critically ill Definitive treatment is ultimately based on the identification and sensitivity of recovered isolates A third-generation cephalosporin or the addition of an aminoglycoside is indicated in the neonatal age group Suggested agents are listed in Table 121.1 Early aggressive antibiotic therapy frequently prevents the need for surgical intervention The duration of hospitalization is determined by the organism involved, the clinical response to treatment, and decreasing CRP levels SEPTIC ARTHRITIS Goals of Treatment The presence of bacterial pathogens within the articular capsule presents a true surgical emergency Delay in the identification and treatment of an infected joint in a child can result in severe and permanent sequelae Early initiation of treatment can preserve normal function of the joint and prevent destruction or ischemic changes due to excessive pressure buildup from the infection Improved outcomes are associated with reduced time to initiation of antibiotic therapy and time to surgery for the septic hip The urgency associated with this diagnosis has given rise to the maxim, “The sun should never rise or set on a septic hip.” The evaluation focuses on distinguishing septic arthritis from more benign causes of joint pain that not require invasive forms of identification and treatment CLINICAL PEARLS AND PITFALLS Resistance or pain with movement of the joint is the principal clinical finding A septic hip is commonly held in abduction and external rotation Inflammatory markers can be helpful in distinguishing inflammatory from infectious etiologies Ultrasound cannot distinguish an inflammatory effusion from an infectious one, but the lack of a joint effusion can rule out septic arthritis Fever is more common with septic arthritis than transient synovitis Lyme disease most commonly manifests as monoarticular arthritis of the knee and most children are still able to ambulate Arthrocentesis is the definitive means of identifying septic arthritis