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* [[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
* [[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
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==Antimicrobial regimen==
===Septic arthritis, Brucella melitensis===
* Septic arthritis, Brucella melitensis <ref>{{cite book | last = Corbel | first = Michael | title = Brucellosis in humans and animals | publisher = World Health Organization | location = Geneva | year = 2006 | isbn = 9241547138 }}</ref>
:* 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
:* Alternative Regimen: [[Doxycycline]] 100 mg PO bid for ≥ 6 weeks {{and}} [[Gentamicin]] 5 mg/kg IV qd for 7 days
===Septic arthritis, candidal===
* Septic arthritis, candidal <ref name="pmid19191635">{{cite journal| author=Pappas PG, Kauffman CA, Andes D, Benjamin DK, Calandra TF, Edwards JE et al.| title=Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2009 | volume= 48 | issue= 5 | pages= 503-35 | pmid=19191635 | doi=10.1086/596757 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19191635  }} </ref>
:* Preferred regimen (1): [[Fluconazole]] 400 mg/day (6 mg/kg/day) for at least 6 weeks 
:* Preferred regimen (2): [[Amphotericin B]] 3–5 mg/kg/day for several weeks {{then}} [[Fluconazole]] to completion
:* Alternative regimen (1): [[Anidulafungin]] 200-mg loading dose {{then}} 100 mg/day 
:* Alternative regimen (2): [[Caspofungin]] 70-mg loading dose {{then}} 50 mg/day 
:* Alternative regimen (3): [[Micafungin]] 100 mg/day
:* Alternative regimen (4): [[Amphotericin B]] deoxycholate 0.5–1 mg/kg/day for several weeks {{then}} [[Fluconazole]] to completion
:* Note: Duration of therapy usually is for at least 6 weeks, but few data are available; Surgical debridement is recommended for all cases; For infected prosthetic joints, removal is recommended for most cases.
===Septic arthritis, gonococcal===
* Septic arthritis, gonococcal <ref name="pmid12364368">{{cite journal| author=Shirtliff ME, Mader JT| title=Acute septic arthritis. | journal=Clin Microbiol Rev | year= 2002 | volume= 15 | issue= 4 | pages= 527-44 | pmid=12364368 | doi= | pmc=PMC126863 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12364368  }} </ref>
:* Preferred regimen: [[Ceftriaxone]] 1 g intramuscularly IM/IV q24h
:* Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h 
:* Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h
:* Alternative regimen (3): [[Spectinomycin]] 2 g IV q12h (Penicillin allergies)
:* Alternative regimen (4): [[Ciprofloxacin]] 500 mg IV q12h {{or}} [[Ofloxacin]] 400 mg IV q12h (β-lactam-allergic patient)
:* Note: The tetracyclines (except in pregnant women) or penicillins may be used if the infecting organism is proven to be susceptible
:* Pediatric regimen:
::* >45 kg
:::* Preferred regimen: [[Ceftriaxone]] 50 mg/kg (Maximum, 2 g/dose) IM/IV single dose for 10 to 14 days
::* <45 kg
:::* Preferred regimen: [[Ceftriaxone]] 50 mg/kg (Maximum, 1 g/dose) IM/IV single dose for 7 days
===Septic arthritis, Gram-negative  bacilli===
* Septic arthritis, Gram-negative  bacilli <ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:* Preferred regimen (1): [[Ceftazidime]] 2 g IV q8h 
:* Preferred regimen (2): [[Cefepime]] 2 g IV q8–12h 
:* Preferred regimen (3): [[Piperacillin-Tazobactam]] 4.5 g IV q6h
:* Alternative regimen (1): [[Aztreonam]] 2 g IV q8h 
:* Alternative regimen (2): [[Imipenem]] 500 mg IV q6h 
:* Alternative regimen (3): [[Meropenem]] 1 g IV q8h 
:* Alternative regimen (4): [[Doripenem]] 500 mg IV q8h 
:* Alternative regimen (5): [[Carbapenems]]
===Septic arthritis, Histoplasmosis===
* Septic arthritis, histoplasmosis<ref name="pmid17806045">{{cite journal| author=Wheat LJ, Freifeld AG, Kleiman MB, Baddley JW, McKinsey DS, Loyd JE et al.| title=Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2007 | volume= 45 | issue= 7 | pages= 807-25 | pmid=17806045 | doi=10.1086/521259 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17806045  }}</ref>
:*1. '''Mild disease'''
::* Preferred regimen: [[Nonsteroidal anti-inflammatory drug]]
:*2. '''Severe disease'''
::* Preferred regimen: [[Prednisone]] 0.5–1.0 mg/kg/day (Maximum, 80 mg/day) in tapering doses over 1–2 weeks {{and}} [[Itraconazole]] 200 mg tid for 3 days, followed by qd or bid for 6–12 weeks
===Septic arthritis, Lyme disease===
* Septic arthritis, Lyme disease <ref name="pmid17029130">{{cite journal| author=Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS et al.| title=The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2006 | volume= 43 | issue= 9 | pages= 1089-134 | pmid=17029130 | doi=10.1086/508667 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17029130  }} </ref>
