The classical presentation of infectious arthritis is acute onset of pain, warmth and swelling of a single joint.
The range of motion is usually decreased.
The knee is the most commonly affected but any joint may be involved.
Fever and chills may be present.
More than 1 joint may be involved in patients with pre-existing joint disease, other inflammatory conditions or severe sepsis, and in some patients infected with certain pathogens eg N gonorrheae, N meningitidis and Salmonella spp.
Infectious arthritis must always be a part of the differential diagnosis in a patient with an acute monoarthritis. 

Principles of Therapy

Principles of antibiotic therapy

  • Appropriate antibiotic treatment should be started once specimens for microbiology studies are submitted
  • Broad-spectrum antibiotics are recommended while culture results are pending because of the serious & destructive nature of the infection
  • Antibiotics should be given by the parenteral route initially
  • Antibiotic therapy should be revised once results of culture & antimicrobial susceptibility are available

Factors affecting choice of antibiotics for empiric therapy

  • Age of patient
  • Clinical history, physical examination findings, risk factors
  • Results of synovial fluid Gram stain
  • Ability of antibiotic to penetrate joint
  • Likely pathogens causing infectious arthritis & their local antimicrobial susceptibility patterns (see below)


Antibiotics for empiric parenteral therapy

Adults: Based on results of synovial fluid Gram stain

    Gram Stain Result Recommended Empiric Antibiotics
    Gram-positive cocci, community-acquired infection or w/o risk for Methicillin-resistant Staphylococcus aureus (MRSA)  Vancomycin
    Gram-positive cocci, hospital-acquired or w/ other risk for MRSA Vancomycin or Clindamycin*
    Gram-negative bacilli 3rd Generation Cephalosporin (Ceftazidime, Ceftriaxone, Cefotaxime) w/ or w/o Aminoglycoside
    Gram-negative cocci Ceftriaxone

*If patient’s isolate turns out to be susceptible to Clindamycin but resistant to Erythromycin, a D test should be done to check for the presence of inducible Macrolide-Lincosamide-Streptogramin B resistance

Adults: Based on patient’s clinical profile

  • Recommendations below may be used to guide antibiotic choice if Gram-negative
    Clinical Profile Recommended Empiric Antibiotics
    No risk factors for atypical organisms Flucloxacillin
    Immunocompetent Vancomycin
    Immunocompromised patients, injection drug users, traumatic bacterial arthritis Vancomycin w/ 3rd generation cephalosporin or an aminoglycoside
    Risk factors for MRSA infection (eg catheters, recent hospital confinement) Vancomycin*
    N gonorrhoeae infection suspected Ceftriaxone

* If patient has allergy or drug intolerance to Vancomycin, Daptomycin, Linezolid, Clindamycin or TMP-SMX are reasonable alternatives

Children: Based on age

    Age of Child Probable Pathogen Recommended Empiric Antibiotics
    Neonate S aureus, Group B streptococci, Gm negative bacilli Antistaphylococcal Penicillin (Nafcillin*, Vancomycin or Clindamycin)**
    plus Cephalosporin (3rd generation) plus Aminoglycoside
    ≤ 5 years old S aureus, S pneumoniae, S pyogenes, H influenzae, K kingae Antistaphylococcal Penicillin (Nafcillin*, Vancomycin or Clindamycin)** plus
    Cephalosporin (2nd or 3rd generation)
    Extended-spectrum Penicillin w/ or w/o β-lactamase inhibitor
    >5 years old S aureus, S pyogenes, S pneumoniae, Group A streptococci Antistaphylococcal Penicillin (Nafcillin*, Vancomycin or Clindamycin)**
    Adolescent, sexually active N gonorrhoeae (Nafcillin*, Vancomycin or Clindamycin)**
    Cephalosporin (3rd generation) (Ceftriaxone, Cefotaxime)

*Nafcillin may be used if <10% of community-acquired S aureus isolates are Methicillin-resistant

**Vancomycin or Clindamycin may be used for empiric treatment if >10% of community-acquired S aureus isolates are Methicillin-resistant

Duration of treatment

  • Parenteral antibiotics are usually given for 2 weeks followed by oral antibiotics for 2 to 4 weeks
  • Duration of antibiotic therapy depends on the site of infection, presence of adjacent osteomyelitis, etiologic agent, clinical & laboratory response
    • Arthritis from S aureus & Gram negative organisms may require longer treatment durations compared to arthritis from S pneumoniae, S pyogenes & H influenzae, P aeruginosa, Enterobacter spp
    • 7-10 days of antibiotic treatment is required for gonococcal arthritis
    • Infectious arthritis of the hip & spine may require a longer period of antibiotic therapy

Oral antibiotic therapy

  • Treatment for infectious arthritis may be continued using oral antibiotics once infection & inflammation are adequately controlled
  • An oral antibiotic w/ appropriate antimicrobial coverage should be chosen
  • Adherence to oral antibiotic regimen should be ensured as well as careful patient monitoring
  • Oral antibiotics often used in infectious arthritis treatment include Cloxacillin, Dicloxacillin, Cefalexin, Clindamycin, Quinolones
  • Oral regimen should have the same coverage as the IV/IM drug that produced improvement of symptoms
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Infectious Diseases - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
Tristan Manalac, 06 Nov 2018
Intravenous cefiderocol thrice daily is noninferior to imipenem-cilastatin for treating complicated urinary tract infection (UTI) patients with multidrug-resistant, Gram-negative infections, according to a recent study.
01 Nov 2018
Genotype 4 hepatitis E virus infection does not appear to be correlated with acute, nontraumatic neurologic disorders, according to a recent China study.
01 Nov 2018
In patients with genotype 3 hepatitis C virus (HCV) infection and decompensated cirrhosis, the rate of achieving sustained virologic response 12 weeks after treatment (SVR12) is high with treatment regimens consisting of sofosbuvir and velpatasvir with or without ribavirin, according to the results of a phase II trial. However, the rate appears to be lower in the subgroup of patients with baseline resistance-associated substitutions in nonstructural protein 5A.
07 Nov 2018
In infants with early-life acute respiratory infection (ARI) with respiratory syncytial virus (RSV), elevated nasopharyngeal Lactobacillus levels protect against wheezing illnesses at 2 years of age, a recent study has found.