eMedicine Specialties > Infectious Diseases > Bone and Joint Infections

Septic Arthritis: Treatment & Medication

Author: John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
Contributor Information and Disclosures

Updated: Aug 25, 2008

Treatment

Medical Care

Medical management of infective arthritis focuses on adequate and timely drainage of the infected synovial fluid, administration of appropriate antimicrobial therapy, and immobilization of the joint to control pain. Acute PJI (<3 wk in duration) can be cured medically if it is of the early type or secondary to hematogenous spread without any evidence of periarticular soft-tissue involvement or joint instability.5

  • In native joint infections, antibiotics usually need to be administered parenterally for at least 2 weeks. However, each case must be evaluated independently. Infection with either methicillin-resistant S aureus (MRSA) or methicillin-susceptible S aureus (MSSA) requires at least 4 full weeks of intravenous antibiotic therapy. Orally administered antimicrobial agents are almost never indicated in the treatment of S aureus infections. Gram-negative native joint infections with a pathogen that is sensitive to quinolones can be treated with oral ciprofloxacin for the final 1-2 weeks of treatment. As a rule, a 2-week course of intravenous antibiotics is sufficient to treat gonococcal arthritis.17
  • Initial antibiotic choices must be empirical, based on the sensitivity pattern of the pathogens of the community. Consider the rise of resistance among potential bacteria when choosing an initial antibiotic regimen. If local incidence of MRSA is high (in particular, marked increase in the resistance of the pneumococcus), prescribe alternate antibiotics initially. Because many isolates of group B streptococci have become tolerant of penicillin, use a combination of penicillin and gentamicin or a later-generation cephalosporin. MRSA is becoming established outside of the hospital. Enterobacteriaceae and P aeruginosa are becoming more resistant to multiple antibiotics. Knowing the resistance patterns in the community, as well as in the hospital, is most important.
  • Preferably, the antibiotic should be bactericidal with some effect against the slow-growing organisms that are protected within a biofilm (eg, CONS). Rifampin fulfills these requirements. It should never be used alone because of the rapid development of bacterial resistance to the drug.
  • The choice of the type of drainage, whether percutaneous or surgical, has not been resolved completely.19,20 In general, use a needle aspirate initially, repeating joint taps frequently enough to prevent significant reaccumulation of fluid. Aspirating the joint 2-3 times a day may be necessary during the first few days. If frequent drainage is necessary, surgical drainage becomes more attractive.
  • If, after 5 days of therapy, the joint shows some degree of improvement, consider an empirical trial of an anti-inflammatory agent.
  • If the joint fails to respond after 5 days of appropriate antibiotic therapy (eg, presence of clinically significant fever, continued synovial purulence, persistently positive findings on culture), reassess the therapeutic approach.
  • Reculture the fluid and reexamine for crystals.
  • Perform appropriate serologies for diagnosis of Lyme disease. If these are positive, treat per current guidelines.
  • If fungal or mycobacterial infection is possible, consider obtaining a synovial biopsy.
  • Consider the possibility of reactive arthritis. Nonsteroidal inflammatory agents are the primary therapeutic agents for reactive arthritis.
  • Perform imaging studies, either radiographs or an MRI, to rule out periarticular osteomyelitis.
  • The use of fluoroquinolones for an extended period should be considered when the removal of an infected prosthesis is not possible. Cure rates as high as 62% have been documented in relatively small series. Generally, such prolonged therapy is seen as suppressive and not curative.21

Surgical Care

Surgical drainage is indicated when one or more of the following occur: the appropriate choice of antibiotic and vigorous percutaneous drainage fails to clear the infection after 5-7 days, the infected joints are difficult to aspirate (eg, hip), or adjacent soft tissue is infected.

  • Routine arthroscopic lavage is rarely indicated. However, drainage through the arthroscope is replacing open surgical drainage. With arthroscopic drainage, the operator can visualize the interior of the joint and can drain pus, debride, and lyse adhesions.
  • Gonococcal-infected joints rarely require surgical drainage.
  • In cases of PJI that require surgery for cure (see above), successful treatment requires appropriate antibiotic therapy combined with removal of the hardware. Despite appropriate antibiotic use, the success rate is only about 20% if the prosthesis is left in place. A 2-stage approach is the most effective technique.
    • First, remove the prosthesis and follow with 6 weeks of antibiotic therapy. Then, place the new joint, impregnating the methylmethacrylate cement with an anti-infective agent (ie, gentamicin, tobramycin). Antibiotic diffusion into the surrounding tissues is the goal. The success rate for this approach is approximately 95% for both hip and knee joints.
    • An intermediate method is to exchange the new joint for the infected joint in a 1-stage surgical procedure with concomitant antibiotic therapy. This method, with concurrent use of antibiotic cement, succeeds in 70-90% of cases.

Consultations

In general, obtain a consultation with an orthopedic surgeon or rheumatologist. If the initial treatment response is poor or the etiology of the synovitis remains unknown, consult with an infectious disease specialist.

