Septic arthritis medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{Septic arthritis}}
{{Septic arthritis}}
{{CMG}}; {{AE}} Jumana Nagarwala, M.D., ''Senior Staff Physician, Department of Emergency Medicine, Henry Ford Hospital''; {{CZ}}; {{AL}}{{VSKP}}
{{CMG}}; {{AE}}{{AL}}{{VSKP}}


==Overview==
==Overview==
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* 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>


=====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 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>
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=====
===Duration of Antimicrobial Therapy===
{| style="border: 2px solid #696969;"
! style="background: #545454; border: 0px solid #696969; padding: 0 5px; width: 300px; color: #F8F8FF;"| Clinical Setting
! style="background: #545454; border: 0px solid #696969; padding: 0 5px; width: 100px; color: #F8F8FF;" | Duration
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Staphylococcus aureus]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3–4 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Streptococcus|Streptococcus groups A, B, C, G]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3–4 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Gram-negative bacilli]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 4 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Brucella]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 6 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Borrelia burgdorferi]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 30 days
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Mycobacterium tuberculosis]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 9 months
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Candida albicans]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 6 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | Prosthetic joint infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 6 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | Post-intraarticular injection or post-arthroscopy || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 14 days
|}


==Antimicrobial Regimen – Empiric Therapy==
==Antimicrobial Regimen – Empiric Therapy==
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!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Second choice antibiotic'''}}
!colspan="1" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Second choice antibiotic'''}}
|-
|-
! rowspan="2" |Staphylococcus aureus
! rowspan="2" |[[Staphylococcus aureus]]
!Methicillin-sensitive
!Methicillin-sensitive
|
|
* Nafcillin 2 g IV QID or   
* [[Nafcillin]] 2 g IV QID or   
* Clindamycin 900 mg IV TID  
* [[Clindamycin]] 900 mg IV TID  
|
|
* Cefazolin 0.25–1 g IV/IM q6–8h,
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h,
* Vancomycin 500 mg IV q6h or 1 g IV q12h
* [[Vancomycin]] 500 mg IV q6h or 1 g IV q12h
|-
|-
!Methicillin-resistant
!Methicillin-resistant
|
|
* Vancomycin  15–20 mg/kg IV q8–12h in adults or 15 mg/kg IV q6h in children or  
* [[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
* [[Linezolid]] 600 mg PO/IV q12h in adults or 10 mg/kg PO/IV q8h in children
|
|
* Sulfamethoxazole-trimethoprim 3.5–4.0 mg/kg PO/IV q8–12h in adults or  
* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole-trimethoprim]] 3.5–4.0 mg/kg PO/IV q8–12h in adults or  
* Minocycline ± rifampin
* [[Minocycline]] ± [[rifampin]]
|-
|-
! rowspan="2" |Coagulase-negative Staphylococcus spp
! rowspan="2" |[[Coagulase-negative Staphylococcus|Coagulase-negative Staphylococcus spp]]
!Methicillin-sensitive
!Methicillin-sensitive
|
|
* Nafcillin 2 g IV QID or  
* [[Nafcillin]] 2 g IV QID or  
* Clindamycin 900 mg IV/IM TID
* [[Clindamycin]] 900 mg IV/IM TID
|
|
* Cefazolin 0.25–1 g IV/IM q6–8h
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h
* vancomycin 500 mg IV q6h or 1 g IV BD
* [[vancomycin]] 500 mg IV q6h or 1 g IV BD
|-
|-
!Methicillin-resistant
!Methicillin-resistant
|
|
* Vancomycin 1 g BD or
* [[Vancomycin]] 1 g BD or


* Linezolid 600 mg BD
* [[Linezolid]] 600 mg BD
|
|
* Sulfamethoxazole-trimethoprim or  
* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole-trimethoprim]] or  
* Minocycline ± rifampin or Clindamycin
* [[Minocycline]] ± [[rifampin]] or [[Clindamycin]]
|-
|-
! colspan="2" |Group A streptococcus, Strep. pyogenes
! colspan="2" |[[Group A streptococcus]], [[Streptococcal|Strep. pyogenes]]
|
|
* Penicillin G 2 million IV/IM every 4 h or
* [[Penicillin]] G 2 million IV/IM every 4 h or


* Ampicillin 2 g IV QID
* [[Ampicillin]] 2 g IV QID
|
|
* Clindamycin 600–1200 mg/day IV/IM q6–12h
* [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h
* Cefazolin 0.25–1 g IV/IM q6–8h
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h
|-
|-
! colspan="2" |Group B streptococcus, Strep. agalactiae
! colspan="2" |[[Group B streptococcal infection|Group B streptococcus]], [[Streptococcus|Strep. agalactiae]]
|
|
* Penicillin G 2 million IV/IM every 4 h or
* [[Penicillin]] G 2 million IV/IM every 4 h or


