Septic arthritis
Summary
Definition
History and exam
Key diagnostic factors
- hot, swollen, tender, restricted joint
Other diagnostic factors
- history of intravenous drug use
- history of diabetes
- history of cutaneous lesions
- prosthetic joint
- history of rheumatoid arthritis or osteoarthritis
- acute onset of symptoms
- fever
- low socioeconomic status
- history of alcohol use disorder
- history of previous corticosteroid injection
Risk factors
- underlying joint disease
- joint prostheses
- immunosuppression
- intravenous drug use
- diabetes
- alcohol use disorder
- skin lesions
- previous intra-articular corticosteroid injection
- recent joint surgery
Diagnostic tests
1st tests to order
- synovial fluid Gram stain and culture
- synovial fluid white cell count
- blood culture
- serum white cell count
- erythrocyte sedimentation rate
- CRP
- plain radiograph
- ultrasound
- synovium biopsy for Mycobacterium tuberculosis
Tests to consider
- synovial glucose, LDH, lactate, procalcitonin
- synovial polymerase chain reaction (PCR)
- serum procalcitonin
- Neisseria gonorrhea culture and nucleic acid amplification testing
- MRI
- cardiac ultrasound
Treatment algorithm
prosthetic joint: suspected infection
native joint: suspected infection with negative Gram stain (or Gram stain not available)
native joint: suspected infection with Gram-positive stain and no risk factors for resistant microorganisms
native joint: suspected infection with Gram-positive stain and risk factors for resistant microorganisms
native joint: suspected infection with Gram-negative stain
native joint: confirmed MSSA infection
native joint: confirmed MRSA infection
native joint: confirmed streptococcal infection
native joint: confirmed gram-negative rods infection
native joint: confirmed gonococcal or meningococcal infection
native joint: infection with fungi/tuberculosis/other organisms
Contributors
Authors
Blerta Green, MD
Fellow in Rheumatology
Section of Rheumatology, Allergy, and Immunology
Yale University School of Medicine
New Haven
CT
Disclosures
RTS declares that he has no competing interests.
Robert T. Schoen, MD, MBA
Clinical Professor of Medicine
Section of Rheumatology, Allergy, and Immunology
Yale University School of Medicine
New Haven
CT
Disclosures
RTS declares that he has no competing interests.
Francine Touzard Romo, MD
Associate Professor of Medicine
Division of Infectious Diseases
Warren Alpert Medical School
Brown University
Providence
Rhode Island
Disclosures
FTR declares that she has no competing interests.
Peer reviewers
Andrew Keat, MBBS
Consultant Physician and Rheumatologist
Northwick Park Hospital
Harrow
UK
Disclosures
AK declares that he has no competing interests.
Cheryl Main, MD, FRCPC
Medical Microbiologist
Infectious Disease Consultant
Hamilton Regional Laboratory Medicine Program
Hamilton Health Sciences
Hamilton
Canada
Disclosures
CM declares that she has no competing interests.
John Ross, MD
Brigham and Women’s Hospital
Hospitalist Section
Boston
MA
Disclosures
JR declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Ross JJ. Septic arthritis of native joints. Infect Dis Clin North Am. 2017 Jun;31(2):203-18. Abstract
Earwood JS, Walker TR, Sue GJC. Septic arthritis: diagnosis and treatment. Am Fam Physician. 2021 Dec 1;104(6):589-97.Full text Abstract
Ravn C, Neyt J, Benito N, et al. Guideline for management of septic arthritis in native joints (SANJO). J Bone Jt Infect. 2023;8(1):29-37.Full text Abstract
Benito N, Martínez-Pastor JC, Lora-Tamayo J, et al. Executive summary: guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP and SECOT. Enferm Infecc Microbiol Clin (Engl Ed). 2024 Apr;42(4):208-14.Full text Abstract
American College of Radiology. ACR appropriateness criteria: suspected osteomyelitis, septic arthritis, or soft tissue infection (excluding spine and diabetic foot). 2022 [internet publication].Full text
Mathews CJ, Coakley G; British Society for Rheumatology. Hot joint update 2017. Mar 2017 [internet publication].Full text
Le Vavasseur B, Zeller V. Antibiotic therapy for prosthetic joint infections: an overview. Antibiotics (Basel). 2022 Apr 5;11(4):486.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Osteoarthritis
- Psoriatic arthritis
- Rheumatoid arthritis
More DifferentialsGuidelines
- Guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2024 update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)
- Executive summary: guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP and SECOT
More GuidelinesPatient information
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