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Bacterial Arthritis

Septic Arthritis

Bacterial arthritis is predominantly caused by Staphylococcus aureus, streptococci, and Neisseria gonorrhoeae. Joint pain and swelling (involving either one or more joints), as well as fever, are three cardinal symptoms seen in these patients. The diagnosis can be made after a proper physical examination, while the determination of the underlying pathogen is achieved through microbiological studies, primarily in the form of blood and synovial fluid cultures.


Bacterial arthritis or infection of the joints and the articular tissues is encountered across all age groups. Overall, Staphylococcus aureus is the most common cause (although Neisseria gonorrhoeae is the number one cause of septic arthritis in younger adults), but streptococcal species (including S. pneumoniae, S. viridans, S. pyogenes), tuberculosis, and a range of both gram-positive and gram-negative bacteria can be responsible for the infection [1]. Several conditions have been described in the literature as potential risk factors for bacterial arthritis, including diabetes mellitus, previous skin infection, rheumatoid arthritis (RA), human immunodeficiency virus (HIV) type 1 infection, as well as increasing age, joint surgery, intravenous drug abuse, and the presence of hip or knee prostheses [2] [3]. The clinical presentation is centered around three main complaints - joint pain, swelling, and fever (about 40% of patients have a fever of >39C) [3] [4]. Either one (monoarticular) or more than one (polyarticular) joint can be affected. Gonococcal arthritis is typically polyarticular [5]. The pain is often severe and is exacerbated with minimal movement, thus a decreased range of motion is also an important finding [4] [6]. Additional less common features of bacterial arthritis include erythema of the skin over the infected joint, rigors, excessive sweating, and constitutional symptoms [1] [3] [4] [6].

