Septic arthritis medical therapy: Difference between revisions

Jump to navigation Jump to search
No edit summary
m (Bot: Removing from Primary care)
 
(73 intermediate revisions by 7 users not shown)
Line 1: Line 1:
__NOTOC____NOEDITSECTION__
__NOTOC__
{{Septic arthritis}}
{{Septic arthritis}}
{{CMG}}; {{AE}} Jumana Nagarwala, M.D., ''Senior Staff Physician, Department of Emergency Medicine, Henry Ford Hospital''; {{CZ}}; {{AL}}
{{CMG}}; {{AE}}{{AL}}{{VSKP}}


==Overview==
==Overview==
Acute non-[[gonococcal]] septic arthritis is a medical emergency requiring prompt drainage followed by empiric antimicrobial therapy according to patient's history, clinical presentation, and [[synovial fluid]] analysis. '''[[Vancomycin]]''' is recommended as empirical therapy for patients with [[Gram-positive cocci]] on a [[synovial fluid]] [[Gram stain]] or as a component of regimen for those with a negative [[Gram stain]] if [[MRSA|methicillin-resistant ''Staphylococcus aureus'' (MRSA)]] is prevalent.  If [[Gram-negative bacilli]] are observed, an anti-[[pseudomonal]] [[cephalosporin]] (e.g., '''[[ceftazidime]]''', '''[[cefepime]]''') should be administered.  '''[[Carbapenems]]''' should be considered in conditions such as colonization or infection by [[ESBL|extended-spectrum β-lactamase]]–producing pathogens.  [[Antibiotic]] regimen may be deescalated as culture results and susceptibility tests permit.  The optimal duration of therapy for septic arthritis remains uncertain.  A minimum 3- to 4-week course is suggested for septic arthritis caused by ''[[S. aureus]]'' or [[Gram-negative bacteria]].  The use of [[corticosteroids]] or intraarticular [[antibiotics]] is not advisable.<ref>{{Cite journal| doi = 10.1016/S0140-6736(09)61595-6| issn = 1474-547X| volume = 375| issue = 9717| pages = 846–855| last1 = Mathews| first1 = Catherine J.| last2 = Weston| first2 = Vivienne C.| last3 = Jones| first3 = Adrian| last4 = Field| first4 = Max| last5 = Coakley| first5 = Gerald| title = Bacterial septic arthritis in adults| journal = Lancet| date = 2010-03-06| pmid = 20206778}}</ref><ref>{{Cite journal| doi = 10.1007/s11926-013-0332-4| issn = 1534-6307| volume = 15| issue = 6| pages = 332| last1 = Sharff| first1 = Katie A.| last2 = Richards| first2 = Eric P.| last3 = Townes| first3 = John M.| title = Clinical management of septic arthritis| journal = Current Rheumatology Reports| date = 2013-06| pmid = 23591823}}</ref>
Acute nongonococcal septic arthritis is a medical emergency which causes severe joint destruction and may increase both morbidity and mortality. So prompt diagnosis and treatment with antibiotic therapy and prompt drainage which reduces long-term complications. '''[[Vancomycin]]''' is recommended as either empirical therapy for patients with [[Gram-positive cocci]] on a [[synovial fluid]] [[Gram stain]] or as a component of regimen for those with a negative [[Gram stain]] if [[MRSA|methicillin-resistant ''Staphylococcus aureus'' (MRSA)]] is prevalent.  If [[Gram-negative bacilli]] are observed, an anti-[[pseudomonal]] [[Cephalosporin]] (e.g., '''[[Ceftazidime]]''', '''[[Cefepime]]''') should be administered.  '''[[Carbapenems]]''' should be considered in conditions such as colonization or infection by [[ESBL|extended-spectrum β-lactamase]]–producing pathogens.  The optimal duration of therapy for septic arthritis remains uncertain.  A minimum 3- to 4 week course is suggested for septic arthritis caused by ''[[S. aureus]]'' or [[Gram-negative bacteria]].  The use of [[Corticosteroids]] or intraarticular [[antibiotics]] is not advisable.<ref>{{Cite journal| doi = 10.1016/S0140-6736(09)61595-6| issn = 1474-547X| volume = 375| issue = 9717| pages = 846–855| last1 = Mathews| first1 = Catherine J.| last2 = Weston| first2 = Vivienne C.| last3 = Jones| first3 = Adrian| last4 = Field| first4 = Max| last5 = Coakley| first5 = Gerald| title = Bacterial septic arthritis in adults| journal = Lancet| date = 2010-03-06| pmid = 20206778}}</ref><ref name="pmid23591823">Sharff KA, Richards EP, Townes JM (2013) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=23591823 Clinical management of septic arthritis.] ''Curr Rheumatol Rep'' 15 (6):332. [http://dx.doi.org/10.1007/s11926-013-0332-4 DOI:10.1007/s11926-013-0332-4] PMID: [https://pubmed.gov/23591823 23591823]</ref>


==Medical Therapy==
==Medical Therapy==
Empiric treatment should be commenced as soon as possible after culture samples have been obtained.  The choice of empiric antibiotics should be determined on the basis of:<ref>{{Cite journal| issn = 0893-8512| volume = 15| issue = 4| pages = 527–544| last1 = Shirtliff| first1 = Mark E.| last2 = Mader| first2 = Jon T.| title = Acute septic arthritis| journal = Clinical Microbiology Reviews| date = 2002-10| pmid = 12364368| pmc = PMC126863}}</ref><ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref><ref>{{Cite journal| doi = 10.1016/S0140-6736(09)61595-6| issn = 1474-547X| volume = 375| issue = 9717| pages = 846–855| last1 = Mathews| first1 = Catherine J.| last2 = Weston| first2 = Vivienne C.| last3 = Jones| first3 = Adrian| last4 = Field| first4 = Max| last5 = Coakley| first5 = Gerald| title = Bacterial septic arthritis in adults| journal = Lancet| date = 2010-03-06| pmid = 20206778}}</ref>
Empiric treatment should be commenced as soon as possible after culture samples have been obtained.  The choice of empiric antibiotics should be determined on the basis of:<ref name="pmid12364368">Shirtliff ME, Mader JT (2002) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12364368 Acute septic arthritis.] ''Clin Microbiol Rev'' 15 (4):527-44. PMID: [https://pubmed.gov/12364368 12364368]</ref><ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref><ref>{{Cite journal| doi = 10.1016/S0140-6736(09)61595-6| issn = 1474-547X| volume = 375| issue = 9717| pages = 846–855| last1 = Mathews| first1 = Catherine J.| last2 = Weston| first2 = Vivienne C.| last3 = Jones| first3 = Adrian| last4 = Field| first4 = Max| last5 = Coakley| first5 = Gerald| title = Bacterial septic arthritis in adults| journal = Lancet| date = 2010-03-06| pmid = 20206778}}</ref>
* [[Gram stain]] results of [[synovial fluid]] analysis
* [[Gram stain]] results of [[synovial fluid]] analysis
* Local prevalence of organisms and resistance patterns
* Local prevalence of organisms and resistance patterns
* Predisposing factors including intravenous drug use, hospitalization, or colonization of infectious pathogens, and risk for [[MRSA|methicillin-resistant ''Staphylococcus aureus'' (MRSA)]]
* Predisposing factors including intravenous drug use, hospitalization, or colonization of infectious pathogens, and risk for [[MRSA|methicillin-resistant ''Staphylococcus aureus'' (MRSA)]]