:*1. '''Patients without clinical evidence of neurologic disease'''
::* Preferred regimen (1): [[Doxycycline]] 100 mg bid for 28 days
::* Preferred regimen (2): [[Amoxicillin]] 500 mg tid for 28 days
::* Preferred regimen (3): [[Cefuroxime axetil]] 500 mg bid for 28 days
::* Pediatric regimen (1): [[Amoxicillin]] 50 mg/kg/day tid (Maximum, 500 mg/dose)
::* Pediatric regimen (2): [[Cefuroxime axetil]] 30 mg/kg/day bid (Maximum, 500 mg/dose) 
::* Pediatric regimen (3): (if the patient is ≥8 years of age) [[Doxycycline]] 4 mg/kg/day bid (Maximum, 100 mg/dose)
:*2. '''Patients with arthritis and objective evidence of neurologic disease'''
::* Preferred regimen: [[Ceftriaxone]] administered parenterally for 2–4 weeks
::* Alternative regimen: [[Cefotaxime]] {{or}} [[Penicillin G]] administered parenterally
::* Pediatric regimen: [[Ceftriaxone]] {{or}} [[Cefotaxime]] {{or}} [[Penicillin G]] administered intravenously
:* Note (1): For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of [[Ceftriaxone]] IV
:* Note (2): If patients have no resolution of arthritis despite intravenous therapy and if PCR results for a sample of synovial fluid (and synovial tissue if available) are negative, symptomatic treatment is recommended, which consist of nonsteroidal anti-inflammatory agents, intra-articular injections of corticosteroids, or disease-modifying antirheumatic drugs (DMARDs), such as Hydroxychloroquine.
===Septic arthritis, Mycobacterium  tuberculosis===
* Septic arthritis, Mycobacterium  tuberculosis<ref>{{Cite book| edition = 4th| publisher = World Health Organization| isbn = 9789241547833| title = Treatment of Tuberculosis: Guidelines| location = Geneva| series = WHO Guidelines Approved by the Guidelines Review Committee| accessdate = 2015-06-08| date = 2010| url = http://www.ncbi.nlm.nih.gov/books/NBK138748/| pmid = 23741786}}</ref>
:*1. '''Septic arthritis caused by susceptible Mycobacterium tuberculosis'''
::*1.1 '''Adults'''
:::*1.1.1 '''Intensive phase'''
::::* Preferred regimen: [[Isoniazid]] 5 mg/kg (max, 300 mg) for 2 months {{and}} [[Rifampin]] 10 mg/kg (max: 600 mg) for 2 months {{and}} [[Pyrazinamide]] 15–30 mg/kg (max: 2 g) for 2 months {{and}} [[Ethambutol]] 15–20 mg/kg (max: 1 g) for 2 months
:::*1.1.2 '''Continuation phase'''
::::* Preferred regimen: [[Isoniazid]] 5 mg/kg (max: 300 mg) for 7 months {{and}} [[Rifampin]] 10 mg/kg (max: 600 mg) for 7 months
::*1.2 '''Pediatric'''
:::*1.2.1 '''Intensive phase'''
::::* Preferred regimen: [[Isoniazid]] 10–15 mg/kg (max: 300 mg) for 2 months {{and}} [[Rifampin]] 10–20 mg/kg (max: 600 mg) for 2 months {{and}} [[Pyrazinamide]] 15–30 mg/kg (max: 2 g) for 2 months {{and}} [[Ethambutol]] 15–20 mg/kg (max: 1 g) for 2 months
:::*1.2.2 '''Continuation phase'''
::::* Preferred regimen: [[Isoniazid]] 10–15 mg/kg (max: 300 mg) for 7 months {{and}} [[Rifampin]] 10–20 mg/kg (max: 600 mg) for 7 months
:*2. '''Specific considerations'''
::*2.1 '''Pregnancy and breastfeeding'''
:::* With the exception of streptomycin, the first line anti-TB drugs are safe for use in pregnancy: [[Streptomycin]] is ototoxic to the fetus and should not be used during pregnancy.
:::* After active TB in the baby is ruled out, the baby should be given 6 months of isoniazid preventive therapy, followed by BCG vaccination.
:::* Pyridoxine supplementation is recommended for all pregnant or breastfeeding women taking isoniazid.
::*2.2 '''Liver disorders'''
:::* Two hepatotoxic drugs (rather than the three in the standard regimen):
::::* 9 months of [[Isoniazid]] {{and}} [[Rifampicin]] {{and}} [[Ethambutol]] (until or unless [[Isoniazid]] susceptibility is documented).
::::* 2 months of [[Isoniazid]] {{and}} [[Rifampicin]] {{and}} [[Streptomycin]] {{and}} [[Ethambutol]], followed by 6 months of [[Isoniazid]] {{and}} [[Rifampicin]].
::::* 6–9 months of [[Rifampicin]] {{and}} [[Pyrazinamide]] {{and}} [[Ethambutol]]
:::* One hepatotoxic drug:
::::* 2 months of [[Isoniazid]] {{and}} [[Ethambutol]] {{and}} [[Streptomycin]], followed by 10 months of [[Isoniazid]] {{and}} [[Ethambutol]]
:::* No hepatotoxic drugs:
::::* 18–24 months of [[Streptomycin]] {{and}} [[Ethambutol]] {{and}} a [[Fluoroquinolone]]
::*2.3 '''Renal failure and severe renal insufficiency'''
:::* The recommended initial TB treatment regimen for patients with renal failure or severe renal insufficiency is 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampicin.
:::* There is significant renal excretion of ethambutol and metabolites of pyrazinamide, and doses should therefore be adjusted.
:::* Three times per week administration of these two drugs at the following doses is recommended: pyrazinamide (25 mg/kg), and ethambutol (15 mg/kg)
