Nongonococcal Infectious Arthritis Medication
- Author: Edward Dwyer, MD; Chief Editor: Herbert S Diamond, MD more...
Medication Summary
Antimicrobial therapy is dictated by the results of a Gram stain and the clinical characteristics of the host. If the Gram stain result is positive for gram-positive cocci, then S aureus and streptococci are the most likely infecting agents. If the patient is a healthy sexually active adult, gonococci and gram-positive cocci are the most likely infecting agents. If the Gram stain result is negative in an elderly or compromised host, gram-negative rods are likely. S epidermidis and gram-negative rods are more likely in a patient with a prosthetic joint or a patient who has undergone a recent operative procedure.
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Nafcillin (Unipen)
Initial therapy for possible penicillin G–resistant streptococcal or staphylococcal infections.
Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants.
Due to thrombophlebitis, particularly in elderly patients, administer parenterally only for short term (1-2 d); change to oral route as clinically indicated.
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Ciprofloxacin (Cipro)
Inhibits bacterial DNA synthesis and, consequently, growth. Active against gram-negative rods; administered with nafcillin
Vancomycin (Vancocin)
Active against S epidermidis. To avoid toxicity, the current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Dose adjustment possible in renal impairment. Base adjustment on CrCl.
Antitubercular agents
Class Summary
These agents are used when therapy for tuberculous arthritis is indicated.
Isoniazid (NIH, Laniazid)
Best combination of effectiveness, low cost, and minor adverse effects. Coadministration of pyridoxine is recommended if peripheral neuropathies develop secondary to isoniazid therapy. Prophylactic doses of 6-50 mg/d of pyridoxine are recommended.
Rifampin (Rifadin, Rimactane)
For use in combination with at least one other antituberculous drug, such as isoniazid; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 mo or until 6 mo have elapsed since conversion to negative sputum culture result.
Antifungals
Class Summary
These agents are used when fungal arthritis, such as candidal arthritis, is documented.
Amphotericin B lipid complex (Abelcet)
Produced from a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal cell membrane, causing intracellular components to leak, with subsequent fungal cell death.
Fluconazole (Diflucan)
Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation. Suggested for use with amphotericin administration
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