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Nongonococcal Infectious Arthritis Medication

  • Author: Edward Dwyer, MD; Chief Editor: Herbert S Diamond, MD  more...
Updated: Mar 15, 2016

Medication Summary

Antimicrobial therapy is dictated by the results of a Gram stain and the clinical characteristics of the host. If the results of a Gram stain of synovial fluid identify no organism, empiric therapy is initiated on the basis of the clinical characteristics of the host. Mycobacterial and fungal infections are treated with agents appropriate to the causative pathogen.



Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.



Nafcillin is used as initial therapy for possible penicillin G–resistant streptococcal or staphylococcal infections. In a patient with severe infections, it should be given parenterally at first, then orally as the patient's condition warrants. Because of the risk thrombophlebitis, particularly in elderly patients, parenteral administration should be continued for a short period (1-2 days) only.

Ceftriaxone (Rocephin)


Ceftriaxone is a third-generation cephalosporin with broad-spectrum gram-negative activity; it has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. It arrests bacterial growth by binding to 1 or more penicillin-binding proteins (PBPs).

Ciprofloxacin (Cipro, Cipro XR)


Ciprofloxacin inhibits bacterial DNA synthesis and thus growth. It is active against gram-negative rods and may be administered with nafcillin.



Vancomycin is active against Staphylococcus epidermidis. To avoid toxicity, the current recommendation is to assay vancomycin trough levels after the third dose in a sample drawn 0.5 hours before the next dose. Dose adjustment is possible in patients with renal impairment; the adjustment should be based on creatinine clearance.


Antitubercular agents

Class Summary

Antitubercular agents are used when therapy for tuberculous arthritis is indicated.



Isoniazid offers the best combination of effectiveness, low cost, and minor adverse effects. Coadministration of pyridoxine is recommended if peripheral neuropathies develop secondary to isoniazid therapy. Prophylactic pyridoxine 6-50 mg/day is recommended.

Rifampin (Rifadin)


Rifampin is given in combination with at least 1 other antituberculous drug (eg, isoniazid); it inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 months or until 6 months have elapsed since conversion to a negative sputum culture result.


Antifungals, Systemic

Class Summary

These agents are used when fungal arthritis, such as candidal arthritis, is documented.

Amphotericin B lipid complex (Abelcet)


Amphotericin B is produced from a strain of Streptomyces nodosus; it can be fungistatic or fungicidal. This agent binds to sterols (eg, ergosterol) in the fungal cell membrane, causing intracellular components to leak, with subsequent fungal cell death.

Fluconazole (Diflucan)


Fluconazole is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation. It is suggested for use in combination with amphotericin.

Contributor Information and Disclosures

Edward Dwyer, MD Associate Professor of Medicine, Columbia University Medical Center

Edward Dwyer, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.


Elliot Goldberg, MD Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine

Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert E Wolf, MD, PhD Professor Emeritus, Department of Medicine, Louisiana State University School of Medicine in Shreveport; Chief, Rheumatology Section, Medical Service, Overton Brooks Veterans Affairs Medical Center

Robert E Wolf, MD, PhD is a member of the following medical societies: American College of Rheumatology, Arthritis Foundation, and Society for Leukocyte Biology

Disclosure: Nothing to disclose.

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