:::* While receiving isoniazid, patients with severe renal insufficiency or failure should also be given pyridoxine in order to prevent peripheral neuropathy.
:::* Because of an increased risk of nephrotoxicity and ototoxicity, [[Streptomycin]] should be avoided in patients with renal failure. If [[Streptomycin]] must be used, the dosage is 15 mg/kg, two or three times per week, to a maximum of 1 gram per dose, and serum levels of the drug should be monitored.
::*2.4 '''Previously treated patients in settings with rapid DST'''
:::* TB patients whose treatment has failed or other patient groups with high likelihood of multidrug-resistant TB (MDR) should be started on an empirical MDR regimen.
:::* TB patients returning after defaulting or relapsing from their first treatment course may receive the retreatment regimen containing first-line drugs 2HRZES/1HRZE/5HRE if country-specific data show low or medium levels of MDR in these patients or if such data are not available.
::*2.5 '''TB treatment in people living with HIV'''
:::* TB patients with known positive HIV status and all TB patients living in HIV prevalent settings should receive daily TB treatment at least during the intensive phase.
:::* For the continuation phase, the optimal dosing frequency is also daily for these patients.
:::* If a daily continuation phase is not possible for these patients, three times weekly dosing during the continuation phase is an acceptable alternative.
:::* It is recommended that TB patients who are living with HIV should receive at least the same duration of TB treatment as HIV-negative TB patients.
===Septic arthritis, pneumococcal===
===Septic arthritis, post-intraarticular injection===
* Septic arthritis, post-intraarticular injection <ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:* NO empiric therapy.
===Septic arthritis, prosthetic joint infection===
* Septic arthritis, prosthetic joint infection (device-related osteoarticular infections) <ref name="pmid23230301">{{cite journal| author=Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM et al.| title=Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2013 | volume= 56 | issue= 1 | pages= 1-10 | pmid=23230301 | doi=10.1093/cid/cis966 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23230301  }} </ref>
:*1. '''Empiric antimicrobial therapy'''
::* It is preferable to delay antibiotic therapy until specimens for culture are obtained by joint aspiration, joint debridement, and/or prosthesis removal.
:*2. '''Pathogen-directed antimicrobial therapy'''
::*2.1 '''Staphylococcus aureus, methicillin-susceptible (MSSA)'''
:::* Preferred regimen (1): [[Nafcillin]] 2 g IV q4–6h 
:::* Preferred regimen (2): [[Oxacillin]] 2 g IV q4–6h
:::* Alternative regimen (1): [[Cefazolin]] 1–2 g IV q8h
:::* Alternative regimen (2): [[Ceftriaxone]] 2 g IV q24h
:::* Alternative regimen (3): (if allergic to penicillins) [[Clindamycin]] 900 mg IV q8h
:::* Alternative regimen (4): (if allergic to penicillins) [[Vancomycin]] 15–20 mg/kg IV q8–12h (Maximum, 2 g/dose)
::*2.2 '''Staphylococcus, methicillin-resistant (MRSA)'''
:::*2.2.1 '''Early-onset or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)'''
::::* Preferred regimen: [[Vancomycin]] {{and}} [[Rifampin]] 600 mg PO qd or 300–450 mg PO bid for 2 weeks
::::* Alternative regimen: ([[Daptomycin]] 6 mg/kg IV q24h {{or}} [[Linezolid]] 600 IV q8h) {{and}} [[Rifampin]] 600 mg PO qd or 300–450 mg PO bid for 2 weeks
::::* Note: The above regimen should be followed by [[Rifampin]] plus a fluoroquinolone, TMP/SMX, a tetracycline or [[Clindamycin]] for 3 or 6 months for hips and knees, respectively.
:::*2.2.2 '''Early-onset spinal implant infections or implants in an actively infected site'''
::::* Initial parenteral therapy plus [[Rifampin]] followed by prolonged oral therapy is recommended.
::::* Long-term oral suppressive antibiotics (eg, TMP-SMX, a tetracycline, a fluoroquinolone [which should be given in conjunction with [[Rifampin]] due to the potential emergence of fluoroquinolone resistance)
::*2.3 '''Streptococci, beta-hemolytic'''
:::* Preferred regimen (1): [[Penicillin]] 12–18 MU/day IV q6h 
:::* Preferred regimen (2): [[Ampicillin]] 2 g IV q6h 
:::* Preferred regimen (3): [[Ceftriaxone]] 1–2 g IV q24h
:::* Alternative regimen (1): (if allergic to penicillins) [[Clindamycin]] 900 mg IV q8h
:::* Alternative regimen (2): (if allergic to penicillins) [[Vancomycin]] 15–20 mg/kg IV q8–12h (Maximum, 2 g/dose)
::*2.4 '''Enterococci'''
:::*2.4.1 '''Monotherapy'''
::::* Preferred regimen (1): [[Ampicillin]] 6-12 g/day q4-6h
::::* Preferred regimen (2): [[Penicillin G]] 18-30 MU/day continuously or q4h
::::* Preferred regimen (3): [[Vancomycin]] 15-20 mg/kg/dose q8-12h (Maximum, 2 g/dose)
