Gonococcal Arthritis Treatment & Management

The management of acute septic arthritis is discussed in the eMedicine article Septic Arthritis. When septic arthritis is suspected, empiric antibiotics directed against likely pathogens should be used until confirmatory laboratory data are available. Antibiotic coverage in healthy hosts should initially include gram-positive organisms, which account for approximately 80% of nongonococcal monoarthritis cases. S aureus accounts for 60%, non–group A Streptococcus species cause 15%, and Streptococcus pneumoniae cause 3%. Gram-negative organisms, accounting for another 18%, should be covered in patients who are immunocompromised, elderly, or otherwise at risk.

Additional management considerations for gonococcal arthritis include the following:

• Most patients with suspected acute infectious arthritis, including gonococcal arthritis, should be hospitalized to establish a diagnosis and to monitor for improvement or complications. Daily synovial fluid drainage is recommended for purulent effusions associated with gonococcal arthritis. Surgical drainage is needed when arthrocentesis is ineffective. The transition to oral antibiotics can usually be made 24-48 hours after clinical improvement.
• A thorough travel history for the patient and any sexual partners is important in selecting initial therapy for gonococcal infections. Quinolone-resistant N gonorrhoeae (QRNG) is common in the Pacific and parts of Asia and is increasing in the United States, particularly on the West Coast.^[4] For this reason, the Centers for Disease Control (CDC) no longer recommends quinolones for the treatment of gonococcal infections.^[11]
• According to 2006 CDC guidelines, the initial treatment of choice for gonococcal arthritis or disseminated gonococcal infection (DGI) in adults is ceftriaxone 1 g intramuscularly (IM) or intravenously (IV) every 24 hours.^[12] Alternatives include ceftizoxime 1 g IV every 8 hours or cefotaxime 1 g IV every 8 hours.^[12] These dosing strategies were affirmed in the 2010 CDC guidelines.^[13]
• In patients intolerant of cephalosporins or in the case of pregnancy, spectinomycin 2 g IM every 12 hours was formerly considered an option^[12] ; however, because this antibiotic is not available in the United States and azithromycin 2 g orally has been recommended as an alternative.^[13]
• As of April 2007, the CDC guidelines stated that fluoroquinolones are no longer recommended in the treatment of gonococcal infections in the United States.^[11] The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP), which showed the proportion of fluoroquinolone-resistant (QRNG) gonorrhea cases in heterosexual men reached 6.7% in the first half of 2006, an 11-fold increase from 0.6% in 2001.^[11] This effectively limits treatment of gonorrhea to drugs in the cephalosporin class (see above).
• Fluoroquinolones may be considered as alternative agents for DGI in patients unable to take cephalosporins if antimicrobial susceptibility can be documented with culture results. Fluoroquinolone regimens include ciprofloxacin (400 mg IV q12h; 400 mg PO bid), ofloxacin (400 mg IV/PO q12h) or levofloxacin (250 mg/d IV; 500 mg/d PO).
• Oral regimens that can be started 24-48 hours after initial improvement include the following:

  • Cefixime 400 mg PO bid^[14] (once again available in the United States via Lupin Pharmaceuticals, Inc., of Baltimore, MD)
  • Cefixime suspension 500 mg PO bid
• Patients should continue oral antibiotics for at least 1 week.
• Special situations include pregnant and pediatric patients (< 8 y). These patients should not be treated with quinolones or tetracyclines. Pregnant patients with gonococcal infections should be treated with a recommended cephalosporin.^[12] Spectinomycin is indicated for patients who cannot tolerate a cephalosporin. Pediatric patients can be treated with ceftriaxone 50 mg/kg/d IV or IM for 7 days. Data are insufficient to support the use of oral cephalosporins for DGI or arthritis in children.
• Examine patients with DGI for clinical evidence of endocarditis and meningitis. These patients require ceftriaxone 1-2 g IV every 12 hours.^[12] Patients with endocarditis require much longer courses of antibiotics (4-6 wk) and may require surgical intervention.
• Patients with confirmed diagnosis of a localized gonococcal infection can probably be discharged with outpatient medications if they are considered reliable for follow-up care. Synovial effusions may require a longer duration of antibiotics, but open drainage is rarely required. Intra-articular antibiotics have no known benefit.
• Because 30%-50% of patients are co-infected with Chlamydia, test all patients and treat with azithromycin (1 g PO as a single dose) or doxycycline (100 mg PO bid for 7 d).^[12] Alternatives for pregnant patients include erythromycin (500 mg PO qid for 7 d) or amoxicillin (500 mg tid for 7 d). Regimens for the treatment of chlamydial infection in children include the following:^[12]

  • Children who weigh less than 45 kg - Erythromycin base or ethylsuccinate 50 mg/kg PO divided qid for 14 days
  • Children who weigh more than 45 kg but who are younger than 8 years - Azithromycin 1 g PO as a single dose
  • Children older than 8 years - Azithromycin 1 g PO in a single dose or doxycycline 100 mg PO bid for 7 days
• Patients should be advised to refer their sexual partners for evaluation and treatment.

Open drainage or arthroscopy of infected joints is needed when arthrocentesis is insufficient. However, joint effusions in gonococcal arthritis rarely result in permanent damage.

• Consider consulting a rheumatologist for assistance in the evaluation and management of septic joints.
• Consider consulting an infectious disease specialist for management of DGI cases and determination of optimal antibiotic therapy later in the course of the disease.
• Consider consulting a cardiologist if acute endocarditis is suspected.
• Consulting an orthopedist may be required for arthroscopic or surgical drainage of an inaccessible joint (eg, hip) or for failure of nonsurgical management (daily aspiration).

Bedrest during inpatient status and brief immobilization of the septic joint aid in decreasing pain, especially when nonsteroidal anti-inflammatory drugs (NSAIDs) are not used.