Septic arthritis medical therapy

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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]Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [4]

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
Methicillin-resistant Staphylococcus aureus (MRSA)

Risk factors for septic arthritis caused by methicillin-resistant Staphylococcus aureus (MRSA) include:[6][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.[7][8]

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) 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
  • 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 3.5–4.0 mg/kg PO/IV q8–12h in adults or
  • Minocycline ± rifampin
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 or
  • Minocycline ± rifampin or Clindamycin
Group A streptococcus, 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
Group B 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
Enterococcus spp.
  • Ampicillin 2 g IV QID or
  • Vancomycin 1 g IV BD
  • Ampicillin-sulbactam 3 g IV QID
  • Linezolid 600 mg PO/IV BD
Escherichia coli
  • 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 8–10 mg/kg/day IV/PO q6–12h
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 8–10 mg/kg/day IV/PO q6–12h
  • Gentamicin 3–5 mg/kg/day IV q6–8h
Proteus vulgaris, 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 3.1 g IV q4–6h
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
Pseudomonas aeruginosa
  • Cefepime 2 gm IV BD or
  • Piperacillin 3 gm IV QID or
  • Imipenem 500 IV QID
  • 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
  • Ciprofloxacine 400 mg IV q8–12h
Neisseria gonorrhea
  • Ceftriaxone 2 g IV OD or
  • Cefotaxime 1 g TID
  • Levofloxacin 500 mg IV/PO OD
  • Ampicillin 2 g IV QID
Bacteroides fragilis group
  • Clindamycin 900 mg IV/IM TID or
  • Metronidazole 500 mg TID
  • Ampicillin-sulbactam 3 g IV QID or
  • Ticarcillin-clavulanic acid 3.1 g IV QID
Brucella melitensis
Haemophilus influenzae
Morganella morganii
Tropheryma whipplei
Borrelia burgdorferi
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.[9]

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.[10]

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.[11]

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. 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.
  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. 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.
  9. Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  10. 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.
  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.