:::*2.4.2 '''Combination therapy (one of the monotherapy agents, and one of the following agents)'''
::::* Preferred regimen (1): [[Gentamicin]] 1 mg/kg IV q8h
::::* Preferred regimen (2): [[Streptomycin]] 7.5 mg/kg IV q12h
::::* Preferred regimen (3): [[Ampicillin]] 2 g/day IV q6h {{and}} [[Ceftriaxone]] 2 g IV q12h
::*2.5 '''Gram-negative bacilli'''
:::* Patients susceptible to fluoroquinolones
::::* Preferred regimen: [[Ciprofloxacin]] 500-750 mg bid
:::*2.5.1 '''P. aeruginosa'''
::::* Preferred regimen (1): [[Cefepime]] 2 g IV q12h 
::::* Preferred regimen (2): [[Meropenem]] 1 g IV q8h
::::* Alternative regimen (1): [[Ciprofloxacin]] 750 mg PO bid
::::* Alternative regimen (2): [[Ceftazidime]] 2 g IV q8h
::*2.6 '''Anaerobes'''
:::*2.6.1'''Propionibacterium acnes'''
::::* Preferred regimen (1): [[Penicillin]] 24 MU/day IV q4h or continuously
::::* Preferred regimen (2): [[Ceftriaxone]] 1-2 g/day IV
::::* Alternative regimen: [[Vancomycin]] {{or}} [[Clindamycin]]
:::*2.6.2 '''Not Propionibacterium acnes'''
:::* Preferred regimen: [[Metronidazole]] 500 mg PO tid
::*2.7 '''Mycobacterium tuberculosis'''
:::* Preferred regimen: see (Septic arthritis, Mycobacterium tuberculosis)
::*2.8 '''Fungi'''
:::* Preferred regimen: see (Septic arthritis, candidal)
::*2.9 '''Culture negative'''
:::* Preferred regimen:  [[Vancomycin]] {{and}} [[Ciprofloxacin]] {{or}} [[Cefazolin]] {{and}} [[Ciprofloxacin]]
===Septic arthritis, staphylococcal===
*1.'''Staphylococcus aureus (methicillin-resistant)'''<ref name="pmid21208910">{{cite journal| author=Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ et al.| 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=Clin Infect Dis | year= 2011 | volume= 52 | issue= 3 | pages= e18-55 | pmid=21208910 | doi=10.1093/cid/ciq146 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21208910  }} </ref><ref name="pmid23591823">{{cite journal| author=Sharff KA, Richards EP, Townes JM| title=Clinical management of septic arthritis. | journal=Curr Rheumatol Rep | year= 2013 | volume= 15 | issue= 6 | pages= 332 | pmid=23591823 | doi=10.1007/s11926-013-0332-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23591823  }} </ref><ref name=name of the journal>{{cite web | title = topic name and journal name| url =http://www.uptodate.com/contents/septic-arthritis-in-adults?source=search_result&search=Septic+arthritis&selectedTitle=1~150#H18 }}</ref>
:* Preferred regime: [[Vancomycin]] 15–20 mg/kg IV q8–12h
:* Alternative regimen (1): [[Daptomycin]] 6 mg/kg IV q24h
:* Alternative regimen (2): [[Linezolid]] 600 mg PO/IV q12h
:* Alternative regimen (3): [[Clindamycin]] 600 mg PO/IV q8h
:* Alternative regimen (4): [[TMP-SMX]] 3.5–4.0 mg/kg PO/IV q8–12h
:* Pediatric regimen(1): [[Vancomycin]] 15 mg/kg IV q6h
:* Pediatric regimen(1): [[Daptomycin]] 6–10 mg/kg IV q24h 
:* Pediatric regimen(1): [[Linezolid]] 10 mg/kg PO/IV q8h 
:* Pediatric regimen(1): [[Clindamycin]] 10–13 mg/kg/dose PO/IV q6–8h
2. '''Staphylococcus aureus (methicillin-susceptible)'''
:* Preferred regimen (1): [[Nafcillin]] 2 g IV q6h 
:* Preferred regimen (2): [[Clindamycin]] 900 mg IV q8h
:* Alternative regimen (1): [[Cefazolin]] 0.25–1 g IV/IM q6–8h
:* Alternative regimen (2): [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
3. '''Staphylococcus epidermidis (methicillin-resistant)'''
:* Preferred regimen (1): [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
:* Preferred regimen (2): [[Linezolid]] 600 mg IV q12h
:* Alternative regimen: (TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h (TMP component) {{or}} [[Minocycline]] 200 mg PO single dose {{then}} 100 mg PO q12h) {{and}} [[Rifampin]] 300–600 mg PO/IV q12h
4. '''Staphylococcus epidermidis (methicillin-susceptible)'''
:* Preferred regimen (1): [[Nafcillin]] 2 g IV q6h 
:* Preferred regimen (2): [[Clindamycin]] 900 mg IV q8h
:* Alternative regimen (1): [[Cefazolin]] 0.25–1 g IV/IM q6–8h
:* Alternative regimen (2): [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
===Septic arthritis, streptococcal===
1. '''Streptococcus agalactiae''' <ref>{{cite web | title = Clinical Management of Septic Arthritis| url =http://www.med.unc.edu/tarc/events/event-files/septic%20arthritis%20management.pdf }}</ref>
:* Preferred regimen (1): [[Penicillin G]] 2 MU IV/IM q4h 
:* Preferred regimen (2): [[Ampicillin]] 2 g IV q6h
:* Alternative regimen (1): [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h
:* Alternative regimen (2): [[Cefazolin]] 0.25–1 g IV/IM q6–8h
2. '''Streptococcus pyogenes'''
:* Preferred regimen (1): [[Penicillin G]] 2 MU IV/IM q4h 
:* Preferred regimen (2): [[Ampicillin]] 2 g IV q6h
:* Alternative regimen (1): [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h
:* Alternative regimen (2): [[Cefazolin]] 0.25–1 g IV/IM q6–8h


