infectious%20arthritis
INFECTIOUS ARTHRITIS
The classical presentation of infectious arthritis is acute onset of pain, warmth and swelling of a single joint.
The range of motion is usually decreased.
The knee is the most commonly affected but any joint may be involved.
Fever and chills may be present.
More than 1 joint may be involved in patients with pre-existing joint disease, other inflammatory conditions or severe sepsis, and in some patients infected with certain pathogens eg N gonorrheae, N meningitidis and Salmonella spp.
Infectious arthritis must always be a part of the differential diagnosis in a patient with an acute monoarthritis. 

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 & destructive nature of the infection
  • Antibiotics should be given by the parenteral route initially
  • Antibiotic therapy should be revised once results of culture & 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 antibiotic to penetrate joint
  • Likely pathogens causing infectious arthritis & 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 w/o risk for Methicillin-resistant Staphylococcus aureus (MRSA)  Vancomycin
    Gram-positive cocci, hospital-acquired or w/ other risk for MRSA Vancomycin or Clindamycin*
    Gram-negative bacilli 3rd Generation Cephalosporin (Ceftazidime, Ceftriaxone, Cefotaxime) w/ or w/o 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-negative
    Clinical Profile Recommended Empiric Antibiotics
    No risk factors for atypical organisms Flucloxacillin
    Immunocompetent Vancomycin
    Immunocompromised patients, injection drug users, traumatic bacterial arthritis Vancomycin w/ 3rd generation cephalosporin or an aminoglycoside
    Risk factors for MRSA infection (eg catheters, recent hospital confinement) Vancomycin*
    N gonorrhoeae infection suspected Ceftriaxone

* If patient has allergy or drug intolerance to Vancomycin, Daptomycin, Linezolid, Clindamycin or TMP-SMX are reasonable alternatives

Children: Based on age

    Age of Child Probable Pathogen Recommended Empiric Antibiotics
    Neonate S aureus, Group B streptococci, Gm negative bacilli Antistaphylococcal Penicillin (Nafcillin*, Vancomycin or Clindamycin)**
    plus Cephalosporin (3rd generation) plus Aminoglycoside
    ≤ 5 years old S aureus, S pneumoniae, S pyogenes, H influenzae, K kingae Antistaphylococcal Penicillin (Nafcillin*, Vancomycin or Clindamycin)** plus
    Cephalosporin (2nd or 3rd generation)
    Extended-spectrum Penicillin w/ or w/o β-lactamase inhibitor
    >5 years old S aureus, S pyogenes, S pneumoniae, Group A streptococci Antistaphylococcal Penicillin (Nafcillin*, Vancomycin or Clindamycin)**
    Adolescent, sexually active N gonorrhoeae (Nafcillin*, Vancomycin or Clindamycin)**
    Cephalosporin (3rd generation) (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 & laboratory response
    • Arthritis from S aureus & Gram negative organisms may require longer treatment durations compared to arthritis from S pneumoniae, S pyogenes & H influenzae, P aeruginosa, Enterobacter spp
    • 7-10 days of antibiotic treatment is required for gonococcal arthritis
    • Infectious arthritis of the hip & spine may require a longer period of antibiotic therapy

Oral antibiotic therapy

  • Treatment for infectious arthritis may be continued using oral antibiotics once infection & inflammation are adequately controlled
  • An oral antibiotic w/ 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 IV/IM drug that produced improvement of symptoms
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