Activity

If the patient's condition responds adequately after 5 days of treatment, begin gentle mobilization of the infected joint. Most patients require aggressive physical therapy to allow maximum postinfection functioning of the joint.

Medication

The empirical choice of antibiotic therapy is based on results of the Gram stain and the clinical picture and background of the patient. When the Gram stain fails to reveal any microorganisms (40-50% of cases), the individual's age and sexual activity become the major determinants to differentiate gonococcal from nongonococcal arthritis. When no evidence suggests infection elsewhere, antibiotics must cover S aureus, streptococcal species, and gonococci (in patients who are sexually active).

Evidence shows that earlier initiation of an appropriate antibiotic regimen produces better functional results. Generally, treatment is administered intravenously for 3-4 weeks. The major exception to this is in the case of joints with gonococcal infection, for which total therapy is approximately 2 weeks, with switch to oral therapy. No indication exists for direct installation of antibiotics into the joint cavity. Such practice may increase the degree of inflammation.

Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. The use of linezolid with or without rifampin should be considered for staphylococcal PJI.


Ceftriaxone (Rocephin)

DOC against N gonorrhoeae and effective against gram-negative enteric rods. Monitor sensitivity data.

Adult

2 g IV qd for 48 h after clinical improvement, followed by 1 wk PO therapy with cefixime

Pediatric

50-75 mg/kg/d IV divided q12h for 4 wk; not to exceed 2 g/d

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding women; avoid predelivery and in neonates; may cause pseudobiliary lithiasis


Ciprofloxacin (Cipro)

Alternative antibiotic to ceftriaxone to treat N gonorrhoeae and gram-negative enteric rods.

Adult

400 mg IV for 48 h after improvement, then 500 mg PO q12h for 1 wk

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in pregnancy; adjust dose in renal impairment; superinfections may occur with prolonged or repeated antibiotic therapy; may cause seizures; avoid in patients with seizure and/or CNS disorders


Cefixime (Suprax)

Third-generation oral cephalosporin with broad activity against gram-negative bacteria. By binding to one or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
PO follow-up to IV ceftriaxone to treat N gonorrhoeae.
Note: After a period of unavailability, oral cefixime is again FDA-approved in tab and susp forms. However, at the time of this writing, tabs remain unavailable in the United States. Wyeth Pharmaceuticals (Collegeville, Pa) discontinued manufacturing Suprax in the United States. In October 2002, the company ceased marketing cefixime tab (200 mg and 400 mg) because of depletion of company inventory. Wyeth's patent for cefixime expired on November 10, 2002.

Adult

400 mg PO q12h for 1 wk

Pediatric

4 mg/kg (elixir) PO q12h for 1 wk

Probenecid may increase effects of cefixime

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment


Oxacillin (Bactocill)

Useful against methicillin-sensitive S aureus.

Adult

2 g IV q4h for 4 wk

Pediatric

12.5-50 mg/kg IV q6h for 4 wk

Oxacillin decreases effects of contraceptives and tetracycline; when administered concomitantly with disulfiram and probenecid, oxacillin levels may increase; effects of anticoagulants increase when large IV doses of oxacillin are administered

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Decrease dose with impaired renal function


Vancomycin (Vancocin)

Anti-infective against methicillin-sensitive S aureus, methicillin-resistant CONS, and ampicillin-resistant enterococci in patients allergic to penicillin.

Adult

15 mg/kg IV q12h, infuse over 60 min; not to exceed 2 g/24 h unless serum levels are monitored

Pediatric

10 mg/kg IV q6h for 1 mo

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; when taken concurrently with aminoglycosides, effects on neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure and neutropenia; too rapid IV infusion (dose administered over a few min) causes red man syndrome; rarely occurs when dose is administered as 2-h administration or as PO or IP administration; red man syndrome is not an allergic reaction


Linezolid (Zyvox)

Alternative in patients allergic to vancomycin and for treatment of vancomycin-resistant enterococci.

Adult

600 mg/kg IV q12h for 1 mo

Pediatric

Not established

Reduce dose of dopamine or epinephrine if concurrent use required

Documented hypersensitivity; MAOI use

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients who are at increased risk for bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, or who may require >2 wk of therapy (monitor platelet counts)

More on Septic Arthritis

Overview: Septic Arthritis
Differential Diagnoses & Workup: Septic Arthritis
Treatment & Medication: Septic Arthritis
Follow-up: Septic Arthritis
References

References

  1. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore). May 2004;83(3):139-48. [Medline].

  2. Berbari EF, Marculescu C, Sia I, Lahr BD, Hanssen AD, Steckelberg JM, et al. Culture-negative prosthetic joint infection. Clin Infect Dis. Nov 1 2007;45(9):1113-9. [Medline].