  • We conclude, that the absence of fever, rigors, blood leucocytosis and positive blood cultures does not rule out the possibility of bacterial arthritis.[ncbi.nlm.nih.gov]
  • In patients with cirrhosis and fever, a high index of suspicion is required for joint infection as a potential cause of fever or deterioration in the cirrhotic's patient general condition.[ncbi.nlm.nih.gov]
  • The clinical presentation is centered around three main complaints - joint pain, swelling, and fever (about 40% of patients have a fever of 39C). Either one (monoarticular) or more than one (polyarticular) joint can be affected.[symptoma.com]
  • HIP JOINT KNEE JOINT High Probability Septic Arthritis Fever 38 Pain with micromotion Refusal to bear weight Labs, X-rays, US, Analgesia Ortho Consult 1 hr US - Effusion Effusion Joint Aspiration IV Antibiotics Admit Ortho* OR Admit Pediatrics Equivocal[chop.edu]
  • Gout and pseudogout can also present with pain, inflammation and, occasionally, spiky fevers and chills. The triad of fever, pain and impaired range of motion is typical.[patient.info]
  • With septic arthritis, patients may experience symptoms and signs that include fever , chills , as well as joint pain , swelling , redness , stiffness , and warmth .[medicinenet.com]
  • […] diaper changes) Fever Not able to move the limb with the infected joint (pseudoparalysis) Fussiness Symptoms in children and adults: Not able to move the limb with the infected joint (pseudoparalysis) Severe joint pain Joint swelling Joint redness Fever Chills[mountsinai.org]
  • Septic arthritis symptoms may include: Chills Fatigue and generalized weakness Fever Inability to move the limb with the infected joint Severe pain in the affected joint, especially with movement Swelling (increased fluid within the joint) Warmth (the[webmd.com]
  • The symptoms may include: severe pain that worsens with movement swelling of the joint warmth and redness around the joint a fever chills fatigue weakness decreased appetite a rapid heart rate irritability Certain people are more likely to get infectious[healthtools.aarp.org]
Reiter's Syndrome
  • "Reactive" (sterile) arthritis, formerly known as Reiter's syndrome, may occur following chlamydial genital infection or bacterial gastroenteritis caused by campylobacter, salmonella, and other agents.[clinicaladvisor.com]
  • syndrome Rheumatoid Arthritis Crystal Disease - gout, pseudogout Treatment 1.Depends on organism and host 2.Antibiotics a.Usually begin with oxacillin (nafcillin) or vancomycin b.Add gentamicin initially until culture results back c.Consider broader[enotes.tripod.com]
  • Reactive arthritis (including Reiter's syndrome, psoriatic arthritis, ankylosing spondylitis and arthritis associated with inflammatory bowel disease) often presents with inflammation in a few large joints, distributed asymmetrically.[patient.info]
  • Reactive arthritis (Reiter's syndrome). American Family Physician. Vol. 60(2): 499-503.[consumer.healthday.com]
  • Reiter’s Syndrome and other reactive arthritis: A Current Review. Semen Arthritis Rehm, 1994; 24:190-210. [PubMed] 12. Hughes JG, Vetter EA, Patel R, Schleck CD, Harmsen S, Turgeant LT, Cockerill FR 3rd.[antimicrobe.org]
  • We conclude, that the absence of fever, rigors, blood leucocytosis and positive blood cultures does not rule out the possibility of bacterial arthritis.[ncbi.nlm.nih.gov]
  • Additional less common features of bacterial arthritis include erythema of the skin over the infected joint, rigors, excessive sweating, and constitutional symptoms.[symptoma.com]
  • Fevers are usually low-grade and rigors are only present in a minority of cases.[patient.info]
High Fever
  • —Staphylococcal arthritis: Usually monarticular (seldom polyarticular), staphy-lococcal arthritis affects the knee, hip, shoulder, elbow, wrist, or ankle, and 90% of patients exhibit high fevers.[rheumaknowledgy.com]
  • Neonates and infants may not appear that unwell and may not always have a high fever. Careful examination and clinical suspicion are important.[pmmonline.org]
  • […] on septicaemia large joint(esp hip)  Often in the superficialRather than joint pain joint(knee, wrist or ankle ) o Pseudoparesis Baby is irritable &  Joints painful, swollenrefuse to feed o Child is ill,rapid pulse & inflamed. and swingingfever Tachycardia[slideshare.net]
