If not promptly diagnosed and adequately treated, septic arthritis in children may be a devastating disease, causing prolonged morbidity and crippling long-term sequelae. Isolation and identification of the causative organism and performance of antibiotic susceptibility testing are crucial factors in making the right therapeutic choice (Trujillo and Nelson, 1997).
In the preantibiotic era, Gram-positive organisms and especially Staphylococ-cus aureus and Streptococcus pyogenes were the most common bacteria isolated from patients with joint infections (Almquist, 1970). With the advent of antimicrobial drugs the incidence of 6-hemolytic streptococci declined, leaving S. aureus as the predominant skeletal system pathogen. In the 1960's, introduction of chocolate-agar plates for the routine culture of synovial fluid specimens resulted in the recognition of Haemophilus influenzae type b as the most common etiology of septic arthritis in young children (Almquist, 1970). Unfortunately, even when chocolate-agar media were routinely employed, the etiology of septic arthritis remained undetermined in a substantial proportion of cases. In 5 large series of pediatric patients with septic arthritis published between 1984 and 1999, no pathogen was isolated in 346 of 1,042 patients (33.2%) (Peltola and Vahvanen, 1984; Speiser et al., 1985; Welkon et al., 1986; Barton et al., 1987; Trujillo and Nelson, 1997).
Failure to isolate the causative organism may be the result of an incorrect diagnosis or previous administration of antibiotic therapy. However, the possibility that some cases of "culture-negative" septic arthritis are caused by fastidious organisms that are not detected by conventional bacteriological methods should also be entertained.
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