If the patient fails to respond to initial treatment, consider:<ref>{{Cite journal| issn = 0893-8512| volume = 15| issue = 4| pages = 527–544| last1 = Shirtliff| first1 = Mark E.| last2 = Mader| first2 = Jon T.| title = Acute septic arthritis| journal = Clinical Microbiology Reviews| date = 2002-10| pmid = 12364368| pmc = PMC126863}}</ref>
If the patient fails to respond to initial treatment, consider:<ref name="pmid12364368">Shirtliff ME, Mader JT (2002) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12364368 Acute septic arthritis.] ''Clin Microbiol Rev'' 15 (4):527-44. PMID: [https://pubmed.gov/12364368 12364368]</ref>
* Misidentification of causative pathogen
* Misidentification of causative pathogen
* Infection with atypical pathogen
* Infection with atypical pathogen
* Concurrent [[osteomyelitis]]
* Concurrent [[osteomyelitis]]
* Occult nidus of infection
* Occult nidus of infection
 
Intra-articular antibiotics are not useful as it may increase infection rate and also causes [[Synovitis|chemical synovitis]] and [[Cartilage|cartilage toxicity]].<ref name="pmid11061294">Stutz G, Kuster MS, Kleinstück F, Gächter A (2000) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11061294 Arthroscopic management of septic arthritis: stages of infection and results.] ''Knee Surg Sports Traumatol Arthrosc'' 8 (5):270-4. [http://dx.doi.org/10.1007/s001670000129 DOI:10.1007/s001670000129] PMID: [https://pubmed.gov/11061294 11061294]</ref>
===Specific Considerations===
 
=====Tailoring antibiotic coverage to clinical scenario=====
* Neonate
: ''[[Staphylococcus aureus]]''
* Infant &lt; 2 years
: [[Haemophilus influenzae]], ''[[Staphylococcus aureus]]''
* Infant &gt; 2 years
: ''[[Staphylococcus aureus]]''
* Young adults (sexually active)
: ''[[Neisseria gonorrhoeae]]''
* Elderly adults
: ''[[Staphylococcus aureus]]'', [[streptococci]], [[Gram-negative bacilli]]
* Post-aspiration or injection
: ''[[Staphylococcus aureus]]''
* Trauma
: [[Gram-negative bacilli]], [[anaerobes]], ''[[Staphylococcus aureus]]''
* Prosthesis
: ''[[Staphylococcus epidermidis]]'' (early infection)
: [[Gram-positive cocci]], [[anaerobes]] (late infection)
* Injecting drug use
: Atypical [[gram-negative bacilli]] including [[Pseudomonas]]
* Rheumatoid arthritis
: ''[[Staphylococcus aureus]]''
* Systemic lupus erythematosus
: [[Salmonella]]
* Sickle cell anemia
: [[Salmonella]]
* Hemophilia
: ''[[Staphylococcus aureus]]'', [[streptococci]], [[Gram-negative bacilli]]
* Immunosuppression
: ''[[Staphylococcus aureus]]'', [[Mycobacterium]], [[fungi]]<ref>{{cite book | last = Firestein | first = Gary | title = Kelley's textbook of rheumatology | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2013 | isbn = 978-1437717389 }}</ref>


=====Methicillin-resistant ''Staphylococcus aureus'' (MRSA)=====
=====Methicillin-resistant ''Staphylococcus aureus'' (MRSA)=====
Risk factors for septic arthritis caused by methicillin-resistant Staphylococcus aureus (MRSA) include:<ref>{{Cite journal| doi = 10.1093/cid/ciq146| issn = 1537-6591| volume = 52| issue = 3| pages = –18-55| last1 = Liu| first1 = Catherine| last2 = Bayer| first2 = Arnold| last3 = Cosgrove| first3 = Sara E.| last4 = Daum| first4 = Robert S.| last5 = Fridkin| first5 = Scott K.| last6 = Gorwitz| first6 = Rachel J.| last7 = Kaplan| first7 = Sheldon L.| last8 = Karchmer| first8 = Adolf W.| last9 = Levine| first9 = Donald P.| last10 = Murray| first10 = Barbara E.| last11 = J Rybak| first11 = Michael| last12 = Talan| first12 = David A.| last13 = Chambers| first13 = Henry F.| last14 = Infectious Diseases Society of America| title = Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2011-02-01| pmid = 21208910}}</ref><ref>{{Cite journal| doi = 10.1007/s11926-013-0332-4| issn = 1534-6307| volume = 15| issue = 6| pages = 332| last1 = Sharff| first1 = Katie A.| last2 = Richards| first2 = Eric P.| last3 = Townes| first3 = John M.| title = Clinical management of septic arthritis| journal = Current Rheumatology Reports| date = 2013-06| pmid = 23591823}}</ref>
Patient at high risk of [[Methicillin-resistant staphylococcus aureus|methicillin-resistant Staphylococcus aureus]] (MRSA) include:<ref>{{Cite journal| doi = 10.1093/cid/ciq146| issn = 1537-6591| volume = 52| issue = 3| pages = –18-55| last1 = Liu| first1 = Catherine| last2 = Bayer| first2 = Arnold| last3 = Cosgrove| first3 = Sara E.| last4 = Daum| first4 = Robert S.| last5 = Fridkin| first5 = Scott K.| last6 = Gorwitz| first6 = Rachel J.| last7 = Kaplan| first7 = Sheldon L.| last8 = Karchmer| first8 = Adolf W.| last9 = Levine| first9 = Donald P.| last10 = Murray| first10 = Barbara E.| last11 = J Rybak| first11 = Michael| last12 = Talan| first12 = David A.| last13 = Chambers| first13 = Henry F.| last14 = Infectious Diseases Society of America| title = Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2011-02-01| pmid = 21208910}}</ref><ref name="pmid23591823">Sharff KA, Richards EP, Townes JM (2013) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=23591823 Clinical management of septic arthritis.] ''Curr Rheumatol Rep'' 15 (6):332. [http://dx.doi.org/10.1007/s11926-013-0332-4 DOI:10.1007/s11926-013-0332-4] PMID: [https://pubmed.gov/23591823 23591823]</ref>
* Known MRSA colonization or infection
* Known [[Methicillin-resistant staphylococcus aureus|MRSA]] colonization or infection
* Recent hospitalization
* Recent hospitalization
* Nursing-home resident
* Nursing-home resident
* Presence of leg ulcers
* Presence of leg ulcers
* Indwelling catheters
* Indwelling [[catheters]]


