Septic arthritis following intra-articular corticosteroid injections: a retrospective analysis

Abstract

Introduction: Septic arthritis is a rare but devastating complication of intra-articular corticosteroid injection (CSI), associated with significant medical morbidity and poor clinical outcomes. Although previous studies have examined risks associated with CSI, few have tracked patients long-term. This study evaluates the incidence, timing, and patient characteristics related to iatrogenic septic arthritis within 6 months of receiving a large joint CSI, offering new insights to inform clinical practice.

Materials and methods: A retrospective, descriptive cohort study was conducted using SlicerDicer, a software stratification system within Epic, to identify patients diagnosed with septic arthritis within six months of receiving an intra-articular CSI of the hip, knee, or shoulder. Data were collected from a single institution over a 10-year period (July 1, 2010 to July 1, 2020). Individual chart review was used to obtain patient demographics, clinical characteristics, and procedural details for identified cases.

Results: Of 15,021 intra-articular corticosteroid injections performed, 14 cases of septic arthritis were identified within 6 months of the procedure, resulting in an incidence rate of 0.093%. Of the affected patients, 21% had underlying inflammatory arthritis, and 21% had underlying comorbidities resulting in immunosuppression. The median time to diagnosis was 3.5 (range 1–16) weeks post-injection, with a bimodal distribution of infections occurring primarily between 1 and 3 and 7–10 weeks post-injection. Staphylococcus aureus (42%) and coagulase-negative Staphylococcus species (36%) were the most commonly isolated organisms.

Conclusions: Large joint intra-articular CSI presents a low risk (< 0.1%) for developing septic arthritis, but can present up to 16 weeks post-injection. The preliminary observation of bimodal timing and delayed presentation of septic arthritis suggests that a standard two-week surveillance window may not be long enough to fully capture all infections, particularly those involving lower-virulence organisms. These findings highlight the need for informed risk stratification and prolonged vigilance well beyond the immediate post-injection period to identify infectious complications after large joint CSI.

Keywords: Corticosteroids; Intra-articular injections; Procedural complications; Septic arthritis.