasing pressure around a non-healthy
joint. Ipsilateral epiphysiodesis of the greater tro-
chanter, to establish a more normal anatomy of the
proximal femur, or around the knee to correct
a mal-alignment are simple procedures with very
satisfactory results if performed at the appropriate
time. Arthrodesis or arthroplasty may be indicated
for a painful joint with severe osteoarthritis in later
stages [67, 68, 74].
Summary
Septic arthritis in children is common and can be
devastating if not properly diagnosed and rapidly
treated. The aetiology can be diverse and the
presentation changes according to the age of the
child and the organism present, making diagnosis
difficult. Long term follow-up is needed in order
to prevent late complications.
It is necessary to make an accurate diagnosis
and to undertake prompt treatment with antibi-
otics and surgical drainage to prevent potential
hazards.
4480
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