  • […] vary from case to case, but the following are the most commonly seen signs and symptoms: Severe pain that worsens with movement Swelling of the joint Warmth and redness around the joint Fever Chills Fatigue Weakness Decreased appetite Rapid heart rate (tachycardia[belmarrahealth.com]
  • Clinical manifestations may include vague complaints like irritability, anxiety, failure to thrive, tachycardia and anemia.[omicsonline.org]
  • Twenty patients with culture-proven bacterial arthritis had higher levels of synovial TNF-alpha than patients with osteoarthritis or with inflammatory arthritis, including gouty arthritis, rheumatoid arthritis, reactive arthritis, and lupus arthritis.[ncbi.nlm.nih.gov]
  • These include septic arthritis in rheumatoid arthritis, rheumatic manifestations of bacterial endocarditis, and infectious complications of prosthetic joints.[ncbi.nlm.nih.gov]
  • The 1991 literature on septic arthritis included a concise review of adult septic arthritis, examples of pseudoseptic arthritis, and two interesting animal studies.[ncbi.nlm.nih.gov]
  • In this comparative analysis of laboratory data, we examined the characteristics of synovial fluid leukocytosis in eighty adult patients with bacterial arthritis, reactive arthritis or rheumatoid arthritis of the knee joint.[ncbi.nlm.nih.gov]
  • Bacterial arthritis or infection of the joints and the articular tissues is encountered across all age groups.[symptoma.com]
Joint Effusion
  • In a prospective diagnostic study, 102 consecutive patients with atraumatic joint effusion were included. Synovial fluid glucose concentrations were determined using both glucometer and automated analyzer respectively.[ncbi.nlm.nih.gov]
  • […] on both sides of a joint if left untreated, reactive juxta-articular sclerosis and, in severe cases, ankylosis will develop Ultrasound useful in superficial joints and in children shows joint effusion echogenic debris may be present colour Doppler may[radiopaedia.org]
  • Radiograph: An x-ray that can be useful in initial stages of the disease to show joint effusion. Ultrasound: Useful in children, can be used to show joint effusion.[belmarrahealth.com]
  • In the affected joint, there is moderate to severe pain accompanied by joint effusion, muscle spasm and decreased range of motion. There is also high grade fever.[boneandspine.com]
Joint Swelling
  • There is a fever and joint swelling that is usually in just one joint. There is also intense joint pain, which gets worse with movement.[mountsinai.org]
  • Symptoms may include: Adults: Warm, red, painful joint Joint swelling Problems moving the joint or limb Fever Children: Crying when a joint is moved, such as during a diaper change Warmth and redness Swelling Problems moving a joint or limb Problems walking[cancercarewny.com]
  • Symptoms of septic arthritis usually come on rapidly with intense pain, joint swelling , and fever.[webmd.com]
  • swelling Intense pain in the affected joint Inability to move the limb with the infected joint Warmth - red and warm to touch Fever and chills Fatigue and weakness Diagnosing septic arthritis If an experienced doctor or GP suspects septic arthritis,[yourlegalfriend.com]
  • Early disseminated - weeks after infection with neurological features (facial nerve palsy, meningitis and rarely meningoencephalitis), heart conduction defects and arthralgia.[pmmonline.org]
  • Tenosynovitis and migratory arthralgias are common, and characteristic pustular (often painful) lesions are found on the skin. Fever may be absent, and a minority will have genitourinary, pharyngeal, or rectal symptoms on presentation.[rheumaknowledgy.com]
  • Gonococcal disease usually presents with fever, arthralgia, multiple skin lesions (dermatitis-arthritis syndrome) and tenosynovitis of the hand joints, knees, wrists, ankles and elbows.[patient.info]
  • Tenosynovitis, dermatitis, and polyarthritis syndrome or dermatitis-arthritis syndrome; the initial manifestations include fever, malaise, and arthralgias following an infection of the cervix, urethra, or pharynx.[atsu.edu]
Large Joint Involvement
  • These levels were lower in patients with small joint involvement than in those with large joint involvement. The median creatinine clearance rate was 80 mL/min in 105 patients tested.[medpagetoday.com]
  • The proportion of patients with large joint involvement (hip and particularly knee) was significantly higher in the antibiotics dexamethasone group (92.3%) than in the antibiotics-only group (58.2%).[pediatrics.aappublications.org]