==References==
==References==

Revision as of 13:03, 12 August 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jumana Nagarwala, M.D., Senior Staff Physician, Department of Emergency Medicine, Henry Ford Hospital; Cafer Zorkun, M.D., Ph.D. [2]; Alejandro Lemor, M.D. [3]

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 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. 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.[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:[6]

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

Specific Considerations

Tailoring antibiotic coverage to clinical scenario
  • Neonate
Staphylococcus aureus
  • Infant < 2 years
Haemophilus influenzae, Staphylococcus aureus
  • Infant > 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[7]
Methicillin-resistant Staphylococcus aureus (MRSA)

Risk factors for septic arthritis caused by methicillin-resistant Staphylococcus aureus (MRSA) include:[8][9]

  • 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.[10][11]

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, 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.[12]

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.[13]

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.[14]

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

Antimicrobial Regimen – Empiric Therapy

Newborn (< 1 week)

High Risk for MRSA

  • Low Risk for MRSA

  • Newborn (1–4 weeks)

    High Risk for MRSA

  • Low Risk for MRSA

  • Infants (1–3 months)

    High Risk for MRSA

  • Low Risk for MRSA

  • Children (3 months–14 years)

  • Adults (Monoarticular)

    At risk for sexually-transmitted disease

  • Not at risk for sexually-transmitted disease

  • Adults (Polyarticular)

  • Antimicrobial Regimen – Synovial Fluid Gram Stain-Based Therapy

    Negative Gram stain

  • Gram-positive cocci

  • Gram-negative cocci

  • Gram-negative bacilli

  • Antimicrobial Regimen – Pathogen-Based Therapy

    Bacteroides fragilis

  • Brucella melitensis

  • Enterococcus

  • Escherichia coli

  • Haemophilus influenzae

  • Morganella morganii

  • Neisseria gonorrhoeae

  • Proteus mirabilis

    • 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)
  • Proteus vulgaris or Proteus rettgeri

  • Pseudomonas aeruginosa

  • Serratia marcescens

  • Staphylococcus aureus (methicillin-resistant)

