Septic arthritis is usually caused by bacterial infection and results in inflammation of the synovial membrane with purulent effusion into the joint capsule. Gram-positive aerobes are the etiologic agent in 80% of cases, regardless of age group. However, practitioners need to be alert for Neisseria gonorrhea infections in sexually active adolescents who present with tenosynovitis, joint pain, fever, and skin lesions. Sixteen percent of the arthritis-dermatitis infections occur in individuals ages 10 to 19 years old and have a female predominance. Arthritis is the most common systemic complication of N. gonorrhea, usually occurring within 1 month of exposure. Up to two thirds of affected patients have migratory polyarthralgias, while one-quarter have pain in a single joint, with the knee being the most common site of purulent gonococcal arthritis.

Septic arthritis is the most destructive arthritis and empiric therapy is essential. Patients with suspected disseminated gonococcal infections (DGIs) should be hospitalized for initial therapy, particularly if concerns for compliance are raised (i.e., being adolescents), the diagnosis is uncertain (joint and blood cultures are rarely positive once arthritis is present), or if purulent synovial effusions or other complications (i.e., perihepatitis, endocarditis, or meningitis) are present. The Centers for Disease Control and Prevention (CDC) recommends ceftriaxone 1 g intramuscular or intravenous every 24 hours for DGI in patients weighing >45 kg (99 lb). This treatment should be continued for 24 to 48 hours. Once the patient improves, therapy can be switched to oral cefixime, ciprofloxacin, ofloxacin, or levofloxacin for at least
1 week (Table 23.1). Children weighing <45 kg should receive ceftriaxone 50 mg/kg in a single daily dose for 7 days. Parenteral cephalosporins are the only recommended therapy in children because of insufficient data on the efficacy of oral cephalosporins for gonococcal infections in this patient population. Quinolones are relatively contraindicated in children weighing <45 kg due to a theoretic risk of articular cartilage damage. Quinolones should not be used to treat men who have sex with men, or patients with a history of recent foreign travel or partners’ travel, infections acquired in California or Hawaii, or infections acquired in other areas with a high quinolone-resistant N. gonorrhea prevalence. Patients with presumed DGI should also be treated for Chlamydia trachomatis infections. The CDC recommends azithromycin 1 g orally or doxycycline 100 mg twice a day for 7 days for patients with uncomplicated infections. Physicians should also test patients with confirmed gonococcal infections for other STDs, including human immunodeficiency virus.