The physician's ability to recognize signs and symptoms of bacterial arthritis through a detailed patient history and a thorough physical examination is essential for making the diagnosis. Information regarding the onset and course of symptoms should be noted, whereas the assessment of preexisting comorbidities that could predispose individuals to this infection is mandatory. Joint pain and swelling, as principal complaints, need to be evaluated during a physical exam, and as soon as valid clinical suspicion is raised, a complete laboratory workup must be conducted. Serum inflammatory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), are often elevated in bacterial arthritis [4]. One of the key steps in solidifying the diagnosis is the analysis of synovial fluid [7]. Many studies have confirmed that the white blood cell count of > 50 × 109/L (with a predominance of polymorphonuclear cells, or PMNs) in synovial fluid is highly indicative of septic arthritis [2] [3] [4]. Furthermore, cultivation of synovial fluid is a definite method for identifying the causative agent of joint infection, and both anaerobic, but more importantly aerobic cultures should be drawn [7]. Gram staining is also described as an important microbiological method in the case of arthritis, but its variable sensitivity is an important limitation [1] [7].

Joint Space Narrowing
  • In later stages, diffuse joint space narrowing due to cartilage destruction may be evident.[patient.info]
  • space narrowing due to destruction of the joint. [8] Ultrasound is effective at detecting joint effusions. [8] CT and MRI are not required for diagnosis; but if the diagnosis is unclear or the joints are hard to examine (ie. sacroiliac or hip joints[en.wikipedia.org]
  • In time significant cartilage damage occurs followed by joint space narrowing. Significant damage to the joint can occur as soon as 3 days in untreated infections.[atsu.edu]
  • As the infection progresses, diffuse joint space narrowing may evolve. In osteomyelitis, the initial finding is also osteopenia, followed by cortical destruction and periosteal new bone formation.[omicsonline.org]
Elevated Sedimentation Rate
  • L ABORATORY DIAGNOSIS The laboratory abnormalities suggestive septic arthritis includes peripheral leucocytosis , elevated sedimentation rate and C-reactive protein.[antimicrobe.org]
Blood Culture Positive
  • cultures Positive in 50-70% of patients with nongonococcal bacterial arthritis Diagnostic if positive Limited usefulness but may be helpful when ruling out other diseases, particularly in children Lower rate of positivity in prosthetic joints Tissue[arupconsult.com]
  • Other important diagnostic tests include blood cultures (positive in 50–70% of acute bacterial arthritides) (27), but in only 30% or less of gonococcal arthritis cases) (38), wound cultures (although these often correlate poorly with synovial fluid culture[the-hospitalist.org]
Listeria Monocytogenes
  • We also look at some unusual microorganisms, eg, group C Streptococcus, Streptococcus viridans, Listeria monocytogenes, Pseudomonas cepacia, Pseudomonas maltophilia, and Neisseria sicca.[ncbi.nlm.nih.gov]
Paracoccidioides Brasiliensis
  • Coccidioides immitis Sporothrix schenckii Blastomyces dermatidis Paracoccidioides brasiliensis Mycobacterial (rare) TB Non-tubercular mycobacterial species -- To view the remaining sections of this topic, please sign in or purchase a subscription -- Last[hopkinsguides.com]


  • The key to successful treatment of acute bacterial arthritis is early diagnosis and initiation of empirical antibacterial therapy. Treatment includes antimicrobial therapy, debridement of the infected joint and treatment of pain.[ncbi.nlm.nih.gov]
  • Thus, we feel that lifelong treatment with antibiotics is a reasonable alternative in cases, where the risk of surgery is very high.[ncbi.nlm.nih.gov]
  • Acute bacterial arthritis continues to be a common occurrence, and despite improved treatment regimens, the prognosis has not improved significantly over the past 20 years.[ncbi.nlm.nih.gov]
  • Rapid diagnosis and treatment may improve the outcome. Semin Arthritis Rheum 31:43-51.[ncbi.nlm.nih.gov]
  • The clinical features, pathophysiology, and treatment of this disorder are reviewed.[ncbi.nlm.nih.gov]


  • Acute bacterial arthritis continues to be a common occurrence, and despite improved treatment regimens, the prognosis has not improved significantly over the past 20 years.[ncbi.nlm.nih.gov]
  • Patients who were older, had a preexisting joint disease, and/or had an infected joint containing synthetic material had the poorest prognosis.[ncbi.nlm.nih.gov]
  • Prognosis: In general, mortality rates are below 5%. Prognosis is poorest in the elderly and those with gram-negative infections, polyarticular involvement, prosthetic joints, or delayed diagnosis.[rheumaknowledgy.com]
  • […] radiographs a fat-fluid level can be a specific sign in the absence of trauma MRI sensitive and more specific for early cartilaginous damage T1 : low signal within subchondral bone T2 : perisynovial oedema C (Gd) : synovial enhancement Treatment and prognosis[radiopaedia.org]


  • […] pain and inflammation (better than acetaminophen) Septic Bursitis 1.Most commonly occurs in olecranon or pre-patellar bursa a.Trauma is major risk factor b.Alcoholism c.Diabetes mellitus d.Typically occurs in middle-aged men involved in manual labor 2.Etiology[enotes.tripod.com]
  • Clinicians are able to deduce the etiology of acute nontraumatic joint pain/swelling within 3-days in most cases, but in an era of “ overdiagnosis ” and “overtreatment” ED providers lack the luxury of a 3-day admission for most monoarticular arthritis[epmonthly.com]
  • Etiology: Most septic arthritis cases are caused by Staphylococcus aureus and streptococci. In neonates and infants younger than 6 months, S aureus and gram-negative anaerobes comprise the majority of infections.[www0.sun.ac.za]
  • Etiology : Most cases of bacterial arthritis are hematogenously disseminated. Others may occur by direct invasion (e.g., trauma) or contiguous spread (e.g., osteomyelitis).[rheumaknowledgy.com]


