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.

Ciprofloxacin (Cipro)

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

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.

Oxacillin (Bactocill)

Useful against methicillin-sensitive S aureus.

Vancomycin (Vancocin)

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

Linezolid (Zyvox)

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

• Search for CME/CE on This Topic »

• Septic Arthritis (Orthopedic Surgery)
• Septic Arthritis, Pediatrics (Orthopedic Surgery)
• Septic Arthritis (Radiology)
• Aspiration Techniques and Indications for Surgery, Septic Arthritis (Orthopedic Surgery)

• Knee Pain Introduction
• Arthritis Center
• Types of Knee Pain
• Bites and Stings Center
• Ticks Overview

• Short Antibiotic Course Helps Clear Septic Arthritis

• Value of MRI After Recent Diagnostic or Surgical Intervention in Children With Suspected Osteomyelitis
• Prosthetic Shoulder Arthritis Related to Propionibacterium acnes
• Beyond Spaghetti and Meatballs: Skin Diseases Associated With the Malassezia Yeasts

• Sepsis Resource Center