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 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 kinga
    e
    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
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