Septic arthritis resident survival guide

Vertigo Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Iqra Qamar M.D.[2], Aditya Ganti M.B.B.S. [3]

Overview

Causes

FIRE

Diagnosis

Treatment

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: Gram stain results of synovial fluid analysis Local prevalence of organisms and resistance patterns Predisposing factors including intravenous drug use, hospitalization, or colonization of infectious pathogens, and risk for methicillin-resistant Staphylococcus aureus (MRSA) If the patient fails to respond to initial treatment, consider: 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. Methicillin-resistant Staphylococcus aureus (MRSA) Patient at high risk of methicillin-resistant Staphylococcus aureus (MRSA) include: Known MRSA colonization or infection Recent hospitalization Nursing-home resident Presence of leg ulcers Indwelling catheters

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 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	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	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	Preferred Regimen Vancomycin 40 mg/kg/day IV q6–8h AND Cefotaxime 50 mg/kg IV q8h	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

Antimicrobial Regimen – Synovial Fluid Gram Stain-Based Therapy:

Gram stain result	First choice antibiotic	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 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	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:

Duration of Antimicrobial Therapy:

Do's

Don'ts

References