Recommendations
Urgent
Think 'Could this be sepsis?' based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[16][17][18]
Use a systematic approach, alongside your clinical judgement, for assessment; urgently consult a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis.[16][17][18][19]
Refer to local guidelines for the recommended approach at your institution for assessment and management of the patient with suspected sepsis.
It is important to make an early, accurate diagnosis of infection and use antibiotics appropriately.
Immediately after you have aspirated the joint, taken blood for culture, and taken any necessary swabs or samples for biological processing, (e.g., genitourinary, skin, respiratory), start empiric intravenous antibiotics in patients with suspected septic arthritis (without systemic involvement).[10]
Consult local protocols and local infectious disease services or microbiology regarding prevalent organisms and their sensitivities.[10]
Base antibiotic choice on individual patient demographic and clinical factors; then narrow your treatment when you get the microscopy and Gram stain or PCR results.[9][10][58]
Aspirate the joint to dryness as often as necessary.[10] This helps remove infection and manage pain by relieving pressure within the joint.
Refer patients with:
Suspected sepsis or other system involvement to the medical department (and to the intensive care unit if organ support or close observation is required)
Prosthetic joint (to orthopaedics)[22]
Inaccessible joint such as hip (to emergency physician or orthopaedics and imaging).
Key Recommendations
Inpatient care
Admit the patient for intravenous antibiotic treatment and joint drainage.[10]
Antibiotics
Seek advice from relevant experts in the following situations as there may be local variations in pathogenic organisms and their sensitivities:[9][10]
Likely unusual organisms (microbiology consultant)
Known colonisation of other organs (e.g., cystic fibrosis)
Intravenous drug use (infectious disease consultant).
Switch to pathogen-targeted antibiotics when microbiology culture and sensitivity results become available and continue intravenous treatment for up to a total of 2 weeks or until signs improve, unless there is an inadequate clinical response.[10]
After 2 weeks of successful intravenous treatment start an oral antibiotic with the same spectrum of activity.[10]
Therapeutic joint aspiration
Repeat joint aspiration to dryness as often as necessary.[10] This helps remove infection and manage pain by relieving pressure within the joint.
Guidelines do not stipulate the best method of aspiration to dryness. In UK practice, repeated arthroscopic washouts are indicated if temperature and inflammatory markers do not improve after the initial aspiration and treatment; a non-specialist doctor may perform this procedure if they have been appropriately trained.
Evacuation of pus with arthrocentesis or surgery by a colleague with appropriate training may be necessary.[28]
Analgesia
Prescribe simple analgesics such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID) if the patient reports ongoing pain. Use NSAIDs with caution in older people and people with comorbidities such as hypertension and heart disease. NSAIDs may increase the risk of acute kidney injury in people with sepsis.
Other measures
Monitor response to treatment with serial white cell count/ erythrocyte sedimentation rate/C-reactive protein/procalcitonin levels, for example every 24 to 48 hours or as per your local protocol.
Check renal and hepatic function immediately on admission and then again in 48 hours, unless there is a clinical reason to do it sooner, to ensure other organs are not affected.
There is no evidence to indicate whether splinting or immobilisation is advisable.[10] Follow local protocols.
Failure to improve
If there is inadequate clinical response, discuss the patient with a senior colleague and review the patient for:[10]
Incorrect diagnosis (e.g., crystal-induced arthritis, inflammatory arthritis, osteoarthritis, tumour) and seek specialist advice
Incorrect causative organism (e.g., a commensal was cultured) and seek advice from microbiology
Incorrect antibiotic therapy (e.g., unexpected microbial resistance) and seek advice from microbiology
Infection elsewhere and seek specialist advice
Inadequate pus removal, in which case an arthroscopic or surgical approach is needed by a senior colleague to facilitate:[10]
Biopsy
Repeat culture
Washout
Debridement.
Septic arthritis is a joint-threatening and life-threatening condition.[10]
The goals of therapy are to:[10]
Preserve life
Avoid progression to systemic infection
Preserve joint function
Prevent morbidity associated with complications (e.g., amputation, arthrodesis, prosthetic surgery, severe functional deterioration).
Quick and accurate diagnosis and investigation will facilitate appropriate treatment of infectious arthritis and help prevent significant morbidity and mortality.
Immediately after you have aspirated the joint, taken blood for culture, and taken any necessary swabs or samples for biological processing, (e.g., genitourinary, skin, respiratory), start empiric intravenous antibiotics in patients with suspected septic arthritis (without systemic involvement).[10]
Empirical choice
Consult your local antibiotic protocol to determine the most appropriate choice based on local pathogen prevalence and antibiotic resistance patterns.
Consult a microbiologist or infectious disease consultant in all cases.
Consult with a senior colleague about your decision to start antibiotics at the earliest opportunity.
It is important to make an early, accurate diagnosis of infection and use antibiotics appropriately.