  • Epidemiology The epidemiology is described above. Prognosis See above. Special considerations for nursing and allied health professionals. NA What's the evidence? Gupta, MN, Sturrock, RD, Field, M.[clinicaladvisor.com]
  • Epidemiology Information concerning the epidemiology of septic arthritis is limited due to several factors.[omicsonline.org]
  • Background Epidemiology Incidence – 2-10/100,000 in the U.S. 30-40/100,000 in patients with rheumatoid arthritis 40-70/100,000 in patients with prosthetic joints Transmission Most cases are hematogenously acquired Other mechanisms for infection Surgery[arupconsult.com]
  • There may be strong epidemiological clues to exposure to unusual pathogens through the travel or occupational history, or there may be a history suggestive of an earlier acute septic arthritis.[emedmd.com]
  • Prompt diagnosis and treatment of infectious arthritis can help prevent significant morbidity and mortality. [ 1 ] Epidemiology Staphylococcus aureus is the most frequent pathogen responsible for septic arthritis in any age group, mainly meticillin-sensitive[patient.info]
Sex distribution
Age distribution


  • Polymerase chain reaction may be an important diagnostic test in culture-negative cases and may be very helpful in understanding the pathophysiology of gonococcal arthritis.[ncbi.nlm.nih.gov]
  • The clinical features, pathophysiology, and treatment of this disorder are reviewed.[ncbi.nlm.nih.gov]
  • We review the pathophysiology of bacterial arthritis, clinical and microbiologic characteristics of its common forms, and current approaches to diagnosis and treatment of this condition.PathophysiologyBacterial arthritis is usually hematogenously acquired[nejm.org]
  • The pathophysiology of septic arthritis – or how the disease occurs – is when organisms such as viruses, bacteria, or fungi enter the joint space directly (as in the case of an injury or injection that breaks the skin) or through the bloodstream from[joybauer.com]
  • Pathophysiology The pathophysiology of bacterial (or fungal) arthritis differs according to the route of entry; that is: Hematogenous (either in the course of a primary bacteremic illness, including endocarditis, or from another focus such as urinary[clinicaladvisor.com]


  • It is important to recognise the coexistence of these two pathologies, so as to avoid a delay in diagnosis and prevent significant morbidity and mortality.[ncbi.nlm.nih.gov]
  • The trend in antibiotic prophylaxis to prevent late infections in total joint replacement is to narrow the targeted hosts to those most at risk, to define the procedures associated with the greatest risk of bacteremia, and to simplify the antibiotic regimen[ncbi.nlm.nih.gov]
  • In a decision-analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be cost-effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients.[ncbi.nlm.nih.gov]
  • Synovectomy, even when performed after 5 days and up to 4 weeks later, could prevent joint destruction in the knee but not in the hip. The average follow-up time was 5 (2-9) years.[ncbi.nlm.nih.gov]
  • Corollary strategies under investigation include corticosteroids to prevent joint damage, monoclonal antibodies to arthritogenic peptides of bacteria or to surface markets of host lymphocytes, and modulators of synovial fluid cytokines.[ncbi.nlm.nih.gov]



  1. Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthritis: review of 190 cases. Clin Infect Dis. 2003;36(3):319-327.
  2. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488.
  3. Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based Diagnostics: Adult Septic Arthritis. Acad Emerg Med. 2011;18(8):781-796.
  4. Smith JW, Chalupa P, Shabaz Hasan M. Infectious arthritis: clinical features, laboratory findings and treatment. Clin Microbiol Infect. 2006;12(4):309-314.
  5. Bardin T. Gonococcal arthritis. Best Pract Res Clin Rheumatol. 2003;17(2):201-208.
  6. Al-Ahaideb A. Septic arthritis in patients with rheumatoid arthritis. J Orthop Surg. 2008;3:33.
  7. Wilson ML, Winn W. Laboratory diagnosis of bone, joint, soft-tissue, and skin infections. Clin Infect Dis. 2008;46(3):453-457.

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Last updated: 2018-06-22 04:49