    • Vancomycin 15–20 mg/kg IV q8–12h in adults or 15 mg/kg IV q6h in children
    • 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
  • Staphylococcus aureus (methicillin-susceptible)

  • Staphylococcus epidermidis (methicillin-resistant)

    • 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
  • Staphylococcus epidermidis (methicillin-susceptible)

  • Streptococcus agalactiae

  • Streptococcus pyogenes

  • Tropheryma whipplei

  • Borrelia burgdorferi

  • Antimicrobial regimen

    Septic arthritis, Brucella melitensis

    • Septic arthritis, Brucella melitensis [15]

    Septic arthritis, candidal

    • Septic arthritis, candidal [16]
    • Preferred regimen (1): Fluconazole 400 mg/day (6 mg/kg/day) for at least 6 weeks
    • Alternative regimen (2): Caspofungin 70-mg loading dose THEN 50 mg/day
    • Alternative regimen (4): Amphotericin B deoxycholate 0.5–1 mg/kg/day for several weeks THEN Fluconazole to completion
    • Note: Duration of therapy usually is for at least 6 weeks, but few data are available; Surgical debridement is recommended for all cases; For infected prosthetic joints, removal is recommended for most cases.

    Septic arthritis, gonococcal

    • Septic arthritis, gonococcal [17]
    • Preferred regimen: Ceftriaxone 1 g intramuscularly IM/IV q24h
    • Alternative regimen (1): Cefotaxime 1 g IV q8h
    • Alternative regimen (3): Spectinomycin 2 g IV q12h (Penicillin allergies)
    • Alternative regimen (4): Ciprofloxacin 500 mg IV q12h OR Ofloxacin 400 mg IV q12h (β-lactam-allergic patient)
    • Note: The tetracyclines (except in pregnant women) or penicillins may be used if the infecting organism is proven to be susceptible
    • Pediatric regimen:
    • >45 kg
    • Preferred regimen: Ceftriaxone 50 mg/kg (Maximum, 2 g/dose) IM/IV single dose for 10 to 14 days
    • <45 kg
    • Preferred regimen: Ceftriaxone 50 mg/kg (Maximum, 1 g/dose) IM/IV single dose for 7 days

    Septic arthritis, Gram-negative bacilli

    • Septic arthritis, Gram-negative bacilli [18]
    • Preferred regimen (2): Cefepime 2 g IV q8–12h
    • Alternative regimen (2): Imipenem 500 mg IV q6h
    • Alternative regimen (3): Meropenem 1 g IV q8h
    • Alternative regimen (4): Doripenem 500 mg IV q8h

    Septic arthritis, Histoplasmosis

    • Septic arthritis, histoplasmosis[19]
    • 1. Mild disease
    • 2. Severe disease
    • Preferred regimen: Prednisone 0.5–1.0 mg/kg/day (Maximum, 80 mg/day) in tapering doses over 1–2 weeks AND Itraconazole 200 mg tid for 3 days, followed by qd or bid for 6–12 weeks

    Septic arthritis, Lyme disease

    • Septic arthritis, Lyme disease [20]
    • 1. Patients without clinical evidence of neurologic disease
    • Preferred regimen (1): Doxycycline 100 mg bid for 28 days
    • Preferred regimen (2): Amoxicillin 500 mg tid for 28 days
    • Pediatric regimen (3): (if the patient is ≥8 years of age) Doxycycline 4 mg/kg/day bid (Maximum, 100 mg/dose)
    • 2. Patients with arthritis and objective evidence of neurologic disease
    • Note (1): For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of Ceftriaxone IV
    • Note (2): If patients have no resolution of arthritis despite intravenous therapy and if PCR results for a sample of synovial fluid (and synovial tissue if available) are negative, symptomatic treatment is recommended, which consist of nonsteroidal anti-inflammatory agents, intra-articular injections of corticosteroids, or disease-modifying antirheumatic drugs (DMARDs), such as Hydroxychloroquine.