Drainage or [[debridement]] of the joint space should always be performed in septic arthritis caused by [[MRSA]].  A 3- or 4-week course of therapy with '''[[vancomycin]]''' (15–20 mg/kg/dose IV every 8–12 hours in adults or 15 mg/kg/dose IV every 6 hours in children), '''[[daptomycin]]''' (6 mg/kg/day IV every 24 hours in adults or 6–10 mg/kg/dose IV every 24 hours in children), '''[[linezolid]]''' (600 mg PO/IV twice daily in adults or 10 mg/kg/dose PO/IV every 8 hours in children), '''[[clindamycin]]''' (600 mg PO/IV every 8 hours in adults or 10–13 mg/kg/dose PO/IV every 6–8 hours in children), and '''[[trimethoprim-sulfamethoxazole]]''' (3.5–4.0 mg/kg PO/IV every 8–12 hours in adults) have been used with success.  A prolonged treatment of 4 to 6 weeks may be required if the condition is complicated by [[osteomyelitis]].<ref>{{Cite journal| doi = 10.1093/cid/ciq146| issn = 1537-6591| volume = 52| issue = 3| pages = –18-55| last1 = Liu| first1 = Catherine| last2 = Bayer| first2 = Arnold| last3 = Cosgrove| first3 = Sara E.| last4 = Daum| first4 = Robert S.| last5 = Fridkin| first5 = Scott K.| last6 = Gorwitz| first6 = Rachel J.| last7 = Kaplan| first7 = Sheldon L.| last8 = Karchmer| first8 = Adolf W.| last9 = Levine| first9 = Donald P.| last10 = Murray| first10 = Barbara E.| last11 = J Rybak| first11 = Michael| last12 = Talan| first12 = David A.| last13 = Chambers| first13 = Henry F.| last14 = Infectious Diseases Society of America| title = Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2011-02-01| pmid = 21208910}}</ref><ref>{{Cite journal| doi = 10.1016/S0140-6736(09)61595-6| issn = 1474-547X| volume = 375| issue = 9717| pages = 846–855| last1 = Mathews| first1 = Catherine J.| last2 = Weston| first2 = Vivienne C.| last3 = Jones| first3 = Adrian| last4 = Field| first4 = Max| last5 = Coakley| first5 = Gerald| title = Bacterial septic arthritis in adults| journal = Lancet| date = 2010-03-06| pmid = 20206778}}</ref>
Drainage or [[debridement]] of the joint space should always be performed in septic arthritis caused by [[MRSA]].  A 3 or 4 week course of therapy with '''[[Vancomycin]]''' (15–20 mg/kg/dose IV every 8–12 hours in adults or 15 mg/kg/dose IV every 6 hours in children), '''[[Daptomycin]]''' (6 mg/kg/day IV every 24 hours in adults or 6–10 mg/kg/dose IV every 24 hours in children), '''[[Linezolid]]''' (600 mg PO/IV twice daily in adults or 10 mg/kg/dose PO/IV every 8 hours in children), '''[[Clindamycin]]''' (600 mg PO/IV every 8 hours in adults or 10–13 mg/kg/dose PO/IV every 6–8 hours in children), and '''[[Trimethoprim-Sulfamethoxazole]]''' (3.5–4.0 mg/kg PO/IV every 8–12 hours in adults) have been used with success.  A prolonged treatment of 4 to 6 weeks may be required if the condition is complicated by [[osteomyelitis]].<ref>{{Cite journal| doi = 10.1093/cid/ciq146| issn = 1537-6591| volume = 52| issue = 3| pages = –18-55| last1 = Liu| first1 = Catherine| last2 = Bayer| first2 = Arnold| last3 = Cosgrove| first3 = Sara E.| last4 = Daum| first4 = Robert S.| last5 = Fridkin| first5 = Scott K.| last6 = Gorwitz| first6 = Rachel J.| last7 = Kaplan| first7 = Sheldon L.| last8 = Karchmer| first8 = Adolf W.| last9 = Levine| first9 = Donald P.| last10 = Murray| first10 = Barbara E.| last11 = J Rybak| first11 = Michael| last12 = Talan| first12 = David A.| last13 = Chambers| first13 = Henry F.| last14 = Infectious Diseases Society of America| title = Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2011-02-01| pmid = 21208910}}</ref><ref>{{Cite journal| doi = 10.1016/S0140-6736(09)61595-6| issn = 1474-547X| volume = 375| issue = 9717| pages = 846–855| last1 = Mathews| first1 = Catherine J.| last2 = Weston| first2 = Vivienne C.| last3 = Jones| first3 = Adrian| last4 = Field| first4 = Max| last5 = Coakley| first5 = Gerald| title = Bacterial septic arthritis in adults| journal = Lancet| date = 2010-03-06| pmid = 20206778}}</ref>


=====Prosthetic joint infection=====
==Antimicrobial Regimen – Empiric Therapy==
Management of prosthetic joint infection typically requires both surgical intervention and extended courses of antimicrobial therapy.  Options of surgical approach include debridement with retention of [[prosthesis]], two-stage procedure (removal of [[prosthesis]] and cement with [[debridement]] of infected tissue and placement of a joint spacer, followed by prolonged [[antibiotics]] and replacement of [[prosthesis]]), one-stage procedure (removal of [[prosthesis]], [[debridement]], and replacement of [[prosthesis]] in a single procedure), permanent resection [[arthroplasty]], and [[amputation]].  The surgical decision should be made by orthopedic surgeon with specialty consultation, such as infectious disease or plastic surgery as necessary.<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref>
{| class="wikitable"
! style="width: 20%;" | '''Newborn (&lt; 1 week)'''
! style="width: 20%;" | '''Newborn (1–4 weeks)'''
! style="width: 20%;" | '''Infants (1–3 months)'''
! style="width: 20%;" | '''Children (3 months–14 years)'''
! style="width: 20%;" | '''Adults'''
|-
| valign = top |
'''High Risk for MRSA'''
* '''Preferred Regimen'''
** [[Vancomycin]] 18 mg/kg/day IV q12h {{and}}
** [[Cefotaxime]] 50 mg/kg IV q12h
'''Low Risk for MRSA'''
** [[Cefotaxime]] 50 mg/kg IV q12h {{and}}
** [[Nafcillin]] 25 mg/kg IV q8h or [[Oxacillin]] 25 mg/kg IV q8h
| valign = top |
'''High Risk for MRSA'''
* '''Preferred Regimen'''
** [[Vancomycin]] 22 mg/kg/day IV q12h {{and}}
** [[Cefotaxime]] 50 mg/kg IV q8h
* '''Alternative Regimen'''
** [[Clindamycin]] 5 mg/kg IV q8h
'''Low Risk for MRSA'''
* '''Preferred Regimen'''
** [[Cefotaxime]] 50 mg/kg IV q8h {{and}}
** [[Nafcillin]] 37 mg/kg IV q6h {{or}} [[Oxacillin]] 37 mg/kg IV q6h
* '''Alternative Regimen'''
** [[Clindamycin]] 5 mg/kg IV q6h
| valign = top |
'''High Risk for MRSA'''
* '''Preferred Regimen'''
** [[Vancomycin]] 40 mg/kg/day IV q6–8h {{and}}
** [[Cefotaxime]] 50 mg/kg IV q8h
'''Low Risk for MRSA'''
* '''Preferred Regimen'''
** [[Cefotaxime]] 50 mg/kg IV q8h {{and}}
** [[Nafcillin]] 37 mg/kg IV q6h {{or}} [[Oxacillin]] 37 mg/kg IV q6h
* '''Alternative Regimen'''
** [[Clindamycin]] 7.5 mg/kg IV q6h
| valign = top |
'''Preferred Regimen'''
* [[Vancomycin]] 40 mg/kg/day IV q6–8h {{and}}
* [[Cefotaxime]] 50 mg/kg IV q8h
| valign = top |
'''Monoarticular'''
* '''At risk for sexually-transmitted disease'''
**'''Preferred Regimen'''
*** [[Ceftriaxone]] 1 g IV q24h {{or}} [[Cefotaxime]] 1 g IV q8h {{or}} [[Ceftizoxime]] 1 g IV q8h
**'''Alternative Regimen'''
*** [[Vancomycin]] 1 g IV q12h
* '''Not at risk for sexually-transmitted disease'''
**'''Preferred Regimen'''
*** [[Vancomycin]] 1 g IV q12h {{and}}
*** [[Ceftriaxone]] 1 g IV q24h {{or}} [[Cefotaxime]] 1 g IV q8h {{or}} [[Ceftizoxime]] 1 g IV q8h
**'''Alternative Regimen'''
*** [[Vancomycin]] 1 g IV q12h {{and}}
*** [[Ciprofloxacin]] 400 mg IV q12h {{or}} [[Levofloxacin]] 750 mg IV q 24 h
'''Polyarticular'''
*'''Preferred Regimen'''
** [[Ceftriaxone]] 1 g IV q24h
|}