* Ampicillin 2 g IV every 6 h
* [[Ampicillin]] 2 g IV every 6 h
|
|
* Clindamycin 600–1200 mg/day IV/IM q6–12h  
* [[Clindamycin]] 600–1200 mg/day IV/IM q6–12h  
* Cefazolin 0.25–1 g IV/IM q6–8h
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h
|-
|-
! colspan="2" |Enterococcus spp.
! colspan="2" |[[Enterococcus|Enterococcus spp]].
|
|
* Ampicillin 2 g IV QID or
* [[Ampicillin]] 2 g IV QID or


* Vancomycin 1 g IV  BD  
* [[Vancomycin]] 1 g IV  BD  
|
|
* Ampicillin-sulbactam 3 g IV QID
* [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 3 g IV QID
* Linezolid 600 mg PO/IV BD
* [[Linezolid]] 600 mg PO/IV BD
|-
|-
! colspan="2" |Escherichia coli
! colspan="2" |[[Escherichia coli]]
|
|
* Ampicillin-sulbactam 3 g IV QID
* [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 3 g IV QID
|
|
* Cefazolin 0.25–1 g IV/IM q6–8h, levofloxacin 500–750 mg IV/PO OD
* [[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  
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h  
* Sulfamethoxazole-trimethoprim 8–10 mg/kg/day IV/PO q6–12h
* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole-trimethoprim]] 8–10 mg/kg/day IV/PO q6–12h
|-
|-
! colspan="2" |Proteus mirabilis
! colspan="2" |[[Proteus mirabilis]]
|
|
* Ampicillin 2 g IV QID or
* [[Ampicillin]] 2 g IV QID or


* Levofloxacin 500 mg IV/PO OD
* [[Levofloxacin]] 500 mg IV/PO OD
|
|
* Cefazolin 0.25–1 g IV/IM q6–8h
* [[Cefazolin]] 0.25–1 g IV/IM q6–8h
* Sulfamethoxazole-trimethoprim 8–10 mg/kg/day IV/PO q6–12h
* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole-trimethoprim]] 8–10 mg/kg/day IV/PO q6–12h
* Gentamicin 3–5 mg/kg/day IV q6–8h
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h
|-
|-
! colspan="2" |Proteus vulgaris, Proteus rettgeri, Morganella morganii
! colspan="2" |[[Proteus vulgaris]], [[Proteus|Proteus rettgeri]], [[Morganella morganii]]
|
|
* Cefotaxime 2 g IV  QID
* [[Cefotaxime]] 2 g IV  QID


* Imipenem 500 mg IV  QID, or
* [[Imipenem]] 500 mg IV  QID, or
* Levofloxacin 500 mg IV/PO OD
* [[Levofloxacin]] 500 mg IV/PO OD
|
|
* Gentamicin 3–5 mg/kg/day IV q6–8h, or  
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h, or  
* Ticarcillin-clavulanate 3.1 g IV q4–6h
* [[Ticarcillin-Clavulanate|Ticarcillin-clavulanate]] 3.1 g IV q4–6h
|-
|-
! colspan="2" |Serratia marcescens
! colspan="2" |[[Serratia marcescens]]
|
|
* Cefotaxime 2 g IV QID
* [[Cefotaxime]] 2 g IV QID
|
|
* Levofloxacin 500 mg IV/PO OD
* [[Levofloxacin]] 500 mg IV/PO OD
* Gentamicin 3–5 mg/kg/day IV q6–8h
* [[Gentamicin]] 3–5 mg/kg/day IV q6–8h
* Imipenem 500 mg IV QID
* [[Imipenem]] 500 mg IV QID
|-
|-
! colspan="2" |Pseudomonas aeruginosa
! colspan="2" |[[Pseudomonas aeruginosa]]
|
|
* Cefepime 2 gm IV BD or
* [[Cefepime]] 2 gm IV BD or


