Emerging treatments

Corticosteroids

Corticosteroids have been introduced as adjuvant therapy in several infectious disease processes. There is some evidence to support their use in septic arthritis, but currently there is insufficient evidence to make a therapeutic recommendation.

Evidence: Corticosteroids in septic arthritis

Evidence is limited on the use of corticosteroids.

  • A systematic review of corticosteroids in septic arthritis published in 2015 (search date November 2014) included 3 studies in humans (all in children, involving a total of 209 participants; 2 were randomised controlled trials (RCTs) and 1 non-RCT) and 3 animal studies.[63] Intravenous corticosteroids reduced the number of days to normalisation of CRP and the duration of antibiotics (meta-analysis of the 2 RCTs; n = 149). The authors concluded that there was a lack of large randomised controlled trial and long-term safety data, and the results were not necessarily generalisable to adults. 

  • A Cochrane systematic review published in 2018 (search date 7 April 2018) on corticosteroids in children with septic arthritis included the same 2 RCTs (n = 149) but reported more outcome measures.[64]

  • At 12 months’ follow-up the risk ratio for absence of pain was 1.33 (95% CI 1.03 to 1.72; P = 0.03) and for normal function of the affected joint was 1.32 (95% CI 1.12 to 1.57; P = 0.001), both favouring corticosteroids.

    • The evidence was rated as low-quality (assessed using GRADE) due to study limitations (high risk of attrition bias and selective reporting) and imprecision.

    • The authors concluded that it is not possible to draw strong conclusions based on these trial results.

  • A 2018 meta-analysis pointed strongly toward a beneficial effect for corticosteroids as adjunctive therapy with antibiotics in children with septic arthritis.[65] Results included fewer days of:

    • Hospitalisation

    • Intravenous antibiotics treatment

    • Oral antibiotics treatment

    • Raised C-reactive protein.

  • The 2006 British Society for Rheumatology guidelines state that if there is any doubt about whether infection might be present, intra-articular corticosteroids should not be used (based on expert opinion).[10]

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