Nongonococcal Infectious Arthritis Treatment & Management

  • Author: Edward Dwyer, MD; Chief Editor: Herbert S Diamond, MD   more...
 
Updated: Jan 19, 2012
 

Medical Care

  • The most important consideration in the treatment of infectious arthritis is the rapid institution of appropriate antimicrobial therapy. Daily joint aspiration must be performed until inflammation subsides.
  • Patients with bacterial arthritis must be hospitalized.
    • Intravenous antibiotic therapy is initiated immediately upon admission. If the results of a Gram stain of synovial fluid identify no organism, initiate empiric therapy based on the clinical characteristics of the host.
    • Healthy adults can be treated with antistaphylococcal penicillin or cephalosporin. Patients who reside in communities with a high prevalence of community-acquired methicillin-resistant S aureus should be initially treated with vancomycin pending culture results.[8]
    • Elderly debilitated patients or patients with chronic medical conditions require expanded antimicrobial coverage to cover gram-negative bacteria. This usually requires the addition of a third-generation cephalosporin, an aminoglycoside, or a quinolone.
    • Patients with nosocomial infections in whom pseudomonal species are considered may need an extended-spectrum penicillin such as piperacillin or carbenicillin.
    • Cultural sensitivities, when available, may help identify appropriate modifications to subsequent therapy.
    • Depending on the causative organism, most experts recommend 2-4 weeks of parenteral therapy.
    • Institute daily arthrocentesis of the affected joint until synovial fluid culture results are negative or considerable clinical improvement in the joint is apparent.
  • Fungal arthritis is appropriately treated with intravenous amphotericin B plus an oral azole. The recommended duration of therapy is 6-12 weeks, for a total dose of 1-3 g of amphotericin B.[9]
  • Mycobacterial arthritis treatment varies depending on the infecting agent.
    • Patients with M tuberculosis infection are treated initially with 4 drugs (rifampin, isoniazid, pyrazinamide, ethambutol [RIPE]) for 2 months; then, depending on the sensitivities, isoniazid and rifampin are continued for a total of 9-12 months.[9]
    • An M marinum infection requires rifampin and ethambutol for 6-12 weeks.
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Surgical Care

  • Joints that do not respond to antimicrobial therapy and daily arthrocentesis require drainage and debridement, either with arthroscopy or with an open procedure.
  • A joint with an infected prosthesis requires removal of the prosthesis and reimplantation after an appropriate course of antimicrobial therapy.
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Consultations

  • Rheumatologist
  • Orthopedic surgeon
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Activity

  • Encourage either passive or active daily range-of-motion exercises.
  • Avoid immobilizing the joint.
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Contributor Information and Disclosures
Author

Edward Dwyer, MD  Assistant Professor, Department of Medicine, Columbia University College of Physicians and Surgeons

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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

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.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD  Adjunct Professor of Medicine, Division of Rheumatology, University of Pittsburgh School of Medicine; 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, and Phi Beta Kappa

Disclosure: Merck Ownership interest Other; Smith Kline Ownership interest Other; Zimmer Ownership interest Other

References

  1. Smith JW, Chalupa P, Shabaz Hasan M. Infectious arthritis: clinical features, laboratory findings and treatment. Clin Microbiol Infect. Apr 2006;12(4):309-14. [Medline].

  2. García-De La Torre I, Nava-Zavala A. Gonococcal and nongonococcal arthritis. Rheum Dis Clin North Am. Feb 2009;35(1):63-73. [Medline].

  3. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford). Jan 2001;40(1):24-30. [Medline].

  4. Kaandorp CJ, Krijnen P, Moens HJ, Habbema JD, van Schaardenburg D. The outcome of bacterial arthritis: a prospective community-based study. Arthritis Rheum. May 1997;40(5):884-92. [Medline].

  5. Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med. Mar 21 1985;312(12):764-71. [Medline].

  6. Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. Oct 2002;15(4):527-44. [Medline].

  7. von Essen R. Culture of joint specimens in bacterial arthritis. Impact of blood culture bottle utilization. Scand J Rheumatol. 1997;26(4):293-300. [Medline].

  8. Chambers HF. Community-associated MRSA--resistance and virulence converge. N Engl J Med. Apr 7 2005;352(14):1485-7. [Medline].

  9. Harrington JT. Mycobacterial and fungal arthritis. Curr Opin Rheumatol. Jul 1998;10(4):335-8. [Medline].

  10. [Best Evidence] Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis. Apr 2007;66(4):440-5. [Medline].

 
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