In practice, look for any of the patient’s recent microbiology results, such as past skin swabs, and any past methicillin-resistant staphylococcus aureus (MRSA) screening results. If patients were identified as carrying MRSA, assume that they need treatment which is effective against MRSA.
Take into account individual patient demographic and clinical factors (e.g., age, immunocompromise) as these may indicate the most likely organism.
Chase the urgent microscopy and Gram stain results from the laboratory.
Although your choice of antibiotic will be guided by local protocols, specialist input, and the individual patient, it is worth bearing in mind recommendations for initial empirical treatment for patients with suspected septic arthritis from the British Society of Rheumatology.[10]
Organisms, risk factors, and suggested empirical antibiotics[10]
Patient group | Factors | Intravenous antibiotic |
|---|---|---|
No risk factors for atypical organisms (staphylococci or streptococci account for 91% of cases)[4][5] |
| Flucloxacillin. Local policy may be to add gentamicin |
High risk of gram-negative organisms |
| Second- or third-generation cephalosporin. Local policy may be to add flucloxacillin |
MRSA risk |
| Vancomycin plus a second- or third-generation cephalosporin |
Suspected gonococcus |
| Ceftriaxone |
Unusual organisms or antimicrobial resistance |
| Discuss with microbiologist or infectious disease consultant |
Anaerobic organisms | Discuss with microbiologist or infectious disease consultant | |
Lyme arthritis[14] |
| Doxycycline or amoxicillin |
Gram stain- or polymerase chain reaction (PCR)-directed antibiotics
Consider narrowing the spectrum of intravenous antibiotics in light of Gram stain results, PCR results, local protocols, and specialist advice.[9][10][58]
Gram staining of synovial fluid is essential for early, targeted antibiotic therapy; perform as soon as possible to guide antibiotic choice.[10]
Pathogen-targeted antibiotics
Switch to pathogen-targeted antibiotics in line with microbiology culture and sensitivity results when they become available.[9][10][58]
Always consult a microbiologist or infectious diseases consultant about appropriate antibiotic choices, route and duration in line with local protocols.
Continue intravenous therapy for 2 weeks. Although there is no specific evidence base to support this duration, it is usual practice to continue intravenous therapy for 14 days before switching to oral antibiotics.[10]
Note that treatment duration varies for some organisms (e.g., Neisseria gonorrhoeae or Borrelia burgdorferi).
If there is inadequate clinical response, review the patient with a senior clinician (see our Failure to improve section).
Oral antibiotics
After 2 weeks of intravenous therapy start oral antibiotics that:
Have the same spectrum of activity as the intravenous antibiotics that achieved clinical response
Are known to achieve adequate intra-articular concentrations.[10]
Follow your local antibiotic protocols.
Practical tip
Check for signs of re-emerging infection 24 to 48 hours after starting oral antibiotic treatment and before discharging the patient home.
Continue oral antibiotics for a further 4 weeks, although there is no specific evidence base to support this duration.[10]
Note that treatment duration may vary for some organisms (e.g., N gonorrhoeae or B burgdorferi).
Evidence: Duration of antibiotics
Evidence suggests that it may be safe to reduce the duration of intravenous antibiotics (with earlier switching to the oral route) and the overall duration of antibiotic therapy for patients with joint infections.
Current British Society for Rheumatology guidelines (published in 2006) state that the joint should be aspirated to remove pus, and that antibiotics are conventionally (based on expert opinion) given intravenously for up to 2 weeks or until signs improve, then orally for around 4 weeks to achieve adequate joint and bone concentrations.[10]
Despite this convention, a large randomised controlled trial (RCT) found that switching to oral antibiotic therapy at an earlier stage has similar results in selected patients.
The Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA) trial (published in 2019) is an RCT of over 1000 adults with osteomyelitis, native or prosthetic joint infection, or orthopaedic fixation-device infection, who would conventionally have been treated with 6 weeks of intravenous antibiotic therapy in addition to surgical intervention.[59]
Patients were randomised to 6 weeks or 1 week of intravenous antibiotic therapy, followed by oral therapy, mostly after surgical debridement or removal of infected prosthetic joints.
The difference in the risk of definitive treatment failure at 1 year (oral group vs. intravenous group) in the intention-to-treat population was -1.4 percentage points (95% CI -5.6 to +2.9), indicating non-inferiority of the oral regimen.
Longer intravenous therapy was associated with significantly longer hospital stay (median 14 [interquartile range: 11 to 21] days vs. 11 [8 to 20] days, P <0.001) and more complications associated with the intravenous catheter (49 of 523 [9.4%] vs. 5 of 523 [1.0%], P <0.001).
However, the authors note that oral antibiotic therapy may not be appropriate for some patients (e.g., those with poor enteral absorption) and some pathogens (e.g., those with resistance to oral agents).
