# Septic Arthritis (Emergency Referral) - Category: infectious - Review status: reviewed (every claim checked against a document named on this page) - Sources: BSR guideline scope: Management of septic arthritis in adults with a hot swollen joint (Rheumatol Adv Pract 2025;9(3):rkaf058) · BSR/BHPR/BOA/RCGP/BSAC guideline for management of the hot swollen joint in adults (Coakley et al, Rheumatology 2006;45:1039-41) · Knee Arthrocentesis - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK470229/ · No dose - emergency referral pathway, no medicine given in primary care · Septic Arthritis: Diagnosis and Treatment (Am Fam Physician 2021;104(6):589-597) - Verified date: 2026-08 ## Verified against - No dose - emergency referral pathway, no medicine given in primary care ## Treatment metadata - No drug therapy in primary care (Emergency Referral) ## Complete treatment card ```text SEPTIC ARTHRITIS (EMERGENCY REFERRAL) Sources: BSR guideline scope: Management of septic arthritis in adults with a hot swollen joint (Rheumatol Adv Pract 2025;9(3):rkaf058) · BSR/BHPR/BOA/RCGP/BSAC guideline for management of the hot swollen joint in adults (Coakley et al, Rheumatology 2006;45:1039-41) · Knee Arthrocentesis - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK470229/ · No dose - emergency referral pathway, no medicine given in primary care · Septic Arthritis: Diagnosis and Treatment (Am Fam Physician 2021;104(6):589-597) Review status: REVIEWED against the source listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Sudden onset of pain confined to one joint, with fever, is the classic presentation [fever] - A young sexually active adult with a shifting pattern of joint pain suggests gonococcal arthritis [joint pain] - In children, local joint symptoms may occur alone or together with systemic illness - A child refusing to move or bear weight on the joint is a key local complaint [refusing to use a limb] - Ill appearance with fussiness and poor appetite are systemic complaints in affected children [poor appetite] SIGNS - what you find (5) - The knee is affected more often than any other joint, followed by hip, shoulder, and ankle - A joint effusion with limited motion and pain on palpation is typical on exam [joint swelling] - A single swollen joint points more toward staph infection, while multiple joints raise suspicion for gonococcus [joint swelling] - A draining sinus tract is typical when a prosthetic joint is infected - Skin lesions, tendon sheath inflammation, and non-erosive joint changes can accompany gonococcal infection [skin lesions] TESTS (8) - A joint fluid white cell count above 50,000 with over 90 percent neutrophils points to a bacterial cause - Growing an organism from the joint fluid confirms the diagnosis - A joint fluid cell count can be falsely low with leukopenia, an early infection, gonococcal disease, or a prosthesis in place - In an infected prosthetic joint, a fluid count near 1100 cells with 64 percent neutrophils is enough to suggest infection - Two blood culture sets should be drawn to check for bloodstream spread - A plain X-ray showing widened joint space or soft tissue bulging supports the diagnosis, but a normal film does not exclude it - MRI picks up early joint fluid and can show how far the infection has spread into surrounding tissue - A bone scan cannot tell infection apart from a sterile inflammatory process IF NOT THIS - what else fits (4) - Gout, pseudogout, and other crystal deposits can inflame a single joint the same way infection does - A joint fracture, meniscal tear, or retained foreign body can mimic an infected joint - Rheumatoid arthritis and the spondyloarthropathies belong on the differential for an inflamed joint - Bleeding into a joint from a clotting disorder or anticoagulant use can resemble septic arthritis Score Kocher criteria - Septic arthritis, or transient synovitis of the hip? Source StatPearls "Septic Arthritis" - disease-level clinical article Status traced to the source above 1. NO DRUG THERAPY IN PRIMARY CARE (EMERGENCY REFERRAL) [1st line] Adult Same-day referral to a hospital specialist who can aspirate the joint. Do NOT start an antibiotic in the clinic first. - Immediate same-day referral Peds The BSR guideline covers adults only; a separate BSR guideline for the hot, swollen or stiff joint in children and young people is still in development. Refer any child with a hot, swollen, painful joint, or a limp with fever, the same day. Do not start an antibiotic first. Source No dose - emergency referral pathway, no medicine given in primary care Why BSR 2006 grade B: the synovial fluid must be aspirated, Gram-stained and cultured prior to starting antibiotics. An antibiotic given before aspiration can sterilise the sample, so the organism is never identified and the six-week course cannot be targeted. BSR 2006 grade C: GPs should refer to a specialist within the hospital who has the expertise to aspirate the joint. Untreated or delayed, the joint is destroyed; the 2006 guideline reports a case fatality of 11%. Caution DO NOT give an antibiotic before the joint is aspirated - it sterilises the sample and the organism is then never identified (BSR 2006, grade B). TIME-CRITICAL: treat any acutely hot, swollen, painful joint as septic until aspiration proves otherwise, even when gout or a flare of known arthritis looks more likely. Normal CRP, ESR or white cell count DO NOT exclude septic arthritis, and neither does the absence of fever (BSR 2025 scope). A prosthetic or otherwise non-native joint must go to an orthopaedic surgeon, and must not be aspirated outside a sterile environment (BSR 2006 grade C; BSR 2025 scope). Risk is higher with previous joint surgery, prosthetic joint, recent joint injection, rheumatoid arthritis, skin infection or ulcer, diabetes, and immunosuppression. If the patient is also systemically unwell with signs of sepsis, the sepsis pathway takes priority - see Suspected Sepsis - and antibiotics should not be withheld waiting for aspiration. In a sexually active adult consider gonococcal septic arthritis, which can present with migratory joint pain, tenosynovitis and a rash (Am Fam Physician 2021). Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)