Infectious%20arthritis Treatment
Principles of Therapy
Principles of Antibiotic Therapy
- Appropriate antibiotic treatment should be started once specimens for microbiology studies are submitted
- Broad-spectrum antibiotics are recommended while culture results are pending because of the serious and destructive nature of the infection
- Antibiotics should be given by the parenteral route initially
- Antibiotic therapy should be revised once results of culture and antimicrobial susceptibility are available
Factors Affecting Choice of Antibiotics for Empiric Therapy
- Age of patient
- Clinical history, physical examination findings, risk factors
- Results of synovial fluid Gram stain
- Ability of the antibiotic to penetrate joint
- Likely pathogens causing infectious arthritis and their local antimicrobial susceptibility patterns (see below)
Pharmacotherapy
Antibiotics for Empiric Parenteral Therapy
Adults: Based on results of synovial fluid Gram stain
Gram Stain Result | Recommended Empiric Antibiotics |
Gram-positive cocci, community-acquired infection or without risk for Methicillin-resistant Staphylococcus aureus (MRSA) | Vancomycin or β-lactam agent (Cefazolin, Nafcillin, Oxacillin, Flucloxacillin) if without allergies to penicillins |
Gram-positive cocci, hospital-acquired or with other risk for MRSA | Vancomycin or Clindamycin* |
Gram-negative bacilli | 3rd generation cephalosporin (Ceftazidime, Ceftriaxone, Cefotaxime) with or without Aminoglycoside |
Gram-negative cocci | Ceftriaxone |
*If patient’s isolate turns out to be susceptible to Clindamycin but resistant to Erythromycin, a D test should be done to check for the presence of inducible Macrolide-Lincosamide-Streptogramin B resistance
Adults: Based on patient’s clinical profile
- Recommendations below may be used to guide antibiotic choice if Gram stain is negative
Clinical Profile | Recommended Empiric Antibiotics |
No risk factors for atypical organisms | Flucloxacillin |
Immunocompetent | Vancomycin |
Immunocompromised patients, injection drug users, traumatic bacterial arthritis | Vancomycin with 3rd generation cephalosporin or an aminoglycoside |
Risk factors for MRSA infection (eg catheters, recent hospital confinement) | Vancomycin* plus 2nd or 3rd generation cephalosporin |
N gonorrhoeae infection suspected | Ceftriaxone plus Azithromycin or Doxycycline |
* If patient has allergy or drug intolerance to Vancomycin, Daptomycin, Linezolid, Clindamycin or Co-trimoxazole are reasonable alternatives
Children: Based on age
Age of Child | Probable Pathogen | Recommended Empiric Antibiotics |
Neonate | S aureus, Group B streptococci, Gram-negative bacilli | Antistaphylococcal penicillin (Nafcillin*, Vancomycin or Clindamycin)** plus 3rd generation cephalosporin plus Aminoglycoside |
≤ 5 years | S aureus, S pneumoniae, S pyogenes, H influenzae, K kingae |
Antistaphylococcal penicillin (Nafcillin*, Vancomycin or Clindamycin)** plus 2nd or 3rd generation cephalosporin |
Extended-spectrum penicillin with or without β-lactamase inhibitor | ||
>5 years | S aureus, S pyogenes, S pneumoniae, Group A streptococci |
Antistaphylococcal penicillin (Nafcillin*, Vancomycin or Clindamycin)** |
Adolescent, sexually active | N gonorrhoeae | 3rd generation cephalosporin (Ceftriaxone, Cefotaxime) |
*Nafcillin may be used if <10% of community-acquired S aureus isolates are Methicillin-resistant
**Vancomycin or Clindamycin may be used for empiric treatment if >10% of community-acquired S aureus isolates are Methicillin-resistant
Duration of Treatment
- Parenteral antibiotics are usually given for 2 weeks followed by oral antibiotics for 2 to 4 weeks
- Duration of antibiotic therapy depends on the site of infection, presence of adjacent osteomyelitis, etiologic agent, clinical and laboratory response
- Arthritis from S aureus and Gram-negative organisms may require longer treatment durations compared to arthritis from S pneumoniae, S pyogenes and H influenzae, P aeruginosa, Enterobacter spp
- 7-10 days of antibiotic treatment is required for gonococcal arthritis
- Infectious arthritis of the hip and spine may require a longer period of antibiotic therapy
Oral Antibiotic Therapy
- Treatment for infectious arthritis may be continued using oral antibiotics once infection and inflammation are adequately controlled
- An oral antibiotic with appropriate antimicrobial coverage should be chosen
- Adherence to oral antibiotic regimen should be ensured as well as careful patient monitoring
- Oral antibiotics often used in infectious arthritis treatment include Cloxacillin, Dicloxacillin, Cefalexin, Clindamycin, Quinolones
- Oral regimen should have the same coverage as the intravenous (IV)/intramuscular (IM) drug that produced improvement of symptoms