Treatment of Septic Arthritis and Abscess
The treatment of septic arthritis requires immediate surgical debridement combined with appropriate antibiotic therapy, while abscesses must be drained within 12 hours of diagnosis using the least invasive effective approach. 1, 2
Diagnosis and Initial Assessment
- Septic arthritis is an orthopedic emergency requiring prompt diagnosis and treatment to prevent cartilage damage and permanent joint dysfunction 1
- Joint aspiration is the definitive diagnostic procedure with synovial fluid white blood cell count ≥50,000 cells/mm³ suggestive of septic arthritis 1
- Synovial fluid culture is positive in approximately 80% of non-gonococcal septic arthritis cases 1
- Imaging with ultrasound (especially for hip joints) and MRI may help detect joint effusions, soft tissue involvement, and concomitant osteomyelitis 1
Surgical Management
- Immediate surgical debridement is essential for septic arthritis treatment 1
- Arthrotomy, irrigation, and debridement are the standard surgical interventions 1
- Arthroscopic debridement is effective in treating septic arthritis with success rates of 91% when combined with appropriate antibiotic therapy 3
- For abscesses, source control measures should be implemented within the first 12 hours after diagnosis 2
- The least invasive effective intervention should be used (e.g., percutaneous rather than surgical drainage of an abscess) 2
- Multiple counter incisions are preferred over a single long incision for large abscesses to prevent wound healing delays 2
Antibiotic Therapy
- Empiric broad-spectrum antibiotic therapy should be initiated after obtaining cultures 2
- IV vancomycin is recommended as first-line therapy for adults with septic arthritis, particularly when MRSA is a concern 1
- Clindamycin is indicated for bone and joint infections including acute hematogenous osteomyelitis caused by Staphylococcus aureus 4
- Duration of antibiotic therapy is typically 3-4 weeks for uncomplicated septic arthritis 1
- Longer courses (12 weeks) are recommended for prosthetic joint infections 1
Specific Pathogen Considerations
- Staphylococcus aureus is the most common pathogen in septic arthritis 5
- In children <4 years, Kingella kingae should be considered 1
- In patients with sickle cell disease, Salmonella species should be considered 1
- For MRSA infections, adding rifampin to the regimen may be beneficial due to its excellent penetration into bone and biofilm 1
Management of Abscesses
- Common sites of complex abscesses include perianal, perirectal, and intravenous drug injection sites 2
- Empiric broad-spectrum antibiotic therapy with coverage of Gram-positive, Gram-negative, and anaerobic bacteria is recommended for complex abscesses 2
- Antibiotic therapy is indicated if systemic signs of infection are present, in immunocompromised patients, if source control is incomplete, or in cases of abscess with significant cellulitis 2
- For abscesses in injection drug users, consider potential contamination from the user (oropharynx, skin, or feces) and the environment 2
- Evaluate for endocarditis if persistent signs of systemic infection are present in injection drug users 2
Pitfalls and Caveats
- Negative joint aspirate culture does not rule out infection; consider percutaneous bone biopsy if clinical suspicion remains high 1
- Concomitant osteomyelitis occurs in up to 30% of children with septic arthritis and requires longer treatment 1
- Delay in diagnosis and treatment can result in permanent morbidity and mortality 5
- For persistent or recurrent joint swelling after a course of antibiotics, re-treatment with another 4-week course of oral antibiotics or 2-4 weeks of IV ceftriaxone is recommended 1
- Foreign bodies, such as broken needles, should be ruled out by radiography in injection drug users 2