Antibiotic selection and duration are determined according to the causative organisms and the surgical intervention performed.  Antimicrobial agent should achieve adequate tissue concentrations and be effective against slow-growing organisms and [[biofilms]] in conformity with local antibiogram.  Liaison with microbiology services is recommended.  Empiric antibiotics may be required while culture results are pending and for the duration of treatment for culture-negative infection.  [[MRSA]] coverage with [[glycopeptide]] (e.g., [[vancomycin]], [[daptomycin]]) or [[Gram-negative]] coverage with [[ceftriaxone]] should be considered when necessary.  Empiric or pathogen-directed antibiotic therapy is generally instituted following the procedure.<ref>{{Cite journal| issn = 1756-1833| volume = 338| pages = –1773| last1 = Matthews| first1 = Philippa C.| last2 = Berendt| first2 = Anthony R.| last3 = McNally| first3 = Martin A.| last4 = Byren| first4 = Ivor| title = Diagnosis and management of prosthetic joint infection| journal = BMJ (Clinical research ed.)| date = 2009| pmid = 19482869}}</ref>
==Antimicrobial Regimen – Synovial Fluid Gram Stain-Based Therapy==
{| border="1"
! colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Gram stain result'''}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''First choice antibiotic'''}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Second choice antibiotic'''}}
|-
!Negative Gram stain
|
* [[Vancomycin]] 15–20 mg/kg q8–12h and
 
* [[Ceftazidime]] 2 g IV q8h or [[Cefepime]] 2 g IV q8–12h
|
* [[Daptomycin]] 6-8 mg/kg IV q24h or [[Linezolid]] 600 mg IV/PO q12h
 
and


The duration of antibiotic treatment varies depending on the surgical procedure undertaken. A six-week course of parenteral therapy is preferred if an infected [[prosthesis]] is retained, while two to four weeks of intravenous antibiotics may be sufficient if revision [[arthroplasty]] is performed. Oral antibiotics are commonly prescribed for three to six months in the setting of retained [[prosthesis]] compared with six weeks for revision [[arthroplasty]].<ref>{{Cite journal| issn = 1756-1833| volume = 338| pages = –1773| last1 = Matthews| first1 = Philippa C.| last2 = Berendt| first2 = Anthony R.| last3 = McNally| first3 = Martin A.| last4 = Byren| first4 = Ivor| title = Diagnosis and management of prosthetic joint infection| journal = BMJ (Clinical research ed.)| date = 2009| pmid = 19482869}}</ref>
* [[Piperacillin-Tazobactam]] 4.5 g IV q6h or [[Aztreonam]] 2 g IV q8h or [[Imipenem]] 500 mg IV q6h or [[Meropenem]] 1 g IV q8h or [[Doripenem]] 500 mg IV q8h or [[Carbapenems]]
|-
!Gram-positive cocci
|
* [[Vancomycin]] 15–20 mg/kg q8–12h
|
* [[Daptomycin]] 6-8 mg/kg IV q24h or
* [[Linezolid]] 600 mg IV/PO q12h
|-
!Gram-negative cocci
| colspan="2" |
* [[Ceftriaxone]] 1 g IV q24h or [[Cefotaxime]] 1 g IV q8h
|-
!Gram-negative bacilli
|
* [[Ceftazidime]] 2 g IV q8h or
* [[Cefepime]] 2 g IV q8–12h or
* [[Piperacillin-Tazobactam]] 4.5 g IV q6h
|
* [[Aztreonam]] 2 g IV q8h or
* [[Imipenem]] 500 mg IV q6h or
* [[Meropenem]] 1 g IV q8h or
* [[Doripenem]] 500 mg IV q8h or
|}
 
==Antimicrobial Regimen – Pathogen Based Therapy==
 
{| border="1"
! colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Microorgnaism'''}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''First choice antibiotic'''}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Second choice antibiotic'''}}
|-
! rowspan="2" |[[Staphylococcus aureus]]
!Methicillin-sensitive
|
* [[Nafcillin]] 2 g IV QID or  
* [[Clindamycin]] 900 mg IV TID
|
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h,
* [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
|-
!Methicillin-resistant
|
* [[Vancomycin]]  15–20 mg/kg IV q8–12h in adults or 15 mg/kg IV q6h in children or
* [[Linezolid]] 600 mg PO/IV q12h in adults or 10 mg/kg PO/IV q8h in children
|
* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole-trimethoprim]] 3.5–4.0 mg/kg PO/IV q8–12h in adults or
* [[Minocycline]] ± [[rifampin]]
|-
! rowspan="2" |[[Coagulase-negative Staphylococcus|Coagulase-negative Staphylococcus spp]]
!Methicillin-sensitive
|
* [[Nafcillin]] 2 g IV QID or
* [[Clindamycin]] 900 mg IV/IM TID
|
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h
* [[vancomycin]] 500 mg IV q6h or 1 g IV BD
|-
!Methicillin-resistant
|
* [[Vancomycin]] 1 g BD or
 
* [[Linezolid]] 600 mg BD
|
* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole-trimethoprim]] or
* [[Minocycline]] ± [[rifampin]] or [[Clindamycin]]
|-
! colspan="2" |[[Group A streptococcus]], [[Streptococcal|Strep. pyogenes]]
|
* [[Penicillin]] G 2 million IV/IM every 4 h or
 
* [[Ampicillin]] 2 g IV QID
|
* [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h
|-
! colspan="2" |[[Group B streptococcal infection|Group B streptococcus]], [[Streptococcus|Strep. agalactiae]]
|
* [[Penicillin]] G 2 million IV/IM every 4 h or
 
* [[Ampicillin]] 2 g IV every 6 h
|
* [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h
|-
! colspan="2" |[[Enterococcus|Enterococcus spp]].
|
* [[Ampicillin]] 2 g IV QID or
 
* [[Vancomycin]] 1 g IV  BD
|
* [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 3 g IV QID
* [[Linezolid]] 600 mg PO/IV BD
|-
! colspan="2" |[[Escherichia coli]]
|
* [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 3 g IV QID
|
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h, levofloxacin 500–750 mg IV/PO OD
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h
* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole-trimethoprim]] 8–10 mg/kg/day IV/PO q6–12h
|-
! colspan="2" |[[Proteus mirabilis]]
|
* [[Ampicillin]] 2 g IV QID or
 
* [[Levofloxacin]] 500 mg IV/PO OD
|
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h
* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole-trimethoprim]] 8–10 mg/kg/day IV/PO q6–12h
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h
|-
! colspan="2" |[[Proteus vulgaris]], [[Proteus|Proteus rettgeri]], [[Morganella morganii]]
|
* [[Cefotaxime]] 2 g IV  QID
 