  3. Cucurull E, Espinoza LR. Gonococcal arthritis. Rheum Dis Clin North Am. May 1998;24(2):305-22. [Medline].

  4. Goldenberg DL, Cohen AS. Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med. Mar 1976;60(3):369-77. [Medline].

  5. Broy SB, Schmid FR. A comparison of medical drainage (needle aspiration) and surgical drainage (arthrotomy or arthroscopy) in the initial treatment of infected joints. Clin Rheum Dis. Aug 1986;12(2):501-22. [Medline].

  6. McGuire NM, Kauffman CA. Septic arthritis in the elderly. J Am Geriatr Soc. Mar 1985;33(3):170-4. [Medline].

  7. Smith JW, Piercy EA. Infectious arthritis. Clin Infect Dis. Feb 1995;20(2):225-30; quiz 231. [Medline].

  8. Baraboutis I, Skoutelis A. Streptococcus pneumoniae septic arthritis in adults. Clin Microbiol Infect. Dec 2004;10(12):1037-9. [Medline].

  9. Raad J, Peacock JE Jr. Septic arthritis in the adult caused by Streptococcus pneumoniae: a report of 4 cases and review of the literature. Semin Arthritis Rheum. Oct 2004;34(2):559-69. [Medline].

  10. [Best Evidence] Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis?. JAMA. Apr 4 2007;297(13):1478-88. [Medline].

  11. Rice PA. Gonococcal arthritis (disseminated gonococcal infection). Infect Dis Clin North Am. Dec 2005;19(4):853-61. [Medline].

  12. Manadan AM, Block JA. Daily needle aspiration versus surgical lavage for the treatment of bacterial septic arthritis in adults. Am J Ther. Sep-Oct 2004;11(5):412-5. [Medline].

  13. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. Oct 14 2004;351(16):1645-54. [Medline].

  14. Kaandorp CJ, Krijnen P, Moens HJ, et al. The outcome of bacterial arthritis: a prospective community-based study. Arthritis Rheum. May 1997;40(5):884-92. [Medline].

  15. Zimmermann B 3rd, Mikolich DJ, Ho G Jr. Septic bursitis. Semin Arthritis Rheum. Jun 1995;24(6):391-410. [Medline].

  16. Wilson ML, Winn W. Laboratory diagnosis of bone, joint, soft-tissue, and skin infections. Clin Infect Dis. Feb 1 2008;46(3):453-7. [Medline].

  17. Wise CM, Morris CR, Wasilauskas BL, et al. Gonococcal arthritis in an era of increasing penicillin resistance. Presentations and outcomes in 41 recent cases (1985-1991). Arch Intern Med. Dec 12-26 1994;154(23):2690-5. [Medline].

  18. Goldenberg DL. Septic arthritis and other infections of rheumatological significance. Rheum Clin NA. 1991;17:149. [Medline].

  19. Garcia-De La Torre I. Advances in the management of septic arthritis. Rheum Dis Clin North Am. Feb 2003;29(1):61-75. [Medline].

  20. Koeppe J, Johnson S, Morroni J, Siracusa-Rick C, Armon, C. Suppressive Antibiotic Therapy for Retained Infected Prosthetic Joints: Case Series and Review of the Literature. Infectious Diseases in Clinical Practice. July 2008;16(4):224-9.

  21. Kaandorp CJ, Dinant HJ, van de Laar MA, et al. Incidence and sources of native and prosthetic joint infection: a community based prospective survey. Ann Rheum Dis. Aug 1997;56(8):470-5. [Medline].

  22. Aliabadi P, Nikpoor N. Imaging osteomyelitis. Arthritis Rheum. May 1994;37(5):617-22. [Medline].

  23. Ince A, Rupp J, Frommelt L, et al. Is "aseptic" loosening of the prosthetic cup after total hip replacement due to nonculturable bacterial pathogens in patients with low-grade infection?. Clin Infect Dis. Dec 1 2004;39(11):1599-603. [Medline].

  24. Rosenthal J, Bole GG, Robinson WD. Acute nongonococcal infectious arthritis. Evaluation of risk factors, therapy, and outcome. Arthritis Rheum. Aug 1980;23(8):889-97. [Medline].

  25. Steere AC, Sikand VK. The presenting manifestations of Lyme disease and the outcomes of treatment. N Engl J Med. Jun 12 2003;348(24):2472-4. [Medline].

Further Reading

Keywords

septic arthritis, infectious arthritis, infective arthritis, suppurative arthritis, reactive arthritis, inflammatory arthritis, bacterial septic arthritides, acute bacterial arthritis, bacterial septic arthritis, bacterial arthritis, viral arthritis, Neisseria gonorrhoeae, N gonorrhoeae, Staphylococcus aureus, S aureus, Streptococcus viridans, S viridans, Streptococcus pneumoniae, S pneumoniae, group B streptococci, crystalline arthritis, Lyme disease, Lyme arthritis, prosthetic joint infections, PJI, rheumatoid arthritis

Contributor Information and Disclosures

Author

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Maria D Mileno, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, Brown University
Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Aaron Glatt, MD, Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, New Island Hospital
Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.