What is the treatment for septic arthritis of the hip?

Treatment of Septic Arthritis of the Hip

The treatment of septic arthritis of the hip requires immediate surgical drainage or debridement of the joint followed by appropriate antibiotic therapy for 3-4 weeks. 1, 2

Diagnosis and Initial Management

• Obtain synovial fluid for analysis before starting antibiotics:

  • Cell count and differential
  • Gram stain
  • Culture and sensitivity
  • Crystal analysis (to rule out crystal arthropathy)

• Elevated inflammatory markers support diagnosis:

  • C-reactive protein (CRP) >2.0 mg/dL is predictive of septic arthritis
  • Elevated ESR (≥40 mm/hour in pediatric cases)

• MRI with contrast is indicated when:

  • Joint aspiration is inconclusive or technically difficult
  • Evaluation of infection extent beyond joint space is needed

Surgical Management

• Drainage or debridement of the joint space should always be performed 1

• Options for drainage include:

  • Surgical debridement (open procedure)
  • Arthroscopic drainage and debridement
  • Image-guided drainage (ultrasound or CT-guided)

• Arthroscopic treatment has shown excellent results with minimal complications 3

Antibiotic Therapy

Empiric Therapy (before culture results)

• Start empiric antibiotics after obtaining synovial fluid if clinical suspicion remains high
• For suspected MRSA infection:
  • IV vancomycin 1, 2
  • If patient is stable without ongoing bacteremia: clindamycin 10-13 mg/kg/dose IV every 6-8 hours (if local clindamycin resistance rate is <10%) 1, 2

Culture-Directed Therapy

• Adjust antibiotics based on culture and sensitivity results:
  • For MRSA: continue vancomycin or use alternatives (linezolid, daptomycin, TMP-SMX)
  • For MSSA: nafcillin, oxacillin, or cefazolin
  • For gram-negative organisms: appropriate antibiotics based on sensitivity (ceftriaxone, fluoroquinolones)
  • For gonococcal arthritis: ceftriaxone with oral doxycycline 4

Duration and Route of Administration

• A 3-4 week course of therapy is recommended for septic arthritis 1, 2
• For Candida septic arthritis:
  • Fluconazole 400 mg daily for 6 weeks OR
  • An echinocandin for 2 weeks followed by fluconazole for at least 4 weeks 1
• Oral antibiotics can be considered after initial parenteral therapy once clinical improvement is observed 5

Special Considerations

Prosthetic Joint Infections

• Prosthetic device removal is recommended 1
• If the prosthetic device cannot be removed, chronic suppression with fluconazole (if susceptible) is recommended 1
• Longer antibiotic courses are typically required

Concurrent Infections

• Evaluate for concurrent osteomyelitis, especially in pediatric patients
• If osteomyelitis is present, extend antibiotic therapy (minimum 8-week course) 1

Monitoring Response to Treatment

• Monitor inflammatory markers (ESR, CRP) to assess treatment response
• Initial immobilization of the joint followed by early range of motion exercises
• Regular clinical assessment for improvement in pain, swelling, and joint function

Common Pitfalls to Avoid

• Delaying joint drainage while waiting for antibiotics to work
• Failing to obtain cultures before starting antibiotics
• Missing concurrent osteomyelitis
• Inadequate duration of antibiotics
• Premature discontinuation of antibiotics based on clinical improvement alone

Early diagnosis and prompt treatment with both surgical drainage and appropriate antibiotics are essential to restore normal function of the infected joint and prevent permanent joint damage 6.