* [[Imipenem]] 500 mg IV  QID, or
* [[Levofloxacin]] 500 mg IV/PO OD
|
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h, or
* [[Ticarcillin-Clavulanate|Ticarcillin-clavulanate]] 3.1 g IV q4–6h
|-
! colspan="2" |[[Serratia marcescens]]
|
* [[Cefotaxime]] 2 g IV QID
|
* [[Levofloxacin]] 500 mg IV/PO OD
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h
* [[Imipenem]] 500 mg IV QID
|-
! colspan="2" |[[Pseudomonas aeruginosa]]
|
* [[Cefepime]] 2 gm IV BD or
 
* [[Piperacillin]] 3 gm IV QID or
* [[Imipenem]] 500 IV QID
|
* [[Ticarcillin-Clavulanate|Ticarcillin-clavulanate]] 3.1 g IV q4–6h
* [[Tobramycin]] 3-5 mg/kg/day IV q6–8h
* [[Amikacin]] 15 mg/kg/day IV/IM q8–12h
* [[Ciprofloxacin]] 400 mg IV q8–12h
|-
! colspan="2" |[[Neisseria gonorrhoeae|Neisseria gonorrhea]]
|
* [[Ceftriaxone]] 2 g IV OD or
 
* [[Cefotaxime]] 1 g TID
|
* [[Levofloxacin]] 500 mg IV/PO OD
* [[Ampicillin]] 2 g IV QID
|-
! colspan="2" |[[Bacteroides fragilis]] group
|
* [[Clindamycin]] 900 mg IV/IM TID or
 
* [[Metronidazole]] 500 mg TID
|
* [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 3 g IV QID or
* [[Ticarcillin-Clavulanate|Ticarcillin-clavulanic acid]] 3.1 g IV QID
|-
! colspan="2" |[[Brucella melitensis]]
|
* [[Doxycycline]] 100 mg PO BD and [[Streptomycin]] 15 mg/kg IM QID or
 
* [[Rifampin]] 600–900 mg QID
|
* [[Doxycycline]] 100 mg PO BD and [[Gentamicin]] 5 mg/kg IV QID
|-
! colspan="2" |[[Haemophilus influenzae]]
|
* [[Amoxicillin-Clavulanate]] 875/125 mg PO BD or
* [[Cefprozil]] 500 mg PO BD or
* [[Cefuroxime]] 500 mg PO BD or
* [[Cefdinir]] 600 mg PO OD
|
* [[Levofloxacin]] 750 mg IV/PO OD or
* [[Moxifloxacin]] 400 mg IV/PO OD or
* [[Clarithromycin]] 500 mg PO BD
|-
! colspan="2" |[[Morganella morganii]]
|
* [[Cefotaxime]] 2 g IV QID or
* [[Imipenem]] 500 mg IV QID or
* [[Levofloxacin]] 500 mg IV/PO OD
|
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h or
* [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h
|-
! colspan="2" |[[Tropheryma whipplei]]
|
* [[Penicillin G]] 2 million units IV q4h for 2 weeks and [[Streptomycin]] 1 g IM/IV OD for 2 weeks, then [[TMP-SMX]] 160mg/800mg PO OD for 1 year
|
* [[Ceftriaxone]] 2 g IV OD, then [[TMP-SMX]] 160mg/800mg PO OD for 1 year
|-
! colspan="2" |[[Borrelia burgdorferi]]
|
* [[Amoxicillin]] 500 mg TID for 28 days or
* [[Doxycycline]] 100 mg BD for 28 days or
* [[Cefuroxime]] 500 mg BD for 28 days
|
* [[Azithromycin]] 500 mg PO OD for 7–10 days or
* [[Clarithromycin]] 500 mg PO BD for 14–21 days or
* [[Erythromycin]] 500 mg PO QID for 14–21 days
|}


===Duration of Antimicrobial Therapy===
===Duration of Antimicrobial Therapy===
Line 92: Line 337:
|}
|}


==Antimicrobial Regimen – Empiric Therapy==
=== Prosthetic joint infection ===
Management of prosthetic joint infection typically requires both surgical intervention and extended courses of antimicrobial therapy.  Options of surgical approach include
* Debridement with retention of [[prosthesis|prosthesis:]]
** Two-stage procedure (removal of [[prosthesis]] and cement with [[debridement]] of infected tissue and placement of a joint spacer, followed by prolonged [[antibiotics]] and replacement of [[prosthesis]])
** One-stage procedure (removal of [[prosthesis]], [[debridement]], and replacement of [[prosthesis]] in a single procedure)
* Permanent resection [[arthroplasty]] and [[amputation]]. 
The surgical decision should be made by orthopedic surgeon with specialty consultation, such as infectious disease or plastic surgery as necessary.<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref>


===Newborn (&lt; 1 week)===
Antibiotic selection and duration are determined according to the causative organisms and the surgical intervention performed.  Antimicrobial agent should achieve adequate tissue concentrations and be effective against slow-growing organisms and [[biofilms]]  in conformity with local antibiogram.  Liaison with microbiology services is recommended.  Empiric antibiotics may be required while culture results are pending and for the duration of treatment for culture-negative infection.  [[MRSA]] coverage with [[glycopeptide]] (e.g., [[Vancomycin]], [[Daptomycin]]) or [[Gram-negative]] coverage with [[Ceftriaxone]] should be considered when necessary.  Empiric or pathogen-directed antibiotic therapy is generally instituted following the procedure.<ref>{{Cite journal| issn = 1756-1833| volume = 338| pages = –1773| last1 = Matthews| first1 = Philippa C.| last2 = Berendt| first2 = Anthony R.| last3 = McNally| first3 = Martin A.| last4 = Byren| first4 = Ivor| title = Diagnosis and management of prosthetic joint infection| journal = BMJ (Clinical research ed.)| date = 2009| pmid = 19482869}}</ref>


====High Risk for MRSA====
The duration of antibiotic treatment varies depending on the surgical procedure undertaken.  A six-week course of parenteral therapy is preferred if an infected [[prosthesis]] is retained, while two to four weeks of intravenous antibiotics may be sufficient if revision [[arthroplasty]] is performed.  Oral antibiotics are commonly prescribed for three to six months in the setting of retained [[prosthesis]] compared with six weeks for revision [[arthroplasty]].<ref>{{Cite journal| issn = 1756-1833| volume = 338| pages = –1773| last1 = Matthews| first1 = Philippa C.| last2 = Berendt| first2 = Anthony R.| last3 = McNally| first3 = Martin A.| last4 = Byren| first4 = Ivor| title = Diagnosis and management of prosthetic joint infection| journal = BMJ (Clinical research ed.)| date = 2009| pmid = 19482869}}</ref>
{{rx|Preferred Regimen}}
* [[Vancomycin]] 18 mg/kg/day IV q12h {{and}}
* [[Cefotaxime]] 50 mg/kg IV q12h
</li>
 
====Low Risk for MRSA====
{{rx|Preferred Regimen}}
* [[Cefotaxime]] 50 mg/kg IV q12h {{and}}
* [[Nafcillin]] 25 mg/kg IV q8h {{or}} [[Oxacillin]] 25 mg/kg IV q8h
</li>
{{rx|Alternative Regimen}}
* [[Clindamycin]] 5 mg/kg IV q8h
</li>
 