    Septic arthritis, Mycobacterium tuberculosis

    • Septic arthritis, Mycobacterium tuberculosis[21]
    • 1. Septic arthritis caused by susceptible Mycobacterium tuberculosis
    • 1.1 Adults
    • 1.1.1 Intensive phase
    • Preferred regimen: Isoniazid 5 mg/kg (max, 300 mg) for 2 months AND Rifampin 10 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months
    • 1.1.2 Continuation phase
    • Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) for 7 months AND Rifampin 10 mg/kg (max: 600 mg) for 7 months
    • 1.2 Pediatric
    • 1.2.1 Intensive phase
    • Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 2 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) for 2 months AND Ethambutol 15–20 mg/kg (max: 1 g) for 2 months
    • 1.2.2 Continuation phase
    • Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) for 7 months AND Rifampin 10–20 mg/kg (max: 600 mg) for 7 months
    • 2. Specific considerations
    • 2.1 Pregnancy and breastfeeding
    • With the exception of streptomycin, the first line anti-TB drugs are safe for use in pregnancy: Streptomycin is ototoxic to the fetus and should not be used during pregnancy.
    • After active TB in the baby is ruled out, the baby should be given 6 months of isoniazid preventive therapy, followed by BCG vaccination.
    • Pyridoxine supplementation is recommended for all pregnant or breastfeeding women taking isoniazid.
    • 2.2 Liver disorders
    • Two hepatotoxic drugs (rather than the three in the standard regimen):
    • One hepatotoxic drug:
    • No hepatotoxic drugs:
    • 2.3 Renal failure and severe renal insufficiency
    • The recommended initial TB treatment regimen for patients with renal failure or severe renal insufficiency is 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampicin.
    • There is significant renal excretion of ethambutol and metabolites of pyrazinamide, and doses should therefore be adjusted.
    • Three times per week administration of these two drugs at the following doses is recommended: pyrazinamide (25 mg/kg), and ethambutol (15 mg/kg)
    • While receiving isoniazid, patients with severe renal insufficiency or failure should also be given pyridoxine in order to prevent peripheral neuropathy.
    • Because of an increased risk of nephrotoxicity and ototoxicity, Streptomycin should be avoided in patients with renal failure. If Streptomycin must be used, the dosage is 15 mg/kg, two or three times per week, to a maximum of 1 gram per dose, and serum levels of the drug should be monitored.
    • 2.4 Previously treated patients in settings with rapid DST
    • TB patients whose treatment has failed or other patient groups with high likelihood of multidrug-resistant TB (MDR) should be started on an empirical MDR regimen.
    • TB patients returning after defaulting or relapsing from their first treatment course may receive the retreatment regimen containing first-line drugs 2HRZES/1HRZE/5HRE if country-specific data show low or medium levels of MDR in these patients or if such data are not available.
    • 2.5 TB treatment in people living with HIV
    • TB patients with known positive HIV status and all TB patients living in HIV prevalent settings should receive daily TB treatment at least during the intensive phase.
    • For the continuation phase, the optimal dosing frequency is also daily for these patients.
    • If a daily continuation phase is not possible for these patients, three times weekly dosing during the continuation phase is an acceptable alternative.
    • It is recommended that TB patients who are living with HIV should receive at least the same duration of TB treatment as HIV-negative TB patients.

    Septic arthritis, pneumococcal

    Septic arthritis, post-intraarticular injection

    • Septic arthritis, post-intraarticular injection [22]
    • NO empiric therapy.

    Septic arthritis, prosthetic joint infection

    • Septic arthritis, prosthetic joint infection (device-related osteoarticular infections) [23]
    • 1. Empiric antimicrobial therapy
    • It is preferable to delay antibiotic therapy until specimens for culture are obtained by joint aspiration, joint debridement, and/or prosthesis removal.
    • 2. Pathogen-directed antimicrobial therapy
    • 2.1 Staphylococcus aureus, methicillin-susceptible (MSSA)
    • Preferred regimen (1): Nafcillin 2 g IV q4–6h
    • Preferred regimen (2): Oxacillin 2 g IV q4–6h
    • Alternative regimen (1): Cefazolin 1–2 g IV q8h
    • Alternative regimen (2): Ceftriaxone 2 g IV q24h
    • Alternative regimen (3): (if allergic to penicillins) Clindamycin 900 mg IV q8h
    • Alternative regimen (4): (if allergic to penicillins) Vancomycin 15–20 mg/kg IV q8–12h (Maximum, 2 g/dose)
    • 2.2 Staphylococcus, methicillin-resistant (MRSA)
    • 2.2.1 Early-onset or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)
    • Preferred regimen: Vancomycin AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
    • Alternative regimen: (Daptomycin 6 mg/kg IV q24h OR Linezolid 600 IV q8h) AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
    • Note: The above regimen should be followed by Rifampin plus a fluoroquinolone, TMP/SMX, a tetracycline or Clindamycin for 3 or 6 months for hips and knees, respectively.
    • 2.2.2 Early-onset spinal implant infections or implants in an actively infected site
    • Initial parenteral therapy plus Rifampin followed by prolonged oral therapy is recommended.
    • Long-term oral suppressive antibiotics (eg, TMP-SMX, a tetracycline, a fluoroquinolone [which should be given in conjunction with Rifampin due to the potential emergence of fluoroquinolone resistance)
    • 2.3 Streptococci, beta-hemolytic
    • Preferred regimen (1): Penicillin 12–18 MU/day IV q6h
    • Preferred regimen (3): Ceftriaxone 1–2 g IV q24h
    • Alternative regimen (1): (if allergic to penicillins) Clindamycin 900 mg IV q8h
    • Alternative regimen (2): (if allergic to penicillins) Vancomycin 15–20 mg/kg IV q8–12h (Maximum, 2 g/dose)
    • 2.4 Enterococci
    • 2.4.1 Monotherapy
    • Preferred regimen (1): Ampicillin 6-12 g/day q4-6h
    • Preferred regimen (2): Penicillin G 18-30 MU/day continuously or q4h
    • Preferred regimen (3): Vancomycin 15-20 mg/kg/dose q8-12h (Maximum, 2 g/dose)
    • 2.4.2 Combination therapy (one of the monotherapy agents, and one of the following agents)
    • 2.5 Gram-negative bacilli
    • Patients susceptible to fluoroquinolones
    • 2.5.1 P. aeruginosa
    • Preferred regimen (1): Cefepime 2 g IV q12h
    • 2.6 Anaerobes
    • 2.6.1Propionibacterium acnes
    • Preferred regimen (1): Penicillin 24 MU/day IV q4h or continuously
    • 2.6.2 Not Propionibacterium acnes
    • Preferred regimen: Metronidazole 500 mg PO tid
    • 2.7 Mycobacterium tuberculosis
    • Preferred regimen: see (Septic arthritis, Mycobacterium tuberculosis)
    • 2.8 Fungi
    • Preferred regimen: see (Septic arthritis, candidal)
    • 2.9 Culture negative

