eMedicine Specialties > Rheumatology > Infectious Arthritis

Gonococcal Arthritis: Treatment & Medication

Author: Michael P Keith, MD, FACP, Chief of Rheumatology, National Naval Medical Center; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences
Coauthor(s): Robert John Oglesby, MD, Chief of Rheumatology Service, Department of Medicine, Walter Reed Army Medical Center; Associate Professor of Medicine, Uniformed Services University of the Health Sciences
Contributor Information and Disclosures

Updated: Jul 27, 2009

Treatment

Medical Care

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 IM or IV every 24 hours.¹² Alternatives include ceftizoxime 1 g IV q8h or cefotaxime 1 g IV q8h.¹² In patients intolerant of cephalosporins, spectinomycin 2 g IM every 12 hours is another option¹² ; however, this antibiotic may not be readily available.¹³
• The April 2007 update of CDC guidelines states 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 bid¹⁴ (once again available in the United States via Lupin Pharmaceuticals, Inc., of Baltimore, MD)
  • Cefixime suspension 500 mg PO bid
  • Cefpodoxime 400 mg PO bid¹³ (clinical study ongoing)
• 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.

Surgical Care

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

Consultations

• 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).

Activity

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.

Medication

The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.

See Medical Care.

Antibiotics

These agents are indicated to treat gonococcal infection. Agents effective against chlamydial infection are included because of the significant co-infection rate.

Ceftriaxone (Rocephin)

Ceftriaxone is the DOC for disseminated gonococcal infection (DGI) or gonococcal arthritis, according to CDC guidelines. Bactericidal action is through inhibition of cell wall synthesis. No activity against Chlamydia.

Cefotaxime (Claforan)

An alternative third-generation cephalosporin to ceftriaxone for DGI or gonococcal arthritis. Bactericidal action is through inhibition of cell wall synthesis. No activity against Chlamydia.

Ceftizoxime (Cefizox)

Third-generation cephalosporin with broad-spectrum, gram-negative activity. May be used as an alternative to ceftriaxone for gonococcal arthritis or DGI. Lower efficacy against gram-positive organisms. Higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Cefixime (Suprax)

By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth. In 2008, Morbidity and Mortality Weekly Report reported that manufacture of this medication resumed in the United States.¹⁴ It is the only oral cephalosporin that the CDC recommends for use in patients with DGI or gonococcal arthritis.

Doxycycline (Vibramycin)

Commonly used as a cotreatment for suspected Chlamydia infection. May be used in complicated cases of gonococcal urethritis but not recommended for septic arthritis from gonococcus or a disseminated infection. Bacteriostatic by inhibiting bacterial protein synthesis.

Azithromycin (Zithromax)

Alternative to doxycycline as cotreatment aimed at Chlamydia infection. Ideal for the noncompliant patient because may be given as a one-time dose. Not a cited DOC for gonococcal arthritis or DGI.

Erythromycin (E-mycin)

Alternative to doxycycline for Chlamydia infection. Medication used to cotreat Chlamydia infection in pregnancy. Not a cited DOC for treatment of gonococcal arthritis or DGI. Acts through inhibition of bacterial protein synthesis.

Amoxicillin (Amoxil, Biomox, Trimox)

According to CDC guidelines, amoxicillin may be used for the treatment of chlamydia in pregnant women. Not a cited DOC for DGI or gonococcal arthritis.

Spectinomycin (Trobicin)

Inhibits protein synthesis in bacterial cells. Site of action is 30S ribosomal subunit and is structurally different from related aminoglycosides. Recommended by the CDC as an option in patients intolerant of cephalosporin antibiotics¹² ; however, this medication is not currently manufactured in the United States and may not be available.¹⁵

Levofloxacin (Levaquin)

Used to treat complicated and uncomplicated skin and skin structure infections. Fluoroquinolones should be used empirically in patients likely to develop exacerbation due to organisms resistant to other antibiotics. This is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive. Good monotherapy with extended coverage against Pseudomonas species, as well as excellent activity against pneumococcus. Agent acts by inhibition of DNA gyrase activity. Oral form has a reported bioavailability of 99%. New CDC guidelines no longer recommend fluoroquinolones because of resistance. May be used as alternative for DGI in patients unable to take cephalosporins if culture shows sensitivity to fluoroquinolones.

Ciprofloxacin (Cipro)

Useful for initial therapy when given intravenously and for oral therapy after initial response to intravenous therapy. Also effective against Chlamydia. Can be used to treat patients who are penicillin allergic. Do not use in pregnant or pediatric persons. New CDC guidelines no longer recommend fluoroquinolones because of resistance. May be used as alternative for DGI in patients unable to take cephalosporins if culture shows sensitivity to fluoroquinolones.

Ofloxacin (Floxin)

Useful medication for initial therapy when given IV and for oral therapy after an initial response to IV therapy. Also effective against Chlamydia and can be used to treat patients who are penicillin allergic. Do not use in pregnant or pediatric population. New CDC guidelines no longer recommend fluoroquinolones because of resistance. May be used as alternative for DGI in patients unable to take cephalosporins if culture shows sensitivity to fluoroquinolones.

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