===Newborn (1–4 weeks)===
 
====High Risk for MRSA====
{{rx|Preferred Regimen}}
* [[Vancomycin]] 22 mg/kg/day IV q12h {{and}}
* [[Cefotaxime]] 50 mg/kg IV q8h
</li>
 
====Low Risk for MRSA====
{{rx|Preferred Regimen}}
* [[Cefotaxime]] 50 mg/kg IV q8h {{and}}
* [[Nafcillin]] 37 mg/kg IV q6h {{or}} [[Oxacillin]] 37 mg/kg IV q6h
</li>
{{rx|Alternative Regimen}}
* [[Clindamycin]] 5 mg/kg IV q6h
</li>
 
===Infants (1–3 months)===
 
====High Risk for MRSA====
{{rx|Preferred Regimen}}
* [[Vancomycin]] 40 mg/kg/day IV q6–8h {{and}}
* [[Cefotaxime]] 50 mg/kg IV q8h
</li>
 
====Low Risk for MRSA====
{{rx|Preferred Regimen}}
* [[Cefotaxime]] 50 mg/kg IV q8h {{and}}
* [[Nafcillin]] 37 mg/kg IV q6h {{or}} [[Oxacillin]] 37 mg/kg IV q6h
</li>
{{rx|Alternative Regimen}}
* [[Clindamycin]] 7.5 mg/kg IV q6h
</li>
 
===Children (3 months–14 years)===
{{rx|Preferred Regimen}}
* [[Vancomycin]] 40 mg/kg/day IV q6–8h {{and}}
* [[Cefotaxime]] 50 mg/kg IV q8h
</li>
 
===Adults (Monoarticular)===
 
====At risk for sexually-transmitted disease====
{{rx|Preferred Regimen}}
* [[Ceftriaxone]] 1 g IV q24h {{or}} [[Cefotaxime]] 1 g IV q8h {{or}} [[Ceftizoxime]] 1 g IV q8h
</li>
{{rx|Alternative Regimen}}
* [[Vancomycin]] 1 g IV q12h
</li>
 
====Not at risk for sexually-transmitted disease====
{{rx|Preferred Regimen}}
* [[Vancomycin]] 1 g IV q12h {{and}}
* [[Ceftriaxone]] 1 g IV q24h {{or}} [[Cefotaxime]] 1 g IV q8h {{or}} [[Ceftizoxime]] 1 g IV q8h
</li>
{{rx|Alternative Regimen}}
* [[Vancomycin]] 1 g IV q12h {{and}}
* [[Ciprofloxacin]] 400 mg IV q12h {{or}} [[Levofloxacin]] 750 mg IV q 24 h
</li>
 
===Adults (Polyarticular)===
{{rx|Preferred Regimen}}
* [[Ceftriaxone]] 1 g IV q24h
</li>
 
==Antimicrobial Regimen – Synovial Fluid Gram Stain-Based Therapy==
 
===Negative Gram stain===
{{rx|Preferred Regimen}}
* [[Vancomycin]] 15–20 mg/kg q8–12h {{and}}
* [[Ceftazidime]] 2 g IV q8h {{or}} [[Cefepime]] 2 g IV q8–12h
</li>
{{rx|Alternative Regimen}}
* [[Daptomycin]] 6-8 mg/kg IV q24h {{or}} [[Linezolid]] 600 mg IV/PO q12h {{and}}
* [[Piperacillin-Tazobactam]] 4.5 g IV q6h {{or}} [[Aztreonam]] 2 g IV q8h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Doripenem]] 500 mg IV q8h {{or}} [[Carbapenems]]
</li>
 
===Gram-positive cocci===
{{rx|Preferred Regimen}}
* [[Vancomycin]] 15–20 mg/kg q8–12h
</li>
{{rx|Alternative Regimen}}
* [[Daptomycin]] 6-8 mg/kg IV q24h {{or}} [[Linezolid]] 600 mg IV/PO q12h
</li>
 
===Gram-negative cocci===
{{rx|Preferred Regimen}}
* [[Ceftriaxone]] 1 g IV q24h {{or}} [[Cefotaxime]] 1 g IV q8h
</li>
 
===Gram-negative bacilli===
{{rx|Preferred Regimen}}
* [[Ceftazidime]] 2 g IV q8h {{or}} [[Cefepime]] 2 g IV q8–12h {{or}} [[Piperacillin-Tazobactam]] 4.5 g IV q6h
</li>
{{rx|Alternative Regimen}}
* [[Aztreonam]] 2 g IV q8h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Doripenem]] 500 mg IV q8h {{or}} [[Carbapenems]]
</li>
 
==Antimicrobial Regimen – Pathogen-Based Therapy==
 
====Bacteroides fragilis====
{{rx|Preferred Regimen}}
* [[Clindamycin]] 900 mg IV/IM q8h {{or}} [[Metronidazole]] 500 mg IV q8
</li>
{{rx|Alternative Regimen}}
* [[Ampicillin-Sulbactam]] 3 g IV q6h {{or}} [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h
</li>
 
====Brucella melitensis====
{{rx|Preferred Regimen}}
* [[Doxycycline]] 100 mg PO bid for ≥ 6 weeks {{and}}
* [[Streptomycin]] 15 mg/kg IM qd for 2–3 weeks {{or}} [[Rifampin]] 600–900 mg qd for ≥ 6 weeks
</li>
{{rx|Alternative Regimen}}
* [[Doxycycline]] 100 mg PO bid for ≥ 6 weeks {{and}}
* [[Gentamicin]] 5 mg/kg IV qd for 7 days
</li>
 
====Enterococcus====
{{rx|Preferred Regimen}}
* [[Ampicillin]] 2 g IV q6h {{or}} [[Vancomycin]] 1 g IV q12h
</li>
{{rx|Alternative Regimen}}
* [[Ampicillin-Sulbactam]] 3 g IV q6h {{or}} [[Linezolid]] 600 mg PO/IV q12h
</li>
 
====Escherichia coli====
{{rx|Preferred Regimen}}
* [[Ampicillin-Sulbactam]] 3 g IV q6h
</li>
{{rx|Alternative Regimen}}
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h {{or}} [[Levofloxacin]] 500–750 mg IV/PO q24h {{or}} [[Gentamicin]] 3–5 mg/kg/day IV q6–8h {{or}} [[TMP-SMX]] 8–10 mg/kg/day IV/PO q6–12h (TMP component)
 
</li>
 
====Haemophilus influenzae====
{{rx|Preferred Regimen}}
* [[Amoxicillin-Clavulanate]] 875/125 mg PO q12h {{or}} [[Cefprozil]] 500 mg PO q12h {{or}} [[Cefuroxime]] 500 mg PO q12h {{or}} [[Cefdinir]] 600 mg PO q24h
</li>
{{rx|Alternative Regimen}}
* [[Levofloxacin]] 750 mg IV/PO q24h {{or}} [[Moxifloxacin]] 400 mg IV/PO q24h {{or}} [[Clarithromycin]] 500 mg PO q12h
</li>
 
====Morganella morganii====
{{rx|Preferred Regimen}}
* [[Cefotaxime]] 2 g IV q6h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Levofloxacin]] 500 mg IV/PO q24h
</li>
{{rx|Alternative Regimen}}
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h {{or}} [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h
</li>
 
====Neisseria gonorrhoeae====
{{rx|Preferred Regimen}}
* [[Ceftriaxone]] 2 g IV q24h {{or}} [[Cefotaxime]] 1 g IV q8h
</li>
{{rx|Alternative Regimen}}
* [[Levofloxacin]] 500 mg IV/PO q24h {{or}} [[Ampicillin]] 2 g IV q6h
</li>
 