    Septic arthritis, staphylococcal

    • 1.Staphylococcus aureus (methicillin-resistant)[24][25]
    • Preferred regime: Vancomycin 15–20 mg/kg IV q8–12h
    • Alternative regimen (1): Daptomycin 6 mg/kg IV q24h
    • Alternative regimen (2): Linezolid 600 mg PO/IV q12h
    • Alternative regimen (3): Clindamycin 600 mg PO/IV q8h
    • Alternative regimen (4): TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h
    • Pediatric regimen(1): Vancomycin 15 mg/kg IV q6h
    • Pediatric regimen(1): Daptomycin 6–10 mg/kg IV q24h
    • Pediatric regimen(1): Linezolid 10 mg/kg PO/IV q8h
    • Pediatric regimen(1): Clindamycin 10–13 mg/kg/dose PO/IV q6–8h

    2. Staphylococcus aureus (methicillin-susceptible)

    • Preferred regimen (2): Clindamycin 900 mg IV q8h
    • Alternative regimen (1): Cefazolin 0.25–1 g IV/IM q6–8h
    • Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h

    3. Staphylococcus epidermidis (methicillin-resistant)

    • Preferred regimen (1): Vancomycin 500 mg IV q6h or 1 g IV q12h
    • Preferred regimen (2): Linezolid 600 mg IV q12h
    • Alternative regimen: (TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h (TMP component) OR Minocycline 200 mg PO single dose THEN 100 mg PO q12h) AND Rifampin 300–600 mg PO/IV q12h

    4. Staphylococcus epidermidis (methicillin-susceptible)

    • Preferred regimen (1): Nafcillin 2 g IV q6h
    • Preferred regimen (2): Clindamycin 900 mg IV q8h
    • Alternative regimen (1): Cefazolin 0.25–1 g IV/IM q6–8h
    • Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h

    Septic arthritis, streptococcal

    1. Streptococcus agalactiae [26]

    • Preferred regimen (1): Penicillin G 2 MU IV/IM q4h
    • Preferred regimen (2): Ampicillin 2 g IV q6h
    • Alternative regimen (1): Clindamycin 600–1200 mg/day IV/IM q6–12h
    • Alternative regimen (2): Cefazolin 0.25–1 g IV/IM q6–8h

    2. Streptococcus pyogenes

    • Preferred regimen (1): Penicillin G 2 MU IV/IM q4h
    • Preferred regimen (2): Ampicillin 2 g IV q6h
    • Alternative regimen (1): Clindamycin 600–1200 mg/day IV/IM q6–12h
    • Alternative regimen (2): Cefazolin 0.25–1 g IV/IM q6–8h

    References

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    2. Sharff, Katie A.; Richards, Eric P.; Townes, John M. (2013-06). "Clinical management of septic arthritis". Current Rheumatology Reports. 15 (6): 332. doi:10.1007/s11926-013-0332-4. ISSN 1534-6307. PMID 23591823. Check date values in: |date= (help)
    3. Shirtliff, Mark E.; Mader, Jon T. (2002-10). "Acute septic arthritis". Clinical Microbiology Reviews. 15 (4): 527–544. ISSN 0893-8512. PMC 126863. PMID 12364368. Check date values in: |date= (help)
    4. Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
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    6. Shirtliff, Mark E.; Mader, Jon T. (2002-10). "Acute septic arthritis". Clinical Microbiology Reviews. 15 (4): 527–544. ISSN 0893-8512. PMC 126863. PMID 12364368. Check date values in: |date= (help)
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    26. "Clinical Management of Septic Arthritis" (PDF).