Expert commentary in a UK National Institute of Health Research (NIHR) signal suggests that this research is potentially significant for patients and the National Health Service (NHS) in the UK because of the freedom afforded to patients and the potential cost savings to the NHS.[59][60]
Another RCT (also published in 2019) found no significant difference in remission of infection in patients (total 154) after surgical drainage of native joint bacterial arthritis (mostly in the hand and wrist) receiving 2 weeks versus 4 weeks of total antibiotic therapy.[61]
Patients receiving 2 weeks of antibiotic therapy received this intravenously for a median of 1 day, while those receiving 4 weeks of therapy received this intravenously for a median of 2 days.
The primary outcome for this study was the remission of infection (defined as a complete absence of clinical, laboratory, or radiological findings after a minimum follow-up of 2 months), which was achieved by 99% of patients in the 2-week group and 97% in the 4-week group (not significantly different).
There was no difference between the groups in the number of adverse events or mechanical or neurological sequelae.
Aspirate the joint to dryness as often as necessary.[10]
This helps remove infection and manage pain (caused by acute increase in pressure) by relieving pressure within the joint.
Guidelines do not stipulate the best method of aspiration to dryness. In UK practice, repeated arthroscopic washouts are indicated if temperature and inflammatory markers do not improve after the initial aspiration and treatment; a non-specialist doctor may perform this procedure if they have been appropriately trained.
How to aspirate synovial fluid from the knee and administer intra-articular medication using a medial approach.
How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.
Practical tip
In practice, you can use as many syringes as necessary to aspirate the joint to dryness. Simply detach the first syringe from the needle and attach the next using aseptic technique. Note that the larger the syringe (e.g., 20 mL) the larger the force required to aspirate, especially if the synovial fluid is very thick.
Evacuation of pus with arthrocentesis or surgery may be necessary, particularly if the pus is thick or dry.[10][28] In practice, a senior colleague with the appropriate skills may be required to perform this procedure.
To assess clinical response, send subsequent joint aspirates for:[9]
White cell count
Polymorphonuclear cell count
Gram stain
Culture.
Refer patients with:
Prosthetic joints to orthopaedic surgery[10][22]
Do not attempt to aspirate synovial fluid from a prosthetic joint
Inaccessible joints (e.g., hip) to an emergency physician or orthopaedics and imaging.[10]
There is no evidence to indicate whether splinting or immobilisation is advisable.[10] Follow local protocols.
Analgesia
Prescribe simple analgesics such as paracetamol or a non-steroidal anti-inflammatory drug (NSAID) (e.g., ibuprofen, diclofenac) if the patient reports ongoing pain.
Practical tip
Beware of prescribing opioids prior to joint aspiration in older people, because respiratory depression may occur when the painful stimulus is removed.[62]
Be cautious when prescribing NSAIDs to older people and people with comorbidities such as hypertension and heart disease. NSAIDs may increase the risk of acute kidney injury in people with sepsis.
Monitor response to treatment with serial white cell count, erythrocyte sedimentation rate, C-reactive protein, and procalcitonin concentrations, for example every 24 to 48 hours or as per your local protocol.
Check renal and hepatic function to ensure other organs are not affected. Guidelines do not stipulate how often to measure these functions. In practice, measure urea, creatinine, electrolytes, and liver function tests at the time of presentation and then every 24 to 48 hours for as long as the patient is unwell or receiving medication that may affect renal or liver function.
Guidelines do not give specific recommendations on how to measure clinical improvement. In practice, pain usually reduces quickly with correct treatment. Worsening of any symptom (including fever, confusion, pain, swelling, etc) warrants a review from a senior colleague.[10] Be aware that you should allow about 48 hours for the effectiveness of treatment to be reflected in some investigation results.
For example, a rise in white blood cell (WBC) count the day after an aspiration does not necessarily indicate treatment failure. However, when looking at a trend in results, a sudden rise in the WBC count when it was otherwise decreasing would be cause for concern.
Discuss with a senior colleague any patient who does not improve as expected.
If there is an inadequate response to antibiotics and drainage, review the patient for:[10]
Incorrect diagnosis (e.g., crystal-induced arthritis, inflammatory arthritis, osteoarthritis, tumour) and seek specialist advice
Incorrect causative organism (e.g., the culture may be a false positive, or a commensal) and seek advice from microbiology
Incorrect antibiotic therapy (e.g., due to microbial resistance) and seek advice from microbiology
Infection elsewhere and seek specialist advice
Inadequate pus removal, in which case an arthroscopic or a surgical approach is needed (with assistance from a senior clinician) to facilitate:[10]
Biopsy
Repeat culture
Washout
Debridement.
Intravenous antibiotics can be administered in the community if the patient has the necessary support and this resource is available in your area.
Practical tip
If the patient is receiving intravenous treatment at home, ensure follow-up in the community to check for signs of re-emerging infection 24 to 48 hours after starting oral antibiotic treatment.
Continue oral antibiotic therapy for 4 weeks.[10]
Arrange an outpatient appointment for the patient with the parent team (orthopaedics or rheumatology as local policies dictate).
Encourage movement as symptoms allow. Arrange for physiotherapy to start as soon as possible.
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