====Proteus mirabilis====
{{rx|Preferred Regimen}}
* [[Ampicillin ]] 2 g IV q6h {{or}} [[Levofloxacin]] 500 mg IV/PO q24h
</li>
{{rx|Alternative Regimen}}
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h {{or}} [[Gentamicin]] 3–5 mg/kg/day IV q6–8h {{or}} [[TMP-SMX]] 8–10 mg/kg/day IV/PO q6–12h (TMP component)
</li>
 
====Proteus vulgaris or Proteus rettgeri====
{{rx|Preferred Regimen}}
* [[Cefotaxime]] 2 g IV q6h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Levofloxacin]] 500 mg IV/PO q24h
</li>
{{rx|Alternative Regimen}}
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h {{or}} [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h
</li>
 
====Pseudomonas aeruginosa====
{{rx|Preferred Regimen}}
* [[Cefepime]] 2 g IV q12h  {{or}} [[Piperacillin]] 3–4 g IV q4–6h {{or}} [[Imipenem]] 500 mg IV q6h
</li>
{{rx|Alternative Regimen}}
* [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h {{or}} [[Tobramycin]] 3-5 mg/kg/day IV q6–8h {{or}} [[Amikacin]] 15 mg/kg/day IV/IM q8–12h {{or}} [[Ciprofloxacin]] 400 mg IV q8–12h
</li>
 
====Serratia marcescens====
{{rx|Preferred Regimen}}
* [[Cefotaxime]] 2 g IV q6h
</li>
{{rx|Alternative Regimen}}
* [[Levofloxacin]] 500 mg IV/PO q24h {{or}} [[Gentamicin]] 3–5 mg/kg/day IV q6–8h {{or}} [[Imipenem]] 500 mg IV q6h
</li>
 
====Staphylococcus aureus (methicillin-resistant)====
{{rx|Preferred Regimen}}
* [[Vancomycin]] 15–20 mg/kg IV q8–12h in adults or 15 mg/kg IV q6h in children
</li>
{{rx|Alternative Regimen}}
* [[Daptomycin]] 6 mg/kg IV q24h in adults or 6–10 mg/kg IV q24h in children {{or}} [[Linezolid]] 600 mg PO/IV q12h in adults or 10 mg/kg PO/IV q8h in children {{or}} [[Clindamycin]] 600 mg PO/IV q8h in adults or 10–13 mg/kg/dose PO/IV q6–8h in children {{or}} [[TMP-SMX]] 3.5–4.0 mg/kg PO/IV q8–12h in adults
</li>
 
====Staphylococcus aureus (methicillin-susceptible)====
{{rx|Preferred Regimen}}
* [[Nafcillin]] 2 g IV q6h {{or}} [[Clindamycin]] 900 mg IV q8h
</li>
{{rx|Alternative Regimen}}
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h {{or}} [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
</li>
 
====Staphylococcus epidermidis (methicillin-resistant)====
{{rx|Preferred Regimen}}
* [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h {{or}} [[Linezolid]] 600 mg IV q12h
</li>
{{rx|Alternative Regimen}}
* [[TMP-SMX]] 3.5–4.0 mg/kg PO/IV q8–12h (TMP component) {{or}} [[Minocycline]] 200 mg PO x 1 dose, then 100 mg PO q12h {{and}}
* [[Rifampin]] 300–600 mg PO/IV q12h
</li>
 
====Staphylococcus epidermidis (methicillin-susceptible)====
{{rx|Preferred Regimen}}
* [[Nafcillin]] 2 g IV q6h {{or}} [[Clindamycin]] 900 mg IV/IM q8h
</li>
{{rx|Alternative Regimen}}
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h {{or}} [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
</li>
 
====Streptococcus agalactiae====
{{rx|Preferred Regimen}}
* [[Penicillin G]] 2 MU IV/IM q4h {{or}} [[Ampicillin]] 2 g IV q6h
</li>
{{rx|Alternative Regimen}}
* [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h {{or}} [[Cefazolin]] 0.25–1 g IV/IM q6–8h
</li>
 
====Streptococcus pyogenes====
{{rx|Preferred Regimen}}
* [[Penicillin G]] 2 MU IV/IM q4h {{or}} [[Ampicillin]] 2 g IV q6h
</li>
{{rx|Alternative Regimen}}
* [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h {{or}} [[Cefazolin]] 0.25–1 g IV/IM q6–8h
</li>
 
====Tropheryma whipplei====
{{rx|Preferred Regimen}}
* [[Penicillin G]] 2 MU IV q4h for 2 weeks {{and}}
* [[Streptomycin]] 1 g IM/IV q24h for 2 weeks, then [[TMP-SMX]] 160mg/800mg PO q24h for 1 year
</li>
{{rx|Alternative Regimen}}
* [[Ceftriaxone]] 2 g IV q24h, then [[TMP-SMX]] 160mg/800mg PO q24h for 1 year
</li>
 
====Borrelia burgdorferi====
{{rx|Preferred Regimen}}
* [[Amoxicillin]] 500 mg q8h for 28 days {{or}} [[Doxycycline]] 100 mg q12h for 28 days {{or}} [[Cefuroxime]] 500 mg q12h for 28 days
</li>
{{rx|Alternative Regimen}}
* [[Azithromycin]] 500 mg PO q24h for 7–10 days {{or}} [[Clarithromycin]] 500 mg PO q12h for 14–21 days {{or}} [[Erythromycin]] 500 mg PO q6h for 14–21 days
</li>


==References==
==References==
Line 374: Line 355:
[[Category:Disease]]
[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]
[[Category:Medical emergencies]]
[[Category:Medical emergencies]]
[[Category:Rheumatology]]
[[Category:Rheumatology]]
[[Category:Signs and symptoms]]
[[Category:Infectious Disease Project]]
[[Category:Emergency mdicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Orthopedics]]

Latest revision as of 00:08, 30 July 2020

Septic arthritis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Septic Arthritis from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

X Ray

CT

MRI

Other Diagnostic Studies

Treatment

Medical Therapy

Surgical Therapy

Primary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Septic arthritis medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Septic arthritis medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Septic arthritis medical therapy

CDC on Septic arthritis medical therapy

Septic arthritis medical therapy in the news

Blogs on Septic arthritis medical therapy

Directions to Hospitals Treating Septic arthritis

Risk calculators and risk factors for Septic arthritis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [3]

Overview

Acute nongonococcal septic arthritis is a medical emergency which causes severe joint destruction and may increase both morbidity and mortality. So prompt diagnosis and treatment with antibiotic therapy and prompt drainage which reduces long-term complications. Vancomycin is recommended as either empirical therapy for patients with Gram-positive cocci on a synovial fluid Gram stain or as a component of regimen for those with a negative Gram stain if methicillin-resistant Staphylococcus aureus (MRSA) is prevalent. If Gram-negative bacilli are observed, an anti-pseudomonal Cephalosporin (e.g., Ceftazidime, Cefepime) should be administered. Carbapenems should be considered in conditions such as colonization or infection by extended-spectrum β-lactamase–producing pathogens. The optimal duration of therapy for septic arthritis remains uncertain. A minimum 3- to 4 week course is suggested for septic arthritis caused by S. aureus or Gram-negative bacteria. The use of Corticosteroids or intraarticular antibiotics is not advisable.[1][2]