* Piperacillin 3 gm IV QID or
* [[Piperacillin]] 3 gm IV QID or
* Imipenem 500 IV QID
* [[Imipenem]] 500 IV QID
|
|
* Ticarcillin-clavulanate 3.1 g IV q4–6h
* [[Ticarcillin-Clavulanate|Ticarcillin-clavulanate]] 3.1 g IV q4–6h
* Tobramycin 3-5 mg/kg/day IV q6–8h
* [[Tobramycin]] 3-5 mg/kg/day IV q6–8h
* Amikacin 15 mg/kg/day IV/IM q8–12h  
* [[Amikacin]] 15 mg/kg/day IV/IM q8–12h  
* Ciprofloxacine 400 mg IV q8–12h
* [[Ciprofloxacin]] 400 mg IV q8–12h
|-
|-
! colspan="2" |Neisseria gonorrhea
! colspan="2" |[[Neisseria gonorrhoeae|Neisseria gonorrhea]]
|
|
* Ceftriaxone 2 g IV OD or
* [[Ceftriaxone]] 2 g IV OD or


* Cefotaxime 1 g TID
* [[Cefotaxime]] 1 g TID
|
|
* Levofloxacin 500 mg IV/PO OD
* [[Levofloxacin]] 500 mg IV/PO OD
* Ampicillin 2 g IV QID
* [[Ampicillin]] 2 g IV QID
|-
|-
! colspan="2" |Bacteroides fragilis group
! colspan="2" |[[Bacteroides fragilis]] group
|
|
* Clindamycin 900 mg IV/IM TID or
* [[Clindamycin]] 900 mg IV/IM TID or


* Metronidazole 500 mg TID
* [[Metronidazole]] 500 mg TID
|
|
* Ampicillin-sulbactam 3 g IV QID or  
* [[Ampicillin-Sulbactam|Ampicillin-sulbactam]] 3 g IV QID or  
* Ticarcillin-clavulanic acid 3.1 g IV QID
* [[Ticarcillin-Clavulanate|Ticarcillin-clavulanic acid]] 3.1 g IV QID
|-
|-
! colspan="2" |Brucella melitensis
! colspan="2" |[[Brucella melitensis]]
|
|
* [[Doxycycline]] 100 mg PO BD and [[Streptomycin]] 15 mg/kg IM QID or  
* [[Doxycycline]] 100 mg PO BD and [[Streptomycin]] 15 mg/kg IM QID or  
Line 301: Line 276:
* [[Doxycycline]] 100 mg PO BD and [[Gentamicin]] 5 mg/kg IV QID
* [[Doxycycline]] 100 mg PO BD and [[Gentamicin]] 5 mg/kg IV QID
|-
|-
! colspan="2" |Haemophilus influenzae
! colspan="2" |[[Haemophilus influenzae]]
|
|
* [[Amoxicillin-Clavulanate]] 875/125 mg PO BD or  
* [[Amoxicillin-Clavulanate]] 875/125 mg PO BD or  
Line 312: Line 287:
* [[Clarithromycin]] 500 mg PO BD
* [[Clarithromycin]] 500 mg PO BD
|-
|-
! colspan="2" |Morganella morganii
! colspan="2" |[[Morganella morganii]]
|
|
* [[Cefotaxime]] 2 g IV QID or  
* [[Cefotaxime]] 2 g IV QID or  
Line 321: Line 296:
* [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h
* [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h
|-
|-
! colspan="2" |Tropheryma whipplei
! 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
* [[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
Line 327: Line 302:
* [[Ceftriaxone]] 2 g IV OD, 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
! colspan="2" |[[Borrelia burgdorferi]]
|
|
* [[Amoxicillin]] 500 mg TID for 28 days or  
* [[Amoxicillin]] 500 mg TID for 28 days or  
Line 338: Line 313:
|}
|}


=====Prosthetic joint infection=====
===Duration of Antimicrobial Therapy===
{| style="border: 2px solid #696969;"
! style="background: #545454; border: 0px solid #696969; padding: 0 5px; width: 300px; color: #F8F8FF;"| Clinical Setting
! style="background: #545454; border: 0px solid #696969; padding: 0 5px; width: 100px; color: #F8F8FF;" | Duration
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Staphylococcus aureus]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3–4 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Streptococcus|Streptococcus groups A, B, C, G]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 3–4 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Gram-negative bacilli]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 4 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Brucella]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 6 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Borrelia burgdorferi]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 30 days
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Mycobacterium tuberculosis]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 9 months
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | [[Candida albicans]] infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 6 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | Prosthetic joint infection || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 6 weeks
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left | Post-intraarticular injection or post-arthroscopy || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | 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  
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:]]
* Debridement with retention of [[prosthesis|prosthesis:]]
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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>
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>
==References==
==References==
{{reflist|2}}
{{reflist|2}}
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Infectious disease]]
[[Category:Medical emergencies]]
[[Category:Medical emergencies]]
[[Category:Rheumatology]]
[[Category:Rheumatology]]
[[Category:Infectious Disease Project]]
[[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

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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.