Medical Therapy

Empiric treatment should be commenced as soon as possible after culture samples have been obtained. The choice of empiric antibiotics should be determined on the basis of:[3][4][5]

If the patient fails to respond to initial treatment, consider:[3]

  • Misidentification of causative pathogen
  • Infection with atypical pathogen
  • Concurrent osteomyelitis
  • Occult nidus of infection

Intra-articular antibiotics are not useful as it may increase infection rate and also causes chemical synovitis and cartilage toxicity.[6]

Methicillin-resistant Staphylococcus aureus (MRSA)

Patient at high risk of methicillin-resistant Staphylococcus aureus (MRSA) include:[7][2]

  • Known MRSA colonization or infection
  • Recent hospitalization
  • Nursing-home resident
  • Presence of leg ulcers
  • Indwelling catheters

Drainage or debridement of the joint space should always be performed in septic arthritis caused by MRSA. A 3 or 4 week course of therapy with Vancomycin (15–20 mg/kg/dose IV every 8–12 hours in adults or 15 mg/kg/dose IV every 6 hours in children), Daptomycin (6 mg/kg/day IV every 24 hours in adults or 6–10 mg/kg/dose IV every 24 hours in children), Linezolid (600 mg PO/IV twice daily in adults or 10 mg/kg/dose PO/IV every 8 hours in children), Clindamycin (600 mg PO/IV every 8 hours in adults or 10–13 mg/kg/dose PO/IV every 6–8 hours in children), and Trimethoprim-Sulfamethoxazole (3.5–4.0 mg/kg PO/IV every 8–12 hours in adults) have been used with success. A prolonged treatment of 4 to 6 weeks may be required if the condition is complicated by osteomyelitis.[8][9]

Antimicrobial Regimen – Empiric Therapy

Newborn (< 1 week) Newborn (1–4 weeks) Infants (1–3 months) Children (3 months–14 years) Adults

High Risk for MRSA

Low Risk for MRSA

High Risk for MRSA

Low Risk for MRSA

High Risk for MRSA

Low Risk for MRSA

Preferred Regimen

Monoarticular

Polyarticular

Antimicrobial Regimen – Synovial Fluid Gram Stain-Based Therapy

Gram stain result First choice antibiotic Second choice antibiotic
Negative Gram stain

and

Gram-positive cocci
Gram-negative cocci
Gram-negative bacilli

Antimicrobial Regimen – Pathogen Based Therapy

Microorgnaism First choice antibiotic Second choice antibiotic
Staphylococcus aureus Methicillin-sensitive
Methicillin-resistant
  • Vancomycin 15–20 mg/kg IV q8–12h in adults or 15 mg/kg IV q6h in children or
  • Linezolid 600 mg PO/IV q12h in adults or 10 mg/kg PO/IV q8h in children
Coagulase-negative Staphylococcus spp Methicillin-sensitive
Methicillin-resistant
Group A streptococcus, Strep. pyogenes
Group B streptococcus, Strep. agalactiae
Enterococcus spp.
Escherichia coli
Proteus mirabilis
Proteus vulgaris, Proteus rettgeri, Morganella morganii
Serratia marcescens
Pseudomonas aeruginosa
Neisseria gonorrhea
Bacteroides fragilis group
Brucella melitensis
Haemophilus influenzae
Morganella morganii
Tropheryma whipplei
Borrelia burgdorferi

Duration of Antimicrobial Therapy

Clinical Setting Duration
Staphylococcus aureus infection 3–4 weeks
Streptococcus groups A, B, C, G infection 3–4 weeks
Gram-negative bacilli infection 4 weeks
Brucella infection 6 weeks
Borrelia burgdorferi infection 30 days
Mycobacterium tuberculosis infection 9 months
Candida albicans infection 6 weeks
Prosthetic joint infection 6 weeks
Post-intraarticular injection or post-arthroscopy 14 days

Prosthetic joint infection

Management of prosthetic joint infection typically requires both surgical intervention and extended courses of antimicrobial therapy. Options of surgical approach include

The surgical decision should be made by orthopedic surgeon with specialty consultation, such as infectious disease or plastic surgery as necessary.[10]

Antibiotic selection and duration are determined according to the causative organisms and the surgical intervention performed. Antimicrobial agent should achieve adequate tissue concentrations and be effective against slow-growing organisms and biofilms in conformity with local antibiogram. Liaison with microbiology services is recommended. Empiric antibiotics may be required while culture results are pending and for the duration of treatment for culture-negative infection. MRSA coverage with glycopeptide (e.g., Vancomycin, Daptomycin) or Gram-negative coverage with Ceftriaxone should be considered when necessary. Empiric or pathogen-directed antibiotic therapy is generally instituted following the procedure.[11]

The duration of antibiotic treatment varies depending on the surgical procedure undertaken. A six-week course of parenteral therapy is preferred if an infected prosthesis is retained, while two to four weeks of intravenous antibiotics may be sufficient if revision arthroplasty is performed. Oral antibiotics are commonly prescribed for three to six months in the setting of retained prosthesis compared with six weeks for revision arthroplasty.[12]

References

  1. Mathews, Catherine J.; Weston, Vivienne C.; Jones, Adrian; Field, Max; Coakley, Gerald (2010-03-06). "Bacterial septic arthritis in adults". Lancet. 375 (9717): 846–855. doi:10.1016/S0140-6736(09)61595-6. ISSN 1474-547X. PMID 20206778.
  2. 2.0 2.1 Sharff KA, Richards EP, Townes JM (2013) Clinical management of septic arthritis. Curr Rheumatol Rep 15 (6):332. DOI:10.1007/s11926-013-0332-4 PMID: 23591823
  3. 3.0 3.1 Shirtliff ME, Mader JT (2002) Acute septic arthritis. Clin Microbiol Rev 15 (4):527-44. PMID: 12364368
  4. Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  5. Mathews, Catherine J.; Weston, Vivienne C.; Jones, Adrian; Field, Max; Coakley, Gerald (2010-03-06). "Bacterial septic arthritis in adults". Lancet. 375 (9717): 846–855. doi:10.1016/S0140-6736(09)61595-6. ISSN 1474-547X. PMID 20206778.
  6. Stutz G, Kuster MS, Kleinstück F, Gächter A (2000) Arthroscopic management of septic arthritis: stages of infection and results. Knee Surg Sports Traumatol Arthrosc 8 (5):270-4. DOI:10.1007/s001670000129 PMID: 11061294
  7. Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.
  8. Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.
  9. Mathews, Catherine J.; Weston, Vivienne C.; Jones, Adrian; Field, Max; Coakley, Gerald (2010-03-06). "Bacterial septic arthritis in adults". Lancet. 375 (9717): 846–855. doi:10.1016/S0140-6736(09)61595-6. ISSN 1474-547X. PMID 20206778.
  10. Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  11. Matthews, Philippa C.; Berendt, Anthony R.; McNally, Martin A.; Byren, Ivor (2009). "Diagnosis and management of prosthetic joint infection". BMJ (Clinical research ed.). 338: –1773. ISSN 1756-1833. PMID 19482869.
  12. Matthews, Philippa C.; Berendt, Anthony R.; McNally, Martin A.; Byren, Ivor (2009). "Diagnosis and management of prosthetic joint infection". BMJ (Clinical research ed.). 338: –1773. ISSN 1756-1833. PMID 19482869.